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. 2024 Apr 30;8(4):102423.
doi: 10.1016/j.rpth.2024.102423. eCollection 2024 May.

Electronic alerts to improve management of heparin-induced thrombocytopenia

Rebecca L Zon  1   2   3 , Katelyn W Sylvester  4 , David Rubins  3   5 , Jessica Grandoni  4 , Julie Kelly  4 , Shreya Timilsina  4 , Mark Akladious  4 , Rajesh Patel  3   6 , Jean M Connors  1   2   3
Affiliations

Electronic alerts to improve management of heparin-induced thrombocytopenia

Rebecca L Zon et al. Res Pract Thromb Haemost. .

Abstract

Background: Heparin-induced thrombocytopenia (HIT) is a difficult clinicopathologic diagnosis to make and to treat. Delays in identification and appropriate treatment can lead to increased morbidity and mortality.

Objectives: To use electronic health alert interventions to improve provider diagnosis and management of heparin-induced thrombocytopenia through guideline-based, accurate care delivery.

Methods: This quality improvement initiative developed 3 electronic health record-based interventions at our 750-bed academic medical center to improve the initial management of suspected HIT between 2018 and 2021: 1. an interruptive alert to recommend discontinuation of active heparin products when signing a heparin-platelet factor 4 test (PF4) order, 2. integrated 4T score calculation in the heparin-PF4 test order, and 3. interruptive alert suggesting not to order heparin-PF4 tests when the 4T score is <4. Changes in practice were assessed over defined time periods pre and post each intervention.

Results: Intervention 1 resulted in heparin discontinuation in more patients, with 65% (191 heparin orders/293 heparin-PF4 enzyme-linked immunosorbent assay tests) of cases continuing heparin prealert and only 54% (127 heparin orders/235 heparin-PF4 enzyme-linked immunosorbent assay tests) postinterruptive alert (95% CI 2.3-19.9; P = .015). Intervention 2 increased appropriate heparin-PF4 test ordering from 40.4% (110/272) preintervention to 79.1% (246/311) (95% CI 30.9-46.4; P < .00001) postintervention, with inappropriate PF4 ordering defined as testing when 4T score was <4. Intervention 3 did not lead to reduction in heparin-PF4 testing in the control group (96 inappropriate orders/402 total orders, 24%) compared to the randomized alert group (56 inappropriate orders/298 total orders; 19%) (95% CI -1.2 to 11.5; P = .13).

Conclusion: Implementation of unique electronic health record interventions, including both diagnostic and management interventions, led to improved guideline-based, accurate care delivery with 4T score calculation and cessation of heparin for patients with suspected HIT.

Keywords: heparin; medical order entry systems; quality improvement; thrombocytopenia.

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Figures

None
Graphical abstract
Figure 1
Figure 1
(A) Electronic health alert recommending discontinuation of heparin products when ordering a platelet factor 4 (PF4) test. (B) Heparin-PF4 test order. HIT, heparin-induced thrombocytopenia; Plt, platelet.
Figure 2
Figure 2
Inappropriate platelet factor 4 (PF4) ordering by provider location. P = .13.
See this image and copyright information in PMC

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