Effectiveness of a Clinical Decision Support System for Reducing the Risk of QT Interval Prolongation in Hospitalized Patients

Abstract

Background We evaluated the effectiveness of a computer clinical decision support system (CDSS) for reducing the risk of QT interval prolongation in hospitalized patients. Methods and Results We evaluated 2400 patients admitted to cardiac care units at an urban academic medical center. A CDSS incorporating a validated risk score for QTc prolongation was developed and implemented using information extracted from patients’ electronic medical records. When a drug associated with torsades de pointes was prescribed to a patient at moderate or high risk for QTc interval prolongation, a computer alert appeared on the screen to the pharmacist entering the order, who could then consult the prescriber on alternative therapies and implement more intensive monitoring. QTc interval prolongation was defined as QTc interval >500 ms or increase in QTc of ≥60 ms from baseline; for patients who presented with QTc >500 ms, QTc prolongation was defined solely as increase in QTc ≥ 60 ms from baseline. End points were assessed before (n=1200) and after (n=1200) implementation of the CDSS. CDSS implementation was independently associated with a reduced risk of QTc prolongation (adjusted odds ratio, 0.65; 95% confidence interval, 0.56–0.89; P<0.0001). Furthermore, CDSS implementation reduced the prescribing of noncardiac medications known to cause torsades de pointes, including fluoroquinolones and intravenous haloperidol (adjusted odds ratio, 0.79; 95% confidence interval, 0.63–0.91; P=0.03). Conclusions A computer CDSS incorporating a validated risk score for QTc prolongation influences the prescribing of QT-prolonging drugs and reduces the risk of QTc interval prolongation in hospitalized patients with torsades de pointes risk factors.

Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association

“…Haugaa et al 497 evaluated an institutionwide (n=1145) QT alert sys tem that identified ECGs with QTc ≥0.50 seconds, with a "semiurgent" email alert to the prescriber. Tisdale et al 498 evaluated a computerized clinical decision sup port system incorporating a validated risk score for QTc prolongation to alert pharmacists when a QTprolong ing cardiac medication was prescribed for cardiac unit inpatients (n=2400) and found a significantly reduced risk of QTc prolongation and decreased prescribing of noncardiac medications known to cause TdP, including fluoroquinolones and intravenous haloperidol. 498 In a quasiexperimental study of 4011 patients re ceiving electrocardiographic monitoring in 10 hospitals, Sandau and colleagues 464 tested a 3part intervention of online education for nurses, electronic notifications to alert nurses when a patient received QTprolonging medication, and computerized calculation of QTc in the electronic health record.…”

“…Tisdale et al 498 evaluated a computerized clinical decision sup port system incorporating a validated risk score for QTc prolongation to alert pharmacists when a QTprolong ing cardiac medication was prescribed for cardiac unit inpatients (n=2400) and found a significantly reduced risk of QTc prolongation and decreased prescribing of noncardiac medications known to cause TdP, including fluoroquinolones and intravenous haloperidol. 498 In a quasiexperimental study of 4011 patients re ceiving electrocardiographic monitoring in 10 hospitals, Sandau and colleagues 464 tested a 3part intervention of online education for nurses, electronic notifications to alert nurses when a patient received QTprolonging medication, and computerized calculation of QTc in the electronic health record. They found that appropriate QTc documentation increased significantly from baseline (17.3%) to 3 months after intervention (58.2%), with a further increase by 6 months after intervention (62.1%), demonstrating that improvements persisted over time.…”

Impact of Pharmacist Intervention on Electrocardiogram Monitoring of Pediatric Patients on Multiple QTc Interval–Prolonging Medications

“…Clinical decision-support tools utilizing the electronic medical record, such as this one, have been found to reduce the risk of QTc interval prolongation secondary to medications in adult patients. 20 Even though it is not yet validated for pediatric use, this type of patient surveillance system could improve monitoring and patient safety without significantly increasing the burden on the health care team.…”

Cardiovascular safety of prokinetic agents: A focus on drug‐induced arrhythmias

“…Examples from several institutions, including our own, have demonstrated that the implementation of CDSS that utilizes validated “QTc risk” scorecards 8,106 composed of independent QTc prolongation risk factors including those listed in Table 1 to identify individuals at highest risk for DI-LQTS/TdP can reduce the inappropriate prescribing of medications with high risk of QTc prolongation and the overall incidence of DI-LQTS. 107,108 However, similar to FDA “black box” warnings, electronic, institution-wide, CDSS-triggered QTc, and drug-drug interaction alerts can still be ignored and/or misinterpreted by healthcare providers. 109 Nevertheless, in most circumstances, DI-LQTS/TdP risk can be identified and mitigated without the use of CDSS by being hypervigilant to the presence of multiple patient-specific and drug-specific risk factors when determining when and what dose of a prokinetic agent (with known hERG/K v 11.1 blocking potential) to prescribe.…”