Improving Appropriate Dosing of Intravenous dilTIAZem in Patients With Atrial Fibrillation or Flutter With Rapid Ventricular Response in the Emergency Department

Atrial fibrillation and atrial flutter are common supraventricular arrhythmias in patients who present to the emergency department. Under the American Heart Association guidelines, dilTIAZem is the calcium channel blocker frequently used by many practitioners for rate control. Currently, institution-specific data have identified that many patients receiving dilTIAZem for atrial fibrillation or atrial flutter are given initial doses that exceed the recommended dose by more than 10%, resulting in hypotension in some patients. ED personnel were surveyed to determine their current knowledge of appropriate intravenous dilTIAZem dosing and methods of prescribing intravenous dilTIAZem to determine the causes of higher dosing. Based on the baseline data, an intervention of adding a text alert when withdrawing dilTIAZem from the automated medication dispensing cabinet was implemented. Following the intervention, 29 patients received intravenous dilTIAZem for rate control of atrial fibrillation or flutter with rapid ventricular response. For the primary outcome, the incidence of high-dose dilTIAZem decreased by 19% (P = 0.03). There was no change in the secondary outcome of a reduction in hypotension (P = 0.3). The interventions of education and medication alerts resulted in a significant increase in the percentage of patients receiving appropriate doses of dilTIAZem and a nonsignificant decrease in the incidence of hypotension. This process-oriented intervention resulted in an improvement in appropriate dilTIAZem doses at our site. Rate control was not statistically significantly different between the 2 groups. Long-term sustainability of this intervention requires further study.