Unique Plan Description: Atrial Fibrillation Admission
Plan Selection Display: Atrial Fibrillation Admission
PlanType: Medical                                 
Version: 2          
Begin Effective Date: 2020-04-21 15:02:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-05-13 15:45:59
Available at all facilities: Yes

Atrial Fibrillation Admission
Admit/Discharge/Transfer
	Admit to Inpatient Status
		T;N, Anticipated LOS 2 midnight or more
	Admit to Critical Care Inpatient Status (MH)
		T;N, Anticipated LOS 2 midnight or more
	Admit to Observation Status
		T;N
	Admit to Critical Care Observation Status (MH)
		T;N
Vital Signs
	BP and Pulse, Orthostatic
		T;N, Once
		T;N, DAILY
	Vital Signs
		T;N, Per protocol
		T;N, Per protocol, if temp >101, obtain blood cultures, UA (culture if positive), chest x-ray if not done in past 48 hours.
Activity
	Activity-Up as Tolerated
		T;N
		T;N
			Comment: With assistance
	Bedrest with Bedside Commode
		T;N
	Bedrest with Bathroom Privileges
		T;N
	Up in Chair
		T;N, TIDWM
	Ambulate
		T;N, With assistance, TID
		T;N, In hall, TID
		T;N, In hall, QID
	Up with Assistance
		
Diet
	NPO
		T;N, After Midnight
		T;N
			Comment: for potential cardioversion
	Regular Diet
		T;N, After Midnight
		T;N
	Diabetic Diet
		T;N, Calorie Level 2000 kcal
		T;N, Calorie Level 1800 kcal
	Clear Liquid Diet
		T;N
	Blenderized Liquid (Full) Diet
		T;N
	Sodium Restricted Diet
		T;N
			Comment: low sodium
	Renal Diet
		T;N
	Cardiac Diet
		T;N
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, spec type = Diagnostic Blood
		T+1;0400, spec type = Therapeutic Blood
Diagnostic Tests

	ECG
		
		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 mcg/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

	Resuscitation Status
		Full Code
		No Code
	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

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