Clinical audit: assessing the quality of ECG monitoring in DR-TB patients

Abstract

INTRODUCTION: multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) are diseases of global concerns which require treatments with complex combinations of drugs. These drugs are associated with several adverse effects (AEs). QTc prolongation is one of those AEs, and it is considered as a risk factor for developing Torsades de Pointe (TdP), an arrhythmia that can lead to sudden cardiac death (SCD). In order to prevent cardiac events, ECG monitoring is recommended in patients treated with QTc-prolonging drugs. DATA/METHODS: four of the main guidelines for ECG monitoring in drug-resistant tuberculosis (DR-TB) patients were reviewed to define the range of recommendations. We reviewed the case records of 10 DR-TB patients managed in the North Central London TB service between 2016 and 2018. We analysed the data to assess the quality of health care provided, including ECG monitoring, and interviewed clinical staff to determine possible barriers to ECG monitoring in daily clinical practice. RESULTS: the recommendations for ECG monitoring in the case of Bedaquiline (BDQ) and Delamanid (DLM) were similar in all four guidelines analysed, while recommendations for Clofazimine (CFZ) and Fluoroquinolones (FQs) where only considered in one of the four guidelines. The care provided at the clinic largely adhered to the recommended guidelines. However, sometimes the results and actions taken were not clearly accessible. For example, we found that only 79.23% of the ECGs performed were compiled in the clinical records. There were not found remarkable barriers in the daily clinical practice, and there is a good team work between nurses and doctors at the clinic. CONCLUSIONS: there is a lack of guidance for the frequency for ECG monitoring in patients on CFZ, FQs or more than one QTc-prolonging drug. There is a quality health care imparted by the clinical staff at the TB service assessed. Due to the complexity of adverse event-monitoring in patients with DR-TB, we propose a standard proforma to record these data during clinic visits. This measure could simplify the work of the clinical staff by providing easy access to previous results. Finally, we also propose to standardize the way ECGs should be storage, either in the patient’s folder or scanned into NHS platform