Development and implementation of a comprehensive heparin-induced thrombocytopenia recognition and management protocol

Quality improvement approaches to heparin-induced thrombocytopenia: a scoping review

Background

Heparin-induced thrombocytopenia (HIT) is a relatively uncommon condition characterized by 2 exceedingly common phenomena in hospitalized patients: thrombocytopenia and heparin exposure. Consequently, HIT is frequently overdiagnosed and inappropriately treated. These issues are the focus of many quality improvement (QI) initiatives.

Objectives

In this scoping review, we identified and characterized all published QI studies on improving the diagnosis and management of HIT.

Methods

We conducted a systematic literature search through April 2022 for studies reporting on QI interventions regarding the diagnosis, treatment, and/or prevention of HIT.

Results

Thirty studies were included in the final review. Studies were separated into 5 groups based on the focus of the interventions: increasing HIT recognition, reducing HIT incidence, reducing HIT overdiagnosis, promoting safer HIT management, and creating HIT task forces. Nine studies focused on the implementation of 4Ts score calculator into electronic medical record orders for HIT testing, while only 1 evaluated the impact of reducing unfractionated heparin use in favor of low-molecular-weight heparin. Six studies focused on the implementation of direct thrombin inhibitor management protocols, while none evaluated the use of alternative anticoagulants in HIT management.

Conclusion

The bulk of published HIT QI research focused on reducing overdiagnosis and promoting safer direct thrombin inhibitor therapy, while minimal attention has been devoted to HIT prevention and the use of evidence-based alternative HIT therapies.

Electronic Health Record Tools to Identify Child Maltreatment: Scoping Literature Review and Key Informant Interviews

OBJECTIVE

To prevent missed cases and standardize care, health systems are beginning to implement EHR-based screens (EHR-CA-S) and clinical decision supports systems (EHR-CA-CDSS) for the identification and management of child maltreatment. This study aimed to 1) document the existing research evidence on the performance of EHR-CA-S and EHR-CA-CDSS and 2) examine clinical perspectives regarding the use of such tools and factors that affect uptake.

METHODS

We searched MEDLINE, Embase, EBSCO, Scopus, and CINAHL databases for English language articles published prior to November 2021 that describe and/or evaluated an EHR-CA-S and/or EHR-CA-CDSS involving 0 to 18-year olds. We performed semistructured interviews with 20 individuals who have experience in identifying, evaluating, and/or treating child maltreatment and/or conducting research on these topics.

RESULTS

Our search identified 574 articles; 16 met inclusion criteria. Studies examined screening, alerts and triggers, and quality improvement. None evaluated long-term clinical outcomes. Sensitivity ranged from 0.14 to 1.00, specificity from 0.865 to 1.00, positive predictive value from 0.03 to 1.00 and negative predictive value from 0.55 to 1.00. A variety of EHR-CA-S and/or EHR-CA-CDSS have been implemented at institutions in our sample. Interviewees cited missed cases, policy requirements, and the lack of standardization of care as impetuses for adopting these tools, yet expressed concerns regarding insufficient evidence, bias, and time-intensiveness of implementation.

CONCLUSIONS

Interviewees and the literature agree that current evidence does not support adoption of a particular CA-S or CA-CDSS. Further refinement and research on EHR-CA-S and EHR-CA-CDSS is necessary for these tools to be feasibly implemented and sustained, reliable for clinical practice, and not cause any unintentional harms.

Systems-based hematology: highlighting successes and next steps

Systems-based hematology is dedicated to improving care delivery for patients with blood disorders. First defined by the American Society of Hematology in 2015, the idea of a systems-based hematologist arose from evolving pressures in the health care system and increasing recognition of opportunities to optimize the quality and cost effectiveness of hematologic care. In this review, we begin with a proposed framework to formalize the discussion of the range of initiatives within systems-based hematology. Classification by 2 criteria, project scope and method of intervention, facilitates comparison between initiatives and supports dialogue for future efforts. Next, we present published examples of successful systems-based initiatives in the field of hematology, including efforts to improve stewardship in the diagnosis and management of complex hematologic disorders (eg, heparin-induced thrombocytopenia and thrombophilias), the development of programs to promote appropriate use of hematologic therapies (eg, blood products, inferior vena cava filters, and anticoagulation), changes in care delivery infrastructure to improve access to hematologic expertise (eg, electronic consultation and disorder-specific care pathways), and others. The range of projects illustrates the broad potential for interventions and highlights different metrics used to quantify improvements in care delivery. We conclude with a discussion about future directions for the field of systems-based hematology, including extension to malignant disorders and the need to define, expand, and support career pathways.

