Incidence and Outcomes of Heparin-Induced Thrombocytopenia Associated with a Heparin Shortage at a Large Academic Medical Center

Heparin-induced thrombocytopenia (HIT) is a life-threatening complication associated with significant morbidity and mortality in hospitalized patients. The 2019 African swine fever outbreak in China resulted in a critical national shortage of porcine-derived heparin products in the United States. As a result, our institution implemented a multitude of mitigation strategies to reduce heparin utilization by >80% and optimize safe and effective alternative therapies. The aim of this study was to determine whether this change in clinical practice impacted the incidence of HIT and associated outcomes. A single-center, retrospective cohort study was performed on patients admitted to Massachusetts General Hospital who were ≥ 18 years of age and had a positive platelet factor 4 (PF4) drawn between February 2019 and January 2020. Patient demographics, comorbidities, baseline labs, serotonin release assay results, timing and magnitude of platelet count fall, and characteristics of heparinoid and non-heparinoid anticoagulant use were collected from the medical record. Thrombotic and hemorrhagic outcomes were characterized. Seventy-five patients were included in the final analysis, of which 56 (75%) were critically-ill. Baseline characteristics were similar between groups including median age 66.8 years, 49% male, 80% Caucasian. Forty-four (59%) patients underwent surgery, 23 (31%) required continuous renal replacement therapy, and 13 (17%) underwent extracorporeal membrane oxygenation. Incidence of HIT with any exposure to heparinoid product was 0.3% and 0.15% (p=0.002) in the pre-shortage and shortage periods, respectively. In those who received therapeutic dose unfractionated heparin, incidence of HIT was 1.26% and 1.05% (p=0.63) in the pre-shortage and shortage groups, respectively. Thrombotic complications were observed in 19 (41%) patients in the pre-shortage group and 11 (38%) in the post-shortage group (p=0.77). Bleeding events were observed in 8 (17%) and 5 (17%) (p=0.99). We observed a lower incidence of HIT resulting from our institution's efforts to conserve unfractionated heparin supply and utilize alternative anticoagulants during a critical national drug shortage. There were no significant differences in associated thrombotic and bleeding events. Disclosures Rosovsky: Bristol-Myers Squibb, Dova, Janssen, Portola: Consultancy; Bristol-Myers Squibb, Janssen: Research Funding.

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P1510INCIDENCE AND OUTCOME HEMODIALYSIS PATIENCE WITH HEPARIN INDUCED THROMBOCYTOPENIA - FOUR YEAR EXPERIENCE ZVEZDARA UNIVERSITY MEDICAL CENTER

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa142.p1510 ◽

2020 ◽

Vol 35 (Supplement_3) ◽

Author(s):

Ana Bulatovic ◽

Vesna Maslarevic Radovic ◽

Katarina Markovic ◽

Petar Djuric ◽

Jelena Tosic Dragovic ◽

...

Keyword(s):

