From the 2018 HVPAA National Conference
FNU Aparna (Crozer-Chester Medical Center), Kshitij Thakur (Crozer-Chester Medical Center)
Heparin-induced thrombocytopenia (HIT) is an antibody-mediated pro thrombotic condition, with affected individuals having a greater than 50% risk of developing new thromboembolic events and the mortality rate is approximately 20%. The 4T scoring system is a validated tool that can significantly reduce the number of unnecessary HIT panels ordered.
We undertook a multifaceted quality-improvement (QI) intervention in a community hospital to decrease unnecessary HIT panels. Our primary aim was to increase the use of 4T scoring system before ordering HIT panels. Secondary aim was to reduce the number of HIT panels with low pretest probability of positive result by 20%.
The Q/I intervention was composed of introduction of HIT order set which provided an option of calculating 4T score at the point of order entry, and extensive education of house staff and faculty about the 4T scoring system. We performed a pre-post analysis, comparing a cohort of patients during the 18-month baseline period before the QI intervention and the 18-month post intervention period. Demographic and clinical data were collected from the electronic medical record.
The baseline (n=154) and intervention (n=103) cohorts were similar in their demographics but showed a significant reduction in total number of HIT orders (p= 0.02852). In the pre intervention cohort 1% of HIT orders had a 4T score documented, this increased to 36% in the intervention cohort. The percentage of low probability HIT panels ordered was reduced from 62% in the pre intervention cohort, to 41% in the intervention cohort.
Implementation of a multifaceted Q/I intervention within a community hospital was associated with significant decrease in the number of HIT panels ordered. Further intervention by making 4T calculation a “HARD STOP” before ordering HIT panels in the EMR can further reduce “low value” HIT panels.
Implications for the Patient
HIT panel is an expensive send-out test with a turn around time of 4-5 days. Reducing unnecessary HIT panels avoids exposure to unnecessary non heparin anticoagulants. Reducing the low probability HIT panels can potentially reduce the length of stay for patient given long turnaround time for the test.