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Antiarrhythmic Management – Adult – Ambulatory [147]

Antiarrhythmic Management – Adult – Ambulatory [147] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols


Delegation Protocol Number: 147

Delegation Protocol Title: Antiarrhythmic Management – Adult – Ambulatory

Delegation Protocol Applies To:
Adult patients seen in UW Health Heart and Vacular Care (HVC) Clinics

Target Patient Population:
Adult patients treated with select antiarrhythmics

Delegation Protocol Champions:
Michael Field, MD - Department of Medicine – Cardiology
Henry Riter, MD - Department of Medicine – Cardiology

Delegation Protocol Reviewers:
Sharon Mladucky, RN, MSN - Heart and Vacular Care
Ted Berei, PharmD - Pharmacy
Judy Olson, PharmD - Pharmacy
Magda Valdes, RN, BSN - Electrophysiology Laboratory
Holly Mucci, RN - Nursing

Responsible Department:
Department of Medicine - Cardiology

Purpose Statement:
This protocol delegates authority, from the Cardiology provider managing the patient’s arrhythmia to the
Registered Nurses (RNs), to order laboratory and diagnostic testing required for monitoring of these medications
and to order prescription refills for these medications.

Who May Carry Out This Protocol:
RNs trained in the use of this delegation protocol.

Guidelines for Implementation:
1. This protocol is activated when a provider places an order for one of the included medications (see Table 1).
2. The RN will use this protocol to determine the required laboratory and diagnostic tests (see Table 1). Prior to
placing any orders, the RN will review the medical record to determine if active orders or current results
exist to avoid duplication.
3. A provider will be consulted for further action if pertinent labs or tests are outside of normal limits or ECG
demonstrates relevant abnormalities requiring further review.
4. Refills
4.1. If needed, RNs may order a refill of sufficient quantity to meet the patient’s needs until the next
indicated office visit.
4.2. Prior to ordering refills, the RN will verify the patient’s most recent lab results and ECG.
4.2.1. If lab results and diagnostic tests are within normal limits and the patient has a current ECG, the
RN may order sufficient medication to get patient to the next testing interval.
4.2.2. If laboratory or diagnostic tests are overdue, the RN will enter orders for these tests and may order
a one-month bridging supply if needed to cover the patient until the tests can be performed.
4.2.3. If lab results or diagnostic tests are outside of normal limits or the ECG demonstrates relevant
abnormalities (see Table 1), the RN will contact a provider for further direction prior to renewing
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

the medication. If a provider is not available and the patient does not have a sufficient supply of
medications to prevent a lapse in therapy, the RN may order a one-month bridging supply.

Table 1. Medication Monitoring and Refill Requirements
Medication Lab Other Office Visit
flecainide
(TAMBOCOR)
Every 12 months:
• Cr

Every 12 months: ECG

Provider must be consulted if ECG shows atrial fibrillation,
new bundle branch block or QTC (corrected) >/= 15%
change or > 500 ms absolute
Every 12
months
propafenone
(RYTHMOL)
None Every 12 months: ECG

Provider must be consulted if ECG shows atrial fibrillation,
new bundle branch block or QTC (corrected) >/= 15%
change or > 500 ms absolute
Every 12
months
mexiletine

None Every 12 months: ECG

Provider must be consulted if ECG shows new bundle
branch block or QTC (corrected) >/= 15% change or > 500
ms absolute
Every 12
months
dofetilide
(TIKOSYN)
Every 6 months:
• Cr
• K
• Mg
Every 6 months: ECG

Provider must be consulted if ECG shows atrial fibrillation,
marked sinus bradycardia or QTC (corrected) >/= 15%
change or > 500 ms absolute
Every 12
months
sotalol
(BETAPACE AF)
Every 6 months:
• Cr
• K
• Mg
Every 6 months: ECG

Provider must be consulted if ECG shows atrial fibrillation,
marked sinus bradycardia or QTC (corrected) >/= 15%
change or > 500 ms absolute
Every 12
months
dronedarone
(MULTAQ)
Every 6 months:
• K
• AST
• ALT
• Bilirubin
Every 12 months: ECG

Provider must be consulted if ECG shows atrial fibrillation,
marked sinus bradycardia or QTC (corrected) >/= 15%
change or > 500 ms absolute
Every 12
months
amiodarone
(CORDARONE)
Every 6 months:
• TSH
• AST
• ALT
Every 12 months: ECG, chest x-ray PA/Lat, PFT with DLCO

Provider must be consulted if ECG shows atrial fibrillation,
marked sinus bradycardia or QTC (corrected) >/= 15%
change or > 500 ms absolute
Every 12
months
ECG = electrocardiogram; PFT = pulmonary function tests; DCLO = diffusing capacity of lungs for carbon
monoxide; Cr = creatinine, K = potassium; Mg = magnesium

Order Mode:
Diagnostic and Laboratory Tests: Cosign Required, Protocol/Policy
Medications: Protocol/Policy, Without Cosign




Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

References:
1. Lexicomp Online® , Lexi-Drugs® , Hudson, Ohio: Lexi-Comp, Inc.; January 29, 2015
2. Rythmol [package insert]. Research Triangle Park, NC: GlaxoSmithKline ; 2011
3. Tikosyn [package insert]. New York, NY: Pfizer; 2014
4. Cordarone [package insert]. New York, NY: Pfizer; 2015
5. Multaq [package insert]. Bridgewater, NJ: Sanofi-Aventis; 2014
6. Betapace AF [package insert]. Wayne, NJ: Bayer; 2011

Collateral Documents/Tools: NA

Approved By:
UW Health Ambulatory Protocol Committee: September 2016
UW Health Laboratory Practices Committee: September 2016
UW Health Pharmacy and Therapeutics Committee: September 2016
UWHC Medical Board: November 2016
UW Health Chief Medical Officer: November 2016

Effective Date: November 2016

Scheduled for Review: November 2019

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org