Unfractionated Heparin ◽

Medical Center ◽

Hemodialysis Patients ◽

Elisa Test ◽

Platelet Factor ◽

Heparin Induced Thrombocytopenia ◽

Heparin Administration ◽

Alternative Anticoagulation ◽

Patients At Risk ◽

Clinical Scoring

Abstract Background and Aims Heparin-induced thrombocytopenia (HIT) is a potentially fatal adverse reaction after administration of unfractionated or fractionated heparin, which underlies the generation of antibodies to the heparin complex and platelet factor 4 (PF4). It occurs in 5% of patients treated with unfractionated heparin and 0.5 - 1.5% fractionated heparin. The aim of the study is to determine the incidence and outcome of hemodialysis patients with HIT over 4 years period. Method Our retrospective study analyzed patients who were tested for evidence of positive anti-heparin antibody in the period from 2015 to 2019 in Zvezdara University Medical Center. The diagnosis was confirmed by the 4T clinical scoring system, a positive antiheparin-PF4 ELISA test and a positive platelet aggregation test with heparin. Results During observation period, total of 54 tests were performed on HIT suspected patients, out of which 21 patients were positive. Out of them, 14 patients were on HD, and other 7 (geriatric, surgery and cardiology departments) received therapy due to peripheral thrombosis, AIM or arrhythmia. All patients treated at nephrology, started hemodialysis (HD) with unfractionated heparin, while others were treated with LMWH. 4T scoring showed that 64% of patients had a moderate risk of developing HIT, while high risk was assessed in 36% of patients. Thrombotic complications in the form of deep venous thrombosis had 50% of patients, pulmonary thromboembolism had 11% of patients. The greatest decrease in Tr was most commonly observed between 10th and 14th day (61% of patients) and 39% from 4th to 10th day from start of heparin administration. In addition to heparin withdrawal and treatment with alternative nonheparin anticoagulation (fondaparinoux), 5 patients needed plasma treatment. 11 patients on HD were transferred to peritoneal dialysis (PD), and 2 patients recovered renal function. Overall mortality was 52%, while in nephrology patients was below 30%. Conclusion HIT should be considered in patients at risk. It is necessary to abolish heparin treatment and use alternative method (PD) or alternative anticoagulation. Hemodialysis patients have better prognosis than other comparable patients.

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Cirrhosis, Thrombosis, Finding FaXts about Doses: Dosing of Unfractionated Heparin for Venous Thromboembolism in Cirrhosis

Annals of Pharmacotherapy ◽

10.1177/1060028019890028 ◽

2019 ◽

Vol 54 (5) ◽

pp. 450-456

Author(s):

Nicholas D. Franz ◽

Adamo Brancaccio ◽

Adam C. Robinson ◽

Randolph E. Regal

Keyword(s):

Venous Thromboembolism ◽

Unfractionated Heparin ◽

Medical Center ◽

Statistical Significance ◽

Severe Disease ◽

Academic Medical Center ◽

The United States ◽

Monitoring Methods ◽

Heparin Infusion ◽

Severe Cirrhosis

Background: Despite known disease-specific alterations to anti–factor Xa (AXA) levels, the physiological response of patients with cirrhosis to unfractionated heparin (UFH) infusions is not well established in clinical settings. Objective: The purpose of this study was to characterize the dosing and safety profile of UFH in patients with varying degrees of cirrhosis when treated for venous thromboembolism (VTE). Methods: This retrospective observational study was conducted at a single academic medical center in the United States. Patients with a diagnosis of cirrhosis who received UFH infusions for greater than 48 hours for treatment of VTE were included. Comparisons between heparin infusion rates, AXA levels, and safety outcomes based on severity of cirrhosis were made to define differences between those groups. Results: When compared by compensation status or by Child-Turcotte-Pugh (CTP) class, patients with more severe disease trended toward lower initial AXA levels on heparin initiation and higher heparin requirements to achieve therapeutic levels and were significantly less likely to achieve therapeutic levels than patients with less severe disease ( P = 0.001 for compensation, P = 0.017 for CTP). Additionally, bleeding rates were higher in patients with more severe disease, without reaching statistical significance. Conclusion and Relevance: Patients with severe cirrhosis required higher doses of heparin to achieve the same therapeutic AXA levels, but also tended to have higher rates of bleeding compared with less severe cirrhosis. These results represent further evidence of changes in heparin response as cirrhosis severity increases and may suggest that current monitoring methods are suboptimal in this patient population.

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Perinatal Mood and Anxiety Disorder Management in Multicenter Community Practices: Clinicians’ Training, Current Practices and Perceived Strategies to Improve Future Implementation

Journal of Primary Care & Community Health ◽

10.1177/2150132721996888 ◽

2021 ◽

Vol 12 ◽

pp. 215013272199688

Author(s):

Ajeng J. Puspitasari ◽

Dagoberto Heredia ◽

Elise Weber ◽

Hannah K Betcher ◽

Brandon J. Coombes ◽

...

