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Example of standing orders to initiate outpatient cardiac rehabilitation

This is an excerpt from Guidelines for Cardiac Rehabilitation Programs 6th Edition With Web Resource by AACVPR.

Appendix A: Example of Standing Orders to Initiate Outpatient CR

1. Initiate monitored exercise program per outpatient CR policies and procedures.
2. Determine target heart rate (THR) via sign- or symptom-limited graded exercise testing (GXT) or sign- or symptom-limited responses to submaximal exercise.
3. Begin with a training duration of up to 30 min to tolerance, one to five times a week.
4. Gradually increase duration of training exercise if patient cardiovascular and physiological responses are within normal limits.
5. Observe participant for signs of exercise intolerance and adapt or terminate exercise as indicated in policies and procedures.
6. Assess lipid profile approximately six weeks postevent.
7. Administer nitroglycerin 0.3 or 0.4 mg sublingually every 5 minutes × 3 as needed for angina discomfort or ischemic symptoms.
8. Provide regular, periodic progress reports to the referring physician. Provide copies of reports to other physicians as needed.
9. Initiate patient education and counseling sessions as patient needs indicate.
10. Consult patient's personal physician or CR supervising physician for any necessary orders.
11. Consult with the CR dietitian to provide individualized nutrition education for each participant.
12. Enter the patient into a non-ECG-monitored maintenance program upon completion of early outpatient CR program.

__________________________________________________________________________________________

Physician's signature

___________________________________________

Date

From American Association of Cardiovascular and Pulmonary Rehabilitation, Guidelines for Cardiac Rehabilitation Programs, 6th ed.
(Champaign, IL: Human Kinetics, 2021).

Appendix B: Example of Outpatient CR Emergency Standing Orders*

Table of Contents

Protocols for Urgent Situations and Emergency Interventions in the Cardiac Rehabilitation Area

I. Cardiopulmonary arrest

II. Angina pectoris

III. Hypoglycemia

IV. Hyperglycemia

V. Hypotension

VI. Hypertension

VII. Dysrhythmias

VIII. Dyspnea

IX. Cerebrovascular accident

X. Placement of intravenous line

XI. Patient transportation

I. Cardiopulmonary Arrest

A. Identify responsiveness and determine if breathing is absent or abnormal (gasping).
B. Call out for help/activate emergency medical system (EMS).

1. Call out for help from coworker. If no one responds and if no other staff member is available to assist, go to the nearest phone and activate EMS. (Emergency numbers with specific scripted instructions are posted at each phone.) Get defibrillator/automated external defibrillator (AED). If no pulse, attach defibrillator/AED and shock if indicated. Begin cardiopulmonary resuscitation (CPR) with compressions.
2. If a second responder is available to assist, that person should activate EMS and then get the defibrillator/AED while the first responder stays with the patient to begin compressions.
3. Staff will meet the EMS team at the appropriate entrance and direct them to the patient.

First Responder

1. Determine responsiveness and absent or abnormal breathing.
2. Send someone to activate EMS and get defibrillator/AED.
3. If pulseless, begin chest compressions at a depth of at least 2 in. and a rate of at least 100 compressions/min until defibrillator/AED arrives. Allow for complete chest recoil, minimize interruptions to

Second Responder

1. After activating EMS, take cart with defibrillator/AED to the patient. Place defibrillator pads or AED on patient and assess cardiac rhythm.
2. Shock if indicated, resume compressions. Follow appropriate algorithm according to ACLS guidelines.

Third Responder (if Available)

1. Direct remaining patients to another area.
2. Direct and control incoming emergency response team and patients.
3. Obtain extra supplies and equipment as needed.
4. Act as the recorder of events until EMS arrives.
5. Prepare records to be sent with patient to the emergency department if needed.
6. Notify patient physician/cardiologist and family.

