A Quality Improvement Project to Improve Lab Safety Monitoring in IBD Patients on Immunomodulators Using the Veterans Affairs IBD Dashboard and a Multidisciplinary Team

Introduction: Patient’s with inflammatory bowel disease (IBD) who are on immunomodulators such as 6-mercaptopurine, azathioprine, and methotrexate require routine lab safety monitoring to monitor for toxicities. Toxicities include leukopenia which can result in sepsis and elevated liver chemistry tests. For patients on chronic therapy, CBC with differential and CMP should be monitored every 3 months. Of the 71 patients on immunomodulators for IBD at the Atlanta VA, 39.2% were up to date on labs on January 5, 2021. For patients who were overdue for labs, there was no process in place to identify these patients, ensure labs orders were up to date, or call patients with reminders. Methods: To track lab safety monitoring, we utilized the IBD dashboard to identify all IBD patients on immunomodulators. We identified those patients who did not have a CBC with differential and CMP within a 3 month period. We tracked the percentage of patients up to date on their labs and tracked this number on a weekly basis for three months. We were also able to compare the Atlanta VA lab adherence rates to the rates at the other VA hospitals in our region. In Figure 1a, we identify some of the missed opportunities for lab safety monitoring. The process map in Figure 1b demonstrates how we implemented this project. Each week, the GI PharmD identified patients who were overdue on labs and notified the IBD nurse manager. The IBD nurse manager called patients with a reminder to complete labs and determined the reason for missed labs. If the patient did labs, they were renewed by the MD or PharmD as appropriate and if labs weren’t done, the PharmD alerted the IBD nurse manager to reach out to the patient again. The actions and tests of change are described in Table 1. Results: We further determined the reasons for the missed labs (Figure 1c). In January, the main reasons included the MD ordering the labs and the patient not getting them done, the MD not ordering the labs, or the CBC being ordered without differential. There was significant improvement during the months of February and March with the implementation of our project. Lab adherence rates in IBD patients on immunomodulators increased from 39.2% to 81.7% at the Atlanta VA (Figure 1d). Conclusion: We implemented a sustainable, multidisciplinary team involving the GI physician, GI PharmD and IBD nurse manager to monitor lab adherence in IBD patients on immunomodulators, increasing the lab adherence from 39.2% to 81.7% and improving the culture of safety at the Atlanta VA.Figure 1.: 1a) Missed opportunities for lab safety monitoring 1b) Process map demonstrating how this QI project was implemented 1c) Reasons for the missed labs 1d) Lab adherence rates at the Atlanta VA and regional VA hospitalsTable 1.: Actions and Tests of Change