Keyword(s):

Anxiety Disorder ◽

Health Services ◽

Behavioral Health ◽

Psychiatric Symptoms ◽

Medical Center ◽

Academic Medical Center ◽

Management Training ◽

The United States ◽

Behavioral Health Services ◽

Perinatal Women

Background: This study aimed to explore clinicians’ perspectives on the current practice of perinatal mood and anxiety disorder (PMAD) management and strategies to improve future implementation. Methods: This study had a cross-sectional, descriptive design. A 35-item electronic survey was sent to clinicians (N = 118) who treated perinatal women and practiced at several community clinics at an academic medical center in the United States. Results: Among clinicians who provided care for perinatal women, 34.7% reported never receiving PMAD management training and 66.3% had less than 10 years of experience. Out of 10 patients who reported psychiatric symptoms, 47.8% of clinicians on average reported providing PMAD management to 1 to 3 patients and 40.7% noted that they conducted screening only when patient expresses PMAD symptoms. Suggested future improvements were providing training, developing a referral list, and establishing integrated behavioral health services. Conclusions: Results from this study indicated that while PMAD screening and management was implemented, improvements are warranted to meet established guidelines. Additionally, clinicians endorsed providing PMAD management to a small percentage of perinatal patients. Suggested strategies to increase adoption and implementation of PMAD management should be explored to improve access to behavioral health services for perinatal women.

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Communications and Screening for 2019 Novel Coronavirus at a Tertiary-Care Medical Center

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.578 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s84-s84

Author(s):

Lorinda Sheeler ◽

Mary Kukla ◽

Oluchi Abosi ◽

Holly Meacham ◽

Stephanie Holley ◽

...

Keyword(s):

Screening Tool ◽

Medical Center ◽

Academic Medical Center ◽

Tertiary Care ◽

The United States ◽

World Health ◽

Communication Campaign ◽

Electronic Screening ◽

Novel Coronavirus ◽

The Impact

Background: In December of 2019, the World Health Organization reported a novel coronavirus (severe acute respiratory coronavirus virus 2 [SARS-CoV-2)]) causing severe respiratory illness originating in Wuhan, China. Since then, an increasing number of cases and the confirmation of human-to-human transmission has led to the need to develop a communication campaign at our institution. We describe the impact of the communication campaign on the number of calls received and describe patterns of calls during the early stages of our response to this emerging infection. Methods: The University of Iowa Hospitals & Clinics is an 811-bed academic medical center with >200 outpatient clinics. In response to the coronavirus disease 2019 (COVID-19) outbreak, we launched a communications campaign on January 17, 2020. Initial communications included email updates to staff and a dedicated COVID-19 webpage with up-to-date information. Subsequently, we developed an electronic screening tool to guide a risk assessment during patient check in. The screening tool identifies travel to China in the past 14 days and the presence of symptoms defined as fever >37.7°C plus cough or difficulty breathing. The screening tool was activated on January 24, 2020. In addition, university staff contacted each student whose primary residence record included Hubei Province, China. Students were provided with medical contact information, signs and symptoms to monitor for, and a thermometer. Results: During the first 5 days of the campaign, 3 calls were related to COVID-19. The number of calls increased to 18 in the 5 days following the implementation of the electronic screening tool. Of the 21 calls received to date, 8 calls (38%) were generated due to the electronic travel screen, 4 calls (19%) were due to a positive coronavirus result in a multiplex respiratory panel, 4 calls (19%) were related to provider assessment only (without an electronic screening trigger), and 2 calls (10%) sought additional information following the viewing of the web-based communication campaign. Moreover, 3 calls (14%) were for people without travel history but with respiratory symptoms and contact with a person with recent travel to China. Among those reporting symptoms after travel to China, mean time since arrival to the United States was 2.7 days (range, 0–11 days). Conclusion: The COVID-19 outbreak is evolving, and providing up to date information is challenging. Implementing an electronic screening tool helped providers assess patients and direct questions to infection prevention professionals. Analyzing the types of calls received helped tailor messaging to frontline staff.Funding: NoneDisclosures: None

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An innovative resident-driven mortality case review curriculum to teach and drive system-based practice improvements in the United States

Journal of Educational Evaluation for Health Professions ◽

10.3352/jeehp.2018.15.31 ◽

2018 ◽

Vol 15 ◽

pp. 31

Author(s):

Nila S. Radhakrishnan ◽

Margaret C. Lo ◽

Rohit Bishnoi ◽

Subhankar Samal ◽

Robert Leverence ◽

...

