Impact of a multidisciplinary workflow on safety and management of patients with heparin-induced thrombocytopenia

Abstract

Purpose Heparin-induced thrombocytopenia (HIT) is a serious complication of heparin administration. Management strategies are complex and include discontinuing heparin products, initiating alternative anticoagulants, interpreting laboratory test results, documenting heparin allergies, and providing patient education. Medication error reports and a retrospective review conducted at an academic medical center revealed an opportunity for a quality improvement initiative and led to the creation of a multidisciplinary workflow for the management of HIT. In a pre-post study, the impact of the multidisciplinary workflow on the safety and management of HIT was evaluated. Methods The preimplementation group consisted of adult patients tested for suspected HIT from April 4, 2014, through May 31, 2016; the postimplementation group consisted of adult patients tested from November 1, 2016, through October 31, 2018. The primary outcome was the incidence of heparin product administration while HIT testing was ongoing. The secondary outcome was the rate of appropriate heparin allergy documentation. Results The incidence of heparin product administration while HIT testing results were pending was significantly reduced, from 54.2% to 20.0% (P < 0.001), after workflow implementation. The rate of appropriate heparin allergy documentation significantly increased, from 95.0% to 100% (P < 0.001). Conclusion Implementation of a multidisciplinary workflow for the management of HIT significantly reduced the incidence of heparin administration while testing was ongoing and improved the rate of appropriate heparin allergy documentation.

Autoimmune Heparin-Induced Thrombocytopenia

“…This is relevant because unaccounted for residual heparin could result in inadvertent detection of heparin-dependent antibodies. The authors point out that ongoing heparin administration occurrs in approximately half of patients whose blood is referred for HIT diagnostic testing [192]. Further, one study [58] found residual heparin (at least 0.1 IU/mL) was present in 62% of samples referred for HIT testing.…”

“Autoimmune HIT” antibodies in diagnostic samples are a potential artifact and not associated with more severe outcomes

“…Our observation that heparin contamination was noted in approximately half of all diagnostic HIT samples is consistent with published findings that heparin administration continued in 54% of patients while HIT testing results were pending. 13 In a recent study, anti-Xa activity testing in a cohort of diagnostic HIT samples demonstrated that contaminating heparin (anti-Xa activity ≥ 0.1 IU/mL) was detected in 21 of 34 (62%) samples. 14 In that study, a comparison of outcome severity in confirmed heparin-negative samples with an aHIT profile (ie, activation in the no-heparin SRA) vs classical HIT demonstrated no differences in platelet nadir or persistence of thrombocytopenia.…”

A little heparin goes a long way: effect of therapeutic levels of unfractionated heparin on the heparin-induced thrombocytopenia-platelet factor 4 ELISA antibody assay

“…On the basis of unfractionated heparin (UFH) half-life of 60-90 min [3], our hospital recommends stopping UFH administration at least 8 h prior to testing for HIT. However, samples are often collected sooner or even while the patient is still receiving UFH [4]. It has been reported that therapeutic levels of UFH may interfere with functional HIT assays, such as the serotonin release assay [5,6].…”