Pediatric Cardiology

Guidelines for

Pediatric Cardiology

I

n The

Name Of Allah The most Gracious, The Most Merciful

C Ministry of Health , 2013 King Fahd National Library Cataloging-in-Publication Data Ministry of Health. General Directorate of Health Centers Guidelines for pediatric cardiology. / Ministry of Health. General Directorate of Health Centers .Riyadh , 2013 144 p : 21 x 29.7 cm ISBN : 978-603-8144-03-9

1- Cardiology etc.

2- Cardiology - Handbooks, manuals,

I-Title

616.1206 dc

1434/8829

L.D. No. 1434/8829 ISBN : 978-603-8144-03-9


Dr. Mansour M. Al Qurashi Consultant Pediatric Cardiologist

Head of Pediatric Cardiology Unit Al yamama hospital, Riyadh

Dr. Khalid Alomran

Consultant Pediatric Cardiologist King saud medical city

Dr. Abdullelah Fattaney Consultant Pediatric Cardiologist

Maternity and children hospital, Jeddah

5

Guidelines for


Introduction Dear Colleagues, It is a great pleasure to present “ guidelines for Pediatric Cardiology “ to be implemented by the ministry of health hospitals as part of its policy to standardize patient care delivery according to best international practices. This edition is considered a fundamental resource book containing policies, procedures, job descriptions and up-to-date clinical guidelines to assist the healthcare professionals to use as a tool to provide suitable care to patients. We hope that these guidelines and standards, will be helpful and practical in application. In conclusion, I would like to extend my heartfelt thanks and appreciation to the dedicated and hardworking team members including the Cardiology committee members and the Saudi heart association for their work in revising the said guidelines. Your comments and suggestions about this work are highly welcomed to improve the next edition , to be sent at the following address: General Directorate Of Hospitals, MOH, Riyadh, KSA.

Dr. Abdul Aziz Bin Hamed Al Ghamdi Director General Of Hospitals , MOH, KSA.

7

Guidelines for


TABLE OF CONTENTS NO

CONTENTS

PAGE NO

1

Cyanotic Congenital Heart Disease

11

2


13

HEART FAILURE AND WEAK PULSES

17

Heart Failure and Cardiogenic Shock

19

THERAPEUTIC MEASURES

20

ECG INTERPRETATION

22

ENDOCARDITIS PROPHYLAXIS

36

Pediatric Cardiology Division Policy and Procedures

39

For General Small Hospitals (50 – 200 beds) DIVISION of Pediatric Cardiology

3

41

Pediatric Cardiology Division Policy and Procedures

71

For General Hospitals (200 – 400 beds) DIVISION of Pediatric Cardiology

73

Pediatric Cardiology Division Policy and Procedures 4

107

For General Hospitals (400 – 600 beds) / Maternity and children Hospitals DIVISION of Pediatric Cardiology

109

9

Guidelines for


Guidelines for


10


Cyanotic Congenital Heart Disease RECOGNITION AND ASSESSMENT Symptoms and signs Ä Main causes are either respiratory or cardiac disease Ä Respiratory illness producing cyanosis will usually have signs of respiratory distress (e.g. cough, tachypnoea, recession and added respiratory sounds) Ä Cyanosis with mild or no respiratory distress likely to be cardiac disease reservoir bag more likely to be cardiac in origin

Causes of cardiac cyanosis a. Significant right-to-left shunt - pulmonary atersia, tricuspid atresia and Fallot’s tetralogy. b. Transposition with inadequate mixing, pulmonary or tricuspid atresia Ä poor response to high concentrations of inspiratory O2 Ä cyanosis worsened by crying, pain or upset Ä Fallot’s tetralogy: hypercyanotic episodes follow emotional or painful upset Ä finger clubbing when longstanding.

Duct-dependent pulmonary circulation o Blue, breathless or shocked Ä Pulmonary atresia


Ä Cyanosis not responding to high flow oxygen (15 L/min) via face mask and

Ä Critical pulmonary valve stenosis Ä Tricuspid atresia Ä Severe Fallot’s tetralogy Ä Transposition of the great arteries without septal defect Ä Single ventricle anatomy.

13

Guidelines for


Acute pulmonary outflow obstruction (cyanotic episodes) Ä Fallot’s tetralogy or other complex congenital cyanotic heart disease - very pale - lose consciousness - convulse

Respiratory distress


Ä Respiratory distress may be triggered in a cardiac patient by an intercurrent infection. The following may help identify when respiratory distress is caused by an underlying cardiac problem: Ä low SpO2 despite supplemental O2 Ä marked tachycardia Ä enlarged heart (clinically or on CXR) Ä gallop rhythm/murmur Ä enlarged liver/raised JVP Ä basal crackles Ä absent femoral pulses

Physical examination Ä Remember to check femoral pulses Ä If coarctation of the aorta suspected: check BP in upper and lower limbs (Dinamap) – normal difference <15 mmHg INVESTIGATIONS If infant cyanosed or in heart failure, discuss urgency of investigations with consultant

SpO2 Ä Check pre - (right arm) and postductal (lower limbs) Ä when breathing air before O2 given Ä after giving 15 L/min O2 by mask with a reservoir bag for 10 min

Guidelines for


14

Chest X-ray Ä For cardiac conditions, specifically record: Ä cardiac situs (normal or right side of chest) Ä aortic arch left or right-sided Ä bronchial situs (is the right main bronchus on the right?) Ä cardiac size and configuration Ä size of pulmonary vessels and pulmonary vascular markings Electrocardiogram Ä Axis of QRS complex Ä P-wave Ä R-S pattern in chest leads Ä P-R, QRS and Q-T intervals Ä P- and T-wave configuration Ä size of QRS in chest leads Nitrogen washout in cyanosed babies Ä Monitor SpO2 in air then in headbox after breathing 100% O2 for 10 min Ä In cyanotic congenital heart disease, PaO2 will remain below 20 kPa with SpO2 unchanged Ä Not as reliable as echocardiogram

Echocardiogram Ä Discuss urgency with consultant before referral to local paediatric cardiac


Ä See ECG interpretation guideline

centre IMMEDIATE TREATMENT If infant cyanosed or in heart failure, discuss urgency of referral to local paediatric cardiac surgical centre with consultant

15

Guidelines for


Duct-dependent congenital heart disease Ä Immediate treatment before transfer to a paediatric cardiac centre: Ä open duct with prostaglandin E2 . Ä start 0.01 microgram/kg per min IV infusion . Ä increasing if necessary to 0.05 microgram/kg per min. Ä (add 0.5 mL of prostaglandin E2 1 mg/mL to 500 mL 10% glucose so 0.6 mL/kg/hr is 0.01 microgram/kg per min).


Ä prostaglandin E1 is an alternative if prostaglandin E2 is not available, see BNFc Ä May cause apnoea and patients may need ventilation (PICU) Ä Beware of giving high concentrations of O2 as this encourages duct closure.

Acute pulmonary outflow obstruction (cyanotic episodes) Ä Immediate treatment before transfer to a paediatric cardiac centre: Ä do not upset child Ä give morphine 100-200 microgram/kg IV over 5 min or IM Ä provide high concentration facemask O2 (15 L/min with reservoir bag) Ä if Fallot’s tetralogy has been diagnosed by echocardiography, discuss with cardiologist use of propranolol starting at 15-20 microgram/kg IV gradually increasing, if necessary, to 100 microgram/kg given 12 hrly if <1 month, 6-8 hrly for 1 month-12 yr

SUBSEQUENT MANAGEMENT Ä On advice of consultant and paediatric cardiac centre

Guidelines for


16

HEART FAILURE AND WEAK PULSES COMMON DIFFERENTIAL DIAGNOSES Ä Aortic stenosis Ä Coarctation of the aorta Ä Hypoplastic left heart Ä Pericardial effusion Ä Myocarditis

RECOGNITION AND ASSESSMENT Presentation Ä Usually during first few weeks of life Ä Later triggered by an intercurrent infection, with associated myocarditis or prolonged arrhythmia Symptoms and signs Ä Failure to thrive Ä Rapid weight gain Ä Sweating Ä Breathlessness, particularly during feeding Ä Rapid respiratory rate Ä Tachycardia Ä Absent or low volume peripheral or central pulses


Ä Cardiomyopathy

Ä Enlarged heart Ä Prominent cardiac impulses Ä Quiet heart sounds in pericardial effusion Ä Thrill Ä Gallop rhythm Ä Enlarged liver

17

Guidelines for


INVESTIGATIONS Ä Check BP in all four limbs (Dinamap: normal <15 mmHg difference)

SpO2 Ä Check pre- (right arm) and postductal (lower limbs)


Ä In air and after giving O2

Chest X-ray Ä For cardiac conditions, specifically record: Ä cardiac situs (normal or right side of chest) Ä aortic arch left- or right-sided Ä bronchial situs (is right main bronchus on the right?) Ä cardiac size and configuration Ä size of pulmonary vessels and pulmonary vascular markings

Electrocardiogram Ä See ECG interpretation guideline Ä Axis of QRS complex Ä P wave Ä R-S pattern in chest leads Ä P-R, QRS and Q-T intervals Ä P and T wave configuration Ä size of QRS in chest leads

Echocardiogram Ä Discuss urgency with consultant before referral to local paediatric cardiac centre

HEART FAILURE AND CARDIOGENIC SHOCK Guidelines for


18

Heart Failure and Cardiogenic Shock Causes Ä Congenital heart malformations Ä Cardiomyopathies Ä Myocarditis Ä Arrhythmias Ä Hypoxia Ä Toxins Recognition of cardiogenic shock The clinical definition of cardiogenic shock is decreased cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume. Ä cardiogenic shock is recognized following cardiopulmonary resuscitation with adequate fluid replacement in patients with: Ä septic shock that fails to improve after adequate fluid replacement (e.g. ≥ 40 mL/kg). Ä a known heart condition and shock Ä a large heart on chest X-ray but previously well Ä shock, who have a history of poisoning Ä a murmur or pulmonary oedema, or both MONITORING Ä ECG monitor


Ä Acidosis

Ä Non-invasive BP Ä Pulse oximetry Ä Core-skin temperature difference Ä Daily weights Ä Intra-arterial BP for continuous pressure monitoring and arterial blood gas sampling Ä CVP: if shocked or ≥ 40 mL/kg fluid resuscitation has been needed Ä Urine output ( ≥ 1 mL/kg/hr)

19

Guidelines for


THERAPEUTIC MEASURES Progressive measures: 1-8 for all patients; 9-11 if cardiogenic shock 1. If breathless, elevate head and trunk 2. If infant not feeding well, give nasogastric feeds 3. In moderate-to-severe failure or if patient hypoxic or distressed, give O2 therapy via nasal cannulae (up to 2 L/min) or via a face mask with reservoir bag (up to 15 L/min)


4. Diuretics: furosemide 1-2 mg/kg orally or by slow IV injection and amiloride 100-200 microgram/kg orally 12 hourly. 5. If serum potassium <4.5 mmol/L, give additional potassium chloride 1 mmol/ kg 12 hrly enterally 6. Correct acidosis, hypoglycaemia and electrolyte imbalance 7. Relieve pain with morphine: loading dose 100-200 microgram/kg slow IV, followed by 50-100 microgram/kg slow IV 4-6 hrly or 10-20 microgram/kg/hr via IV infusion 8. If anaemic (Hb <10 g/dL), correct with slow infusion of packed cells to bring Hb to 12-14 g/dL 9. Monitor CVP and ensure adequate pre-load: give Human Albumin Solution (HAS) 4.5% 10 mL/kg as IV bolus or, if HAS not available, sodium chloride 0.9% 10 mL/kg as IV bolus 10. If shock severe , start mechanical ventilation with positive endexpiratory pressure early; if pulmonary oedema present, start urgently 11. If shock severe, give early inotropic drug support: dopamine, dobutamine, adrenaline or noradrenaline as per NICU/PICU protocols

DUCT-DEPENDENT CONGENITAL HEART DISEASE Ä May present in first two weeks of life

Duct-dependent systemic circulation Ä Breathless, grey, collapsed, poor pulses Ä severe coarctation of the aorta Ä critical aortic stenosis Guidelines for


20

Ä hypoplastic left heart syndrome Duct-dependent pulmonary circulation Ä Blue, breathless or shocked Ä pulmonary atresia Ä critical pulmonary valve stenosis Ä tricuspid atresia Ä severe Fallot’s tetralogy Ä transposition of the great arteries


Treatment Ä See Cyanotic congenital heart disease guideline

21

Guidelines for


ECG INTERPRETATION PAPER SPEED Ä ECG normally recorded at 25 cm/sec Ä 1 mm (1 small square) = 0.04 sec Ä 5 mm (1 large square) = 0.2 sec


P WAVE Ä Reflects atrial activity Ä Duration shorter than in adults Ä infants: 0.04-0.07 sec Ä adolescents: 0.06-0.1 sec Ä Height ≤ 2.5 mm Ä Varying P wave morphology may indicate wandering atrial pacemaker

Right atrial hypertrophy (RAH) Ä Increased P wave amplitude in leads II, V1, and V4R

Causes Ä Pulmonary hypertension Ä Pulmonary stenosis Ä Pulmonary atresia Ä Tricuspid atresia

Left atrial hypertrophy (LAH) Ä Biphasic P wave (later depolarization of LA)

Causes Ä Mitral valve disease Ä LV obstruction and disease Guidelines for


22

P-R INTERVAL Ä Atrial depolarization varies with age and rate Normal range of P-R interval (time in sec) Heart Rate

P-R interval (sec) 0-12 months

1-12 yr

12-16 yr

<60

-

-

-

0.1-0.19

60-99

-

-

0.1-0.16

0.1-0.17

100-139

0.08-0.11

0.08-0.12

0.1-0.14

-

140-180

0.08-0.11

0.08-0.12

0.1-0.14

-

>180

0.08-0.09

0.08-0.11

-

-


0-1 month

Prolonged P-R interval Ä Normal Ä Myocarditis Ä Ischaemia Ä Drugs Ä Hyperkalaemia

Short P-R interval Ä Wolff-Parkinson-White syndrome Ä Lown-Ganong-Levine syndrome Ä Glycogen storage disease

Variable P-R interval Ä Wandering atrial pacemaker Ä Wenckebach phenomenon

QRS COMPLEX Ä Ventricular activity Ä Duration: 0.06-0.08 sec

23

Guidelines for


Prolonged Ä Ventricular hypertrophy Ä Bundle branch block Ä Electrolyte disturbance Ä Metabolic disease Ä Drugs (e.g. digoxin) Normal range of R and S waves (height in mm)


Age

R and S Waves (height in mm) V4-R

V1-R

V1-S

V5-R

V6-R

V6-S

Birth

4-12

5-20

0-20

2-20

1-13

0-15

6-12 months

2-7

3-17

1-25

10-28

5-25

0-10

1-10 yr

0-7

2-16

1-12

5-30

5-25

0-7

>10 yr

0-6

1-12

1-25

5-40

5-30

0-5

Q WAVE Ä Normal in II; III; aVF; V5-6 Ä Depth 2-3 mm Ä pathological if >4 mm (i.e. septal hypertrophy) Ä May be found in other leads in: Ä anomalous coronary arteries Ä hypertrophic obstructive cardiomyopathy Ä transposition of great arteries (with opposite polarity)

Q-T INTERVAL Inversely proportional to rate Ä Calculate ratio of Q-T interval to R-R interval Ä QTc is usually less than 0.44 s Ä prolonged QTc is associated with sudden death: alert consultant immediately

Guidelines for


24

Prolonged Q-T interval Ä Hypocalcaemia Ä Myocarditis Ä Jervell-Lange-Nielsen syndrome Ä Romano-Ward syndrome Ä Head injuries or cerebrovascular episodes Ä Diffuse myocardial disease Ä Antiarrhythmics


Short Q-T interval Ä Hypercalcaemia Ä Digitalis effect

T WAVE Ä Ventricular repolarization

Normal Ä T inversion V4R/V1 (from third day of life until 10 yr) Ä Amplitude is 25-30% of R-wave Ä <1 yr: V5 ≤ 11 mm; V6 ≤ 7 mm Ä >1 yr: V5 ≤ 14 mm; V6 ≤ 9 mm Ä Adolescence reduces amplitude

Peaked T wave Ä Hyperkalaemia Ä LVH Ä Cerebrovascular episode Ä Post-MI

25

Guidelines for


Flat T wave Ä Normal newborn Ä Hypothyroidism Ä Hypokalaemia Ä Hyper/hypoglycaemia Ä Hypocalcaemia Ä Peri/myocarditis


Ä Ischaemia Ä Digoxin effect

MEAN QRS AXIS Vertical plane (limb leads) Normal axis in vertical plane Birth

+60° to +180°

(av +135°)

1 yr

+10° to +100°

(av +60°)

10 yr

+30° to +90°

(av +65°)

Right axis deviation Ä Right ventricular hypertrophy (RVH) Ä Left posterior hemiblock Ä Ostium secundum atrial septal defect (ASD)/right bundle branch block (RBBB)

Left axis deviation Ä Left ventricular hypertrophy (LVH) Ä Ostium primum ASD (+ RBBB) Ä Often in conduction defects

Guidelines for


26

Horizontal plane (anterior chest leads) Normal Ä Transition at around V3 Clockwise rotation Ä S>R in V4 = RA/RV hypertrophy Anticlockwise rotation Ä R>S in V2 = cardiac shift (e.g. pneumothorax)


LEFT VENTRICULAR HYPERTROPHY Diagnosis Ä SV1 + RV5 ≥ 40 mm (30 mm <1 yr) Ä ± prolonged QRS Ä Flat T wave Ä T wave inversion V5-V6 (LV strain) Ä Left bundle branch block Causes include: Ä Aortic stenosis Ä Aortic regurgitation Ä Hypertension Ä Moderate VSD Ä Hypertrophic obstructive cardiomyopathy Ä Patent ductus arteriosus Ä Mitral regurgitation

RIGHT VENTRICULAR HYPERTROPHY Diagnosis Ä RAD and RV1 > SV1 (>1 yr) Ä SV6 above maximum for age: Ä 0-6 months 15 mm 27

Guidelines for


Ä > 6 months 10 mm Ä >12 months 7 mm Ä 10 yr 5 mm Ä R waves in V4R/V1 >normal Ä T wave changes Ä upright in V1/V4R (from 3 days to 10 yr)


Causes include: Ä Pulmonary stenosis/atresia Ä Transposition of great arteries Ä Pulmonary regurgitation Ä Total anomalous pulmonary drainage Ä Tricuspid regurgitation Ä Fallot’s tetralogy Ä Pulmonary hypertension

BIVENTRICULAR HYPERTROPHY Diagnosis Ä R + S >50 mm in V3-V4 Ä LVH + bifid R <8 mm in V1 Ä RVH + LV strain Ä Q waves V3-V6 imply septal hypertrophy

TYPICAL ECG ABNORMALITIES Heart Lesion PDA VSD ASD Eisenmenger’s Aortic stenosis Aortic regurgitation Guidelines for


28

ECG Abnormalities LVH > RVH; LAH LVH > RVH; ± RBBB; T inv LV. leads Secundum RAD; RBBB; ± increased P-R; AF Primum LAD; RBBB; BVH; RAH RVH; P pulmonale LVH + strain LVH

Coarctation Mitral regurgitation Pulmonary stenosis Ebstein’s anomaly Fallot›s tetralogy Pulmonary atresia Tricuspid atresia

Newborn: RVH Older: Normal or LVH ± strain; RBBB LVH RVH; RAH Prolonged P-R interval; gross RAH; RBBB Newborn: Normal or T +ve V1 Older: RVH; RAH RAH LAD; RAH; LVH

TACHYCARDIA AND BRADYCARDIA

Early diagnosis and effective management of supraventricular tachycardia(SVT) are vital as there is a small risk of mortality.