Keyword(s):

Quality Improvement ◽

Systems Of Care ◽

Medical Center ◽

Academic Medical Center ◽

Tertiary Care ◽

The United States ◽

Case Review ◽

Failure To Rescue ◽

Internal Medicine Residents ◽

Mortality Case

Purpose: Traditionally, the morbidity and mortality conference (M&MC) is a forum where possible medical errors are discussed. Although M&MCs can facilitate identification of opportunities for systemwide improvements, few studies have described their use for this purpose, particularly in residency training programs. This paper describes the use of M&MC case review as a quality improvement activity that teaches system-based practice and can engage residents in improving systems of care. Methods: Internal medicine residents at a tertiary care academic medical center reviewed 347 consecutive mortalities from March 2014 to September 2017. The residents used case review worksheets to categorize and track causes of mortality, and then debriefed with a faculty member. Selected cases were then presented at a larger interdepartmental meeting and action items were implemented. Descriptive statistics and thematic analysis were used to analyze the results. Results: The residents identified a possible diagnostic mismatch at some point from admission to death in 54.5% of cases (n= 189) and a possible need for improved management in 48.0% of cases. Three possible management failure themes were identified, including failure to plan, failure to communicate, and failure to rescue, which accounted for 21.9%, 10.7 %, and 10.1% of cases, respectively. Following these reviews, quality improvement initiatives proposed by residents led to system-based changes. Conclusion: A resident-driven mortality review curriculum can lead to improvements in systems of care. This novel type of curriculum can be used to teach system-based practice. The recruitment of teaching faculty with expertise in quality improvement and mortality case analyses is essential for such a project.

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Depression Screening and Measurement-Based Care in Primary Care

Journal of Primary Care & Community Health ◽

10.1177/2150132720931261 ◽

2020 ◽

Vol 11 ◽

pp. 215013272093126

Author(s):

Kimberly A. Siniscalchi ◽

Marion E. Broome ◽

Jason Fish ◽

Joseph Ventimiglia ◽

Julie Thompson ◽

...

Keyword(s):

Primary Care ◽

Task Force ◽

Medical Center ◽

Academic Medical Center ◽

Unmet Need ◽

The United States ◽

Depression Screening ◽

Improvement Project ◽

Measurement Based Care

The health issue addressed is the unmet need to universally screen and treat depression, which is one of the most common mental health disorders among adults in the United States. The US Preventive Services Task Force recommends screening adults for depression in primary care and using evidence-based protocols. This quality improvement project implemented VitalSign6, a measurement-based care program, to improve depression screening and treatment of adults in primary care at an academic medical center. A pre-post design was used to determine effectiveness of changes in screening, outcomes, and satisfaction. Of 1200 unique adult patients, 95.4% received initial screening. Providers diagnosed and administered measurement-based care to 236 patients. After 14 weeks, 27.5% returned for at least 1 follow-up. Results showed a statistically significant decrease in self-reported depression scores from baseline to follow-up. VitalSign6 was effective in improving identification and management of depression in primary care.

