Electronic Alerts to Improve Management of Heparin-Induced Thrombocytopenia

Introduction 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. Methods This quality improvement initiative developed three electronic health record-based interventions at our 750-bed academic medical center to improve the initial management of suspected HIT between 2018-2021: 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 was < 4. Changes in practice were assessed over a 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 ELISA tests) of cases continuing heparin pre-alert and only 54% (127 heparin orders/235 heparin-PF4 ELISA tests) post-interruptive alert (p = 0.015). Intervention 2 increased appropriate heparin-PF4 test ordering from 40.4% (110/272) pre-intervention to 79.1% (246/311) (p< 0.00001), with inappropriate heparin-PF4 ordering defined as testing when 4T score < 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%) (p=0.13). 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.