RECOGNITION AND ASSESSMENT Symptoms and signs Ä Recurrent condition Ä family may identify as ‘another attack’ Ä Infants Ä gradual onset of increasing tachypnoea Ä poor feeding Ä pallor Ä occasionally more dramatic presentation with a rapid onset of severe cardiac failure Ä Toddlers


SUPRAVENTRICULAR TACHYCARDIA

Ä recurrent episodes of breathlessness, cold sweats and pallor Ä Older children Ä recurrent palpitations, episodes of dizziness and pallor

Investigations If known to suffer from episodes of supraventricular tachycardia: Ä Confirm diagnosis with 12-lead ECG

29

Guidelines for


Ä Continuous ECG monitoring is essential Ä Assess for cardiac failure Differential diagnosis Ä Sinus tachycardia, particularly in infants, can be >200/min. However, rates of 220–300/min are more likely to be SVT. Ä If first presentation, check for any other cause of cardiac failure Ä Failure to respond to adenosine can be used to distinguish origin of a


tachycardia in a stable patient Causes of tachyarrhythmias Ä Re-entrant congenital conduction pathway abnormality (common) Ä Poisoning Ä Metabolic disturbance Ä After cardiac surgery Ä Cardiomyopathy Ä Long QT syndrome

ECG DIAGNOSIS Infants Ä Majority have a P wave before every QRS complex, usually by >70 msec (2 mm at 25 mm/sec) Ä QRS complexes are generally normal but may be wide Ä Accessory pathway frequently capable of anterograde as well as retrograde conduction Ä this will be revealed during normal sinus rhythm by short P-R interval and presence of a delta wave (classic Wolff-Parkinson-White syndrome) Older children Ä Nodal tachycardias become more common with increasing age Ä characterized by fast, regular, narrow QRS complexes without visible P waves Ä Wide QRS complex or bundle branch block in childhood is rare Ä changes also present in sinus rhythm Guidelines for


30

Ä review previous ECGs If in doubt, seek more experienced help IMMEDIATE TREATMENT Ä Resuscitate (ABC) first Ä If first presentation, refer to consultant Ä See following algorithms Vagal Manoeuvres Ä Diving reflex Ä wrap infants in a towel and immerse their whole face into iced water for about 5-10 sec Ä in children, place a bag or rubber glove containing iced water over face Ä One side carotid massage Ä Valsalva manoeuvre Ä Where possible, maintain ECG monitoring and recording during all procedures Do NOT use eyeball pressure because of risk of ocular damage Adenosine Ä Drug of choice as it has a rapid onset of action and not negatively inotropic Ä Very short half-life (10-15 sec) giving short-lived side-effects (flushing, nausea, dyspnoea, chest tightness) Ä Effective in >80% of junctional tachycardias and will not precipitate ventricular tachycardias into ventricular fibrillation


These may include:

Ä Can be used in broad-complex tachycardia of uncertain origin Ä Must be given as a rapid bolus IV via a large peripheral or central vein and followed by sodium chloride 0.9% flush Ä In patients with sinus tachycardia, heart rate will slow to bradycardia but will rapidly increase again Other drugs Ä If adenosine ineffective, seek advice from a paediatric cardiologist Ä In refractory Wolff-Parkinson-White tachycardia, flecainide is particularly useful 31

Guidelines for


Ä In refractory atrial tachycardia, amiodarone is useful Do not use verapamil and propranolol in same patient as both have negative inotropic effects. Do not use verapamil in children <1 yr.

Supraventricular Tachycardia Shock Present


No

Yes

Vagal manoeuvres

Adenosine 100 microgram/kg

2 min

Vagal manoeuvres (if no delay)

Yes

Establish vascular access if quicker than obtaining deﬁb

No Adenosine 200 microgram/kg

Synchronous DC shock 1 J/kg

2 min Adenosine 300 microgram/kg

Synchronous DC shock !

Amiodarone Discuss with cardiologist Consider: o adenosine 600 microgram/kg (>1 month) o synchronous DC shock o amiodarone o other anti-arrhythmics (seek advice)

Guidelines for


32

Adenosine may be used in preference to electrical shock An anaesthetic must be given for DC shock if patient responsive to pain

WIDE COMPLEX TACHYCARDIA RECOGNITION AND ASSESSMENT Definition Ä Ventricular tachycardia Ä ≥ 3 successive ectopic ventricular beats Ä sustained if it continues >30 sec Causes congenital heart disease) Ä Poisoning (e.g. phenothiazines, tricyclic antidepressants, quinidine and procainamide) Ä Electrolyte disturbance (e.g. hypokalaemia, hypomagnesaemia) Ä Ventricular tachycardia can degenerate into ventricular fibrillation Diagnosis Ä Wide-QRS SVT (SVT with aberrant conduction) is uncommon in infants and children. Correct diagnosis and differentiation from VT depends on careful analysis of at least a 12-lead ECG ± an oesophageal lead Ä Assess patient and obtain family history to identify presence of an underlying condition predisposing to stable ventricular tachycardia Ä SVT or VT can cause haemodynamic instability: response to adenosine can help identify underlying aetiology of the arrhythmia, but adenosine should be used with extreme caution in haemodynamically stable children with widecomplex tachycardia because of the risk of acceleration of tachycardia and significant hypotension – this should not delay definitive treatment in children


Ä Underlying cause (e.g. myocarditis, cardiomyopathy, or patient with

with shock Ä Seek advice Ä Ventricular tachycardia not always obvious on ECG – clues are: Ä rate varies between 120 and 250 beats/min (rarely 300 beats/min) Ä QRS complexes are almost regular though wide Ä QRS axis abnormal for age (normal for >6 months is <+90°) Ä no preceding P wave, or A-V dissociation 33

Guidelines for


Ä fusion beats (normally conducted QRS complex merges with an abnormal discharge)

IMMEDIATE TREATMENT IMMEDIATE TREATMENT Ventricular Tachycardia Ventricular Tachycardia No


VF Protocol

Pulse Present

An anaesthetic must be given for DC shock if patient responsive to pain

Yes No

Hypotensive

Yes

Amiodarone 5 mg/kg (max 300 mg) over 30 min


Consider:


synchronous DC shock seek advice

!

Amiodarone Ä Treatment of haemodynamically stable child with ventricular tachycardia should always include early consultation with a paediatric cardiologist. They may suggest amiodarone [5 mg/kg (max 300mg) over 60 min]: can cause hypotension, which should be treated with volume expansion Ä Use synchronous shocks initially, as these are less likely than an asynchronous shock to produce ventricular fibrillation. If synchronous shocks are ineffectual, and child is profoundly hypotensive, subsequent attempts will have to be asynchronous Ä Treatment of torsade de pointes ventricular tachycardia is magnesium sulphate 25-50 mg/kg (up to 2 g) diluted to a 10% solution (5x volume) over 10-15 min Ä Amiodarone 5 mg/kg may be given over 3 min in ventricular tachycardia if child in severe shock Guidelines for


34

BRADYARRHYTHMIAS Ä Urgently manage: Ä pre-terminal event in hypoxia or shock Ä raised intracranial pressure Ä vagal stimulation Investigations Ä ECG to look for: Ä after conduction pathway damage during cardiac surgery


Ä congenital heart block (rare) Ä long QT syndrome Management Ä ABC approach – ensure adequate oxygenation and ventilation Ä If vagal stimulation is cause, give atropine 20 microgram/kg (min 100 microgram; max 600 microgram) Ä Consider IV isoprenaline infusion Ä Contact cardiologist for advice Ä Fax ECG to cardiologist.

35

Guidelines for


ENDOCARDITIS PROPHYLAXIS INDICATIONS Cardiac Factors Ä Acquired valvular heart disease with stenosis or regurgitation Ä Valve replacement Ä Structural congenital heart disease, including surgically corrected or palliated


structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect or fully repaired patent ductus arteriosus, and closure devices that are judged to be endothelialised Ä Previous infective endocarditis Ä Hypertrophic cardiomyopathy If there is uncertainty, seek advice from the cardiology team at local paediatric cardiac surgical centre

Antibiotic Treatment Ä Investigate and treat promptly any episodes of infection in infants and children at risk of infective endocarditis Ä Offer an antibiotic that covers organisms that cause infective endocarditis if patient at risk of infective endocarditis because they are undergoing a gastrointestinal or genitourinary procedure at a site with suspected infection (see table)

MANAGEMENT Ä Give patients at risk of infective endocarditis clear and consistent information about prevention, including: Ä benefits and risks of antibiotic prophylaxis, explain why antibiotic prophylaxis is no longer routinely recommended Ä importance of maintaining good oral health Ä symptoms that may indicate infective endocarditis and when to seek expert advice

Guidelines for


36

Ä risks of undergoing invasive procedures, including non-medical procedures such as body piercing or tattooing. Ä Do not offer chlorhexidine mouthwash as prophylaxis against infective endocarditis to people at risk undergoing dental procedures Suggested antibiotic prophylaxis in patients at risk of endocarditis for procedures where infection may exist. Antibiotics Amoxicillin

If allergic to penicillin teicoplanin plus gentamicin

Comment Give just before procedure or at induction of anaesthesia

Give just before procedure or at induction of anaesthesia

Ä Antibiotic prophylaxis against infective endocarditis is no longer recommended: Ä for people undergoing dental procedures Ä for people undergoing non-dental procedures at the following sites: - upper and lower gastrointestinal tract - genitourinary tract; this includes urological, gynaecological and obstetric procedures, and childbirth


plus gentamicin

Dose/Route Single IV dose <5 yr: 250 mg 5-9 yr: 500 mg ≥ 10 yr: 1 g plus 2.0 mg/kg IV single dose (120 mg 10-18 yr) Single dose IV < 14 yr: 6 mg/kg (max 400 mg) ≥ 14 yr: 400 mg plus 1.5 mg/kg IV single dose

- upper and lower respiratory tract; this includes ear, nose and throat procedures and bronchoscopy

37

Guidelines for


Guidelines for


38

Pediatric Cardiology Division Policy and Procedures For General Small Hospitals (50 – 200 beds)

DIVISION of Pediatric Cardiology POLICIES AND PROCEDURES 1. APPLICATION: This policy applies to all staff in the division of pediatric cardiology for small hospitals (50 – 200 beds).

- To provide diagnostic and management services for routine and emergency pediatric cardiology conditions in the hospital. In this connection, pediatric patients are defined as those aged 12 years and below. - To provide education to: Staff & Patients. 3. STAFFING: Staff of pediatric cardiology division would consist of the following: - Consultant pediatric cardiologist (Head of the division) - SPECIALIST - RESIDENT - Echo technician - ECG technician - Two Registered nurse for pediatric cardiology outpatient unit& echo lab - Cardiac Coordinator Appointment. - Division secretary 4. JOB DESCRIPTION: Qualifications and experience: HEAD OF PEDIATRIC CARDIOLOGY / CONSULTANT PEDIATRIC CARDIOLOGIST 1. TITLE : HEAD OF PEDIATRIC CARDIOLOGY DIVISION and CONSULTANT

For General Small Hospitals (50 – 200 beds)

2. PURPOSE:

PEDIATRIC CARDIOLOGIST 2. DEPARTMENT : PEDIATRIC -CARDIOLOGY DIVISION 3. REPORTS TO : CHAIRMAN, PEDIATRIC Department 4. LIASES WITH : Consultants, Head of Cardiology with his/her colleagues other specialties within the department, nursing staff, other health care professionals, patients and their families. 41

Guidelines for


5. RESPONSIBLE FOR : Duties contained in this Job Description 6. JOB SUMMARY : As Head of Paediatric Cardiology Division, he is responsible for selection of well-qualified and competent staff to work in the Paediatric Cardiology Division.


It will be his constant endeavour to encourage and guide the staff working under him, to give their best and be accountable. He would report members of the staff who do not come to the expectations, so that the Paediatric Cardiology Department improves the standards with a goal to provide excellent care to the patients. He will be responsible in providing care for his/her patients (in-patient and out-patient) maintaining a high level of professional performance in accordance with, Professional medical ethics, Hospital medical by-laws, Laws of Ministry of Health in Kingdom of Saudi Arabia and any other applicable regulations according to the department quality plan. He is committed to provide effective and dynamic leadership in; 1. Improving the quality and competence of cardiology staff, needed to provide best care to the cardiac patients. 2. Continuous medical education to ensure the staff is up to date in terms of knowledge, guidelines regarding management of patients with ACS etc. 3. To liaise with other department heads to ensure good communication and best Consultation services to variety of patients. 4. To arrange regular meetings with the staff working under him to improve understanding and working atmosphere and to set targets to be achieved. 5. To strive constantly to improve services in terms of the equipment needed, commensurate with advances in technology, i.e. Echocardiography, Non-invasive monitoring. 6. To give advice to medical record, appointment office to improve patient follow-up, patient medical records and patient compliance. 7. To ensure disease-oriented research to follow the cardiac disease prevalence in our Saudi community, for future planning of cardiology services in the kingdom.

Guidelines for


42

8. To encourage young and gifted cardiologist by new incentives. To train the Saudi doctors in cardiology for future. 9. To improve the intensive care services for cardiac patients to a degree far excellence. 10. To regularize call duties, referral systems and response to emergencies in accordance with international standards.

7.1. Provides patient care within the parameters of their professional competences as reflected in the scope of their clinical privileges for both in-patient and out-patients. 7.2. Practices within the framework of clinically relevant and scientifically valid standards, guidelines and criteria. 7.3. To perform his duties in the cardiology clinic evaluating patients with cardiovascular diseases. 7.4. To provide care to his patients in the PICU, NICU and other Paediatric wards. 7.5. To perform cardiac procedures: EKG interpretation, Echocardiogram and Doppler, etc. 7.6. To provide consultation services to the in-patients in his/her area of expertise. 7.7. Conducts regular ward rounds on his own and/or as a team to formulate a multidisciplinary treatment plan. 7.8. Performs diagnostic and therapeutic procedures on his/her patients within the range of the specialty. 7.9. Assessment and referral of appropriate patients under his/her medical care to other appropriate medical facilities as well as accepting referrals of patients with medical problems in his/her field of specialty. 7.10. Participates in the on-call rotation schedule of the department for patients care and admission.


7. DUTIES AND RESPONSIBILITIES:

7.11. Responds to emergencies to offer advice and actively participate with problems if required to his/her specialty. 7.12. Observes and upholds the patient’s rights of security, confidentiality and privacy.

43

Guidelines for


7.13. Maintains appropriate records of all patients with accurate, timely legible completion of patient’s medical records. 7.14. Consultants have a leadership role in the organization performance. 7.15. Supervision of duties of assigned junior staff. 7.16. Provides leadership for performance-improvement functions in the process


of measurement, assessment and improvement of both clinical and nonclinical process as part of the departmental quality plan. 7.17. Active participation in Continued Medical Education (C.M.E.) through educational hospital activities (morning report meetings, grand rounds, clinical tutorials and seminars, journal club, radiology or clinic-pathological conferences). Also, through national and international meetings, conferences and symposia. 7.18. Active participation in training program related to his/her field and organization within the hospital for training of junior medical staff and inservice training for nursing staff and technicians. 7.19. Continuous update of his/her knowledge in the medical field as well as continuously upgrading level of skills in his/her field of profession. 7.20. Participation in committee meetings assigned to him/her (Quality Improvement, Infection Control). 7.21. Abides by Department Policies and Procedures, as well as hospital bylaws, rules and regulations. 7.22. To carry out any other assignments as directed by Hospital Administration and or the department head and within the realm of his/her knowledge, skills and abilities. 7.23. Department specific duties and responsibilities: 7.23.1. Leads a group or is a part of his team. 7.23.2. Has on the average 1 specialists and 1 resident, under his Supervision. 7.23.3. Makes two rounds a day, morning round and sign out round. 7.23.4. Makes business rounds in the morning using the SOAP approach. 7.23.5. Teaches during the round important aspects of clinical care. 7.23.6. Consults with other services if needed. 7.23.7. Make a grand round at least once a week. Guidelines for


44

7.23.8. On the on-call day, answer faxes from other institutional punctually. 7.23.9. Has 1-2 clinics a week. 7.23.10. Engages in doctor and student teaching. 7.23.11. Participates in department activities like presentations, club journal, Morbidity and mortality meetings and audits. 7.23.12. Reviews and sing all discharge summaries. 7.23.14. Encourages scientific research, papers, and evidence based medicine. 7.23.15. Review charts in the Medical Records Department. 7.23.16. Studies medico-legal cases. 7.23.17. Supervise Intensive Cardiac Care Unit on a rotational basis. 7.23.18. Performs stress test and echocardiogram. 7.23.19. Reads electrocardiogram. 7.23.20. Inserts temporary pacemakers if needed. 7.23.21. Other duties as directed by Ministry of Health within his/her specialty. 8. QUALIFICATIONS: 8.1. EDUCATION/LICENSURE: 8.1.1. Saudi Fellowship, Arab Fellowship, American Fellowship, Canadian Fellowship, European Fellowship, or Equivalent in Paediatric Cardiology Sub-specialty or (Saudi Board in Paediatric or Equivalent to plus Paediatric Cardiology Sub-specialty degree). 8.2. PROFESSIONAL/EXPERIENCE: 8.2.1. Minimum of one (1) years experience Post Qualification in the Cardiology field.


7.23.13. Evaluates all staff under his/her supervision.

8.2.2. Current valid license to practice Cardiology specialty. 8.2.3. Registration in Saudi Medical Council and/or Current license to practice Cardiology in Saudi Arabia. 8.3. SPECIALIZED KNOWLEDGE/SKILLS: 8.3.1. Demonstrates leadership and administrative skills. 45

Guidelines for


8.3.2. Fluent in verbal and written English. 8.3.3. Exhibits professionalism and excellent interpersonal communication skills. 8.3.4. Is knowledgeable of the Medical by-laws.


8.3.5. Knowledge of computer application. SPECIALIST IN PEDIATRIC CARDIOLOGY 1. TITLE : SPECIALIST IN PEDIATRIC CARDIOLOGY 2. DEPARTMENT : PEDIATRIC -CARDIOLOGY DIVISION 3. REPORTS TO : CHAIRMAN, PEDIATRIC Department 4. LIASES WITH : Consultants, Head of Cardiology with his/her other specialties within the department, nursing staff, other health care professionals, patients and their families. 5. RESPONSIBLE FOR : Duties contained in this Job Description 6. JOB SUMMARY : The cardiologist is a staff member of the Cardiology Division. Responsibilities are divided between the out-patient and in-patient services: consultations, admissions and cardiac

procedures (Echo, EKG, Holters,

etc.) and general cardiac duties. 6.1. Responsible for providing care for his/her patients (in-patient and out-patient) maintaining a high level of professional performance in accordance with, Professional medical ethics. Hospital medical bylaws, Laws of Ministry of Health in Kingdom of Saudi Arabia and any other applicable regulations according to the department quality plan. 7. DUTIES AND RESPONSIBILITIES: 7.1. History taking, physical examinations, interpretation of common diagnostic tests and document patient condition on admission in the specified admission sheet.

Guidelines for


46

7.2. Can admit patients from the hospital Emergency Room after appropriate discussion and approval of the Consultant under whose name admission is done. 7.3. Evaluates new admission and coordinates with Consultant a plan to establish a diagnosis and a management course. Executes the plan approved by the Consultant. the concerned Consultant with regards to care of his in-patients. 7.5. Documents plan of patient management and maintain appropriate records of all patients with accurate timely legible completion of patient’s medical records. 7.6. Keeping an updated follow-up in the progress notes. 7.7. Should seek the advice of or help of the Consultant whenever the condition of a patient merits further expertise. Works under supervision and instructions of assigned Consultant. 7.8. Prepares all discharge summaries, death reports and special reports on related patients. 7.9. Presentation of new admissions to the department through the daily morning reports. 7.10. Participates actively in the on-call rota of the department for patients care and admissions. Responds to emergencies to offer medical care and advice on problems related to his specialty. 7.11. Assist staff (Consultant) in performing diagnostic or therapeutic procedures to patients in his/her field of department. 7.12. Supervise the Junior Staff in conducting their duties and responsibilities as designated by the department. 7.13. Actively participates in department’s educational and training activities.


7.4. Conducts daily ward rounds to all in-patients in the department. Liaises with

7.14. Abides by departmental Policies and Procedures as well as hospital by laws, Rules and Regulations. 7.15. To carry out any other assignments as directed by the Head of Department and within the realm of his/her knowledge, skills, and abilities.

