Abstract
Background Subtle decreases in platelet count may impede timely recognition of heparin-induced thrombocytopenia (HIT), placing the patient at increased risk of thrombotic events. Objective A clinical decision support system (CDSS) was developed to alert physicians using computerized provider order entry when a patient with an active order for heparin experienced platelet count decreases consistent with HIT. Methods Comparisons for timeliness of HIT identification and treatment were evaluated for the year preceding and year following implementation of the CDSS in patients with laboratory confirmation of HIT. Results During the intervention time period, the CDSS alert occurred 41,922 times identifying 2,036 patients who had 2,338 inpatient admissions. The CDSS had no significant impact on time from fall in platelet count to HIT laboratory testing (control 2.3 days vs intervention 3.0 days P = 0.30) and therapy (control 19.3 days vs intervention 15.0 days P = 0.45), and appeared to delay discontinuation of heparin products (control 1.3 days vs. intervention 2.9 days P = 0.04). However, discontinuation of heparin following shorter exposure duration and after smaller decrease in platelet count occurred during the intervention period. The HIT CDSS sensitivity and specificity were each 87% with a negative predictive value of 99.9% and positive predictive value of 2.3%. Conclusions Implementation of a CDSS did not appear to improve the ability to detect and respond to potential HIT, but resulted in increased laboratory testing and changes in clinician reactions to decreasing platelet counts that deserve further study.
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Warkentin TE (2003) Heparin-induced thrombocytopenia: pathogenesis and management. Br J Haematol 121:535–555
Girolami B, Prandoni P, Stefani PM et al (2003) The incidence of heparin-induced thrombocytopenia in hospitalized medical patients treated with subcutaneous unfractionated heparin: a prospective cohort study. Blood 101:2955–2959
Spencer FA (2000) Heparin-induced thrombocytopenia patient profiles and clinical manifestations. J Thromb Thrombolysis 10:S21–S25
Warkentin TE, Roberts RS, Hirsh J, Kelton JG (2003) An improved definition of immune heparin-induced thrombocytopenia in postoperative orthopedic patients. Arch Intern Med 163:2518–2524
Warkentin TE, Greinacher A (2004) Heparin induced thrombocytopenia: recognition, treatment and prevention: The seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 126:311S–337S
Warkentin TE, Kelton JG (2001) Temporal aspects of heparin-induced thrombocytopenia. N Engl J Med 344:1286–1292
Warkentin TE, Levin MN, Hirsch J et al (1995) Heparin-induced thrombocytopenia with low-molecular-weight heparin or unfractionated heparin. N Engl J Med 332:1330–1335
Greinacher A, Warkentin TE (2006) Recognition, treatment, and prevention of heparin-induced thrombocytopenia: review and update. Thromb Res 118:165–176
Spinler SA, Dager W (2003) Overview of heparin-induced thrombocytopenia. Am J Health Syst Pharm 60:S5–S11
Walgenga JM, Jeske WP, Messmore HL (2000) Mechanisms of venous and arterial thrombosis in heparin-induced thrombocytopenia. J Thromb Thrombolysis 10:S13–S20
Spinler SA (2003) Managing heparin-induced thrombocytopenia: preventing life-and limb-threatening thrombosis. Am J Health Syst Pharm 60:S2–S4
Warkentin TE, Kelton JG (1996) A 14-year study of heparin-induced thrombocytopenia. Am J Med 101:502–507
Bates DW, Gawande AA (2003) Improving safety with information technology. N Engl J Med 348:2526–2534
Wallis DE, Workman DL, Lewis BE, Steen L, Pifarre R, Moran PF (1999) Failure of early heparin cessation as treatment for heparin-induced thrombocytopenia. Am J Med 106:629–635
Fabris F, Luzzatto G, Soini B et al (2002) Risk factors for thrombosis in patients with immune mediated heparin-induced thrombocytopenia. J Intern Med 252:149–154
Warkentin TE (2002) Platelet count monitoring and laboratory testing for heparin-induced thrombocytopenia: recommendations of the college of American pathologists. Arch Pathol Lab Med 126:1415–1423
Arepally GM, Ortel TL (2006) Heparin-induced thrombocytopenia. N Engl J Med 355:809–817
Classen DC (1998) Clinical decision support systems improve clinical practice and quality of care. JAMA 280:1360–1361
Garg AX, Adhikari NK, McDonald et al (2005) Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA 293:1223–1238
Chaudhry B, Wang J, Wu S et al (2006) Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med 144:742–752
Warkentin TE, Greinacher A, Koster A, Lincoff AM (2008) Treatment and prevention of heparin-induced thrombocytopenia: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 133(6 Suppl):340S–380S
Van der Sijs H, Aarts J, Vulto A, Berg M (2006) Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc 13(2):138–147
Warkentin TE (2000) Heparin-induced thrombocytopenia and its treatment. J Thromb Thrombolysis 9:S29–S35
Greinacher A, Eichler P, Lubenow N, Kwasny H, Luz M (2000) Heparin-induced thrombocytopenia with thromboembolic complications: meta-analysis of 2 prospective trials to assess the value of parenteral treatment with lepirudin and its therapeutic aPTT range. Blood 96:846–851
Hunt DL, Haynes RB, Hanna SE, Smith K (1998) Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review. JAMA 280:1339–1346
Mosen D, Elliot CG, Egger MJ et al (2004) The effect of a computerized reminder system on the prevention of postoperative venous thromboembolism. Chest 125:1635–1641
Durieux P (2005) Electronic medical alerts—so simple, so complex. N Engl J Med 352:1034–1036
Dexter PR, Perkins S, Overhage JM, Maharry K, Kohler RB, McDonald CJ (2001) A computerized reminder system to increase the use of preventative care for hospitalized patients. N Engl J Med 345:965–970
Raschke RA, Gollihare B, Wunderlich TA et al (1998) A computer alert system to prevent injury from adverse drug events. JAMA 280:1317–1320
Durieux P, Nizard R, Ravaud P, Mounier N, Lepage E (2000) A clinical decision support system for prevention of venous thromboembolism: effect on physician behavior. JAMA 283:2816–2821
Hirsh J, Heddle N, Kelton JG (2004) Treatment of heparin-induced thrombocytopenia: a critical review. Arch Intern Med 164:361–369
Macdonald D, Bhalla P, Cass W et al (2002) Computerized management of oral anticoagulant therapy: experience in major joint arthroplasty. Can J Surg 45:47–52
Wilson JW, Oyen LJ, Ou NN et al (2005) Hospital rules-based system: the next generation of medical informatics for patient safety. Am J Health Syst Pharm 62:499–505
Evans RS, Pestotnik SL, Classen DC et al (1998) A computer-assisted management program for antibiotics and other antiinfective agents. New Eng J Med 338:232–238
Wachter RM (2006) Expected and unanticipated consequences of the quality and information technology revolutions. JAMA 295:2780–2783
Kucher N, Koo S, Quiroz R et al (2005) Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med 352:969–977
Blumenthal D, Glaser JP (2007) Information technology comes to medicine. New Eng J Med 356:2527–2534
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Special thanks to TJUH Information Systems (Arlene Peters, Renee Brandell-Marino, Mary McNichol, Michael Ekshtut, et al).
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Riggio, J.M., Cooper, M.K., Leiby, B.E. et al. Effectiveness of a clinical decision support system to identify heparin induced thrombocytopenia. J Thromb Thrombolysis 28, 124–131 (2009). https://doi.org/10.1007/s11239-008-0279-x
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DOI: https://doi.org/10.1007/s11239-008-0279-x