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Clinical Ordering Practices of the SARS-CoV-2 Antibody Test at a Large Academic Medical Center

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa406 ◽

2020 ◽

Vol 7 (10) ◽

Author(s):

Joesph R Wiencek ◽

Carter L Head ◽

Costi D Sifri ◽

Andrew S Parsons

Keyword(s):

United States ◽

Medical Center ◽

Academic Medical Center ◽

Antibody Test ◽

The United States ◽

Molecular Testing ◽

Antibody Testing ◽

Academic Medical ◽

Public Health Epidemiology ◽

Testing Costs

Abstract Background The novel severe acute respiratory coronavirus 2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19) originated in December 2019 and has now infected almost 5 million people in the United States. In the spring of 2020, private laboratories and some hospitals began antibody testing despite limited evidence-based guidance. Methods We conducted a retrospective chart review of patients who received SARS-CoV-2 antibody testing from May 14, 2020, to June 15, 2020, at a large academic medical center, 1 of the first in the United States to provide antibody testing capability to individual clinicians in order to identify clinician-described indications for antibody testing compared with current expert-based guidance from the Infectious Diseases Society of America (IDSA) and the Centers for Disease Control and Prevention (CDC). Results Of 444 individual antibody test results, the 2 most commonly described testing indications, apart from public health epidemiology studies (n = 223), were for patients with a now resolved COVID-19-compatible illness (n = 105) with no previous molecular testing and for asymptomatic patients believed to have had a past exposure to a person with COVID-19-compatible illness (n = 60). The rate of positive SARS-CoV-2 antibody testing among those indications consistent with current IDSA and CDC guidance was 17% compared with 5% (P < .0001) among those indications inconsistent with such guidance. Testing inconsistent with current expert-based guidance accounted for almost half of testing costs. Conclusions Our findings demonstrate a dissociation between clinician-described indications for testing and expert-based guidance and a significantly different rate of positive testing between these 2 groups. Clinical curiosity and patient preference appear to have played a significant role in testing decisions and substantially contributed to testing costs.

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Healthcare personnel absenteeism, presenteeism, and staffing challenges during epidemics

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.453 ◽

2020 ◽

pp. 1-4

Author(s):

Douglas W. Challener ◽

Laura E. Breeher ◽

JoEllen Frain ◽

Melanie D. Swift ◽

Pritish K. Tosh ◽

...

Keyword(s):

Seasonal Influenza ◽

Medical Center ◽

Academic Medical Center ◽

The United States ◽

Healthcare Personnel ◽

Linear Regression Models ◽

Influenza Like Illness ◽

Healthcare Workforce ◽

Academic Medical ◽

Hourly Employees

Abstract: Objective: Presenteeism is an expensive and challenging problem in the healthcare industry. In anticipation of the staffing challenges expected with the COVID-19 pandemic, we examined a decade of payroll data for a healthcare workforce. We aimed to determine the effect of seasonal influenza-like illness (ILI) on absences to support COVID-19 staffing plans. Design: Retrospective cohort study. Setting: Large academic medical center in the United States. Participants: Employees of the academic medical center who were on payroll between the years of 2009 and 2019. Methods: Biweekly institutional payroll data was evaluated for unscheduled absences as a marker for acute illness-related work absences. Linear regression models, stratified by payroll status (salaried vs hourly employees) were developed for unscheduled absences as a function of local ILI. Results: Both hours worked and unscheduled absences were significantly related to the community prevalence of influenza-like illness in our cohort. These effects were stronger in hourly employees. Conclusions: Organizations should target their messaging at encouraging salaried staff to stay home when ill.

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Shed-MEDS: pilot of a patient-centered deprescribing framework reduces medications in hospitalized older adults being transferred to inpatient postacute care

Therapeutic Advances in Drug Safety ◽

10.1177/2042098618781524 ◽

2018 ◽

Vol 9 (9) ◽

pp. 523-533 ◽

Cited By ~ 9

Author(s):

Alec W. Petersen ◽

Avantika S. Shah ◽

Sandra F. Simmons ◽

Matthew S. Shotwell ◽

J. Mary Lou Jacobsen ◽

...

Keyword(s):

Older Adults ◽

Usual Care ◽

Medical Center ◽

Academic Medical Center ◽

The United States ◽

Patient Centered ◽

Convenience Sample ◽

Point Reduction ◽

Significant Difference ◽

Hospitalized Older Adults

Background: Polypharmacy is common in hospitalized older adults. Deprescribing interventions are not well described in the acute-care setting. The objective of this study was to describe a hospital-based, patient-centered deprescribing protocol (Shed-MEDS) and report pilot results. Methods: This was a pilot study set in one academic medical center in the United States. Participants consisted of a convenience sample of 40 Medicare-eligible, hospitalized patients with at least five prescribed medications. A deprescribing protocol (Shed-MEDS) was implemented among 20 intervention and 20 usual care control patients during their hospital stay. The primary outcome was the total number of medications deprescribed from hospital enrollment. Deprescribed was defined as medication termination or dose reduction. Enrollment medications reflected all prehospital medications and active in-hospital medications. Baseline characteristics and outcomes were compared between the intervention and usual care groups using simple logistic or linear regression for categorical and continuous measures, respectively. Results: There was no significant difference between groups in mean age, sex or Charlson comorbidity index. The intervention and control groups had a comparable number of medications at enrollment, 25.2 (±6.3) and 23.4 (±3.8), respectively. The number of prehospital medications in each group was 13.3 (±4.6) and 15.3 (±4.6), respectively. The Shed-MEDS protocol compared with usual care significantly increased the mean number of deprescribed medications at hospital discharge and reduced the total medication burden by 11.6 versus 9.1 ( p = 0.032) medications. The deprescribing intervention was associated with a difference of 4.6 [95% confidence interval (CI) 2.5–6.7, p < 0.001] in deprescribed medications and a 0.5 point reduction (95% CI −0.01 to 1.1) in the drug burden index. Conclusions: A hospital-based, patient-centered deprescribing intervention is feasible and may reduce the medication burden in older adults.

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Rapid implementation of outpatient teleneurology in rural Appalachia: barriers and disparities

Neurology Clinical Practice ◽

10.1212/cpj.0000000000000906 ◽

2020 ◽

pp. 10.1212/CPJ.0000000000000906 ◽

Cited By ~ 2

Author(s):

Roy E. Strowd ◽

Lauren Strauss ◽

Rachel Graham ◽

Kristen Dodenhoff ◽

Allysen Schreiber ◽

...

Keyword(s):

Rural Communities ◽

Urban Communities ◽

Medical Center ◽

Academic Medical Center ◽

The United States ◽

Urban Status ◽

Rural And Urban ◽

Academic Medical ◽

Black Patients ◽

Rural Appalachia

ABSTRACTObjective:To describe rapid implementation of telehealth during the COVID-19 pandemic and assess for disparities in video visit implementation in the Appalachian region of the United States.Methods:A retrospective cohort of consecutive patients seen in the first four weeks of telehealth implementation was identified from the Neurology Ambulatory Practice at a large academic medical center. Telehealth visits defaulted to video and when unable phone-only visits were scheduled. Patients were divided into two groups based on the telehealth visit type: video or phone-only. Clinical variables were collected from the electronic medical record including age, sex, race, insurance status, indication for visit, and rural-urban status. Barriers to scheduling video visits were collected at the time of scheduling. Patient satisfaction was obtained by structured post-visit telephone call.Results:Of 1011 telehealth patient-visits, 44% were video and 56% phone-only. Patients who completed a video visit were younger (39.7 vs 48.4 years, p<0.001), more likely to be female (63% vs 55%, p<0.007), be White or Caucasian (p=0.024), and not have Medicare or Medicaid insurance (p<0.001). The most common barrier to scheduling video visits was technology limitations (46%). While patients from rural and urban communities were equally likely to be scheduled for video visits, patients from rural communities were more likely to consider future telehealth visits (55% vs 42%, p=0.05).Conclusion:Rapid implementation of ambulatory telemedicine defaulting to video visits successfully expanded video telehealth. Emerging disparities were revealed, as older, male, black patients with Medicare or Medicaid insurance were less likely to adopt video visits.

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