Emergency in Other Locations

7. Protocols should be developed for emergencies occurring in locations other than the cardiac rehabilitation gym including but not limited to:

• Locker room/restrooms
• Lobby/waiting area
• Patient education area
• Parking lots

II. Angina Pectoris

A. If a patient develops unstable angina while in the exercise area, the patient should immediately discontinue exercise and sit or lie down. Note the exercise workload, HR, and BP at which the symptoms occurred.

B. The following protocol should be followed by the CR staff:

1. Check pulse, BP, cardiac rhythm (attach telemetry monitor if not already monitored), and oxygen saturation.
2. Rate angina on a scale of 1 to 10.
3. If no relief with 1 to 3 min of rest, give 1 nitroglycerine (NTG) 0.4 mg SL or spray.
4. Obtain 12-lead ECG and call supervising physician.

C. If pain is relieved:

1. If this angina is of new onset, the patient should be evaluated by the supervising physician. The primary care physician should be notified of the results of the evaluation and recommended treatment, if any.
2. If the patient experiences chronic stable angina, exercise intensity should be decreased or halted until the angina is relieved. Patient may resume exercise at a lower workload dependent on the clinical judgment of the medical director and professional staff.
   OR
   The patient can be discharged but should be instructed to report any increase in frequency or severity of angina to their physician.

D. If pain is not relieved:

1. Monitor pulse, BP, cardiac rhythm, and oxygen saturation closely.
2. Place on oxygen at 2 to 4 L per nasal prongs if oxygen saturation is <94%.
3. Patient to chew aspirin 160 to 325 mg.
4. Repeat NTG 0.4 mg SL or spray every 5 min for unrelieved angina symptoms.
5. The supervising physician will evaluate and determine the course of action.

III. Hypoglycemia

A. If patient displays any symptoms of hypoglycemia:

1. Obtain finger-stick blood glucose level.
2. If BG results are
3. Retest BG in 15 min. If BG is not >90 mg/dL, repeat 15 g CHO and recheck BG in 15 min.
4. If patient is uncooperative or unconscious, contact supervising physician, give glucose gel or establish IV access and give 50 cc (1 amp) 50% dextrose solution. Arrange for transport to ED.

IV. Hyperglycemia

A. A participant with a BG >300 mg/dL should not exercise unless the patient's referring physician and the program medical director give their consent.

B. Frequency of BG checks should be determined according to the patient profile and ITP.

C. BG evaluations may be performed by rehabilitation staff or the patient according to the ITP.

D. The CR staff may request a blood glucose evaluation on any patient based on suspected signs and symptoms of hyperglycemia (nausea, flushing, polyuria, polydipsia, fruity breath, tachypnea).

V. Hypotension

A. Remove the patient from the exercise area if possible.

B. Place patient in a supine position. Consider elevating legs or placing in Trendelenburg position.

C. Attach a telemetry monitor if not already monitored.

D. Check BP, pulse, cardiac rhythm, and oxygen saturation.

E. If no response to the position change, call the supervising physician. If the patient condition continues to deteriorate or becomes progressively symptomatic, or if BP continues to drop, start an IV of normal saline at 100 mL/h and arrange for transport to the ED. After evaluation and treatment of the patient, the supervising physician should notify the patient's primary care physician of the hypotensive episode and discuss any further treatment if necessary.

F. If patient responds to the supine position, keep supine until SBP is >100, then gradually assist to sitting position. Continue to monitor BP, pulse, and rhythm. Encourage fluids. Notify the patient's primary physician of the episode.

VI. Hypertension

A. Check every patient's BP before exercise and compare with previous recordings.

B. If the SBP reading is >170 mm Hg or the diastolic reading is >100 mm Hg, have the patient sit and recheck the BP in 5 min.

C. If the BP remains elevated, do not have patient exercise. Notify the primary care physician or supervising physician to evaluate and determine course of action.

