EHR Alerts Improve Quality of Care in Heparin-Induced Thrombocytopenia, Study Finds

For patients with heparin-induced thrombocytopenia (HIT), the implementation of electronic alerts was shown to benefit disease management, diagnosis, and care delivery, according to a study recently posted in Research and Practice in Thrombosis and Haemostasis.¹

Blood Platelet Concept | image credit: Dr_Microbe - stock.adobe.com

HIT is known as the most serious, nonbleeding adverse reaction a patient can have to the anticoagulant heparin.² This complication is immune mediated and can within hours or days of an individual’s exposure to heparin. Adverse reactions to heparin cause the body to produce antibodies against the drug, leading to aggregation and activation of platelets in the blood, which subsequently increases the production of thrombin. After this process, the resulting removal of platelets leaves patients at a heightened risk for thrombocytopenia.

An estimated 0.5% to 5% of adults being administered heparin therapy experience HIT, and undiagnosed instances are linked to mortality rates of 20% to 30%.¹ At present, assessing HIT involves the calculation of a 4T score (0-8, with higher scores indicating higher HIT probability). Should a patient’s score be above 3, they are recommended to stop heparin therapy, substitute it for a nonheparin anticoagulant, and undergo an immunoassay for antibodies against heparin-platelet factor 4 (PF4).

The present authors, of the Hemostatic and Antithrombotic (HAT) Stewardship team at Brigham and Women’s Hospital (BWH), discovered that the calculation and documentation of 4T scores, the sending of heparin-PF4 tests, and instructions to cease heparin were being mishandled by providers. In response, the HAT Stewardship collaborated with a clinical decision support team to develop electronic health record (EHR)–based interventions with the hopes of bettering patient safety, care, and disease management in HIT.

At BWH, 3 EHR interventions were developed. These interventions included an alert to providers to stop heparin therapy if HIT was suspected (first), mandatory 4T score calculation to analyze patients’ pretest HIT probability (second), and an additional patient information alert to deter providers from ordering a heparin-PF4 test if a patient’s 4T score was under 4 (indicating a lower probability of HIT; third).

The first intervention began in 2018 and led to a reduction in inappropriate heparin continuation of 11% (65% to 54%; P = .015). The authors noted that this alert exhibited the most success at their institution, namely because of its clarity and the fact that no one could move on from the alert without acknowledging it first. As discontinuation of heparin in at-risk patients is a critical step in their treatment, they add that this alert is being refined to continue adding benefits to patient safety measures.

The second intervention was initiated in 2020. Of 272 patient cases that were eligible for this part of the investigation, only 85 (31%) had documented 4T scores in the EHR prior to the alert. In this group, 59 individuals (69.4%) had what were deemed appropriate heparin-PF4 tests. Among patients without 4T score documentation (n = 187), the researchers found that 51 (27.2%) had 4T scores above 3. In total, the authors assessed that just over 40% (n = 110) of heparin-PF4 tests were appropriate to order. “Given the risk of false positive heparin-PF4 results, tests sent for low 4T scores can lead to unnecessary additional testing, inappropriate use of expensive non-heparin anticoagulants, and increased economic burden,” they added.

In the postalert analysis for the second intervention, 100% (n = 311) of patients had a documented 4T score and appropriate tests were ordered for 79.1% (n = 246) patients. This increase of appropriate testing reached statistical significance (P < .00001).

The third intervention was also implemented in 2020 with the aim of reducing rates of overdiagnoses and unnecessary tests. This alert did not have a significant impact on clinical practice, as the authors noted that testing orders did not substantially differ between control groups (96 of 402 had an inappropriate order; 24%) and providers who received the alert (56 of 298; 19%).

As the authors concluded, they mentioned that electronic alert measures are ongoing. Their study demonstrated the efficacy of these EHR-embedded alerts to improve safety and delivery of care for patients with or suspected of having HIT; therefore, the improvement of these alerts should further better the care, management, and diagnosis of HIT.

References

1. Zon RL, Sylvester KW, Rubins D, et al. Electronic alerts to improve management of heparin-induced thrombocytopenia. Res Pract Thromb Haemost. Published online April 30, 2024. doi:10.1016/j.rpth.2024.102423

2. Alhanshani AA. Heparin induced thrombocytopenia - pathophysiology, diagnosis and treatment: a narrative review. Int J Gen Med. 2023;16:3947-3953. doi:10.2147/IJGM.S420327