47

Guidelines for


8. QUALIFICATIONS: 8.1. EDUCATION/LICENSURE: 8.1.1. University Master Degree in his/her Specialty or Equivalent. 8.2. PROFESSIONAL/EXPERIENCE: 8.2.1. Minimum of two (2) years experience in his/her specialty after obtaining


Master’s Degree. 8.2.2. Registration in Saudi Medical Council and/or Current license to practice Paediatric Cardiology in Saudi Arabia. 8.2.3. Current valid license to practice Paediatric Cardiology specialty. 8.3. SPECIALIZED KNOWLEDGE/SKILLS: 8.3.1. Fluent in verbal and written English. 8.3.2. Exhibits professionalism and excellent interpersonal communication skills. 8.3.3. Is knowledgeable of the Medical by-laws. 8.3.4. Knowledge of computer application. RESIDENT IN CARDIOLOGY 1. TITLE : RESIDENT IN CARDIOLOGY 2. DEPARTMENT : Paediatric -CARDIOLOGY DIVISION 3. REPORTS TO : CHAIRMAN, Paediatric Department 4. LIASES WITH : Consultants, Head of Paediatric Cardiology, with his/her other specialties within the department, nursing staff, other health care professionals, patients and their families. 5. RESPONSIBLE FOR : Duties contained in this Job Description 6. JOB SUMMARY : The resident is a staff member of the Cardiology Division. Responsibilities are divided between the out-patient and in-patient services: consultations, admissions and general

cardiac duties. Responsible for

providing care for his/her patients (in-patient and out-patient) Guidelines for


48

maintaining

a high level of professional performance in accordance with, Professional medical ethics. Hospital medical by-laws, Laws of Ministry of Health in Kingdom of Saudi Arabia and any other applicable regulations according to the department quality plan. 7. DUTIES AND RESPONSIBILITES: Program Directors. The resident is responsible to his/her Program Director for performance in all phases of training. 7.1. To assist in the organization and provision of clinical care and patient management. 7.2. To participate in in-service training. 7.3. The resident is expected to take a history and perform a physical examination on all the newly admitted patients under his/her team. 7.4. It is the resident’s duty to confirm that any (informed consent) has been signed and obtain such consent from the patient’s parent/guardian. 7.5. The resident is expected to make daily ward rounds, usually in conjunction with and a mutual convenient time for the team specialist consultant. This includes writing daily progress notes and appropriate orders, organizing and following up on investigations, writing fluid orders, starting IV’s and drawing blood as necessary. 7.6. Residents should attend the out-patient clinics of the consultants on their team. 7.7. Residents are supposed to take referral calls from other department including the Emergency, under the close supervision of the Cardiology Specialist on duty. 7.8. Residents are responsible for the Record Keeping and all entries in the record should be dated and timed as well as signed. Entries should be


Specific duties and responsibilities of the resident will be outlined by the individual

made clearly in black ink and it is helpful to print your name and page number. At discharge, a summary should be completed and sent to the patient’s GP as well as to the referring consultant and all other activities involved in the patient’s care. 7.9. All residents must attend all regular clinical teaching session and residents may be called on to present patients, comment on X-rays or review papers. 49

Guidelines for


7.10. Participate in safe, effective and compassionate patient care. 7.11. Developing an understanding of ethical, socio-economic and medical/legal issues that affect graduate medical education and of how to apply cost containment measures in the provision of patient care. 7.12. Participation in the education activities of the training program and, as


appropriate, assumption of responsibility for teaching and supervising other residents and student, and participation in institutional orientation and education programs and other activities involving the clinical staff. 7.13. Participation in institutional committees and councils to which the resident is appointed or invited; and performance of these duties in accordance with the established practices, procedures and policies of the institution, and those of its programs, clinical departments, and other institutions to which the resident is assigned; including, among others, state licensure requirements for physicians in training, where these exist. 7.14. Carries out the clinical and other duties allocated to him/her by the Consultant in Charge. 7.15. Responsible for the basic medical care within the department. Evaluate patients under his care, formulating plans of investigation and treatment. Visits in-patients daily and documents daily progress of his/her patients, and their new investigation results. 7.16. Takes on call duty according to Rota. 7.17. Writes discharge and death summaries. 7.18. Accompanies Consultant on ward rounds and in out-patient clinics. 7.19. Assist in education activities. 7.20. Performs other applicable tasks and duties assigned within the realm of his/her knowledge. 8. QUALIFICATIONS: 8.1. EDUCATION/LICENSURE: 8.1.1. Graduate of Recognized Medical School. 8.1.2. Registration in the Saudi Medial Council and must be valid and recent. 8.2. PROFESSIONAL/EXPERIENCE: N/A 8.3. SPECIALIZED KNOWLEDGE/SKILLS: Guidelines for


50

8.3.1. Fluent in verbal and written English. 8.3.2. Exhibits professionalism and excellent interpersonal communication skills. 8.3.3. Knowledgeable of the Medical bi-laws. Cardiac Division Secretary Qualifications: - Medical Secretary Diploma

JOB DESCRIPTION OF DIVISION SECRETARY - Make files for all cardiac unit staff. The file of each staff member should contain C.V, medical degrees; academic activities attendance certificate, vacation forms incidental reports, etc. Make directory for all cardiac unit staff members and the related department’s staff, which should include the pager numbers, telephone extensions numbers. - Make on call schedules for doctors and technician in the cardiac unit on regular basis. - Responsible for collecting and distributing memos concerning cardiac unit, directed from hospital administration, relevant departments and department chief. - Fill the vacation forms for unit staff including annual leave, study leave emergency leave and process the forms through hospital administration offices. Organize the annual vacations for all unit staff members. - Fill the forms requesting participation in academic activities including symposium, seminar, and courses for any unit staff and process them through CME office. Attach boosters of symposium, workshops and other academic activities in assigned board.


- Knowledge and experience in using computer.

- Prepare MCQ lectures and slides for presentation concerning cardiac unit staff. - Organize all meeting for chief of cardiac unit and attend such meetings to write comments and final decisions. - Orientation of new staff joined to cardiac unit regarding the place and regulations. 51

Guidelines for


- Typing all reports regarding cardiac unit including reports of the tests performed in the non-invasive cardiac lab such as Echocardiography reports, Holter analysis reports. Stress echo reports. Etc. - Typing fax reports to communicate with other cardiac centers and typing urgent medical reports in order to transfer cardiac patients to other cardiac centers.


Transcription department of the hospital should type discharge summaries and regular medical reports. - Communicate with cardiac centers coordinator directly by telephone for occasional sick patients in order to facilitate their transfer. - Regular secretary work including filing the papers, typing reports concerning the department. - Help the cardiac staff members in processing their paper through various hospital departments for any reason e.g. housing, payroll, passport, travel arrangement and transport. The secretary can help by direct contact with personnel or other units in the hospital through telephone. - Responsible of the appointment arrangement for the departmental head during regular working hours.

9. DEPARTMENTAL ORGANIZATION: 9.1 ON CALL DUTIES SYSTEM: a.) Consultants would be on call on rotational basis for 24 hours including weekends. According to rosters drawn up by the chief of department. b.) The pediatric cardiologist would care for patients in his sub-specialty during working hours with his team, the general pediatrician would cover this service after working hours and pediatric cardiologist may however be called when an emergency arises in his sub-specialty. c.) The pediatric cardiologist/specialist on call would response to referrals from all hospital units whether urgent or non urgent. The urgent will be seen immediately while the non urgent will be seen on the same working day provided that the non urgent case was referred before 12:00 pm. Guidelines for


52

d.) The pediatric cardiologist/specialist on call would also response to referrals from other hospitals through either fax or telephone. The response to fax is based on receiving date by hospital administration. e.) Immediate care of cardiac patients in the general wards or NICU, PICU and cardiac ward during regular working hours is responsibility of treating pediatric cardiologist.

consultant; however on call cardiologist should attend this round for all inpatients. Grand round involving all the cardiology team will be on every Saturday morning. g.) All newly admitted cardiac patients should be seen by the on call pediatric cardiologist on the same day with clear document in the patient file, including elective admissions for OPD or from other hospitals. The consultant who accepted the elective admission patient should also see it, on the same working day. h.) Patients are seen in the emergency department by ER Doctors on 24 hours basis. However, pediatric cardiology senior registrar/consultant on call can be called upon to look after any seriously ill patient in the emergency room.

9.2 ADMISSION REGULATION: Children with cardiac disease are admitted by different ways. - From cardiac clinic, the admitted child will be under the name of the consultant who attended the clinic (elective admission). - Accepted by consultant cardiologist on call from other hospitals through fax, the child will be admitted under the name of the consultant who


f.) Regular ward rounds for inpatients are direct responsibility of treating

accepted the child (elective admission). - Children referred from other units in the hospital (non cardiac) will admitted under the name of the on call cardiologist from the next full working day. - Admission from Emergency department: i. New patients will admitted under the name of on call cardiologist 53

Guidelines for


ii. Old patients will be admitted under the name of the previous treating consultant. 9.3 CARDIAC CONSULTATION: All children referred to pediatric cardiologist should have the following: o 12-lead ECG o Chest x-ray


o Oxygen saturation by pulse oxymeter or ABG o Blood pressure from all limbs. OUT PATIENT CONSULTATION All referrals should be discussed with the most senior physician in general pediatric at OPD who will give priorities before booking for cardiology clinic or he may directly contact the cardiologist. All other areas than OPD should go through pediatric cardiology consultation service (inpatient consultation). Referral from other hospitals for cardiologist should also go through pediatric cardiology consultation service. THE OPD PRIORITY GUIDELINES ARE AS FOLLOWS: a. First priority should be given to neonates with neonates with cyanosis; consultation should be done immediately without delay for further actions, even if neonate is not sick looking. Consultation should be done with cardiologist on call. b. Children with suspected infective endocarditis, new rheumatic fever, recent history of arrhythmia and neonates with heart murmur who are also symptomatic or having abnormal vital signs should be discussed with cardiologist on call. c. All neonates with heart murmur otherwise normal, stable vital signs including oxygen saturation, blood pressure in all limbs, should be given appointment in cardiac clinic within 2 weeks. Older age group with similar finding should be given appointment within 1 month. d. Known case of rheumatic fever, neuromuscular dystrophy, thalssmia, sickle cell anemia, metabolic, endocrine and infants with various syndromes for screening should be given appointment within 4 month. Guidelines for


54

Any other cases should be discussed with OPD consultant before booking. The appointment will be made through hospital appointment office. Inpatient consultation a. Urgent consultation: contact directly by phone to on call cardiologist especially from NICU or PICU. b. Routine consultation: consultation form should be filled out and sent to

Consultation forms will review by cardiologist on call on the same day, however it is advised that routine consultation forms should be send to cardiology ward before 1:00 pm. 9.4 FOLLOW UP OF CARDIAC PATIENTS i. Admitted children will be given appointment in the cardiac clinic for follow up after discharge from hospital. ii. The appointment is decided by treating cardiologist and should be available before the patient leave the hospital iii. The cardiologist should specify in the patient’s file the necessary investigations for the next visit in the cardiac clinic such as chest x-ray, INR, ECG.etc iv. Scheduled patient’s files should be reviewed before the clinic time by registrar/consultant to order the required investigations. v. Follow up appointments should not exceed 12 months from the discharge date.

9.5 MANAGEMENT OF REFERRED PATIENTS Consultant pediatric cardiologist should response as soon as possible to


cardiac ward nurse station.

urgent referrals from various units in the hospital. Non-urgent referrals should be responded during same working day. The management of referred child for cardiac consultation is based on the underlying pathology, the number of the system involved in the disease process and also on the system which is mainly affected. The following items are guidelines for the management of referred child. 55

Guidelines for


A. The child may be completely transferred under cardiology service and discharged from referring service (non-cardiac) e.g. congenital heart disease, rheumatic fever with cardiac disease, Kawasaki disease with coronary aneurysms...etc B. The child may be followed by the non-cardiac service mainly, however


the cardiologist will be his opinions when he is consulted e.g. child with leukemia and heart failure. C. Mainly the cardiology team may follow the child, while the non-cardiac service is consulted for opinions and follow up management in their subspecialty e.g. congenital heart disease with significant infection. D. The child may have combined management by cardiologist and other subspecialty consultant e.g. infant of diabetic mother with cardiomyopathy will be managed by both cardiologist and neonatology consultant. Children with multiple problems will be followed by different sub-specialties e.g. VACTERL association, however the child will be under the name of neonatologist or accepting consultant. Notice: All children who have mainly cardiac disease will be admitted under cardiology team or transferred to their service and they will be followed in cardiac clinic after discharge from hospital. 10. OUT PATIENT SERVICE: 10.1 Doctors’ Schedule: Based on the increase number of cardiac patients and because the majority of the cardiac patients are ambulatory, it was suggested to increase the number of cardiac clinics to 3 clinic per week. The doctors will be distributed for these clinics according to the published schedules. In the event consultant being unavailable (e.g. being on vacation). On his clinic day, the chief of department will arrange for such clinic to be covered by appropriate personnel. 10.2 Space: Pediatric cardiology consultant/ specialist need one room in ground floor near Echo lab for management of ambulatory cardiac patients. Guidelines for


56

10.3 Staff: A. Doctors. Consultant pediatric cardiologist and specialist attend cardiac clinic in one room. B. Nurses; two nurses. The clinic is attended with one registered nurse to take vital signs, body doctors in examining the child. The clinic also required another nurse to help in sedation of children who need investigations like ECG and also help in organizing for follow up appointment in the clinic. Both nurses assigned 3 days in week for cardiac clinic and for the remaining 2days in the week they are assigned in Echo and ECG lab. Both of them should be trained in CPR and sedation of children. 10.4 Regulations of Cardiac Clinic a.) Patients are referred to the pediatric cardiology clinic from general pediatric clinics in the hospital. Patients are also referred from other hospitals directly to pediatric cardiology clinic; however such patients need approval of administration office and the cardiologist before booking to the cardiac clinic. b.) Total number of booked patients per clinic should not exceed 8 patients and all booking is done through hospital appointment office. c.) Maximum two patients can be added to each clinic. This slot of the two patients per clinic is kept purposely to add patients who require near follow up appointment after discharge form hospital and should be approved by the consultant. d.) Consultant cardiologist conducts pediatric Cardiology clinics. Occasionally specialist may participate in the management of ambulatory Cardiac


weight, and oxygen saturation by pulse oxymeter and also to assist the

Patient. e.) Consultant or specialist who will attend the clinic should review the patient’s files prior to the clinic time for ordering the necessary investigation.

57

Guidelines for


f.) Patients are seen and examined by the cardiologist and investigated on outpatient basis, following such examination and investigation may be admitted to the ward. g.) Admission from the clinics would normally be processed directly to the ward without passing through ER, except for sick patient who need stabilization in the ER unit before sending to the ward. Or until the bed is


ready in the ward or PICU. h.) Very sick patients when attend cardiac clinic should be send to Emergency unit rather than examining in the clinic. A nurse should accompany the patient to emergency unit and on call cardiologist should be inform immediately. i.) Prior to admission, the cardiologist should discuss with the patient’s responsible adult, the nature of treatment and its possible outcome. Necessary papers and consent should be completed before admitting the patient. j.) Files for ambulatory cardiac patients should be reviewed on regular basis by the cardiology staff to improve the quality of the work. k.) Follow up appointments of ambulatory cardiac patients should not exceed 6 months, and at each visit the cardiologist should write clearly the plan of the management and the necessary investigation for next visit. l.) Regulations for medical reports, sick leaves and clinic attendance forms are according to MOH regulations and measure. m.) Regular ambulatory cardiac patients who grow out the pediatric age (12 years) should be referred to adult cardiology service with detail typed medical report, prepared by treating consultant. The report should indicate the reason for referral and should be sending through administration office to other hospitals.

Guidelines for


58

11. ECHOCARDIOGRAPHY AND ELECTROCARDIOGRAPHY LABORATORY (NONINVASIVE CARDIOLOGY LAB): 11.1 SPACE: 3 rooms in the ground floor near the cardiac OPD. § First room will contain large modern 3D – Echo machine with multiple probes. This room will be used for regular Transthoracic Echo. It will be Echocardiography session) § The second room is assigned for regular ECG recording, both 12 Leeds and long stip. The ECG will be performed for both outpatients and inpatients. It contains ECG machines for 12 led recording. § The third room is assigned for sedation of the infants before ECG or Echocardiography. It also used to measure oxygen saturation by pulse oxymeter, blood pressure, and body weight. This room should contain all the necessary equipments for the Purposes mentioned above.

11.2 EQUIPMENT: § Advanced Echocardiogram machine with full option including multiple transthoracic probes. § One ECG printer machine for 12 lead analyses. § Crush card trolley with advance biphasic defibrillator and module for external cutaneous pacing § Pulse oxymeter § Blood pressure monitoring device. With recording for systolic, diastolic and MAP


used 5days per week, (3 days together with cardiac clinics and 2days for

§ Suction machine § Cardiac monitor

59

Guidelines for


11.3 STAFF § Consultant cardiologist § Echo technician. § ECG technician.


§ Registered nurse (2). § Coordinator for Cardiac Appointment

QUALIFICATIONS: Echo-cardiograph technician - Obtain a Bachelor degree in X-ray or a Diploma in Echo-cardiograph. - Have a year experience. ECG & Holter Technician - Obtain ECG Diploma - Have a year experience. Nurse in Pediatric Cardiac Unit: - Obtain a Bachelor degree in Nursing. - B.L.S - Experience in Pediatrics diseases not less than a year.

JOB DESCRIPTION OF CONSULTANT CARDIOLOGIST IN NON-INVASIVE CARDIAC LAB:

a.) Echo lab - Perform complete study in Echo lab for new patients including Tran thoracic Echo. - Review all studies done by Echo technician before approval. He should review the study while the patient is in the echo lab - Teach joiner staff including specialist, resident rotating in the cardiology unit and technician - Write clear reports in the Echo forms and send for typing before approval

Guidelines for


60

b.) ECG lab - Analysis of all ECG prints done in the pediatric hospital then signing the prints, according to cardiologist schedule in the ECG lab and usually for ECG prints done in the previous 4 days.

JOB DESCRIPTION OF THE TECHNICIAN IN THE NONINVASIVE CARDIAC

a.) ECG lab Technician: - Attend and actively participate in CPR in emergency situation in the noninvasive cardiac lab. - He should response to all ECG request in the pediatric hospital during working hours and priority should be given to urgent requests. - Responsible for maintenance and cleanness of the all machines in the ECG lab - Responsible for availability of ECG papers, in addition to ECG leads plastic holder and the other disposables items in the ECG lab.

b.) Echo Lab Technician: - Perform Echo study alone for children referred to cardiology service for Echo study only e.g. oncology patient referred for measurement of cardiac function. However even such studies should be reviewed by cardiologist before sending the patient back to ward or home, he may repeat part or the whole study. - All Echo studies performed by cardiologist should be attended by the Echo technician in order to enter patient data in the machine, attach ECG leads to the patient, make the measurements for LV function or other calculations and build the experience in the pediatrics Echo.


LAB

- Responsible for availability of jell, printer paper and CD, so he continuous supply of these item and should inform the chief of unit 4 weeks in advance for any lack of supply from stores. (He should keep extra material in the unit of emergency situation).

61

Guidelines for


- Log in CD number and Echo study number in the log in book for all patients and pull out any required CD for regular meeting or conference in the hospital. He will be responsible also for archiving these CD in proper place.

JOB DESCRIPTION FOR REGISTERED NURSES IN THE NON INVASIVE


CARDIAC LAB The nurses should be available every day during regular working hours, except weekends. a) Measurement of vital signs including heart rate. Respiratory rate and body temperature in addition to body weight of all infants require sedation before echo study. b) Measurement of blood pressure from all limbs in infants and from right arm in children for all patients attend Echo lab before performing the study. c) Recording the oxygen saturation by pulse oxymeter from all neonates, cyanosed or distressed infants and children attending Echo lab. d) Sedation of patients with chloral hydrate orally and monitoring the child till sleep and then transfer him/her to Echo room. e) Assist the cardiologist or technician during Echo study. f) Responsible for monitoring equipment in the sedation room e.g. cardiac monitor, pulse oxymeter, BP monitors. g) The nurse should have valid CPR certificate and she should participate actively in resuscitation of any collapsed patient in the non-invasive cardiac lab. h) She should also perform 12 lead ECG in the unit especially if ECG technician is not available.

11.4 SCHEDULES FOR NON-INVASIVE CARDIAC LAB Consultant Cardiologist Consultant cardiologist will have 4-day duty in the non-Invasive cardiac Lab per week according to the schedule for the goals mentioned above. He is responsible for non-urgent and the urgent Echo studies and ECG. Guidelines for


62

Non urgent Echo studies or ECG include the following: · Admitted patients in the hospital wards who need routine echo study e.g. Down's syndrome for screening (new cardiac patients admitted in the wards or ICU or sick patients under general pediatric service who need urgent echo is responsibility of on call cardiologist). · Patients with routine appointment for Echo studies, either new patients or

· Reviewing all ECG tests done in the previous 3 days for inpatients.

ECHO Technician/ECG TECHNICIAN · Echo Technician should attend Echo lab daily during regular working hours. · ECG Technician should attend ECG lab daily during regular working hours, he will be assigned for regular and urgent ECG request from different wards, ICU, ER, nursery and outpatient request. · On call duties of Echo technician/ECG technician will be for whole week but he/she cover only regular working days and during regular working hours. The nurses in the ER or ICU or nursery perform ECG test on weekends or after working hours. · ECG Technician should help in the Echo lab when there is shortage off staff in the Echo lab for any reason and ECG technician during the cover of echo lab will have same responsibilities of Echo technician.

Nurses duties in the Non-Invasive Cardiac Lab: Two nurses are assigned for the non-invasive cardiac lab, both nurses also assigned for the cardiac clinics. They organized the work between themselves according to patient’s number in these areas; however the following points are


follow up patients.

guidelines. · They should attend the non-invasive cardiac lab daily during the regular working hours.

63

Guidelines for


· Both of them should cover the clinic responsibilities during clinic time and cover the Echo lab ECG at other time, however if there are patients in the clinics and also in the ECG room or Echo rooms then one should cover clinic services and other should cover the Echo lab service. · One of the nurses should be assigned for the sedation of the infants before


Echo or ECG test while the other nurse should take the rest of responsibility when her college is busy with sedation of the infants at that specific time. · Both of them should have valid CPR certificate

11.5 REGULATIONS OF NON INVASIVE CARDIAC LAB Echocardiography booking for both Inpatients and Outpatients · There will be four Echocardiography sessions per week. · Booking is done only through Echo technician. For both inpatient and outpatients. · Total number of the children’s (including inpatients and outpatients) for each echocardiography day should not exceed 5 patients; extra two slots per day are spared for urgent unbooked patients.