Interventions designed to improve the safety and quality of therapeutic anticoagulation in an inpatient electronic medical record

IMPORTANCE

Anticoagulants are high-risk medications with the potential to cause significant patient harm or death. Digital transformation is occurring in hospital practice and it is essential to implement effective, evidence-based strategies for these medications in an electronic medical record (EMR).

OBJECTIVE

To systematically appraise the literature to determine which EMR interventions have improved the safety and quality of therapeutic anticoagulation in an inpatient hospital setting.

METHODS

PubMed, Embase, CINAHL, and the International Pharmaceutical Database were searched for suitable publications. Articles that met eligibility criteria up to September 2018 were included. The review was registered with PROSPERO (CRD42018104899). The web-based software platform Covidence® was used for screening and data extraction. Studies were grouped according to the type of intervention and the outcomes measured. Where relevant, a bias assessment was performed.

RESULTS

We found 2624 candidate articles and 27 met inclusion criteria. They included 3 randomised controlled trials, 4 cohort studies and 20 pre/post observational studies. There were four major interventions; computerised physician order entry (CPOE) (n = 4 studies), clinical decision support system (CDSS) methods (n = 21), dashboard utilisation (n = 1) and EMR implementation in general (n = 1). Seven outcomes were used to summarise the study results. Most research focused on prescribing or documentation compliance (n = 18). The remaining study outcome measures were: medication errors (n = 9), adverse drug events (n = 5), patient outcomes (morbidity/mortality/length of hospital stay/re-hospitalisation) (n = 5), quality use of anticoagulant (n = 4), end-user acceptance (n = 4), cost effectiveness (n = 1).

CONCLUSION

Despite the research cited, limited benefits have been demonstrated to date. It appears healthcare organisations are yet to determine optimal, evidence-based-methods to improve EMR utilisation. Further evaluation, collaboration and work are necessary to measure and leverage the potential benefits of digital health systems. Most research evaluating therapeutic anticoagulation management within an EMR focused on prescribing or documentation compliance, with less focus on clinical impact to the patient or cost effectiveness. Evidence suggests that CPOE in conjunction with CDSS is needed to effectively manage therapeutic anticoagulation. Targets for robust research include the integration of 'stealth' alerts, nomograms into digital systems and the use of dashboards within clinical practice.

Integration of physical abuse clinical decision support at 2 general emergency departments

OBJECTIVE

The study sought to develop and evaluate an electronic health record-based child abuse clinical decision support system in 2 general emergency departments.

MATERIALS AND METHODS

A combination of a child abuse screen, natural language processing, physician orders, and discharge diagnoses were used to identify children <2 years of age with injuries suspicious for physical abuse. Providers received an alert and were referred to a physical abuse order set whenever a child triggered the system. Physician compliance with clinical guidelines was compared before and during the intervention.

RESULTS

A total of 242 children triggered the system, 86 during the preintervention and 156 during the intervention. The number of children identified with suspicious injuries increased 4-fold during the intervention (P < .001). Compliance was 70% (7 of 10) in the preintervention period vs 50% (22 of 44) in the intervention, a change that was not statistically different (P = .55). Fifty-two percent of providers said that receiving the alert changed their clinical decision making. There was no relationship between compliance and provider or patient demographics.

CONCLUSIONS

A multifaceted child abuse clinical decision support system resulted in a marked increase in the number of young children identified as having injuries suspicious for physical abuse in 2 general emergency departments. Compliance with published guidelines did not change; we hypothesize that this is related to the increased number of children identified with suspicious, but less serious injuries. These injuries were likely missed preintervention. Tracking compliance with guidelines over time will be important to assess whether compliance increases as physician comfort with evaluation of suspected physical abuse in young children improves.

