A multifaceted quality improvement intervention:A high-value approach to Heparin Induced Thrombocytopenia(HIT)

From the 2018 HVPAA National Conference

Fnu Aparna (Crozer-Chester Medical Center), Jian Liang Tan (Crozer-Chester Medical Center), Fnu Anshul (Crozer-Chester Medical Center), Naveed Jan (Crozer-Chester Medical Center)


The incidence of HIT is on the rise with more use of heparin in the hospital setting. 4Ts score is a validated screening tool with a high negative predictive value in excluding HIT type II when a low probability score is present.


The aim of this study was to assess the outcomes of pre and post-implementations of 4Ts scoring system.


We conducted a retrospective chart review of patients who had HIT antibody tests ordered. There was a pre-intervention phase (January 2013 – June 2014) which served as a control, and a post-intervention phase (August 2015 – February 2017) which served as a comparison. Pre-intervention: A total of 154 patients had the HIT antibody testing ordered prior to the hardwiring of 4Ts scoring system in the EMR. Then, there was an extensive in-house education provided to the healthcare providers regarding the need of completing 4Ts score prior to ordering the HIT antibody tests over the 13 months period. Post-intervention: A total of 103 patients had the HIT antibody testing ordered after the 4Ts scoring system was created in the EMR. Inclusion criteria: Patients who were suspected to have HIT type II and HIT antibody tests sent out. Exclusion criteria: Age under 18-year-old. The number of 4Ts scores documented and the appropriateness of HIT antibody tests ordered between pre- and post-interventions were compared.


Pre-intervention, only 1.3% (2/154 patients) had their 4Ts score documented in the chart, which significantly improved to 34% (35/103 patients) post-intervention [1.3% vs 34%, p < 0.00001]. Pre-intervention, 62.3 % (96/154 patients) with low probability score had unnecessary HIT antibody testing ordered, which significantly reduced to 40.8% (42/103 patients) post-intervention [62.3% vs 40.8%, p = 0.00068]. The total average cost of HIT antibody testing per patient was around $5,000. As the test takes 3 – 5 days to return, the average length of stay in hospital ($7,000/day) will inadvertently be prolonged. Hence, if the physician complies to the use of 4Ts score, an estimated cost savings per patient is between $26,000 – $40,000.


It is evident that the implementation of 4Ts scoring system in EMR had significantly reduced the number of inappropriate HIT antibody testing in low probability group. Clinicians are encouraged to utilize the 4T scoring system prior to sending HIT panels to reduce unnecessary testing and practice cost-effective medicine.

Implications for the Patient

Diagnosis of HIT type II is rather challenging as affected individual often has other causes of thrombocytopenia and a delayed discontinuation of heparin in HIT type II is associated with a mortality rate of 20-30%.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog