Unique Plan Description: Atrial Fibrillation
Plan Selection Display: Atrial Fibrillation
PlanType: Medical                                 
Version: 2          
Begin Effective Date: 2020-04-21 15:01:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2023-02-14 13:50:07
Available at all facilities: Yes

Atrial Fibrillation
Laboratory
Today's Lab
	CBC with Diff
		T;N, Stat, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Stat, spec type = Blood
	INR - MH/WH/JE
		T;N, Stat, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N, Stat, spec type = Diagnostic Blood
		T;N, Stat, spec type = Therapeutic Blood
	PTT - MH/WH/JE
		T;N, Stat, spec type = Blood
	Partial Thromboplastin Time (PTT) - FH
		T;N, Stat, spec type = Diagnostic Blood
	Thyroid Panel
		T;N, Stat, spec type = Blood
	Magnesium Level
		T;N, Stat, spec type = Blood
Tomorrow's Lab
	Basic Metabolic Panel
		T+1;0400, Routine, spec type = Blood
	Hemoglobin and Hematocrit
		T+1;0400, Routine, spec type = Blood
	INR - MH/WH/JE
		T+1;0400, Routine, Q24H, spec type = Blood
	Prothrombin Time (PT) - FH
		T+1;0400, Q24H, Routine, spec type = Diagnostic Blood
		T+1;0400, Q24H, Routine, spec type = Therapeutic Blood
Diagnostic Tests

	ECG
		T;N, Stat, Indication: Atrial Fibrillation/Flutter
		T;N, Routine, Indication: Atrial Fibrillation/Flutter
	Chest 1 View
		Atrial fibrillation, T;N, Routine, Abnormal EKG
	TEE Transesophageal Echocardiogram
		T;N, Indication: Atrial Fibrillation | Atrial flutter
	Echo w Doppler resting
		Indication: Atrial flutter | Atrial Fibrillation
IV Solutions
	esmolol 2,500mg/250mL premix diluent IV
		2,500 mg, EVERY BAG, 50 mcg/kg/min
		250 mL, IV, Routine, Start: T;N, Increment Increase: 50 mcg/kg/min, Increment Decrease: 50 mcg/kg/min, Increment Freq: 5 min(s), Max Dose: 300 mg/kg/min
			Comment: If the dose has been titrated twice within the specified timeframe and goal parameter is not achieved, the titration dose can be doubled until the ordered parameter is achieved or maximum dose is reached.  IV may be re-initiated after weaning within 12hours, re-initiate at the last dosing rate that maintained Goal parameter. Discontinue order after 12hr if patient does not require IV re-initiation.
Medications
Rate Control
Anticoagulants
	Lovenox
		1 mg/kg, Syringe, SUBCUTANEOUS, Once, STAT
		1 mg/kg, Syringe, SUBCUTANEOUS, Q12H
		1 mg/kg, Syringe, SUBCUTANEOUS, Q24H
			Comment: For ClCr < 30ml/min
	apixaban
		5 mg, Tab, By Mouth, BID
		2.5 mg, Tab, By Mouth, BID
			Comment: If 2 of the following apply: age >= 80, wt <= 60kg, scr >=1.5
	Pradaxa
		150 mg, Capsule, By Mouth, BID
		75 mg, Capsule, By Mouth, BID
			Comment: CrCl=15-30mL/min
	Xarelto
		20 mg, Tab, By Mouth, DAILYW/SUPPER
		15 mg, Tab, By Mouth, DAILYW/SUPPER
			Comment: CrCl=15-50mL/min
	warfarin
		2.5 mg, Tab, By Mouth, Once, T;1600
		5 mg, Tab, By Mouth, Once, T;1600
		7.5 mg, Tab, By Mouth, Once, T;1600
	Lopressor
		5 mg, Solution-Injection, IV Push, Once, PRN for pulse > (see comment)
			Comment: HR >100. Do not give if SBP <90.
		5 mg, Solution-Injection, IV Push, Q5MIN, PRN for pulse > (see comment), duration: 2 Dose(s)/Time(s)
			Comment: HR >100. Do not give if BP <90.
		25 mg, Tab, By Mouth, BID
			Comment: Hold this Beta-Blocker 12 hours prior to any ordered Dobutamine Stress Echo (DSE).
Patient Care

	Cardiac Telemetry Monitoring
		T;N, Telemetry Indications: ACS/Arrhythmia/QTc
			Comment: CONTINUOUSLY
	Notify MD
		T;N, if patient has chest pain.
	Order ECG
		T;N, if patient converts to normal sinus rhythm.
Therapies
	Pulse Oximetry Spot Check RT
		Stat
Consults/Follow-up
	Consult Cardiologist
		Reason for Referral: Atrial Fibrillation with RVR
	Consult EP Cardiologist
		Reason for Referral: Atrial Fibrillation with RVR

Oxygen Protocol
Therapies
Respiratory Therapy
	Oxygen Therapy
		T;N
	Pulse Oximetry Spot Check RT
		T;N, BID
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID

Diltiazem (Cardizem) Protocol
IV Solutions

	Cardizem 100 mg/100 mL NS Premix IV
		100 mg, EVERY BAG, 10 mg/hr
		100 mL, IV, Routine, Start: T;N, Maintain Parameter Goal: HR< 100, Increment Increase: 5 mg/hr, Increment Decrease: 5 mg/hr, Increment Freq: 15 min(s), Max Dose: 15 mg/hr
			Comment: ACTIVATION REQUIRED PRIOR TO USE.  increase infusion to 15mg/hr if heart rate greater than or equal to 120 after second bolus.  Discontinue Diltiazem infusion 1 hour after oral dose initiated.  Begin  Tiazac 180 mg po when HR rate has been less than 100 bpm for 4 hours, and or sinus rhythm has returned, if infusion rate 5mg/hr. Begin Tiazac 240 mg po when heart rate has been less than 100 bpm for 4 hours, and or sinus rhythm has returned, if infusion rate 10 mg/h.  Begin Tiazac 300 mg po when heart rate has been less than 100 bpm for 4 hours, and or sinus rhythm has returned, if infusion rate 15 mg/hr.  Enter oral diltiazem order from Atrial Fibrillation Powerplan.
	Cardizem 100 mg/100 mL NS Premix IV (JE)
		100 mg, EVERY BAG, 10 mg/hr
		100 mL, IV, Routine, Start: T;N, Maintain Parameter Goal: HR< 100, Increment Increase: 5 mg/hr, Increment Decrease: 5 mg/hr, Increment Freq: 15 min(s), Max Dose: 15 mg/hr
			Comment: ACTIVATION REQUIRED PRIOR TO USE.  increase infusion to 15mg/hr if heart rate greater than or equal to 120 after second bolus.  Once HR rate has been less than 100bpm for 4 hours, and or sinus rhythm has returned, contact MD for further oral orders.
	diltiazem 100 mg/NS 100 mL (FH)
		100 mg, EVERY BAG, 10 mg/hr
		100 mL, IV, Routine, Start: T;N, Maintain Parameter Goal: HR< 100, Increment Increase: 5 mg/hr, Increment Decrease: 5 mg/hr, Increment Freq: 15 min(s), Max Dose: 15 mg/hr
Medications
	Cardizem
		0.25 mg/kg, Injection, IV Push, Once, PRN see comment
			Comment: PRN heart rate >/= 120bpm, for 20 minutes. Give over 2 minutes, then begin diltiazem infusion at 10mg/hr. Max dose 20mg
		0.35 mg/kg, Injection, IV Push, Once, PRN see comment
			Comment: PRN heart rate > 120bpm 30 min after 1st bolus given. Give over 2 minutes, if heart rate greater than 120 bpm after bolus, increase infusion to 15mg/hr.  Max dose 25mg
Oral
	Tiazac
		180 mg, Capsule-Extended-Release, By Mouth, Q24H
			Comment: begin when heart rate has been less than 100 bpm for 4 hours, and or sinus rhythm has returned, if infusion rate 5mg/hr
		300 mg, Capsule-Extended-Release, By Mouth, Q24H
			Comment: begin when heart rate has been less than 100 bpm for 4 hours, and or sinus rhythm has returned, if infusion rate 15 mg/hr
		240 mg, Capsule-Extended-Release, By Mouth, Q24H
			Comment: begin when heart rate has been less than 100 bpm for 4 hours, and or sinus rhythm has returned, if infusion rate 10 mg/hr
Patient Care