Development of an electronic medical record-based child physical abuse alert system

Objective

Physical abuse is a leading cause of pediatric morbidity and mortality. Physicians do not consistently screen for abuse, even in high-risk situations. Alerts in the electronic medical record may help improve screening rates, resulting in early identification and improved outcomes.

Methods

Triggers to identify children < 2 years old at risk for physical abuse were coded into the electronic medical record at a freestanding pediatric hospital with a level 1 trauma center. The system was run in "silent mode"; physicians were unaware of the system, but study personnel received data on children who triggered the alert system. Sensitivity, specificity, and negative and positive predictive values of the child abuse alert system for identifying physical abuse were calculated.

Results

Thirty age-specific triggers were embedded into the electronic medical record. From October 21, 2014, through April 6, 2015, the system was in silent mode. All 226 children who triggered the alert system were considered subjects. Mean (SD) age was 9.1 (6.5) months. All triggers were activated at least once. Sensitivity was 96.8% (95% CI, 92.4-100.0%), specificity was 98.5% (95% CI, 98.3.5-98.7), and positive and negative predictive values were 26.5% (95% CI, 21.2-32.8%) and 99.9% (95% CI, 99.9-100.0%), respectively, for identifying children < 2 years old with possible, probable, or definite physical abuse.

Discussion/Conclusion

Triggers embedded into the electronic medical record can identify young children with who need to be evaluated for physical abuse with high sensitivity and specificity.

Assessing the impact of a heparin-induced thrombocytopenia protocol on patient management, outcomes and cost

Establishing the diagnosis of heparin induced thrombocytopenia (HIT) is challenging as laboratory tests for HIT vary in specificity and availability. As HIT suspicion far exceeds confirmation of diagnosis, overtreatment is an emerging concern. This pilot study evaluated the impact of a HIT Recognition and Management Protocol on direct thrombin inhibitor (DTI) prescribing, outcomes, and cost. The primary endpoint was DTI cessation within 12 hours of receipt of negative HIT serology. An observational cohort study using a pre-post design was performed. Sixty-one patients were in the pre-period (before implementation) and 46 in the post-period (after implementation). DTI therapy was discontinued within 12 hours of negative serology in 19.4% of pre-period patients compared to 40% of post-period patients, p=.058. DTI therapy was discontinued within 24 hours of receipt of a negative PF4/heparin ELISA more often in the post-period ; 7/23 (30.4%) pre-period patients versus 16/26 (61.5%) post-period patients, p <0.05. Protocol implementation resulted in a significant improvement in timely initiation of DTI therapy (within 12 hours of HIT antibody testing) in those with a moderate to high suspicion of HIT; 8/31 (25.8%) of pre-period patients versus 24/31 (77.4%) of post-period patients, p <0.0001. Thrombotic events occurred in significantly more patients in the pre-period as compared to the post-period; 21/61 (34.4%) versus 6/46 (13%), respectively, p = 0.01. Major bleeding was reduced by 6.6 % after protocol implementation. The projected annual cost savings from decreased inappropriate DTI use was over $450,000. Protocol implementation had a positive impact on DTI prescribing, outcomes and cost.

The role of hematologists in a changing United States health care system

Major and ongoing changes in health care financing and delivery in the United States have altered opportunities and incentives for new physicians to specialize in nonmalignant hematology. At the same time, effective clinical tools and strategies continue to rapidly emerge. Consequently, there is an imperative to foster workforce innovation to ensure sustainable professional roles for hematologists, reliable patient access to optimal hematology expertise, and optimal patient outcomes. The American Society of Hematology is building a collection of case studies to guide the creation of institutionally supported systems-based clinical hematologist positions that predominantly focus on nonmalignant hematology. These roles offer a mix of guidance regarding patient management and the appropriate use and stewardship of clinical resources, as well as development of new testing procedures and protocols.

Recent Publications on Medications and Pharmacy

Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest regarding a broad scope of topics are abstracted monthly. Suggestions or comments may be addressed to Flint Russett, St. Claire Regional Medical Center, 222 Medical Circle, Morehead, KY 40351, or e-mail: FSRussett@st-claire.org .