D. Patients may exercise with elevated BP if directed by the primary care physician and medical director.

E. Investigate whether patient is complying with medications and sodium restrictions.

VII. Dysrhythmias

Premature Ventricular Contractions (PVCs)

A. Observe for the following:

1. Frequency
2. Whether multifocal or unifocal
3. Pairs or runs, sustained or paroxysmal
4. Associated signs or symptoms
5. Palpate pulse to evaluate for peripheral perfusion

B. Document any new arrhythmias or increase in severity with a rhythm strip and make notation on chart. Notify supervising physician and referring physician, where appropriate, to discuss treatment.

C. Discontinue exercise if PVCs become symptomatic and check pulse, BP, and oxygen saturation. Provide oxygen at 2 to 4 L if hypoxemic, and obtain IV access if directed by a physician.

D. Notify the supervising physician for evaluation and treatment.

Bradycardia

A. If patient develops symptomatic bradycardia, stop exercise.

B. Monitor HR and rhythm, BP, and oximetry. Provide oxygen at 2 to 4 L if hypoxemic. Obtain 12-lead ECG if available.

C. Assess for symptoms of instability or altered mental status, ischemic chest discomfort, HF, or hypotension and notify supervising physician for evaluation and treatment. Notify the supervising physician and if available, obtain IV access, and prepare to administer atropine or external pacing per ACLS guidelines.

D. Prepare for transfer to ED.

Tachycardia

A. If patient develops a new wide or narrow complex tachycardia, stop exercise.

B. Monitor HR and rhythm, BP, and oximetry. Provide oxygen at 2 to 4 L if hypoxemic. Obtain 12-lead ECG if available.

C. Assess for symptoms of instability or altered mental status, ischemic chest discomfort, HF, or hypotension, and notify supervising physician for evaluation and treatment. If directed by a physician, obtain IV access and prepare for synchronized cardioversion. If stable, may utilize vagal maneuvers or antiarrhythmic agents per ACLS guidelines.

D. Prepare for transfer to ED.

VIII. Dyspnea

A. If patient develops acute dyspnea, stop exercise and have patient sit down.

B. Monitor heart rate and rhythm, BP, respiratory rate, lung sounds, and oximetry. Provide oxygen at 2 to 4 L for oxygen saturation <94%.

C. If patient has a metered-dose inhaler, it may be administered as prescribed.

D. If condition deteriorates, notify supervising physician to evaluate for treatment options and possible transfer to ED.

E. If condition improves, notify primary care physician for further recommendations.

IX. Cerebrovascular Accident

A. If patient develops signs and symptoms of a stroke such as sudden arm or leg weakness, confusion, trouble speaking, dizziness, loss of balance or coordination, severe headache, or facial droop, immediately evaluate with rapid out-of-hospital stroke assessment.

B. If stroke is suspected, initiate EMS for immediate transport to a stroke facility.

C. Establish time of last known neurological baseline.

D. Maintain airway, breathing, and circulation.

E. Provide supplemental oxygen if hypoxemic or if oxygen saturation is unknown.

F. Check blood glucose.

G. Alert receiving hospital when patient is in transport.

X. Placement of IV Line

Purpose: To provide immediate access to administer emergency medication and IV fluids.

A. An attempt will be made to notify the supervising physician.

B. Place a saline lock in participant when one or more of the following apply:

1. Angina pectoris protocol has been followed and chest pain persists.
2. ECG, vital signs or participant appears to be clinically unstable or symptomatic.
3. Physician directs the placement of IV line.

XI. Patient Transportation

Staff will meet and direct ambulance personnel to the patient treatment area.

Staff will prepare medical records to be sent with the patient as needed.

Staff will alert the emergency department of the patient transfer.

Cardiac Rehabilitation Department Emergency Procedures and Standing Orders Were Reviewed and Approved

___________________________________________

Physician's name

___________________________________________

Signature

___________________________________________

Date of most recent review

*Appendix B should be used only as an example of standing orders that might be considered and adopted for use in freestanding outpatient or community-based programs.

From American Association of Cardiovascular and Pulmonary Rehabilitation, Guidelines for Cardiac Rehabilitation Programs, 6th ed.
(Champaign, IL: Human Kinetics, 2021).

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