INSTRUCTIONS FOR SEDATION: 1. The patient for morning session should arrive at 9:00 A.M. and the patients for afternoon session should arrive at 1:00 P.M. 2. Child should be N.P.O. one hour before sedation (child should not take anything to eat or drink for one hour before sedation). 3. Vital signs including blood pressure, oxygen saturation and body weight should be recorded on flow sheet. 4. Pediatric cardiologist should approve sedation of small infants less than 3kg, severely cyanosed infants and sick infants. 5. The drug used for Sedation is chloral hydrate, which is given orally at the dose of (50-80 mg/kg). § The drug can be repeated at half dose if child is not sleeping in 1 hour.

Guidelines for


64

6. Sedated infant should be connected to the ECG Leeds and pulse oxymeter during ECHO study. 7. The child is required to rest in the sedation room or waiting area after ECHO study, until he/she is fully awake. 8. The child should have near OPD appointment with pediatric cardiologist.

All ECHO request forms should be submitted to ECHO lab station. Follow-up with appointment should be through ECHO technicians (Mrs. xxx: Ext 000) ECHO PRECEDURE LOCATION: All patients in pediatric wards should be brought to ECHO lab except sick patients or patients in NICU & PICU. Echo done for them at bed side by on-call Cardiologist and on-call Echo technician. All ambulatory patients for Cardiac clinic and Echo appointments will have Echo procedure in Echo Lab. 12. Service Information: 12.1 Rotating Pediatric Resident/specialist: I. Pediatric Cardiology is one of the fundamental branches in Pediatrics. The unit is expecting rotation of Residents and specialist. II. The rotating resident/specialist is important part of Pediatric Cardiology team. He or she will be exposed to Clinical Pediatric Cardiology.

12.2 Duties of Rotating Residents/specialist: - Daily ward rounds to inpatients assigned for pediatric cardiology service, as


REFERRAL FOR ECHO:

well as for patients consulted by other services such as NICU, PICU and other ward. Documentations of round with consultation should be written on the patients note. - Receive all consultations, either by direct contact for urgent consultation or by consultation form situated in cardiac ward nurse station for routine cases. 65

Guidelines for


- The resident/specialist is expected to prepare and review the cases including all investigations before discussion with Consultant Cardiologist. This will facilitate more interaction and informative discussion. Urgent Cases should be discussed as soon as possible with the consultant for further management plans.


- The resident/ specialist should see and examine patients admitted under cardiology. Further management plans will be discussed according to Echo findings. - He/she will participate actively in referring patients to other institutions for further management or surgery (such as preparing discharge summaries, contact receiving hospital by phone etc.) see communication section for referral center information.

13. CARDIOLOGY INPATIENT SERVICE: § There is no need for separate cardiac ward but one room should be assigned for cardiac patients with total capacity of 2 beds. This room is located in the pediatric ward however this room can be utilized by other subspecialties or general pediatric patients in case of emergency admissions after approval of cardiologist on call and should be returned back to cardiac service within 2-3 days. § The rooms under cardiac service are equipped with cardiac monitors, pulse oxymeters and suction machines in addition to oxygen supply slots and vacuum slots in the wall. § Cardiac patient with infectious diseases will be admitted in the ward assigned for children with infectious diseases until he/she become non infectious then may be transferred to cardiac rooms. § The service of cardiac patients is in the pediatric wards is achieved by the specialist or resident assigned to the cardiology unit. § Nurses caring for the cardiac patients will be trained in the hospital or other hospitals to this purpose and should become familiar with equipments in the cardiac rooms. Guidelines for


66

§ Nurse station in the ward assigned for cardiac patients will serve as place to receive referral forms from other units for cardiac consultation and any inquiry about cardiac services. Cardiologist covering the service of cardiac patients (on call cardiologist) will have regular visit to this ward daily and will response to these referral forms, but the fax reports from other hospitals will be reviewed by on call cardiologist in the administration office at least the cardiologist on call directly.

Ward Procedure: § The nursing staff informs the concerned resident about the admission. § Soon after admission the resident completes full checking of the patient, ordering any additional investigations overlooked. § Residents on finding anything abnormal with the other systems of the patients will immediately inform the specialist concerned. § The specialist concerned before retiring will make certain that the condition of all his patients is satisfactory with further instructions to the resident or nursing staff as necessary. § In case of any problem patient and the concerned specialist not being available later, he should contact the specialist on call and instruct him fully of the condition of this patient. § In case of serious complication, the specialist concerned may transfer the patient to ICU in consultation with the cardiologist and ICU specialist in charge and the nursing supervisor. § The specialist and/or consultant cardiologist is expected to perform daily clinical rounds in the ward or ICU with the responsible nurse and the


3 time per day except the emergency fax reports which should be send to

resident to record daily progress of the patient and other instructions regarding treatment. § The patient discharge is entirely responsibility of the cardiologist, the relevant forms and papers i.e. admission and discharge forms and sending feedback to the referring doctor are completed by resident/specialist and signed by him. 67

Guidelines for


§ The cardiologist concerned should explain to the mother or other responsible adult relative, particular medical technique that may become necessary, the expected outcome and number of days the patient may be expected to remain in hospital.


14. Emergency Room: § Cardiac patients arriving at ER with acute or chronic medically distressing conditions should be seen. § Initially these patient seen and resuscitated in the ER by the pediatric resident and registrar covering the ER department and if the management of the cardiac patient require pediatric cardiologist the specialist on call of general pediatric should contact pediatric cardiologist by telephone. § The cardiologist on call should see such patient either in the ER department or in the PICU/ward after admission. § Cardiac illness requiring specialized treatment for which this hospital is not equipped to render will be transferred to other hospital after preliminary resuscitation and stabilization are made. After appropriate arrangement with the concerned doctors at the other hospital.

15. GENERAL RULES: § The Pediatric Cardiology Consultant will be totally responsible for all patients as admitted under him or being treated by him. § The general pediatric Specialist/Consultant may take decisions regarding management of common pediatric symptoms in cardiac patients. § Close cooperation between the Medical and Nursing staff is encouraged and there will be grand clinical rounds by the Specialist/Consultant with the Nurses to explain to them, in more details the condition and treatment of the patients. § Ensure adequate liaison with other departments such as Cardiac Surgery, Radiology, and Laboratory.

Guidelines for


68

16. Communications: 16.1 Dictation of discharge summaries: -

It is the responsibility of the resident/ specialist assigned in pediatric cardiology services to dictate discharge summary immediately upon discharge to provide copy to patients.

- Please do not use any abbreviation in your dictation, e.g. do not abbreviate

16.2 Patient Data Sheet: The resident/ specialist should complete the patient data sheet provided by the charge nurse (for any difficulty he should contact consultant-in-charge). 16.3 Referral Centers: The following are tertiary care referral pediatric cardiac centers: 1. King Faisal Specialist Hospital & Research Center: Pediatric Cardiology Coordinator:

Ext: 39175, pager:8388

Ext: 39176, pager:6612 Coordinator Office: 01-464-7272 Ext: 32094 Direct line: 4424486 Fax: 01-442-7498 2. King Abdulaziz Cardiac Center/King Fahad National Guard: Coordinator: Ext: 6683, pager:1144 Ext. & pager: 6686 Tel: 10-252-0088 Ext: 6682 Fax: 01-252-0088 Ext: 6684


Pulmonary Artesia as “PA” etc.

3. Prince Sultan Cardiac Center: Secretary Office: 4783000 Ext: 8795;Direct Fax: 473-0049

69

Guidelines for


16.4 Academic Activity of Cardiology Division The pediatric cardiologist in the unit is expected to participate in the following academic activity: · Pediatric club monthly meeting. · Supervising interns, residents, and registrar for clinical presentation in the


daily morning reports. · Participate in the other academic activates in the hospital including hospital lectures, symposium, seminars, clinical courses, written courses, etc. · Participate in the academic activities concerning cardiology e.g. cardiology day, pediatric cardiology symposium in other centers. · Attend cardio-surgery meeting in other cardiac centers according to schedule arranged by the department head. Other activities of the Department Staff: · Participate in the Public health educations through different media channels · Participate in hospital committees e.g. infection, quality assurance, and credential · Participate in regular monthly mortality and morbidity meeting · Participate in the medical education of nurses, technician and other staff in the hospital.

Guidelines for


70

Pediatric Cardiology Division Policy and Procedures For General Hospitals (200 – 400 beds)

DIVISION of Pediatric Cardiology POLICIES AND PROCEDURES 1. APPLICATION: This policy applies to all staff in the division of pediatric cardiology, for medium size general hospitals (200 – 400 beds).

- To provide diagnostic and management services for routine and emergency pediatric cardiology conditions in the hospital. In this connection, pediatric patients are defined as those aged 12 years and below. - To provide education to: Staff & Patients. 3. STAFFING: - Staff of pediatric cardiology - Division would consist of the following: - Chief of pediatric cardiology - Consultant pediatric cardiologist - SPECIALIST - RESIDENT - Echo technician - ECG technician - Two Registered nurses for pediatric cardiology outpatient unit& echo lab. - Division secretary - Receptionist for cardiac lab. - Ward cleric - Coordinator for Cardiac Appointment 4. JOB DESCRIPTION:


2. PURPOSE:

Qualifications and experience: 1. TITLE : HEAD OF PEDIATRIC CARDIOLOGY DIVISION 2. DEPARTMENT : PEDIATRIC -CARDIOLOGY DIVISION 3. REPORTS TO : CHAIRMAN, PEDIATRIC Department 73

Guidelines for


4. LIASES WITH : Consultants, Head of Cardiology with his/her colleagues in other specialties within the department, nursing staff, other health care professionals, patients

and their families.


5. RESPONSIBLE FOR : Duties contained in this Job Description 6. JOB SUMMARY : As Head of Paediatric Cardiology Division, he is responsible for selection of well-qualified and competent staff to work in the Paediatric Cardiology Division. It will be his constant endeavour to encourage and guide the staff working under him, to give their best and be accountable. He would report members of the staff who do not come to the expectations, so that the Paediatric Cardiology Department improves the standards with a goal to provide excellent care to the patients. He will be responsible in providing care for his/her patients (in-patient and out-patient) maintaining a high level of professional performance in accordance with, Professional medical ethics, Hospital medical by-laws, Laws of Ministry of Health in Kingdom of Saudi Arabia and any other applicable regulations according to the department quality plan. He is committed to provide effective and dynamic leadership in; 1. Improving the quality and competence of cardiology staff, needed to provide best care to the cardiac patients. 2. Continuous medical education to ensure the staff is up to date in terms of knowledge, guidelines regarding management of patients with ACS etc. 3. To liaise with other department heads to ensure good communication and best Consultation services to variety of patients. 4. To arrange regular meetings with the staff working under him to improve understanding and working atmosphere and to set targets to be achieved. 5. To strive constantly to improve services in terms of the equipment needed, commensurate with advances in technology, i.e. Echocardiography, Non-invasive monitoring. 6. To give advice to medical record, appointment office to improve patient follow-up, patient medical records and patient compliance. Guidelines for


74

7. To ensure disease-oriented research to follow the cardiac disease prevalence in our Saudi community, for future planning of cardiology services in the kingdom. 8. To encourage young and gifted cardiologist by new incentives. To train the Saudi doctors in cardiology for future. 9. To improve the intensive care services for cardiac patients to a degree 10. To regularize call duties, referral systems and response to emergencies in accordance with international standards. 5. DUTIES AND RESPONSIBILITIES: 5.1. Provides patient care within the parameters of their professional competences as reflected in the scope of their clinical privileges for both in-patient and out-patients. 5.2. Practices within the framework of clinically relevant and scientifically valid standards, guidelines and criteria. 5.3. To perform his duties in the cardiology clinic evaluating patients with cardiovascular diseases. 5.4. To provide care to his patients in the PICU, NICU and other Paediatric wards. 5.5. To perform cardiac procedures:

EKG interpretation, holter monitors,

Echocardiogram and Doppler, etc. 5.6. To provide consultation services to the in-patients in his/her area of expertise. 5.7. Conducts regular ward rounds on his own and/or as a team to formulate a multidisciplinary treatment plan. 5.8. Performs diagnostic and therapeutic procedures on his/her patients within the range of the specialty. 5.9. Assessment and referral of appropriate patients under his/her medical care to other appropriate medical facilities as well as accepting referrals of


far excellence.

patients with medical problems in his/her field of specialty. 5.10. Participates in the on-call rotation schedule of the department for patients care and admission. 5.11. Responds to emergencies to offer advice and actively participate with problems if required to his/her specialty.

75

Guidelines for


5.12. Observes and upholds the patient’s rights of security, confidentiality and privacy. 5.13. Maintains appropriate records of all patients with accurate, timely legible completion of patient’s medical records. 5.14. Consultants have a leadership role in the organization performance.


5.15. Supervision of duties of assigned junior staff. 5.16. Provides leadership for performance-improvement functions in the process of measurement, assessment and improvement of both clinical and nonclinical process as part of the departmental quality plan. 5.17. Active participation in Continued Medical Education (C.M.E.) through educational hospital activities (morning report meetings, grand rounds, clinical tutorials and seminars, journal club, radiology or clinic-pathological conferences). Also, through national and international meetings, conferences and symposia. 5.18. Active participation in training program related to his/her field and organization within the hospital for training of junior medical staff and inservice training for nursing staff and technicians. 5.19. Continuous update of his/her knowledge in the medical field as well as continuously upgrading level of skills in his/her field of profession. 5.20. Participation in committee meetings assigned to him/her (Quality Improvement, Infection Control). 5.21. Abides by Department Policies and Procedures, as well as hospital bylaws, rules and regulations. 5.22. To carry out any other assignments as directed by Hospital Administration and or the department head and within the realm of his/her knowledge, skills and abilities. 5.23. Department specific duties and responsibilities: 5.23.1. Leads a group or is a part of his team. 5.23.2. Has on the average 1 specialist, 2 residents, and 1-2 interns under his Supervision. 5.23.3. Makes two rounds a day, morning round and sign out round. 5.23.4. Makes business rounds in the morning using the SOAP approach. 5.23.5. Teaches during the round important aspects of clinical care. Guidelines for


76

5.23.6. Consults with other services if needed. 5.23.7. Make a grand round at least once a week. 5.23.8. On the on-call day, answer faxes from other institutional punctually. 5.23.9. Has 1-2 clinics a week. 5.23.10. Engages in doctor and student teaching. journal, Morbidity and mortality meetings and audits. 5.23.12. Reviews and sing all discharge summaries. 5.23.13. Evaluates all staff under his/her supervision. 5.23.14. Encourages scientific research, papers, and evidence based medicine. 5.23.15. Review charts in the Medical Records Department. 5.23.16. Studies medico-legal cases. 5.23.17. Supervise Intensive Cardiac Care Unit on a rotational basis. 5.23.18. Performs stress test and echocardiogram. 5.23.19. Reads electrocardiogram. 5.23.20. Inserts temporary pacemakers if needed. 5.23.21. Other duties as directed by Ministry of Health within his/her specialty. 6. QUALIFICATIONS: 6.1. EDUCATION/LICENSURE: 6.1.1. Saudi Fellowship, Arab Fellowship, American Fellowship, Canadian Fellowship, European Fellowship, or Equivalent in Paediatric Cardiology Sub-specialty or (Saudi Board in Paediatric or Equivalent to plus Paediatric Cardiology Sub-specialty degree). 6.2. PROFESSIONAL/EXPERIENCE:


5.23.11. Participates in department activities like presentations, club

6.2.1. Minimum of one (1) years experience Post Qualification in the Cardiology field. 6.2.2. Current valid license to practice Cardiology specialty. 6.2.3. Registration in Saudi Medical Council and/or Current license to practice Cardiology in Saudi Arabia. 77

Guidelines for


6.3. SPECIALIZED KNOWLEDGE/SKILLS: 6.3.1. Demonstrates leadership and administrative skills. 6.3.2. Fluent in verbal and written English. 6.3.3. Exhibits professionalism and excellent interpersonal communication skills.


6.3.4. Is knowledgeable of the Medical by-laws. 6.3.5. Knowledge of computer application. CONSULTANT PEDIATRIC CARDIOLOGIST 1. TITLE : CONSULTANT PEDIATRIC CARDIOLOGIST 2. DEPARTMENT : PEDIATRIC - CARDIOLOGY DIVISION 3. REPORTS TO : CHAIRMAN, PEDIATRIC Department 4. LIASES WITH : Consultants, Head of Paediatric Cardiology, with his/her colleagues in other specialties within the department, nursing staff, other health care professionals, patients and their families. 5. RESPONSIBLE FOR : Duties contained in this Job Description 6. JOB SUMMARY : The cardiologist is a staff member of the Cardiology Division. Responsibilities are divided between the out-patient and in-patient services: consultations, admissions and cardiac

procedures (Echo, EKG,

Stress testing, Holters, etc.) and general cardiac duties. 6.1. Responsible for providing care for his/her patients (in-patient and out-patient) maintaining a high level of professional performance in accordance with, Professional medical ethics. Hospital medical bylaws, Laws of Ministry of Health in Kingdom of Saudi Arabia and any other applicable regulations according to the department quality plan. 6.2. Provides effective leadership of the department maintaining an appropriate quality plan using measurable performance improvement standards in the field of cardiology and provide a state of art, care to patients admitted to Coronary Care Unit. Guidelines for


78

7. DUTIES AND RESPONSIBILITIES: 7.1. Provides patient care within the parameters of their professional clinical privileges for both in-patient and out-patients. 7.2. Patients within the framework of clinically relevant and scientifically valid standards, guidelines and criteria. 7.3. To perform his duties in the cardiology clinic evaluating patients with 7.4. To provide care to his patients in the PICU, NICU and other medical wards. 7.5. To perform cardiac procedures:

EKG interpretation, Holter monitors,

Echocardiogram and Doppler study, etc. 7.6. To provide consultation services to the in-patients in his/her area of expertise. 7.7. Conducts regular ward rounds on his own/or as a team to formulate a multidisciplinary treatment plan. 7.8. Performs diagnostic and therapeutic procedures on his/her patients within the range of the specialty. 7.9. Assessment and referral of appropriate patients under his/her medical care to other appropriate medical facilities as well as accepting referrals of patients with medical problems in his/her field of specialty. 7.10. Participate in the on-call rotation schedule of the department for patient care and admission. 7.11. Responds to emergencies to offer advice and actively participate with problems if required, related to his/her specialty. 7.12. Observes and upholds the patient’s rights of security, confidentiality and privacy. 7.13. Maintains appropriate records of all patients with accurate, timely legible completion of patient’s medical records. 7.14. Consultant has a leadership role in the organization performance.


cardiovascular diseases.

7.15. Supervision of duties of assigned junior staff. 7.16. Provides leadership for performance-improvement functions in the process of measurement, assessment and improvement of both clinical and nonclinical process as part of the department quality plan. 7.17. Active participation in Continued Medical Education (CME) through educational hospital activities (morning report meetings, grand rounds, 79

Guidelines for


clinical tutorials and seminars, journal club, radiology or clinico-pathological conferences(. Also, through national and international meetings, conferences and symposia. 7.18. Active participation in training program related to his field and within the hospital for training of junior medical staff and in-service training for nursing


staff and technicians. 7.19. Continuous update of his knowledge in the medical field as well as continuously upgrading level of skills in his/her field of profession. 7.20. Participation in committee meetings assigned to him/her (Quality Improvement, Infection Control). 7.21. Abides by Department Policies and Procedures, as well as hospital bylaws, rules and regulations. 7.22. To carry out any other assignments as directed by Hospital Administration and/or the department head and within the realm of his knowledge, skills and abilities. 7.23. Department specific duties and responsibilities: 7.23.1. Leads a group or is a part of its team. 7.23.2. Has on the average 1 specialist, 2 residents, and 1-2 interns under his supervision. 7.23.3. Makes daily rounds. 7.23.4. Makes business rounds in the morning using the SOAP approach. 7.23.5. Consults with other services if needed. 7.23.6. Make a grand round at least once a week. 7.23.7. On the on-call day, answer faxes from other institutions punctually. 7.23.8. Has one 1-2 clinic a week. 7.23.9. Engages in doctor and student teaching. 7.23.10. Participates in department activities like presentations, club journal, morbidity and mortality meetings and audits. 7.23.11. Reviews and signs all discharge summaries. 7.23.12. Evaluates all staff under his supervision. 7.23.13. Encourages scientific research, papers and evidence based medicine. Guidelines for


80

7.23.14. Review charts in the Medical Records Department. 7.23.15. Studies medico-legal cases. 7.23.16. Performs echocardiogram. 7.23.17. Reads electrocardiogram. 7.23.18. Inserts temporary pacemakers if indicated. specialty. 8. QUALIFICATIONS: 8.1. EDUCATION/LICENSURE: 8.1.1. Saudi Fellowship, Arab Fellowship, American Fellowship, Canadian Fellowship, European Fellowship, or Equivalent in Paediatric Cardiology Sub-specialty or (Saudi Board in paediatric or Equivalent to plus Paediatric Cardiology Sub-specialty degree). 8.1.2. Administration and management Degree/Course is essential. 8.1.3. Certified in BLS, PALS. 8.2. PROFESSIONAL/EXPERIENCE: 8.2.1. Registration in Saudi Medical Council and/or Current license to practice Paediatric Cardiology in Saudi Arabia. 8.3. SPECIALIZED KNOWLEDGE/SKILLS: 8.3.1. Demonstrates leadership and administrative skills. 8.3.2. Fluent in verbal and written English. 8.3.3. Exhibits professionalism and excellent interpersonal communication skills. 8.3.4. Is knowledgeable of the Medical by-laws. 8.3.5. Knowledge of computer application.

