Baseline screening and long-term monitoring of QTc prolongation through routine EKG in patients on  Hydroxychloroquine:  A quality improvement project Cristine K. Arcilla MD, Gurjit Kaeley MD, Myint Thway MD University of Florida Jacksonville

Summary: Hydroxychloroquine (Plaquenil) is one of the pivotal drugs in Rheumatology reported with its good safety profile and tolerance among patients with rheumatologic conditions.  However, the era of COVID-19 disputed its safety identifying its potential synergistic cardiotoxicity effects such as prolonging QTc interval and increasing risk for fatal conduction abnormalities that could lead to sudden cardiac death if not adequately monitored. Results vary as to the outcomes related to chronic use of hydroxychloroquine especially in patients who have increased risks related to preexisting rheumatic diseases and concurrent drug interactions.  EKG is a simple and inexpensive screening clinical tool that could be employed for baseline cardiovascular risk assessment, especially for high-risk patients on Hydroxychloroquine. It is crucial to investigate the impact of a quality improvement intervention focused on improving baseline screening and monitoring of QTc prolongation among patients on Hydroxychloroquine through routine EKG. We collected all patients 18 years and older on Hydroxychloroquine who were seen in our two rheumatology outpatient clinics from June 2023 until December 2023. Exclusion criteria included pregnant patients and patients with noncompliance to Hydroxychloroquine and loss of follow-up. We randomly used 50 deidentified patients' data from this generated list as our pre-interventional data. A retrospective chart review was undertaken to determine if QTc monitoring through routine EKG was completed within the last 6 months. We included age, gender, rheumatologic diagnosis, duration of Hydroxychloroquine use (more or less than 5 years), dose of Hydroxychloroquine (more or less than 5 mg/kg), preexisting conditions or concurrent QT-prolonging medications for baseline data.  In addition, we want to identify documentation of QTc through routine EKG as part of high-risk Hydroxychloroquine monitoring on the clinics' electrical medical records. Our new, implemented intervention consisted of inter-departmental coordination with cardiology with default EKG orders automatically routed to Cardiology department. In this regard, we created an order set with a diagnosis code and order code for EKG, along with a new dot phrase ".rheumEKG" where the EKG parameters from EKG performed from the Cardiology department will be documented in the patients' chart in the electronic medical record system. We added the EKG order in the face sheet to facilitate this process of scheduling with the front desk. A retrospective chart review of 50 patients will be randomly done after six months to analyze the impact of interventions. Descriptive statistics is used to analyze baseline demographic data. The preliminary result of this project shows that among 538 patients seen in our clinic within the last 6 months, only 12% had baseline EKG. Among 50 randomly collected patients as samples, only 12% also had baseline EKG (Graph 1). Table 1 shows the patient demographics and clinical baseline characteristics. Among these 50 patients, 80% were female, 46% diagnosed with rheumatoid arthritis/juvenile rheumatoid arthritis, 28% with systemic lupus erythematosus, and 42% were using Hydroxychloroquine for at least 5 years. All 50 patients are on adequate dosing for Hydroxychloroquine. With regards to comorbidities and concurrent medications, 40% have cardiovascular risks, which include a history of cardiac arrhythmias, myocardial infarction, and heart failure, while 18% have preexisting renal disease. Forty-two percent (42%) of the patients are on concurrent medications causing QT prolongation such as serotonin/serotonin and norepinephrine reuptake inhibitors,  among others for concurrent fibromyalgia and depression/anxiety treatment. Significantly, 28% of the patients have more than one of the above comorbidities, and 6%  have all three comorbidities. Screening and monitoring QTc prolongation through routine EKG in rheumatologic patients on Hydroxychloroquine is critical. This study is still ongoing.