The Phoenix Children’s Hospital (PCH) Inflammatory Bowel Disease (IBD) Clinic provides care for nearly 500 patients. As a group, PCH is part of the ImproveCareNow (ICN) network—a collaboration of over 100 centers worldwide to improve IBD care. Patient care has followed ICN guidelines including a weekly pre-visit planning (PVP) session. PVP is a time intensive process of manual chart review and data gathering for upcoming clinic patients. To improve this process and patient care, our group created a real-time IBD dashboard. OBJECTIVES: The aims of the dashboard were to identify and validate our patient population, improve efficiency by automating data gathering for PVP, and create a visual representation . Secondary aim, was to optimize processes including documentation, order entry and timely follow-up. METHODS: Data is sourced from the Allscripts electronic medical record (EMR). Data retrieval is contingent upon documentation. Our population of patients with IBD was identified based on a charted ICD-10 diagnosis of CD, UC or IC. PCH has a data warehouse of orders, results, Admission-Discharge-Transfer documentation, and flowsheets from the EMR and external data sources. Data is harvested and hosted using Microsoft Power BI for live review at weekly PVP. Once desired data points were hosted, focus was on process improvement (proper documentation, follow-up orders, and patient visits every 200 days). RESULTS: The dashboard hosts patients seen within the last 200 days, provider follow-up order placement, and physician global assessment (PGA) since January 2021. The percent of patients with follow-up orders placed was 61% in 2021. With dashboard enhancements and data visibility, this improved to 99% as of October 17, 2022. Physician global assessment (PGA) was recorded in 81% of encounters in 2021. Our most recent documentation rate is 92% on October 17, 2022. Our group had seen 82% of patients within the 200 days in 2021. Currently we have seen 89% of patients within 200 days as of October 17, 2022 (of these 91% of patients with active disease have been seen). We have instituted a work-flow process with schedulers to ensure patients are contacted and scheduled and not transitioned or moved. Figure 1 Historical Data from 1/2021-10/2021 Figure 2 Current Data as of 10/17/2022 CONCLUSIONS: With time, the IBD dashboard has proven to be a powerful tool in improving process measures. Our hope is these improvements will lend themselves to improved patient outcomes. With the ability to view data in real time in an automated fashion, staff hours have been saved and reallocated to other patient care needs. With continuous review of the data and introduction of accountability, we continue to see improvement. We now have the capacity to add additional metrics to the dashboard and our this can be viewed as a proof of concept for use in other specialties and chronic disease states.
The coronavirus disease of 2019 (COVID-19) caused by SARS-CoV-2 virus led to a worldwide pandemic. Emergency use of an investigational medication, Paxlovid, was approved for patient 12 and older who tested positive for COVID-19 and at high risk for severe infection. Inflammatory Bowel Disease (IBD) is a chronic condition causing inflammation in the gastrointestinal tract. Ulcerative Colitis (UC) is a type of IBD centralized in colon and commonly treated with Immunosuppressive drugs. We present an adolescent with UC treated with paxlovid due to being on tacrolimus who developed with suspected tacrolimus toxicity. CASE REPORT: A 13-year-old female with UC presented to the ED with vomiting and fatigue after paxlovid ttreatment for COVID. The patient’s UC treatment included tacrolimus along with ustekinumab. She had been diagnosed with SARS-CoV-2 and prescribed Paxlovid bid x 5 days due to immunosuppressive status. Tacrolimus was held during treatment. Once paxlovid completed, tacrolimus was restarted. Two days later, patient presented to ER for vomiting, fatigue, headaches and myalgia. Labs revealed a tacrolimus level of >60 ng/ml . Electrolytes and Creatinine were normal. Toxicology felt this was due to interaction between paxlovid and tacrolimus. Patient advised to hold tacrolimus for 48 hours and repeat levels were 15.8 ng/mL. Symptoms resolved and level repeated three days later and was 2.9 ng/mL DISCUSSION: Tacrolimus is an immunosuppressant, commonly used for management of organ transplants but also been found effective in treatment of IBD. Tacrolimus requires close monitoring as toxicity may lead to acute or chronic kidney disease. The normal concentration is between 5-15 ng/mL. Due to rapid escalation of the COVID-19 pandemic, Paxlovid was approved for emergency use for treatment of high-risk patients. It is administered as a 5-day oral course consisting of nirmatrelvir and ritonavir. Our patient was prescribed Paxlovid due to risk secondary to immunosuppression. She was appropriately instructed to stop tacrolimus. Ritonavir is a cytochrome P450 3A inhibitor and can increase plasma concentration of tacrolimus. She restarted tacrolimus treatment 12 hours after her last dose of Paxlovid and presented with symptoms and a level consistent with toxicity. This level was concluded to be due to drug interaction between tacrolimus and Paxlovid. After further withholding of tacrolimus, symptoms improved, and levels normalized. Previous reports in transplant population stress importance of decreasing the dose of tacrolimus or withholding during the course of paxlovid treatment. This case demonstrates the importance of not only ceasing tacrolimus when administering paxlovid, but continuing discontinuation for longer period post completion of therapy to minimize interactions.
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