81

Guidelines for


7.23.19. Other duties as directed by Ministry of Health within his/her


SPECIALIST IN PEDIATRIC CARDIOLOGY 1. TITLE : SPECIALIST IN PEDIATRIC CARDIOLOGY 2. DEPARTMENT : PEDIATRIC -CARDIOLOGY DIVISION


3. REPORTS TO : CHAIRMAN, PEDIATRIC Department

4. LIASES WITH : Consultants, Head of Cardiology, with his/her colleagues in other specialties within the department, nursing staff, other health care professionals, patients

and their families.

5. RESPONSIBLE FOR : Duties contained in this Job Description 6. JOB SUMMARY : The cardiologist is a staff member of the Cardiology Division. Responsibilities are divided between the out-patient and in-patient services: consultations, admissions and cardiac


Stress testing, Holters, etc.) and general cardiac duties. 6.1. Responsible for providing care for his/her patients (in-patient and out-patient) maintaining a high level of professional performance in accordance with, Professional medical ethics. Hospital medical bylaws, Laws of Ministry of Health in Kingdom of Saudi Arabia and any other applicable regulations according to the department quality plan. 7. DUTIES AND RESPONSIBILITIES: 7.1. History taking, physical examinations, interpretation of common diagnostic tests and document patient condition on admission in the specified admission sheet. 7.2. Can admit patients from the hospital Emergency Room after appropriate discussion and approval of the Consultant under whose name admission is done. 7.3. Evaluates new admission and coordinates with Consultant a plan to establish a diagnosis and a management course. Executes the plan approved by the Consultant. Guidelines for


82

7.4. Conducts daily ward rounds to all in-patients in the department. Liaises with the concerned Consultant with regards to care of his in-patients. 7.5. Documents plan of patient management and maintain appropriate records of all patients with accurate timely legible completion of patient’s medical records. 7.6. Keeping an updated follow-up in the progress notes. 7.7. Should seek the advice of or help of the Consultant whenever the condition of of assigned Consultant. 7.8. Prepares all discharge summaries, death reports and special reports on related patients. 7.9. Presentation of new admissions to the department through the daily morning reports. 7.10. Participates actively in the on-call rota of the department for patients care and admissions. Responds to emergencies to offer medical care and advice on problems related to his specialty. 7.11. Assist staff (Consultant) in performing diagnostic or therapeutic procedures to patients in his/her field of department. 7.12. Supervise the Junior Staff in conducting their duties and responsibilities as designated by the department. 7.13. Actively participates in department’s educational and training activities. 7.14. Abides by departmental Policies and Procedures as well as hospital by laws, Rules and Regulations. 7.15. To carry out any other assignments as directed by the Head of Department and within the realm of his/her knowledge, skills, and abilities. 8. QUALIFICATIONS: 8.1. EDUCATION/LICENSURE: 8.1.1. University Master Degree in his/her Specialty or Equivalent.


a patient merits further expertise. Works under supervision and instructions

8.2. PROFESSIONAL/EXPERIENCE: 8.2.1. Minimum of two (2) years experience in his/her specialty after obtaining Master’s Degree. 8.2.2. Registration in Saudi Medical Council and/or Current license to practice Paediatric Cardiology in Saudi Arabia. 83

Guidelines for


8.2.3. Current valid license to practice Paediatric Cardiology specialty. 8.3. SPECIALIZED KNOWLEDGE/SKILLS: 8.3.1. Fluent in verbal and written English. 8.3.2. Exhibits professionalism and excellent interpersonal communication skills.


8.3.3. Is knowledgeable of the Medical by-laws. 8.3.4. Knowledge of computer application. RESIDENT IN CARDIOLOGY 1. TITLE : RESIDENT IN CARDIOLOGY 2. DEPARTMENT : Paediatric -CARDIOLOGY DIVISION 3. REPORTS TO : CHAIRMAN, Paediatric Department 4. LIASES WITH : Consultants, Head of Paediatric Cardiology, with his/her colleagues in other specialties within the department, nursing staff, other health care professionals, patients and their families. 5. RESPONSIBLE FOR : Duties contained in this Job Description 6. JOB SUMMARY : The resident is a staff member of the Cardiology Division. Responsibilities are divided between the out-patient and in-patient services: consultations, admissions and general cardiac duties. Responsible for providing care for his/her patients (in-patient and out-patient) maintaining a high level of professional performance in accordance with, Professional medical ethics. Hospital medical by-laws, Laws of Ministry of Health in Kingdom of Saudi Arabia and any other applicable regulations according to the department quality plan. 7. DUTIES AND RESPONSIBILITES: Specific duties and responsibilities of the resident will be outlined by the individual Program Directors. The resident is responsible to his/her Program Director for performance in all phases of training.

Guidelines for


84

7.1. To assist in the organization and provision of clinical care and patient management. 7.2. To participate in in-service training. 7.3. The resident is expected to take a history and perform a physical examination on all the newly admitted patients under his/her team. 7.4. It is the resident’s duty to confirm that any (informed consent) has been 7.5. The resident is expected to make daily ward rounds, usually in conjunction with and a mutual convenient time for the team specialist consultant. This includes writing daily progress notes and appropriate orders, organizing and following up on investigations, writing fluid orders, starting IV’s and drawing blood as necessary. 7.6. Residents should attend the out-patient clinics of the consultants on their team. 7.7. Residents are supposed to take referral calls from other department including the Emergency, under the close supervision of the Cardiology Specialist on duty. 7.8. Residents are responsible for the Record Keeping and all entries in the record should be dated and timed as well as signed. Entries should be made clearly in black ink and it is helpful to print your name and page number. At discharge, a summary should be completed and sent to the patient’s GP as well as to the referring consultant and all other activities involved in the patient’s care. 7.9. All residents must attend all regular clinical teaching session and residents may be called on to present patients, comment on X-rays or review papers. 7.10. Participate in safe, effective and compassionate patient care. 7.11. Developing an understanding of ethical, socio-economic and medical/legal issues that affect graduate medical education and of how to apply cost


signed and obtain such consent from the patient’s parent/guardian.

containment measures in the provision of patient care. 7.12. Participation in the education activities of the training program and, as appropriate, assumption of responsibility for teaching and supervising other residents and student, and participation in institutional orientation and education programs and other activities involving the clinical staff.

85

Guidelines for


7.13. Participation in institutional committees and councils to which the resident is appointed or invited; and performance of these duties in accordance with the established practices, procedures and policies of the institution, and those of its programs, clinical departments, and other institutions to which the resident is assigned; including, among others, state licensure


requirements for physicians in training, where these exist. 7.14. Carries out the clinical and other duties allocated to him/her by the Consultant in Charge. 7.15. Responsible for the basic medical care within the department. Evaluate patients under his care, formulating plans of investigation and treatment. Visits in-patients daily and documents daily progress of his/her patients, and their new investigation results. 7.16. Takes on call duty according to Rota. 7.17. Writes discharge and death summaries. 7.18. Accompanies Consultant on ward rounds and in out-patient clinics. 7.19. Assist in education activities. 7.20. Performs other applicable tasks and duties assigned within the realm of his/her knowledge. 8. QUALIFICATIONS: 8.1. EDUCATION/LICENSURE: 8.1.1. Graduate of Recognized Medical School. 8.1.2. Registration in the Saudi Medial Council and must be valid and recent. 8.2. PROFESSIONAL/EXPERIENCE: N/A 8.3. SPECIALIZED KNOWLEDGE/SKILLS: 8.3.1. Fluent in verbal and written English. 8.3.2. Exhibits professionalism and excellent interpersonal communication skills. 8.3.3. Knowledgeable of the Medical bi-laws. Cardiac Division Secretary Qualifications: - Medical Secretary Diploma - Knowledge and experience in using computer. Guidelines for


86

JOB DESCRIPTION OF DIVISION SECRETARY - Make files for all cardiac unit staff. The file of each staff member should contain C.V, medical degrees; academic activities attendance certificate, vacation forms incidental reports, etc. Make directory for all cardiac unit staff members and the related department’s staff, which should include the pager numbers, telephone extensions numbers.

basis. - Responsible for collecting and distributing memos concerning cardiac unit, directed from hospital administration, relevant departments and department chief. - Fill the vacation forms for unit staff including annual leave, study leave emergency leave and process the forms through hospital administration offices. Organize the annual vacations for all unit staff members. - Fill the forms requesting participation in academic activities including symposium, seminar, and courses for any unit staff and process them through CME office. Attach boosters of symposium, workshops and other academic activities in assigned board. - Prepare MCQ lectures and slides for presentation concerning cardiac unit staff. - Organize all meeting for chief of cardiac unit and attend such meetings to write comments and final decisions. - Orientation of new staff joined to cardiac unit regarding the place and regulations. - Typing all reports regarding cardiac unit including reports of the tests performed in the non-invasive cardiac lab such as Echocardiography reports, Holter analysis reports. Stress echo reports. Etc.


- Make on call schedules for doctors and technician in the cardiac unit on regular

- Typing fax reports to communicate with other cardiac centers and typing urgent medical reports in order to transfer cardiac patients to other cardiac centers. Transcription department of the hospital should type discharge summaries and regular medical reports.

87

Guidelines for


- Communicate with cardiac centers coordinator directly by telephone for occasional sick patients in order to facilitate their transfer. - Regular secretary work including filing the papers, typing reports concerning the department.


- Help the cardiac staff members in processing their paper through various hospital departments for any reason e.g. housing, payroll, passport, travel arrangement and transport. The secretary can help by direct contact with personnel or other units in the hospital through telephone. - Responsible of the appointment arrangement for the departmental head during regular working hours.

9. DEPARTMENTAL ORGANIZATION: 9.1 ON CALL DUTIES SYSTEM: a.) Consultants would be on call on rotational basis for 24 hours including weekends. According to rosters drawn up by the chief of department. b.) The pediatric cardiologist would care for patients in his sub-specialty during working hours with his team, the general pediatrician would cover this service after working hours and pediatric cardiologist may however be called when an emergency arises in his sub-specialty. c.) The pediatric cardiologist/ specialist on call would response to referrals from all hospital units whether urgent or non urgent. The urgent will be seen immediately while the non urgent will be seen on the same working day provided that the non urgent case was referred before 12:00 pm. d.) The pediatric cardiologist on call would also response to referrals from other hospitals through either fax or telephone. The response to fax is based on receiving date by hospital administration. e.) Immediate care of cardiac patients in the general wards or NICU, PICU and cardiac ward during regular working hours is responsibility of treating pediatric cardiologist. f.) Regular ward rounds for inpatients are direct responsibility of treating Guidelines for


88

consultant; however on call cardiologist should attend this round for all inpatients. Grand round involving all the cardiology team will be on every Saturday morning. g.) All newly admitted cardiac patients should be seen by the on call pediatric cardiologist on the same day with clear document in the patient file, including elective admissions for OPD or from other hospitals. The it, on the same working day. h.) Patients are seen in the emergency department by ER Doctors on 24 hours basis. However, pediatric cardiology specialist/consultant on call can be called upon to look after any seriously ill patient in the emergency room.

9.2 ADMISSION REGULATION: Children with cardiac disease are admitted by different ways. - From cardiac clinic, the admitted child will be under the name of the consultant who attended the clinic (elective admission). - Accepted by consultant cardiologist on call from other hospitals through fax, the child will be admitted under the name of the consultant who accepted the child (elective admission). - Children referred from other units in the hospital (non cardiac) will admitted under the name of the on call cardiologist from the next full working day. - Admission from Emergency department: i. New patients will admitted under the name of on call pediatric cardiologist ii. Old patients will be admitted under the name of the previous treating consultant.


consultant who accepted the elective admission patient should also see

9.3 CARDIAC CONSULTATION: All children referred to pediatric cardiologist should have the following: o 12-lead ECG o Chest x-ray 89

Guidelines for


o Oxygen saturation by pulse oxymeter or ABG o Blood pressure from all limbs. OUT PATIENT CONSULTATION All referrals should be discussed with the most senior physician in general pediatric at OPD who will give priorities before booking for cardiology clinic


or he may directly contact the cardiologist. All other areas than OPD should go through pediatric cardiology consultation service (inpatient consultation). Referral from other hospitals for cardiologist should also go through pediatric cardiology consultation service. THE OPD PRIORITY GUIDELINES ARE AS FOLLOWS: a. First priority should be given to neonates with neonates with cyanosis; consultation should be done immediately without delay for further actions, even if neonate is not sick looking. Consultation should be done with cardiologist on call. b. Children with suspected infective endocarditis, new rheumatic fever, recent history of arrhythmia and neonates with heart murmur who are also symptomatic or having abnormal vital signs should be discussed with cardiologist on call. c. All neonates with heart murmur otherwise normal, stable vital signs including oxygen saturation, blood pressure in all limbs, should be given appointment in cardiac clinic within 2 weeks. Older age group with similar finding should be given appointment within 1 month. d. Known case of rheumatic fever, neuromuscular dystrophy, thalssmia, sickle cell anemia, metabolic, endocrine and infants with various syndromes for screening should be given appointment within 4 month. Any other cases should be discussed with OPD consultant before booking. The appointment will be made through hospital appointment office. Inpatient consultation a. Urgent consultation: contact directly by phone to on call cardiologist especially from NICU or PICU.

Guidelines for


90

b. Routine consultation: consultation form should be filled out and sent to cardiac ward nurse station.

Consultation forms will review by cardiologist on call on the same day, however it is advised that routine consultation forms should be send to cardiology

9.4 FOLLOW UP OF CARDIAC PATIENTS: i. Admitted children will be given appointment in the cardiac clinic for follow up after discharge from hospital. ii. The appointment is decided by treating cardiologist and should be available before the patient leave the hospital iii. The cardiologist should specify in the patient’s file the necessary investigations for the next visit in the cardiac clinic such as chest x-ray, INR, ECG.etc iv. Scheduled patient’s files should be reviewed before the clinic time by specialist /consultant to order the required investigations. v. Follow up appointments should not exceed 12 months from the discharge date.

9.5 MANAGEMENT OF REFERRED PATIENTS: Consultant pediatric cardiologist on call should response as soon as possible to urgent referrals from various units in the hospital. Non-urgent referrals should be responded during same working day. The management of referred child for cardiac consultation is based on the underlying pathology, the number of the system involved in the disease process and also on the system which


ward before 1:00 pm.

is mainly affected. The following items are guidelines for the management of referred child. A. The child may be completely transferred under cardiology service and discharged from referring service (non-cardiac) e.g. congenital heart disease, rheumatic fever with cardiac disease, Kawasaki disease with coronary aneurysms...etc 91

Guidelines for


B. The child may be followed by the non-cardiac service mainly, however the cardiologist will be his opinions when he is consulted e.g. child with leukemia and heart failure. C. Mainly the cardiology team may follow the child, while the non-cardiac service is consulted for opinions and follow up management in their sub-


specialty e.g. congenital heart disease with significant infection. D. The child may have combined management by cardiologist and other subspecialty consultant e.g. infant of diabetic mother with cardiomyopathy will be managed by both cardiologist and neonatology consultant. Children with multiple problems will be followed by different sub-specialties e.g. VACTERL association, however the child will be under the name of neonatologist or accepting consultant. Notice: All children who have mainly cardiac disease will be admitted under cardiology team or transferred to their service and they will be followed in cardiac clinic after discharge from hospital. 10. OUT PATIENT SERVICE: 10.1 Doctors’ Schedule: Based on the increase number of cardiac patients and because the majority of the cardiac patients are ambulatory, it was suggested to increase the number of cardiac clinics to 3 clinic per week. The doctors will be distributed for these clinics according to the published schedules. In the event of any consultant being unavailable (e.g. being on vacation) on his clinic day, the chief of department will arrange for such clinic to be covered by appropriate personnel. 10.2 Space: Pediatric cardiology consultant/ specialist need two rooms in ground near Echo lab for management of ambulatory cardiac patients.

Guidelines for


92

floor

10.3 Staff: A. Doctors. Consultant pediatric cardiologist and specialist attend cardiac clinic

in two

separate rooms. B. Nurses: The clinic is attended with one registered nurse to take vital signs, body weight, and oxygen saturation by pulse oxymeter and also to assist the doctors in examining the child. The clinic also required another nurse to help in the second cardiac clinic room, help in sedation of children who need investigations like ECG and also help in organizing for follow up appointment in the clinic. Both nurses assigned 3 days in week for cardiac clinic and for the remaining 2days in the week they are assigned in Echo and ECG lab. Both of them should be trained in CPR and sedation of children. 10.4

Regulations of Cardiac Clinic

a.) Patients are referred to the pediatric cardiology clinic from general pediatric clinics in the hospital. Patients are also referred from other hospitals directly to pediatric cardiology clinic; however such patients need approval of administration office and the cardiologist before booking to the cardiac clinic. b.) Total number of booked patients per clinic should not exceed 8 patients and all booking is done through hospital appointment office. c.) Maximum two patients can be added to each clinic. This slot of the two patients per clinic is kept purposely to add patients who require near follow up appointment after discharge form hospital and should be approved by the consultant.


two nurses are required for the Pediatric cardiology clinic.

d.) Consultant cardiologist conducts pediatric Cardiology clinics. Occasionally senior registrars may participate in the management of ambulatory Cardiac Patient. e.) Consultant or specialties who will attend the clinic should review the patient’s files prior to the clinic time for ordering the necessary investigation.

93

Guidelines for


f.) Patients are seen and examined by the cardiologist and investigated on outpatient basis, following such examination and investigation may be admitted to the ward. g.) Admission from the clinics would normally be processed directly to the ward without passing through ER, except for sick patient who need


stabilization in the ER unit before sending to the ward. Or until the bed is ready in the ward or PICU. h.) Very sick patients when attend cardiac clinic should be send to Emergency unit rather than examining in the clinic. A nurse should accompany the patient to emergency unit and on call cardiologist should be inform immediately. i.) Prior to admission, the cardiologist should discuss with the patient’s responsible adult, the nature of treatment and its possible outcome. Necessary papers and consent should be completed before admitting the patient. j.) Files for ambulatory cardiac patients should be reviewed on regular basis by the cardiology staff to improve the quality of the work. k.) Follow up appointments of ambulatory cardiac patients should not exceed 6 months, and at each visit the cardiologist should write clearly the plan of the management and the necessary investigation for next visit. l.) Regulations for medical reports, sick leaves and clinic attendance forms are according to MOH regulations and measure. m.) Regular ambulatory cardiac patients who grow out the pediatric age (12 years) should be referred to adult cardiology service with detail typed medical report, prepared by treating consultant. The report should indicate the reason for referral and should be sending through administration office to other hospitals.

Guidelines for


94

11. ECHOCARDIOGRAPHY AND ELECTROCARDIOGRAPHY LABORATORY (NONINVASIVE CARDIOLOGY LAB): 11.1 SPACE: 3 rooms in the ground floor near the cardiac OPD. § First room is assigned for main Echo lab; it will contain large modern 3D – Echo machine with multiple probes. This room will be used for 5days per week, (3 days together with cardiac clinics and 2days for Echocardiography session). § The second room is assigned for regular ECG recording, both 12 Leeds and long stip. The ECG will be performed for both outpatients and inpatients. It contains ECG machines for 12 led recording. § The third room is assigned for sedation of the infants before ECG or Echocardiography. It also used to measure oxygen saturation by pulse oxymeter, blood pressure, and body weight. This room should contain all the necessary equipments for the Purposes mentioned above.

11.2 EQUIPMENT: § Advanced Echocardiogram machine with full option including multiple probes and Fetal Echo prob. § Portable Echocardiogram machine with multiple probes. § Two ECG printer machines for 12 lead analysis. § Crush card trolley with advance biphasic defibrillator and module for external cutaneous pacing § Pulse oxymeter § Blood pressure monitoring device. With recording for systolic, diastolic


regular Transthoracic Echo, fetal echo, contrast Echo. It will be used

and MAP § Suction machine § Cardiac monitor

95

Guidelines for


11.3 STAFF § Consultant cardiologist § Echo technician § ECG technician


§ Two Registered nurse § Cardiac service secretary § Social worker § Health Educator § Receptionist for Cardiac lab § Nutrition Specialist § Coordinator for Cardiac Appointment

QUALIFICATIONS: Echo-cardiograph technician - Obtain a Bachelor degree in X-ray or a Diploma in Echo-cardiograph. - Have a year experience. ECG & Holter Technician - Obtain ECG Diploma - Have a year experience. Nurse in Pediatric Cardiac Unit: - Obtain a Bachelor degree in Nursing. - B.L.S - Experience in Pediatrics diseases not less than a year.


a.) Echo lab - Perform complete study in Echo lab for new patients including Tran thoracic Guidelines for


96

Echo, fetal Echo, contrast echo - Review all studies done by Echo technician before approval. He should review the study while the patient is in the echo lab - Teach joiner staff including specialist, resident rotating in the cardiology unit and technician

b.) ECG lab - Analysis of all ECG prints done in the pediatric hospital then signing the prints, according to cardiologist schedule in the ECG lab and usually for ECG prints done in the previous 4 days.

JOB DESCRIPTION OF THE TECHNICIAN IN THE NONINVASIVE CARDIAC LAB :

a.) ECG lab Technician: - Attend and actively participate in CPR in emergency situation in the noninvasive cardiac lab. - He should response to all ECG request in the pediatric hospital during working hours and priority should be given to urgent requests. - Responsible for maintenance and cleanness of the all machines in the ECG lab - Responsible for availability of ECG papers, in addition to ECG leads plastic holder and the other disposables items in the ECG lab.

b.) Echo Lab Technician: - Perform Echo study alone for children referred to cardiology service for


- Write clear reports in the Echo forms and send for typing before approval

Echo study only e.g. oncology patient referred for measurement of cardiac function. However even such studies should be reviewed by cardiologist before sending the patient back to ward or home, he may repeat part or the whole study.

97

Guidelines for


- All Echo studies performed by cardiologist should be attended by the Echo technician in order to enter patient data in the machine, attach ECG leads to the patient, make the measurements for LV function or other calculations and build the experience in the pediatrics Echo. - Responsible for availability of jell, printer paper and CD, so he continuous


supply of these item and should inform the chief of unit 4 weeks in advance for any lack of supply from stores. (He should keep extra material in the unit of emergency situation). - Log in CD number and Echo study number in the log in book for all patients and pull out any required CD for regular meeting or conference in the hospital. He will be responsible also for archiving these CD in proper place. - Prepare equipments for fetal Echo and contrast Echo. He should participate actively in performing such studies with cardiologist.

JOB DESCRIPTION FOR REGISTERED NURSES IN THE NON INVASIVE CARDIAC LAB: The nurses should be available every day during regular working hours, except weekends. a) Measurement of vital signs including heart rate. Respiratory rate and body temperature in addition to body weight of all infants require sedation before echo study. b) Measurement of blood pressure from all limbs in infants and from right arm in children for all patients attend Echo lab before performing the study. c) Recording the oxygen saturation by pulse oxymeter from all neonates, cyanosed or distressed infants and children attending Echo lab. d) Sedation of patients with chloral hydrate orally and monitoring the child till sleep and then transfer him/her to Echo room. e) Assist the cardiologist or technician during Echo study including fetal Echo, contrast Echo. f) Responsible for monitoring equipment in the sedation room e.g. cardiac

Guidelines for


98

monitor, pulse oxymeter, BP monitors. g) The nurse should have valid CPR certificate and she should participate actively in resuscitation of any collapsed patient in the non-invasive cardiac lab. h) She should also perform 12 lead ECG in the unit especially if ECG

11.4 SCHEDULES FOR NON-INVASIVE CARDIAC LAB Consultant Cardiologist Each consultant will have two day duty in the non-Invasive cardiac Lab per week according to the schedule for the goals mentioned above. He is responsible for non-urgent Echo studies and ECG, while the urgent Echo studies or ECG analysis is the responsibility of cardiologist on call. Non urgent Echo studies or ECG include the following: - Admitted patients in the hospital wards who need routine echo study e.g. Down's syndrome for screening (new cardiac patients admitted in the wards or ICU or sick patients under general pediatric service who need urgent echo is responsibility of on call cardiologist). - Patients with routine appointment for Echo studies, either new patients or follow up patients. - Reviewing all ECG tests done in the previous 3 days for inpatients, holter analysis interpretation is responsibility of treating consultant.

ECHO Technician/ECG TECHNICIAN - Echo Technician should attend Echo lab daily during regular working hours. - ECG Technician should attend ECG lab daily during regular working hours,


technician is not available.

he will be assigned for regular and urgent ECG request from different wards, ICU, ER, nursery and outpatient requests. ECG Technician will participate in the Holter recording analysis. - On call duties of Echo technician/ECG technician will be for whole week but he/she cover only regular working days and during regular working hours.

99

Guidelines for


The nurses in the ER or ICU or nursery perform ECG test on weekends or after working hours. - ECG Technician should help in the Echo lab when there is shortage off staff in the Echo lab for any reason and ECG technician during the cover of echo


lab will have same responsibilities of Echo technician.

Nurses duties in the Non-Invasive Cardiac Lab: Two nurses are assigned for the non-invasive cardiac lab, both nurses also assigned for the cardiac clinics. They organized the work between themselves according to patient’s number in these areas; however the following points are guidelines. - They should attend the non-invasive cardiac lab daily during the regular working hours. - Both of them should cover the clinic responsibilities during clinic time and cover the Echo lab ECG at other time, however if there are patients in the clinics and also in the ECG room or Echo rooms then one should cover clinic services and other should cover the Echo lab service. - One of the nurses should be assigned for the sedation of the infants before Echo or ECG test while the other nurse should take the rest of responsibility when her college is busy with sedation of the infants at that specific time. - Both of them should have valid CPR certificate

11.5 REGULATIONS OF NON INVASIVE CARDIAC LAB Echocardiography booking for both Inpatients and Outpatients - There will be four Echocardiography sessions per week. -

Booking is done only through Echo technician. For both inpatient and outpatients.

- Total number of the children’s (including inpatients and outpatients) for each echocardiography day should not exceed 5 patients; extra two slots per day are spared for urgent unbooked patients.

Guidelines for


100

INSTRUCTIONS FOR SEDATION: 1. The patient for morning session should arrive at 9:00 A.M. and the patients for afternoon session should arrive at 1:00 P.M. 2. Child should be N.P.O. one hour before sedation (child should not take anything to eat or drink for one hour before sedation). 3. Vital signs including blood pressure, oxygen saturation and body weight should 4. Pediatric cardiologist should approve sedation of small infants less than 3kg, severely cyanosed infants and sick infants. 5. The drug used for Sedation is chloral hydrate, which is given orally at the dose of (50-80 mg/kg). § The drug can be repeated at half dose if child is not sleeping in 1 hour. 6. Sedated infant should be connected to the ECG Leeds and pulse oxymeter during ECHO study. 7. The child is required to rest in the sedation room or waiting area after ECHO study, until he/she is fully awake. 8. The child should have near OPD appointment with pediatric cardiologist. REFERRAL FOR ECHO: All ECHO request forms should be submitted to ECHO lab station. Follow-up with appointment should be through ECHO technicians (Mrs. xxx: Ext 000) ECHO PRECEDURE LOCATION: All patients in pediatric wards should be brought to ECHO lab except sick patients or patients in NICU & PICU. Echo done for them at bed side by on-call Cardiologist and on-call Echo technician. All ambulatory patients for Cardiac clinic and Echo appointments will have Echo


be recorded on flow sheet.

procedure in Echo Lab. 12. Service Information: 12.1 Rotating Pediatric Resident/ specialties: I. Pediatric Cardiology is one of the fundamental branches in Pediatrics. 101

Guidelines for


The unit is expecting rotation of Arab Board/Saudi Board Residents and Registrars. II. The rotating resident/specialist is important part of Pediatric Cardiology team. He or she will be exposed to Clinical Pediatric Cardiology.


12.2 Duties of Rotating Residents/ specialties: - Daily ward rounds to inpatients assigned for pediatric cardiology room, as well as for patients consulted by other services such as NICU, PICU and other ward. Documentations of round with consultation should be written on the patients note. - Receive all consultations, either by direct contact for urgent consultation or by consultation form situated in cardiac ward nurse station for routine cases. - The resident/ specialist are expected to prepare and review the cases including all investigations before discussion with Consultant Cardiologist in charge. This will facilitate more interaction and informative discussion. Urgent Cases should be discussed as soon as possible with the consultant for further management plans. - The resident/ specialist should see and examine patients admitted under cardiology. Further management plans will be discussed according to Echo findings. - He/she will participate actively in referring patients to other institutions for further management or surgery (such as preparing discharge summaries, contact receiving hospital by phone etc.) see communication section for referral center information.

13. CARDIOLOGY INPATIENT SERVICE: § There is no need for separate cardiac ward but 2 rooms should be assigned for cardiac patients with total capacity of 5 beds. These rooms are located in the single pediatric ward however these rooms can be utilized by other subspecialties or general pediatric patients in case of emergency Guidelines for


102

admissions after approval of cardiologist on call and should be returned back to cardiac service within 2-3 days. § The rooms under cardiac service should be equipped with cardiac monitors, pulse oxymeters , BP monitors and suction machines in addition to oxygen supply slots and vacuum slots in the wall.

assigned for children with infectious diseases until he/she become non infectious then may be transferred to cardiac rooms. § The service of cardiac patients is in the pediatric wards is achieved by the specialist or resident assigned to the cardiology unit. § Nurses caring for the cardiac patients will be trained in the hospital or other hospitals to this purpose and should become familiar with equipments in the cardiac rooms. § Nurse station in the ward assigned for cardiac patients will serve as place to receive referral forms from other units for cardiac consultation and any inquiry about cardiac services. Cardiologist covering the service of cardiac patients (on call cardiologist) will have regular visit to the this ward daily and will response to these referral forms, but the fax reports from other hospitals will be reviewed by on call cardiologist in the administration office at least 3 time per day except the emergency fax reports which should be send to the cardiologist on call directly.

Ward Procedure: § The nursing staff informs the concerned resident about the admission. § Soon after admission the resident completes full checking of the patient, ordering any additional investigations overlooked.


§ Cardiac patient with infectious diseases will be admitted in the ward

§ Residents on finding anything abnormal with the other systems of the patients will immediately inform the specialist concerned.

103

Guidelines for


§ The specialist concerned before retiring will make certain that the condition of all his patients is satisfactory with further instructions to the resident or nursing staff as necessary. § In case of any problem patient and the concerned specialist not being available later, he should contact the specialist on call and instruct him


fully of the condition of this patient. § In case of serious complication, the specialist concerned may transfer the patient to ICU in consultation with the cardiologist and ICU specialist in charge and the nursing supervisor. § The specialist and/or consultant cardiologist is expected to perform daily clinical rounds in the ward or ICU with the responsible nurse and the resident to record daily progress of the patient and other instructions regarding treatment. § The patient discharge is entirely responsibility of the cardiologist, the relevant forms and papers i.e. admission and discharge forms and sending feedback to the referring doctor are completed by resident/specialist and signed by him. § The cardiologist concerned should explain to the mother or other responsible adult relative, particular medical technique that may become necessary, the expected outcome and number of days the patient may be expected to remain in hospital.

14. Emergency Room: § Cardiac patients arriving at ER with acute or chronic medically distressing conditions should be seen. § Initially these patient seen and resuscitated in the ER by the pediatric resident and registrar covering the ER department and if the management of the cardiac patient require pediatric cardiologist the specialist on call of general pediatric should contact pediatric cardiologist by telephone. § The cardiologist on call should see such patient either in the ER department or in the PICU/ward after admission. Guidelines for


104

§ Cardiac illness requiring specialized treatment for which this hospital is not equipped to render will be transferred to other hospital after preliminary resuscitation and stabilization are made. After appropriate arrangement with the concerned doctors at the other hospital.

§ The Pediatric Cardiology Consultant will be totally responsible for all patients as admitted under him or being treated by him. § The general pediatric Specialist/Consultant may take decisions regarding management of common pediatric symptoms in cardiac patients. § Close cooperation between the Medical and Nursing staff is encouraged and there will be grand clinical rounds by the Specialist/Consultant with the Nurses to explain to them, in more details the condition and treatment of the patients. § Ensure adequate liaison with other departments such as Cardiac Surgery, Radiology, and Laboratory.


It is the responsibility of the resident/ specialist assigned in pediatric cardiology services to dictate discharge summary immediately upon discharge to provide copy to patients and to send copy of the report to the referring institution or hospital.

- Please do not use any abbreviation in your dictation, e.g. do not abbreviate Pulmonary Artesia as “PA” etc.


15. GENERAL RULES:

16.2 Patient Data Sheet: The resident/ specialist should complete the patient data sheet provided by the charge nurse (for any difficulty he should contact consultant-in-charge).

105

Guidelines for


16.3 Referral Centers: The following are tertiary care referral pediatric cardiac centers: 1. King Faisal Specialist Hospital & Research Center: Pediatric Cardiology Coordinator: Ext: 39175, pager:8388 Ext: 39176, pager:6612


Coordinator Office: 01-464-7272 Ext: 32094 Direct line: 4424486 Fax: 01-442-7498 2. King Abdulaziz Cardiac Center/King Fahad National Guard: Coordinator: Ext: 6683, pager:1144 Ext. & pager: 6686 Tel: 10-252-0088 Ext: 6682 Fax: 01-252-0088 Ext: 6684 3. Prince Sultan Cardiac Center: Coordinator: Secretary Office: 4783000 Ext: 8795;Direct Fax: 473-0049 17. Academic Activity of Cardiology Division The pediatric cardiologist in the unit is expected to participate in the following academic activity: - Pediatric club monthly meeting. - Supervising interns, residents, and registrar for clinical presentation in the daily morning reports. - Participate in the other academic activates in the hospital including hospital lectures, symposium, seminars, clinical courses, written courses, etc. - Participate in the academic activities concerning cardiology e.g. cardiology day, pediatric cardiology symposium in other centers. -

Attend cardio-surgery meeting in other cardiac centers according to schedule arranged by the department head.

Other activities of the Department Staff: - Participate in the Public health educations through different media channels - Participate in hospital committees e.g. infection, quality assurance, and credential - Participate in regular monthly mortality and morbidity meeting - Participate in the medical education of nurses, technician and other staff in the hospital. Guidelines for


106

Pediatric Cardiology Division Policy and Procedures For General Hospitals (400 – 600 beds) / Maternity and children Hospitals

DIVISION of Pediatric Cardiology POLICIES AND PROCEDURES 1. APPLICATION: This policy applies to all staff in the division of pediatric cardiology, for large general hospitals (400 – 600 beds) and it also applied to pediatric cardiology unit

2. PURPOSE: - To provide diagnostic and management services for routine and emergency pediatric cardiology conditions in the hospital. In this connection, pediatric patients are defined as those aged 12 years and below. - To provide education to: Staff & Patients. 3. STAFFING: - Staff of pediatric cardiology - Division would consist of the following: - Chief of pediatric cardiology - Consultant pediatric cardiologist - SPECIALIST (2) - RESIDENT

(3)

- Echo technician (2) - ECG technician (2) - Two Registered nurses (for pediatric cardiology outpatient unit& echo lab). - Nutrition Specialist - Social worker - Health Educator - Division secretary


in Maternity and children hospitals.

- Receptionist for cardiac lab. - Ward cleric - Coordinator for Cardiac Appointment

109

Guidelines for


4. JOB DESCRIPTION: Qualifications and experience: 1. TITLE : HEAD OF PEDIATRIC CARDIOLOGY DIVISION


2. DEPARTMENT : PEDIATRIC -CARDIOLOGY DIVISION 3. REPORTS TO : CHAIRMAN, PEDIATRIC DEPARTMENT 4. LIASES WITH : Consultants, Head of Cardiology with his/her other specialties within the department, nursing staff, other health care professionals, patients and their families. 5. RESPONSIBLE FOR : Duties contained in this Job Description 6. JOB SUMMARY : As Head of Paediatric Cardiology Division, he is responsible for selection of well-qualified and competent staff to work in the Paediatric Cardiology Division. It will be his constant endeavour to encourage and guide the staff working under him, to give their best and be accountable. He would report members of the staff who do not come to the expectations, so that the Paediatric Cardiology Department improves the standards with a goal to provide excellent care to the patients. He will be responsible in providing care for his/her patients (in-patient and out-patient) maintaining a high level of professional performance in accordance with, Professional medical ethics, Hospital medical by-laws, Laws of Ministry of Health in Kingdom of Saudi Arabia and any other applicable regulations according to the department quality plan. He is committed to provide effective and dynamic leadership in; 1. Improving the quality and competence of cardiology staff, needed to provide best care to the cardiac patients. 2. Continuous medical education to ensure the staff is up to date in terms of knowledge, guidelines regarding management of patients with ACS etc. 3. To liaise with other department heads to ensure good communication and best Consultation services to variety of patients. Guidelines for


110

4. To arrange regular meetings with the staff working under him to improve understanding and working atmosphere and to set targets to be achieved. 5. To strive constantly to improve services in terms of the equipment needed, commensurate with advances in technology, i.e. Echocardiography, Non-invasive monitoring. follow-up, patient medical records and patient compliance. 7. To ensure disease-oriented research to follow the cardiac disease prevalence in our Saudi community, for future planning of cardiology services in the kingdom. 8. To encourage young and gifted cardiologist by new incentives. To train the Saudi doctors in cardiology for future. 9. To improve the intensive care services for cardiac patients to a degree far excellence. 10. To regularize call duties, referral systems and response to emergencies in accordance with international standards. 5. DUTIES AND RESPONSIBILITIES: 5.1. Provides patient care within the parameters of their professional competences as reflected in the scope of their clinical privileges for both in-patient and out-patients. 5.2. Practices within the framework of clinically relevant and scientifically valid standards, guidelines and criteria. 5.3. To perform his duties in the cardiology clinic evaluating patients with cardiovascular diseases. 5.4. To provide care to his patients in the PICU, NICU and other Paediatric wards. 5.5. To perform cardiac procedures:

EKG interpretation, holter monitors,

Echocardiogram and Doppler, etc.


6. To give advice to medical record, appointment office to improve patient

5.6. To provide consultation services to the in-patients in his/her area of expertise. 5.7. Conducts regular ward rounds on his own and/or as a team to formulate a multidisciplinary treatment plan. 5.8. Performs diagnostic and therapeutic procedures on his/her patients within the range of the specialty. 111

Guidelines for


5.9. Assessment and referral of appropriate patients under his/her medical care to other appropriate medical facilities as well as accepting referrals of patients with medical problems in his/her field of specialty. 5.10. Participates in the on-call rotation schedule of the department for patients care and admission.


5.11. Responds to emergencies to offer advice and actively participate with problems if required to his/her specialty. 5.12. Observes and upholds the patient’s rights of security, confidentiality and privacy. 5.13. Maintains appropriate records of all patients with accurate, timely legible completion of patient’s medical records. 5.14. Consultants have a leadership role in the organization performance. 5.15. Supervision of duties of assigned junior staff. 5.16. Provides leadership for performance-improvement functions in the process of measurement, assessment and improvement of both clinical and nonclinical process as part of the departmental quality plan. 5.17. Active participation in Continued Medical Education (C.M.E.) through educational hospital activities (morning report meetings, grand rounds, clinical tutorials and seminars, journal club, radiology or clinic-pathological conferences). Also, through national and international meetings, conferences and symposia. 5.18. Active participation in training program related to his/her field and organization within the hospital for training of junior medical staff and inservice training for nursing staff and technicians. 5.19. Continuous update of his/her knowledge in the medical field as well as continuously upgrading level of skills in his/her field of profession. 5.20. Participation in committee meetings assigned to him/her (Quality Improvement, Infection Control). 5.21. Abides by Department Policies and Procedures, as well as hospital bylaws, rules and regulations. 5.22. To carry out any other assignments as directed by Hospital Administration and or the department head and within the realm of his/her knowledge, skills and abilities. Guidelines for


112

5.23. Department specific duties and responsibilities: 5.23.1. Leads a group or is a part of his team. 5.23.2. Has on the average 1 specialist, 2 residents, and 1-2 interns under his Supervision. 5.23.3. Makes two rounds a day, morning round and sign out round. 5.23.4. Makes business rounds in the morning using the SOAP approach. 5.23.6. Consults with other services if needed. 5.23.7. Make a grand round at least once a week. 5.23.8. On the on-call day, answer faxes from other institutional punctually. 5.23.9. Has 1-2 clinics a week. 5.23.10. Engages in doctor and student teaching. 5.23.11. Participates in department activities like presentations, club journal, Morbidity and mortality meetings and audits. 5.23.12. Reviews and sing all discharge summaries. 5.23.13. Evaluates all staff under his/her supervision. 5.23.14. Encourages scientific research, papers, and evidence based medicine. 5.23.15. Review charts in the Medical Records Department. 5.23.16. Studies medico-legal cases. 5.23.17. Supervise Intensive Cardiac Care Unit on a rotational basis. 5.23.18. Performs stress test and echocardiogram. 5.23.19. Reads electrocardiogram. 5.23.20. Inserts temporary pacemakers if needed. 5.23.21. Other duties as directed by Ministry of Health within his/her specialty.


5.23.5. Teaches during the round important aspects of clinical care.

6. QUALIFICATIONS: 6.1. EDUCATION/LICENSURE: 6.1.1. Saudi Fellowship, Arab Fellowship, American Fellowship, Canadian Fellowship, European Fellowship, or Equivalent in Paediatric Cardiology Sub-specialty or (Saudi Board in Paediatric or Equivalent to plus Paediatric Cardiology Sub-specialty degree). 113

Guidelines for


6.2. PROFESSIONAL/EXPERIENCE: 6.2.1. Minimum of one (1) years experience Post Qualification in the Cardiology field. 6.2.2. Current valid license to practice Cardiology specialty. 6.2.3. Registration in Saudi Medical Council and/or Current license to


practice Cardiology in Saudi Arabia. 6.3. SPECIALIZED KNOWLEDGE/SKILLS: 6.3.1. Demonstrates leadership and administrative skills. 6.3.2. Fluent in verbal and written English. 6.3.3. Exhibits professionalism and excellent interpersonal communication skills. 6.3.4. Is knowledgeable of the Medical by-laws. 6.3.5. Knowledge of computer application. CONSULTANT PEDIATRIC CARDIOLOGIST 1. TITLE : CONSULTANT PEDIATRIC CARDIOLOGIST 2. DEPARTMENT : PEDIATRIC - CARDIOLOGY DIVISION 3. REPORTS TO : CHAIRMAN, PEDIATRIC DEPARTMENT 4. LIASES WITH : Consultants, Head of Paediatric Cardiology with his/her other specialties within the department, nursing staff, other health care professionals, patients and their families. 5. RESPONSIBLE FOR : Duties contained in this Job Description 6. JOB SUMMARY : The cardiologist is a staff member of the Cardiology Division. Responsibilities are divided between the out-patient and in-patient services: consultations, admissions and cardiac


Stress testing, Holters, etc.) and general cardiac duties. 6.1. Responsible for providing care for his/her patients (in-patient and out-patient) maintaining a high level of professional performance in Guidelines for


114

accordance with, Professional medical ethics. Hospital medical bylaws, Laws of Ministry of Health in Kingdom of Saudi Arabia and any other applicable regulations according to the department quality plan. 6.2. Provides effective leadership of the department maintaining an appropriate quality plan using measurable performance improvement standards in the field of cardiology and provide a state of art, care to

7. DUTIES AND RESPONSIBILITIES: 7.1. Provides patient care within the parameters of their professional clinical privileges for both in-patient and out-patients. 7.2. Patients within the framework of clinically relevant and scientifically valid standards, guidelines and criteria. 7.3. To perform his duties in the cardiology clinic evaluating patients with cardiovascular diseases. 7.4. To provide care to his patients in the PICU, NICU and other medical wards. 7.5. To perform cardiac procedures:

EKG interpretation, Holter monitors,

Echocardiogram and Doppler study, etc. 7.6. To provide consultation services to the in-patients in his/her area of expertise. 7.7. Conducts regular ward rounds on his own/or as a team to formulate a multidisciplinary treatment plan. 7.8. Performs diagnostic and therapeutic procedures on his/her patients within the range of the specialty. 7.9. Assessment and referral of appropriate patients under his/her medical care to other appropriate medical facilities as well as accepting referrals of patients with medical problems in his/her field of specialty. 7.10. Participate in the on-call rotation schedule of the department for patient care and admission.


patients admitted to Coronary Care Unit.

7.11. Responds to emergencies to offer advice and actively participate with problems if required, related to his/her specialty. 7.12. Observes and upholds the patient›s rights of security, confidentiality and privacy.

115

Guidelines for


7.13. Maintains appropriate records of all patients with accurate, timely legible completion of patient›s medical records. 7.14. Consultant has a leadership role in the organization performance. 7.15. Supervision of duties of assigned junior staff. 7.16. Provides leadership for performance-improvement functions in the process


of measurement, assessment and improvement of both clinical and nonclinical process as part of the department quality plan. 7.17. Active participation in Continued Medical Education (CME) through educational hospital activities (morning report meetings, grand rounds, clinical tutorials and seminars, journal club, radiology or clinico-pathological conferences(. Also, through national and international meetings, conferences and symposia. 7.18. Active participation in training program related to his field and within the hospital for training of junior medical staff and in-service training for nursing staff and technicians. 7.19. Continuous update of his knowledge in the medical field as well as continuously upgrading level of skills in his/her field of profession. 7.20. Participation in committee meetings assigned to him/her (Quality Improvement, Infection Control). 7.21. Abides by Department Policies and Procedures, as well as hospital bylaws, rules and regulations. 7.22. To carry out any other assignments as directed by Hospital Administration and/or the department head and within the realm of his knowledge, skills and abilities. 7.23. Department specific duties and responsibilities: 7.23.1. Leads a group or is a part of its team. 7.23.2. Has on the average 1 specialists, 2 residents, and 1-2 interns under his supervision. 7.23.3. Makes daily rounds. 7.23.4. Makes business rounds in the morning using the SOAP approach. 7.23.5. Consults with other services if needed. 7.23.6. Make a grand round at least once a week. 7.23.7. On the on-call day, answer faxes from other institutions punctually. Guidelines for


116

7.23.8. Has one 1-2 clinic a week. 7.23.9. Engages in doctor and student teaching. 7.23.10. Participates in department activities like presentations, club journal, morbidity and mortality meetings and audits. 7.23.11. Reviews and signs all discharge summaries. 7.23.13. Encourages scientific research, papers and evidence based medicine. 7.23.14. Review charts in the Medical Records Department. 7.23.15. Studies medico-legal cases. 7.23.16. Performs echocardiogram. 7.23.17. Reads electrocardiogram. 7.23.18. Inserts temporary pacemakers if indicated. 7.23.19. Other duties as directed by Ministry of Health within his/her specialty. 8. QUALIFICATIONS: 8.1. EDUCATION/LICENSURE: 8.1.1. Saudi Fellowship, Arab Fellowship, American Fellowship, Canadian Fellowship, European Fellowship, or Equivalent in Paediatric Cardiology Sub-specialty or (Saudi Board in paediatric or Equivalent to plus Paediatric Cardiology Sub-specialty degree). 8.1.2. Administration and management Degree/Course is essential. 8.1.3. Certified in BLS, PALS. 8.2. PROFESSIONAL/EXPERIENCE: 8.2.1. Registration in Saudi Medical Council and/or Current license to


7.23.12. Evaluates all staff under his supervision.

practice Paediatric Cardiology in Saudi Arabia. 8.3. SPECIALIZED KNOWLEDGE/SKILLS: 8.3.1. Demonstrates leadership and administrative skills. 8.3.2. Fluent in verbal and written English. 8.3.3. Exhibits professionalism and excellent interpersonal communication skills. 117

Guidelines for


8.3.4. Is knowledgeable of the Medical by-laws. 8.3.5. Knowledge of computer application. SPECIALIST IN PEDIATRIC CARDIOLOGY


1. TITLE : SPECIALIST IN PEDIATRIC CARDIOLOGY 2. DEPARTMENT : PEDIATRIC -CARDIOLOGY DIVISION 3. REPORTS TO : CHAIRMAN, PEDIATRIC DEPARTMENT 4. LIASES WITH : Consultants, Head of Cardiology, with his/her other specialties within the department, nursing staff, other health care professionals, patients and their families. 5. RESPONSIBLE FOR : Duties contained in this Job Description 6. JOB SUMMARY : The cardiologist is a staff member of the Cardiology Division. Responsibilities are divided between the out-patient and in-patient services: consultations, admissions and cardiac


Stress testing, Holters, etc.) and general cardiac duties. 6.1. Responsible for providing care for his/her patients (in-patient and out-patient) maintaining a high level of professional performance in accordance with, Professional medical ethics. Hospital medical bylaws, Laws of Ministry of Health in Kingdom of Saudi Arabia and any other applicable regulations according to the department quality plan. 7. DUTIES AND RESPONSIBILITIES: 7.1. History taking, physical examinations, interpretation of common diagnostic tests and document patient condition on admission in the specified admission sheet. 7.2. Can admit patients from the hospital Emergency Room after appropriate discussion and approval of the Consultant under whose name admission is done.

Guidelines for


118

7.3. Evaluates new admission and coordinates with Consultant a plan to establish a diagnosis and a management course. Executes the plan approved by the Consultant. 7.4. Conducts daily ward rounds to all in-patients in the department. Liaises with the concerned Consultant with regards to care of his in-patients. 7.5. Documents plan of patient management and maintain appropriate records records. 7.6. Keeping an updated follow-up in the progress notes. 7.7. Should seek the advice of or help of the Consultant whenever the condition of a patient merits further expertise. Works under supervision and instructions of assigned Consultant. 7.8. Prepares all discharge summaries, death reports and special reports on related patients. 7.9. Presentation of new admissions to the department through the daily morning reports. 7.10. Participates actively in the on-call rota of the department for patients care and admissions. Responds to emergencies to offer medical care and advice on problems related to his specialty. 7.11. Assist staff (Consultant) in performing diagnostic or therapeutic procedures to patients in his/her field of department. 7.12. Supervise the Junior Staff in conducting their duties and responsibilities as designated by the department. 7.13. Actively participates in department’s educational and training activities. 7.14. Abides by departmental Policies and Procedures as well as hospital by laws, Rules and Regulations. 7.15. To carry out any other assignments as directed by the Head of Department and within the realm of his/her knowledge, skills, and abilities.


of all patients with accurate timely legible completion of patient’s medical

8. QUALIFICATIONS: 8.1. EDUCATION/LICENSURE: 8.1.1. University Master Degree in his/her Specialty or Equivalent.

119

Guidelines for


8.2. PROFESSIONAL/EXPERIENCE: 8.2.1. Minimum of two (2) years experience in his/her specialty after obtaining Master’s Degree. 8.2.2. Registration in Saudi Medical Council and/or Current license to practice Paediatric Cardiology in Saudi Arabia.


8.2.3. Current valid license to practice Paediatric Cardiology specialty. 8.3. SPECIALIZED KNOWLEDGE/SKILLS: 8.3.1. Fluent in verbal and written English. 8.3.2. Exhibits professionalism and excellent interpersonal communication skills. 8.3.3. Is knowledgeable of the Medical by-laws. 8.3.4. Knowledge of computer application. RESIDENT IN PEDIATRIC CARDIOLOGY 1. TITLE : RESIDENT IN PEDIATRIC CARDIOLOGY 2. DEPARTMENT : Paediatric -CARDIOLOGY DIVISION 3. REPORTS TO : CHAIRMAN, Paediatric Department 4. LIASES WITH : Consultants, Head of Paediatric Cardiology with his/her other specialties within the department, nursing staff, other health care professionals, patients and their families. 5. RESPONSIBLE FOR : Duties contained in this Job Description 6. JOB SUMMARY : The resident is a staff member of the Cardiology Division. Responsibilities are divided between the out-patient and in-patient services: consultations, admissions and general cardiac duties. Responsible for providing care for his/her patients (in-patient and out-patient)

maintaining a high level

of professional performance in accordance with, Professional medical ethics. Hospital medical by-laws, Laws of Ministry of Health in Kingdom of Saudi Arabia and any other applicable regulations according to the department quality plan. Guidelines for


120

7. DUTIES AND RESPONSIBILITES: Specific duties and responsibilities of the resident will be outlined by the individual Program Directors. The resident is responsible to his/her Program Director for performance in all phases of training. 7.1. To assist in the organization and provision of clinical care and patient management. 7.3. The resident is expected to take a history and perform a physical examination on all the newly admitted patients under his/her team. 7.4. It is the resident’s duty to confirm that any (informed consent) has been signed and obtain such consent from the patient’s parent/guardian. 7.5. The resident is expected to make daily ward rounds, usually in conjunction with and a mutual convenient time for the team specialist consultant. This includes writing daily progress notes and appropriate orders, organizing and following up on investigations, writing fluid orders, starting IV’s and drawing blood as necessary. 7.6. Residents should attend the out-patient clinics of the consultants on their team. 7.7. Residents are supposed to take referral calls from other department including the Emergency, under the close supervision of the Cardiology Specialist on duty. 7.8. Residents are responsible for the Record Keeping and all entries in the record should be dated and timed as well as signed. Entries should be made clearly in black ink and it is helpful to print your name and page number. At discharge, a summary should be completed and sent to the patient’s GP as well as to the referring consultant and all other activities involved in the patient’s care. 7.9. All residents must attend all regular clinical teaching session and residents


7.2. To participate in in-service training.

may be called on to present patients, comment on X-rays or review papers. 7.10. Participate in safe, effective and compassionate patient care. 7.11. Developing an understanding of ethical, socio-economic and medical/legal issues that affect graduate medical education and of how to apply cost containment measures in the provision of patient care.

121

Guidelines for


7.12. Participation in the education activities of the training program and, as appropriate, assumption of responsibility for teaching and supervising other residents and student, and participation in institutional orientation and education programs and other activities involving the clinical staff. 7.13. Participation in institutional committees and councils to which the resident


is appointed or invited; and performance of these duties in accordance with the established practices, procedures and policies of the institution, and those of its programs, clinical departments, and other institutions to which the resident is assigned; including, among others, state licensure requirements for physicians in training, where these exist. 7.14. Carries out the clinical and other duties allocated to him/her by the Consultant in Charge. 7.15. Responsible for the basic medical care within the department. Evaluate patients under his care, formulating plans of investigation and treatment. Visits in-patients daily and documents daily progress of his/her patients, and their new investigation results. 7.16. Takes on call duty according to Rota. 7.17. Writes discharge and death summaries. 7.18. Accompanies Consultant on ward rounds and in out-patient clinics. 7.19. Assist in education activities. 7.20. Performs other applicable tasks and duties assigned within the realm of his/her knowledge. 8. QUALIFICATIONS: 8.1. EDUCATION/LICENSURE: 8.1.1. Graduate of Recognized Medical School. 8.1.2. Registration in the Saudi Medial Council and must be valid and recent. 8.2. PROFESSIONAL/EXPERIENCE: N/A 8.3. SPECIALIZED KNOWLEDGE/SKILLS: 8.3.1. Fluent in verbal and written English. 8.3.2. Exhibits professionalism and excellent interpersonal communication skills. 8.3.3. Knowledgeable of the Medical bi-laws. Guidelines for


122

Cardiac Division Secretary Qualifications: - Medical Secretary Diploma - Knowledge and experience in using computer.

- Make files for all cardiac unit staff. The file of each staff member should contain C.V, medical degrees; academic activities attendance certificate, vacation forms incidental reports, etc. Make directory for all cardiac unit staff members and the related department’s staff, which should include the pager numbers, telephone extensions numbers. - Make on call schedules for doctors and technician in the cardiac unit on regular basis. - Responsible for collecting and distributing memos concerning cardiac unit, directed from hospital administration, relevant departments and department chief. - Fill the vacation forms for unit staff including annual leave, study leave emergency leave and process the forms through hospital administration offices. Organize the annual vacations for all unit staff members. - Fill the forms requesting participation in academic activities including symposium, seminar, and courses for any unit staff and process them through CME office. Attach boosters of symposium, workshops and other academic activities in assigned board. - Prepare MCQ lectures and slides for presentation concerning cardiac unit staff. - Organize all meeting for chief of cardiac unit and attend such meetings to write


JOB DESCRIPTION OF DIVISION SECRETARY

comments and final decisions. - Orientation of new staff joined to cardiac unit regarding the place and regulations. - Typing all reports regarding cardiac unit including reports of the tests performed in the non-invasive cardiac lab such as Echocardiography reports, Holter analysis reports. Stress echo reports. Etc. 123

Guidelines for


- Typing fax reports to communicate with other cardiac centers and typing urgent medical reports in order to transfer cardiac patients to other cardiac centers. Transcription department of the hospital should type discharge summaries and regular medical reports. - Communicate with cardiac centers coordinator directly by telephone for


occasional sick patients in order to facilitate their transfer. - Regular secretary work including filing the papers, typing reports concerning the department. - Help the cardiac staff members in processing their paper through various hospital departments for any reason e.g. housing, payroll, passport, travel arrangement and transport. The secretary can help by direct contact with personnel or other units in the hospital through telephone. - Responsible of the appointment arrangement for the departmental head during regular working hours.

9. DEPARTMENTAL ORGANIZATION: 9.1 ON CALL DUTIES SYSTEM: a.) Consultants would be on call on rotational basis for 24 hours including weekends. According to rosters drawn up by the chief of department. b.) The pediatric cardiologist would care for patients in his sub-specialty during working hours with his team, the general pediatrician would cover this service after working hours and pediatric cardiologist may however be called when an emergency arises in his sub-specialty. c.) The pediatric cardiologist/ specialties on call would response to referrals from all hospital units whether urgent or non urgent. The urgent will be seen immediately while the non urgent will be seen on the same working day provided that the non urgent case was referred before 12:00 pm. d.) The pediatric cardiologist on call would also response to referrals from other hospitals through either fax or telephone. The response to fax is based on receiving date by hospital administration. Guidelines for


124

e.) Immediate care of cardiac patients in the general wards or NICU, PICU and cardiac ward during regular working hours is responsibility of treating pediatric cardiologist. f.) Regular ward rounds for inpatients are direct responsibility of treating consultant; however on call cardiologist should attend this round for all inpatients. Grand round involving all the cardiology team will be on every

g.) All newly admitted cardiac patients should be seen by the on call pediatric cardiologist on the same day with clear document in the patient file, including elective admissions for OPD or from other hospitals. The consultant who accepted the elective admission patient should also see it, on the same working day. h.) Patients are seen in the emergency department by ER Doctors on 24 hours basis. However, pediatric cardiology specialist/consultant on call can be called upon to look after any seriously ill patient in the emergency room.

9.2 ADMISSION REGULATION: Children with cardiac disease are admitted by different ways. - From cardiac clinic, the admitted child will be under the name of the consultant who attended the clinic (elective admission). - Accepted by consultant cardiologist on call from other hospitals through fax, the child will be admitted under the name of the consultant who accepted the child (elective admission). - Children referred from other units in the hospital (non cardiac) will admitted under the name of the on call cardiologist from the next full working day.


Saturday morning.

- Admission from Emergency department: i. New patients will admitted under the name of on call pediatric cardiologist ii. Old patients will be admitted under the name of the previous treating consultant.

125

Guidelines for


9.3 CARDIAC CONSULTATION: All children referred to pediatric cardiologist should have the following: o 12-lead ECG o Chest x-ray o Oxygen saturation by pulse oxymeter or ABG


o Blood pressure from all limbs. OUT PATIENT CONSULTATION All referrals should be discussed with the most senior physician in general pediatric at OPD who will give priorities before booking for cardiology clinic or he may directly contact the cardiologist. All other areas than OPD should go through pediatric cardiology consultation service (inpatient consultation). Referral from other hospitals for cardiologist should also go through pediatric cardiology consultation service. THE OPD PRIORITY GUIDELINES ARE AS FOLLOWS: a. First priority should be given to neonates with neonates with cyanosis; consultation should be done immediately without delay for further actions, even if neonate is not sick looking. Consultation should be done with cardiologist on call. b. Children with suspected infective endocarditis, new rheumatic fever, recent history of arrhythmia and neonates with heart murmur who are also symptomatic or having abnormal vital signs should be discussed with cardiologist on call. c. All neonates with heart murmur otherwise normal, stable vital signs including oxygen saturation, blood pressure in all limbs, should be given appointment in cardiac clinic within 2 weeks. Older age group with similar finding should be given appointment within 1 month. d. Known case of rheumatic fever, neuromuscular dystrophy, thalssmia, sickle cell anemia, metabolic, endocrine and infants with various syndromes for screening should be given appointment within 4 month. Any other cases should be discussed with OPD consultant before booking. The appointment will be made through hospital appointment office. Guidelines for


126

Inpatient consultation a. Urgent consultation: contact directly by phone to on call cardiologist especially from NICU or PICU. b. Routine consultation: consultation form should be filled out and sent to cardiac ward nurse station.

it is advised that routine consultation forms should be send to cardiology ward before 1:00 pm. 9.4 FOLLOW UP OF CARDIAC PATIENTS i. Admitted children will be given appointment in the cardiac clinic for follow up after discharge from hospital. ii. The appointment is decided by treating cardiologist and should be available before the patient leave the hospital iii. The cardiologist should specify in the patient’s file the necessary investigations for the next visit in the cardiac clinic such as chest x-ray, INR, ECG.etc iv. Scheduled patient’s files should be reviewed before the clinic time by specialist /consultant to order the required investigations. v. Follow up appointments should not exceed 12 months from the discharge date.

9.5 MANAGEMENT OF REFERRED PATIENTS Consultant pediatric cardiologist on call should response as soon as possible to urgent referrals from various units in the hospital. Non-urgent referrals should be responded during same working day. The management of referred


Consultation forms will review by cardiologist on call on the same day, however

child for cardiac consultation is based on the underlying pathology, the number of the system involved in the disease process and also on the system which is mainly affected. The following items are guidelines for the management of referred child.

127

Guidelines for


A. The child may be completely transferred under cardiology service and discharged from referring service (non-cardiac) e.g. congenital heart disease, rheumatic fever with cardiac disease, Kawasaki disease with coronary aneurysms...etc B. The child may be followed by the non-cardiac service mainly, however


the cardiologist will be his opinions when he is consulted e.g. child with leukemia and heart failure. C. Mainly the cardiology team may follow the child, while the non-cardiac service is consulted for opinions and follow up management in their subspecialty e.g. congenital heart disease with significant infection. D. The child may have combined management by cardiologist and other subspecialty consultant e.g. infant of diabetic mother with cardiomyopathy will be managed by both cardiologist and neonatology consultant. Children with multiple problems will be followed by different sub-specialties e.g. VACTERL association, however the child will be under the name of neonatologist or accepting consultant. Notice: All children who have mainly cardiac disease will be admitted under cardiology team or transferred to their service and they will be followed in cardiac clinic after discharge from hospital. 10. OUT PATIENT SERVICE: 10.1 Doctors’ Schedule: Based on the increase number of cardiac patients and because the majority of the cardiac patients are ambulatory, it was suggested to increase the number of cardiac clinics to 3 clinic per week. The doctors will be distributed for these clinics according to the published schedules. In the event of any consultant being unavailable (e.g. being on vacation) on his clinic day, the chief of department will arrange for such clinic to be covered by appropriate personnel.

Guidelines for


128

10.2 Space: Pediatric cardiology consultant/ specialist need two rooms in ground

floor

near Echo lab for management of ambulatory cardiac patients. 10.3 Staff: A. Doctors. in two

separate rooms. B. Nurses: two nurses are required for the Pediatric cardiology clinic. The clinic is attended with one registered nurse to take vital signs, body weight, and oxygen saturation by pulse oxymeter and also to assist the doctors in examining the child. The clinic also required another nurse to help in the second cardiac clinic room, help in sedation of children who need investigations like ECG and also help in organizing for follow up appointment in the clinic. Both nurses assigned 3 days in week for cardiac clinic and for the remaining 2days in the week they are assigned in Echo and ECG lab. Both of them should be trained in CPR and sedation of children. 10.4 Regulations of Cardiac Clinic a.) Patients are referred to the pediatric cardiology clinic from general pediatric clinics in the hospital. Patients are also referred from other hospitals directly to pediatric cardiology clinic; however such patients need approval of administration office and the cardiologist before booking to the cardiac clinic. b.) Total number of booked patients per clinic should not exceed 8 patients and all booking is done through hospital appointment office.


Consultant pediatric cardiologist and specialist attend cardiac clinic

c.) Maximum two patients can be added to each clinic. This slot of the two patients per clinic is kept purposely to add patients who require near follow up appointment after discharge form hospital and should be approved by the consultant.

129

Guidelines for


d.) Consultant cardiologist conducts pediatric Cardiology clinics. Occasionally senior registrars may participate in the management of ambulatory Cardiac Patient. e.) Consultant or specialties who will attend the clinic should review the patient’s files prior to the clinic time for ordering the necessary investigation.


f.) Patients are seen and examined by the cardiologist and investigated on outpatient basis, following such examination and investigation may be admitted to the ward. g.) Admission from the clinics would normally be processed directly to the ward without passing through ER, except for sick patient who need stabilization in the ER unit before sending to the ward. Or until the bed is ready in the ward or PICU. h.) Very sick patients when attend cardiac clinic should be send to Emergency unit rather than examining in the clinic. A nurse should accompany the patient to emergency unit and on call cardiologist should be inform immediately. i.) Prior to admission, the cardiologist should discuss with the patient’s responsible adult, the nature of treatment and its possible outcome. Necessary papers and consent should be completed before admitting the patient. j.) Files for ambulatory cardiac patients should be reviewed on regular basis by the cardiology staff to improve the quality of the work. k.) Follow up appointments of ambulatory cardiac patients should not exceed 6 months, and at each visit the cardiologist should write clearly the plan of the management and the necessary investigation for next visit. l.) Regulations for medical reports, sick leaves and clinic attendance forms are according to MOH regulations and measure. m.) Regular ambulatory cardiac patients who grow out the pediatric age (12 years) should be referred to adult cardiology service with detail typed medical report, prepared by treating consultant. The report should indicate the reason for referral and should be sending through administration office to other hospitals. Guidelines for


130

11. ECHOCARDIOGRAPHY AND ELECTROCARDIOGRAPHY LABORATORY (NONINVASIVE CARDIOLOGY LAB): 11.1 SPACE: 4 rooms in the ground floor near the cardiac OPD. § First room is assigned for main Echo lab; it will contain large modern 3D – Echo machine with multiple probes. This room will be used for also contains mini station for data management and archiving of data in main server. It also assigned for Holter recorder analysis. It contains crush trolley with defibrillator, which also have specific module for external coetaneous pacing. § The second room is assigned for regular transthoracic echo. It will be used 5days per week, (3 days together with cardiac clinics and 2days for Echocardiography session). It contains heavy-duty echocardiography machine. § The third room is assigned for regular ECG recording, both 12 Leeds and long stip. The ECG will be performed for both outpatients and inpatients. It contains ECG machines for 12 led recording. § The forth room is assigned for sedation of the infants before ECG or Echocardiography. It also used to measure oxygen saturation by pulse oxymeter, blood pressure, and body weight. This room should contain all the necessary equipments for the Purposes mentioned above.

11.2 EQUIPMENT: § Advanced Echocardiogram machine with full option including multiple probes and Fetal Echo prob. § Standard Echocardiogram machine with multiple probes.


regular Transthoracic Echo, fetal echo, contrast Echo, stress Echo. It

§ Portable Echocardiogram machine with multiple probes. § Mini station for data management and archiving of data in main server with connection to both Echo machines § Holter analysis computer with holter recorders

131

Guidelines for


§ Two ECG printer machines for 12 lead analysis with module for pacemaker analysis. § Crush card trolley with advance biphasic defibrillator and module for external cutaneous pacing


§ Pulse oxymeter § Blood pressure monitoring device. With recording for systolic, diastolic and MAP § Suction machine § Cardiac monitor

11.3 STAFF § Consultant cardiologist § Echo technician (2) § ECG technician (2) § Registered nurse (2) § Cardiac service secretary § Social worker § Health Educator § Receptionist for Cardiac lab. § Nutrition Specialist § Coordinator for Cardiac Appointment

QUALIFICATIONS: Echo-cardiograph technician - Obtain a Bachelor degree in X-ray or a Diploma in Echo-cardiograph. - Have a year experience.

Guidelines for


132

ECG & Holter Technician - Obtain ECG Diploma - Have a year experience. Nurse in Pediatric Cardiac Unit: - Obtain a Bachelor degree in Nursing. - Experience in Pediatrics diseases not less than a year.


a.) Echo lab - Perform complete study in Echo lab for new patients including Tran thoracic Echo, TEE, fetal Echo, contrast echo. - Review all studies done by Echo technician before approval. He should review the study while the patient is in the echo lab - Teach joiner staff including specialist, resident rotating in the cardiology unit and technician - Write clear reports in the Echo forms and send for typing before approval b.) ECG lab - Reed holter reports and make his comments then send for typing before final approval. - Analysis of all ECG prints done in the pediatric hospital then signing the prints, according to cardiologist schedule in the ECG lab and usually for ECG prints done in the previous 4 days.


- B.L.S

JOB DESCRIPTION OF THE TECHNICIAN IN THE NONINVASIVE CARDIAC LAB

a.) ECG lab Technician: - Attach Holter recorder to patient’s chest for certain period of time and after removing these recording devices, reconnect them to the Holter analyzing computer. He should print the final report and send it to the cardiologist for 133

Guidelines for


reviewing before approval. These reports should be signed before sending to medical records. - Attend and actively participate in CPR in emergency situation in the noninvasive cardiac lab. - He should response to all ECG request in the pediatric hospital during working


hours and priority should be given to urgent requests. - Responsible for maintenance and cleanness of the all machines in the ECG lab - Responsible for availability of ECG papers, holter computer papers in addition to ECG leads plastic holder and the other disposables items in the ECG lab. b.) Echo Lab Technician: - Perform Echo study alone for children referred to cardiology service for Echo study only e.g. oncology patient referred for measurement of cardiac function. However even such studies should be reviewed by cardiologist before sending the patient back to ward or home, he may repeat part or the whole study. - All Echo studies performed by cardiologist should be attended by the Echo technician in order to enter patient data in the machine, attach ECG leads to the patient, make the measurements for LV function or other calculations and build the experience in the pediatrics Echo. - Responsible for availability of jell, printer paper and CD, so he continuous supply of these item and should inform the chief of unit 4 weeks in advance for any lack of supply from stores. (He should keep extra material in the unit of emergency situation). - Log in CD number and Echo study number in the log in book for all patients and pull out any required CD for regular meeting or conference in the hospital. He will be responsible also for archiving these CD in proper place. - Prepare equipments for fetal Echo and contrast Echo. He should participate actively in performing such studies with cardiologist.

Guidelines for


134

JOB DESCRIPTION FOR REGISTERED NURSES IN THE NON INVASIVE CARDIAC LAB The nurses should be available every day during regular working hours, except weekends. a) Measurement of vital signs including heart rate. Respiratory rate and body temperature in addition to body weight of all infants require sedation

b) Measurement of blood pressure from all limbs in infants and from right arm in children for all patients attend Echo lab before performing the study. c) Recording the oxygen saturation by pulse oxymeter from all neonates, cyanosed or distressed infants and children attending Echo lab. d) Sedation of patients with chloral hydrate orally and monitoring the child till sleep and then transfer him/her to Echo room. e) Assist the cardiologist or technician during Echo study including fetal Echo, contrast Echo. f) Responsible for monitoring equipment in the sedation room e.g. cardiac monitor, pulse oxymeter, BP monitors. g) The nurse should have valid CPR certificate and she should participate actively in resuscitation of any collapsed patient in the non-invasive cardiac lab. h) She should also perform 12 lead ECG in the unit especially if ECG technician is not available.

11.4 SCHEDULES FOR NON-INVASIVE CARDIAC LAB Consultant Cardiologist


before echo study.

Each consultant will have two day duty in the non-Invasive cardiac Lab per week according to the schedule for the goals mentioned above. He is responsible for non-urgent Echo studies and ECG, while the urgent Echo studies or ECG analysis is the responsibility of cardiologist on call.

135

Guidelines for


Non urgent Echo studies or ECG include the following: - Admitted patients in the hospital wards who need routine echo study e.g. Down's syndrome for screening (new cardiac patients admitted in the wards or ICU or sick patients under general pediatric service who need urgent echo is responsibility of on call cardiologist). - Patients with routine appointment for Echo studies, either new patients or follow up patients. - Reviewing all ECG tests done in the previous 3 days for inpatients, holter analysis interpretation is responsibility of treating consultant.

ECHO Technician/ECG TECHNICIAN - Echo Technicians should attend Echo lab daily during regular working hours, one Echo technician will be assigned for each Echo room, however if one of them is on leave the other will cover both Echo room. - ECG Technicians should attend ECG lab daily during regular working hours, on call ECG Technician will be assigned for regular and urgent ECG request from different wards, ICU, ER and nursery while the other is assigned for outpatient request however if one is in leave the other will cover both inpatient and outpatient requests. Both ECG Technician will participate in the Holter recording analysis alternating weekly, these special services should be covered by the ECG technician who is not on call. - On call duties of Echo technician/ECG technician will be for whole week but he/she cover only regular working days and during regular working hours. The nurses in the ER or ICU or nursery perform ECG test on weekends or after working hours. - ECG Technician should help in the Echo lab when there is shortage off staff in the Echo lab for any reason and ECG technician during the cover of echo lab will have same responsibilities of Echo technician.

Guidelines for


136

Nurses duties in the Non-Invasive Cardiac Lab: Two nurses are assigned for the non-invasive cardiac lab, both nurses also assigned for the cardiac clinics. They organized the work between themselves according to patient’s number in these areas; however the following points are guidelines. - They should attend the non-invasive cardiac lab daily during the regular working hours. - Both of them should cover the clinic responsibilities during clinic time and cover the Echo lab ECG at other time, however if there are patients in the clinics and also in the ECG room or Echo rooms then one should cover clinic services and other should cover the Echo lab service. - One of the nurses should be assigned for the sedation of the infants before Echo or ECG test while the other nurse should take the rest of responsibility when her college is busy with sedation of the infants at that specific time. - Both of them should have valid CPR certificate

11.5 REGULATIONS OF NON INVASIVE CARDIAC LAB Echocardiography booking for both Inpatients and Outpatients - There will be four Echocardiography sessions per week. - Booking is done only through Echo technician. For both inpatient and outpatients. - Total number of the children’s (including inpatients and outpatients) for each echocardiography day should not exceed 5 patients; extra two slots per day are spared for urgent unbooked patients.

INSTRUCTIONS FOR SEDATION: 1. The patient for morning session should arrive at 9:00 A.M. and the patients for afternoon session should arrive at 1:00 P.M. 2. Child should be N.P.O. one hour before sedation (child should not take anything to eat or drink for one hour before sedation). 3. Vital signs including blood pressure, oxygen saturation and body weight should be recorded on flow sheet. 137

Guidelines for


4. Pediatric cardiologist should approve sedation of small infants less than 3kg, severely cyanosed infants and sick infants. 5. The drug used for Sedation is chloral hydrate, which is given orally at the dose of (50-80 mg/kg). § The drug can be repeated at half dose if child is not sleeping in 1 hour. 6. Sedated infant should be connected to the ECG Leeds and pulse oxymeter during ECHO study. 7. The child is required to rest in the sedation room or waiting area after ECHO study, until he/she is fully awake. 8. The child should have near OPD appointment with pediatric cardiologist. REFERRAL FOR ECHO: All ECHO request forms should be submitted to ECHO lab station. Follow-up with appointment should be through ECHO technicians (Mrs. xxx: Ext 000) ECHO PRECEDURE LOCATION: All patients in pediatric wards should be brought to ECHO lab except sick patients or patients in NICU & PICU. Echo done for them at bed side by on-call Cardiologist and on-call Echo technician. All ambulatory patients for Cardiac clinic and Echo appointments will have Echo procedure in Echo Lab. 12. Service Information: 12.1 Rotating Pediatric Resident/ specialist: I. Pediatric Cardiology is one of the fundamental branches in Pediatrics. The unit is expecting rotation of Arab Board/Saudi Board Residents and specialists. II. The rotating resident/specialist is important part of Pediatric Cardiology team. He or she will be exposed to Clinical Pediatric Cardiology.

Guidelines for


138

12.2 Duties of Rotating Residents/ specialties: - Daily ward rounds to inpatients assigned for pediatric cardiology room, as well as for patients consulted by other services such as NICU, PICU and other ward. Documentations of round with consultation should be written on the patients note. - Receive all consultations, either by direct contact for urgent consultation or by consultation form situated in cardiac ward nurse station for routine cases. - The resident/specialist is expected to prepare and review the cases including all investigations before discussion with Consultant Cardiologist in charge. This will facilitate more interaction and informative discussion. Urgent Cases should be discussed as soon as possible with the consultant for further management plans. - The resident/specialist should see and examine patients admitted under cardiology. Further management plans will be discussed according to Echo findings. - He/she will participate actively in referring patients to other institutions for further management or surgery (such as preparing discharge summaries, contact receiving hospital by phone etc.) see communication section for referral center information.

13. CARDIOLOGY INPATIENT SERVICE: § There is no need for separate cardiac ward but 4 rooms should be assigned for cardiac patients with total capacity of 10 beds. These rooms are located in the single pediatric ward however these rooms can be utilized by other subspecialties or general pediatric patients in case of emergency admissions after approval of cardiologist on call and should be returned back to cardiac service within 2-3 days. § The rooms under cardiac service should be equipped with cardiac monitors, pulse oxymeters ,BP monitors and suction machines in addition to oxygen supply slots and vacuum slots in the wall.

139

Guidelines for


§ Cardiac patient with infectious diseases will be admitted in the ward assigned for children with infectious diseases until he/she become non infectious then may be transferred to cardiac rooms. § The service of cardiac patients is in the pediatric wards is achieved by the specialist or resident assigned to the cardiology unit. § Nurses caring for the cardiac patients will be trained in the hospital or other hospitals to this purpose and should become familiar with equipments in the cardiac rooms. § Nurse station in the ward assigned for cardiac patients will serve as place to receive referral forms from other units for cardiac consultation and any inquiry about cardiac services. Cardiologist covering the service of cardiac patients (on call cardiologist) will have regular visit to this ward daily and will response to these referral forms, but the fax reports from other hospitals will be reviewed by on call cardiologist in the administration office at least 3 time per day except the emergency fax reports which should be send to the cardiologist on call directly.

Ward Procedure: § The nursing staff informs the concerned resident about the admission. § Soon after admission the resident completes full checking of the patient, ordering any additional investigations overlooked. § Residents on finding anything abnormal with the other systems of the patients will immediately inform the specialist concerned. § The specialist concerned before retiring will make certain that the condition of all his patients is satisfactory with further instructions to the resident or nursing staff as necessary. § In case of any problem patient and the concerned specialist not being available later, he should contact the specialist on call and instruct him fully of the condition of this patient. § In case of serious complication, the specialist concerned may transfer the patient to ICU in consultation with the cardiologist and ICU specialist in Guidelines for


140

charge and the nursing supervisor. § The specialist and/or consultant cardiologist is expected to perform daily clinical rounds in the ward or ICU with the responsible nurse and the resident to record daily progress of the patient and other instructions regarding treatment. § The patient discharge is entirely responsibility of the cardiologist, the relevant forms and papers i.e. admission and discharge forms and sending feedback to the referring doctor are completed by resident/specialist and signed by him. § The cardiologist concerned should explain to the mother or other responsible adult relative, particular medical technique that may become necessary, the expected outcome and number of days the patient may be expected to remain in hospital.

14. Emergency Room: § Cardiac patients arriving at ER with acute or chronic medically distressing conditions should be seen. § Initially these patient seen and resuscitated in the ER by the pediatric resident and registrar covering the ER department and if the management of the cardiac patient require pediatric cardiologist the specialist on call of general pediatric should contact pediatric cardiologist by telephone. § The cardiologist on call should see such patient either in the ER department or in the PICU/ward after admission. § Cardiac illness requiring specialized treatment for which this hospital is not equipped to render will be transferred to other hospital after preliminary resuscitation and stabilization are made. After appropriate arrangement with the concerned doctors at the other hospital. 10. GENERAL RULES: § The Pediatric Cardiology Consultant will be totally responsible for all patients as admitted under him or being treated by him.

141

Guidelines for


§ The general pediatric Specialist/Consultant may take decisions regarding management of common pediatric symptoms in cardiac patients. § Close cooperation between the Medical and Nursing staff is encouraged and there will be grand clinical rounds by the Specialist/Consultant with the Nurses to explain to them, in more details the condition and treatment of the patients. § Ensure adequate liaison with other departments such as Cardiac Surgery, Radiology, and Laboratory.


It is the responsibility of the resident/specialist assigned in pediatric cardiology services to dictate discharge summary immediately upon discharge to provide copy to patients and to send copy of the report to the referring institution or hospital.

- Please do not use any abbreviation in your dictation, e.g. do not abbreviate Pulmonary Artesia as “PA” etc. 15.2 Patient Data Sheet: The resident/specialist should complete the patient data sheet provided by the charge nurse (for any difficulty he should contact consultant-in-charge). 15.3 Referral Centers: The following are tertiary care referral pediatric cardiac centers: 1. King Faisal Specialist Hospital & Research Center: Pediatric Cardiology Coordinator:

Ext: 39175, pager:8388

Ext: 39176, pager:6612 Coordinator Office: 01-464-7272 Ext: 32094 Direct line: 4424486 Fax: 01-442-7498 2. King Abdulaziz Cardiac Center/King Fahad National Guard: Coodinaror: Ext: 6683, pager:1144 Ext. & pager: 6686 Guidelines for


142

Tel: 10-252-0088 Ext: 6682 Fax: 01-252-0088 Ext: 6684 3. Prince Sultan Cardiac Center: Coordinator: Secretary Office: 4783000 Ext: 8795;Direct Fax: 473-0049 16. Academic Activity of Cardiology Division The pediatric cardiologist in the unit are expected to participate in

the

following academic activity: - Pediatric club monthly meeting. - Teaching of Saudi board/Arab board resident with slides, MCQ, clinical sessions, according to the schedule arranged by postgraduate training office when it is applicable. - Supervising interns, residents, and registrar for clinical presentation in the daily morning reports. - Participate in the other academic activates in the hospital including hospital lectures, symposium, seminars, clinical courses, written courses, etc. - Participate in the academic activities concerning cardiology e.g. cardiology day, pediatric cardiology symposium in other centers. - Attend cardio-surgery meeting in other cardiac centers according to schedule arranged by the department head. Other activities of the Department Staff: · Participate in the Public health educations through different media channels · Participate in hospital committees e.g. infection, quality assurance, and credential · Participate in regular monthly mortality and morbidity meeting · Participate in the medical education of nurses, technician and other staff in the hospital.

143

Guidelines for


Pediatric Cardiology

Recommend Documents