EMR Tool Impact on HIT Documentation and Management
Condition: Heparin; Thrombocytopenia; Electronic Health Records
MeSH terms: Thrombocytopenia
Study type: Observational

Summary: 
      Heparin-induced thrombocytopenia (HIT) is an immune-mediated adverse drug reaction to heparin
      products which results in a prothrombotic state. Heparin-induced thrombocytopenia generally
      occurs several days after the start of unfractionated heparin or low molecular weight heparin
      and is diagnosed based on clinical presentation, and presence of thrombocytopenia. HIT has an
      incidence of 0.1% to 5% and if recognized early can help prevent major complications. As of
      November 2014, the responsibility for documenting heparin allergies in the electronic medical
      record (EMR) has shifted from the physician/medical resident to the pharmacy resident. The
      purpose of this study is to compare the number, rate, and appropriateness of heparin allergy
      documentation in order to help decrease adverse medical events related to heparin.
    

Detailed description: 
      Heparin-induced thrombocytopenia is a unique form of drug induced thrombocytopenia associated
      with increased clotting risk. The incidence of HIT ranges from 0.1% to 5%. Heparin-induced
      thrombocytopenia occurs when an antibody forms a complex with platelet factor 4 and heparin.
      This complex activates platelets which increases the risk of thrombus formation. Normally,
      HIT presents 5 to 14 days after exposure, but can occur with heparin exposure within the past
      100 days. The presentation of HIT is often first suspected secondary to a decrease in
      platelet counts of 50% or more from baseline.

      At Rush University Medical Center (RUMC), HIT is diagnosed through a combination of clinical
      factors and laboratory tests. When HIT is first suspected, a 4T HIT score, which is used to
      estimate the probability of true HIT, is calculated. The following score ranges correspond to
      the probability of true HIT; score of 0-3 indicates a low probability, score of 4-5 indicates
      an intermediate probability, and a score of 6-8 indicates a high probability of true HIT.

      If the score indicates a likelihood of HIT, a HIT-Ab is sent off. This test has a sensitivity
      of more than 95% and a specificity of 74% to 86%. Accordingly, if this HIT-Ab test result is
      negative, HIT is ruled out. If the result is equivocal or positive, a confirmatory Serotonin
      Release Assay (SRA) test should be performed (sensitivity of 89% to 100% and a specificity of
      88 % to 100%).

      Prior to 2014, there was no formal process for evaluation of patients with HIT. In November
      of 2014, an EMR tool was created in an effort to improve heparin allergy documentation and
      HIT management. This EMR tool prompts the medical team to perform the 4T score, displays the
      appropriate HIT labs, alternative anticoagulation strategies, instructs the nurse to apply an
      allergy bracelet, and notifies the pharmacy resident through the order verification queue.
      The pharmacy resident then performs an independent 4T score, discontinues all heparin
      products, documents the heparin allergy in the medical record, and assesses the need for
      alternative anticoagulation.

      Many studies have shown the value of the 4T HIT scoring system and the use of pharmacists in
      reducing the inappropriate use of alternative anticoagulation and unnecessary testing.
      Pharmacists have helped to improve patient outcomes and decrease costs associated with HIT.
      The purpose of this study is to evaluate the impact of an EMR tool and pharmacy residents on
      allergy documentation and the management of HIT.
    

Intervention name(s): Electronic medical record order panel and resident involvement
Intervention type(s): Other
Intervention description(s): Prior to 2014, there was no formal process for evaluation of patients with HIT. In November of 2014, an EMR tool was created in an effort to improve heparin allergy documentation and HIT management. This EMR tool prompts the medical team to perform the 4T score, displays the appropriate HIT labs, alternative anticoagulation strategies, instructs the nurse to apply an allergy bracelet, and notifies the pharmacy resident through the order verification queue. The pharmacy resident then performs an independent 4T score, discontinues all heparin products, documents the heparin allergy in the medical record, and assesses the need for alternative anticoagulation.
Observational model: Cohort
Time perspective: Retrospective
Sampling method: Non-Probability Sample
Study population: 
        The study will be retrospective, and collected data will be a result of routine care. Adult
        patients 18 years of age or older with an order for a HIT-Ab while admitted to RUMC will be
        assessed for inclusion

        Patients will be reviewed from 01/01/2014 to 09/30/2015. A list of patients will be
        generated by a laboratory order for HIT-Ab (Heparin Induced Thrombocytopenia AB
        [LAB0002639]).
      
Keywords: HIT; Heparin Induced Thrombocytopenia; Electronic Medical Record; Electronic Health Records