	Notify MD
		Notify Cardiologist in AM of initiation of protocol
		Notify Cardiologist if systolic BP < 100mmHg, ventricular response > 120 bpm, angina/chest pain. After initiation of protocol.
Therapies
	Pulse Oximetry Spot Check RT
		Stat

zzHeparin Non DVT/PE (Low dose) Xa Monitoring (FH)
Admit/Discharge/Transfer
		This plan is to be used for patients with the following diagnoses: atrial fibrillation, chest pain, stroke, MI(NOTE)*
Laboratory
	INR - MH/WH/JE
		Stat, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N, Stat, spec type = Diagnostic Blood
		T;N, Stat, spec type = Therapeutic Blood
	PTT - MH/WH/JE
		Stat, spec type = Blood
		T+2;0400, Timed, Q48H, spec type = Blood
	Partial Thromboplastin Time (PTT) - FH
		T+2;0400, Q48H, Routine, spec type = Diagnostic Blood
		T;N, Stat, spec type = Diagnostic Blood
	Heparin Anti-Xa Heparin
		Stat, spec type = Blood
		T;N+360, Timed, Q6H, spec type = Blood
IV Solutions
	HEParin 25,000 units/premixed diluent 250 mL
		250 mL, IV, Routine
			Comment: conc: 100 units/mL. Titrate according to Low Dose Weight Based Heparin Protocol.  MAXIMUM INITIAL rate is 1000unit/hr.1)  Anti-factor Xa UFH <than 0.1 units/mL, bolus 60 units/kg & increase rate by 300 units/hr.2)  Anti-factor Xa UFH = 0.1-0.19 units/mL, bolus 30 units/kg & increase rate by 200 units/hr.3)  Anti-factor Xa UFH = 0.2-0.29 units/mL, Do not give bolus & increase rate by 100units/hr.  4) Anti-factor Xa UFH = 0.3-0.7 units/mL (therapeutic range)  Do not bolus and do not change rate.5)  Anti-factor Xa UFH = 0.71-0.8 units/mL, do not bolus. Decrease rate by 100 units/hr.6)  Anti-factor Xa UFH = 0.81-1.7 units/mL, do not give bolus.  Stop infusion for 60 minutes and decrease rate by 200 units/hr when restarted.  7) Anti-factor Xa UFH > 1.7 units/ml.  Stop infusion for 2 hours & decrease rate by 300 units/hr when restarted.
		25,000 units, EVERY BAG, 12 unit/kg/hr
Medications
		No IM injections while on anticoagulants(NOTE)*
	HEParin 1000 units/mL injectable soln
		60 units/kg, Injection, IV Push, Once, STAT
			Comment: Dose = 60 units/kg Bolus.  Patient on Low Dose Heparin Protocol.  Pharmacy to calculate dose. Begin heparin bolus and infusion immediately after initial stat labs are drawn.  (MAXIMUM INITIAL bolus = 5000 units)
		60 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 60 units/kg Bolus.  Anti-factor Xa UFH level < 0.1 units/mL, Patient on Low Dose Heparin Protocol.  Pharmacy to calculate dose. (MAXIMUM bolus = 5000 units)
		30 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 30 units/kg Bolus.  Anti-factor Xa UFH level between 0.1-0.19 units/mL.  Patient on Low Dose Heparin Protocol.  Pharmacy to calculate dose.  (MAXIMUM bolus = 5000 units)
Patient Care
	Notify MD
		T;N, For surgical patients, contact surgeon for approval to start heparin protocol if ordered post surgery
		T;N, if 2 consecutive 60 unit/kg boluses of heparin given and the resulting anti-factor-Xa UFH is not in therapeutic range within 12 hours
		T;N, if 2 consecutive anti-factor-Xa UFHs are greater or equal to 0.96 units/ml
		T;N, if initial stat anti-factor-Xa UFH comes back elevated.
		T;N, If baseline PTT is >42 seconds (5 seconds above upper normal limit of 22-37 seconds).
		T;N, if critical PTT >135.
	Order Lab
		T;N, Enter orders for anti-factor-Xa UFH Q6Hr timed after initiation of therapy or any dosage change until 2 consecutive anti-factor-Xa UFH in therapeutic range, then q24h in am.
	Avoid IM Injections if possible while on anticoagulants

hs Troponin T - MH/WH/JE
Laboratory
	hs Troponin T - MH/WH/JE
		Stat, spec type = Blood
		T;N+120, Timed, spec type = Blood
		T;N+360, Timed, spec type = Blood

hs Troponin I - FH (Stat and 2hr and 6hr)
	hs Troponin I - FH
		T;N, Stat, spec type = Blood
		T;N+120, Timed, spec type = Blood
		T;N+360, Timed, spec type = Blood

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase