Dissemination and Implementation of QT Risk Clinical Decision Support

Torsades des Pointes (TdP) is a life-threatening, uncommon cardiac arrhythmia, characterized by a prolonged heart rate-corrected QT interval (QTc) noted on an electrocardiogram (ECG). Risk factors for TdP include heart failure, advanced age, female sex, electrolyte imbalances, and certain medications. Over 150 prescribed medications can prolong QTc intervals. For someone with a TdP risk factor, taking a QTc interval-prolonging medication can have significant consequences, including death. Mitigating the risk of TdP can be a challenge for healthcare providers, as there is a lack of knowledge of TdP, its risk factors, and the significance of the QT interval. The use of a clinical decision support (CDS) tool could help providers identify those patients at risk for developing cardiac arrhythmias that could lead to TdP.

This research developed and disseminated CDS that incorporates an adapted cardiac QTc risk score (QTc-RS) to identify patients at risk of increased QTc intervals and subsequent TdP. A continuing medical education program was developed and made available online to educate clinicians and pharmacists on TdP, QTc, and management of patients at risk. Finally, the use of the CDS and impact was evaluated.

The specific aims of the research were as follows:

• Adapt, implement, and distribute a QTc-RS CDS in urban and rural inpatient care facilities across varying acuity levels.
• Develop and deliver an educational program on QTc interval prolongation, TdP, and the QTc-RS to inpatient healthcare providers.
• Evaluate the effectiveness of a QTc-RS CDS with respect to process changes within facilities, patient-focused clinical outcomes, and end-user satisfaction.

The CDS was incorporated as an advisory into an existing medication alert system in a commercial electronic health record at Banner Health in their 30 hospitals in 6 western States. The existing system alerts ordering providers about medications with a known risk of TdP. If the order is continued, the advisory appears with the patient’s QT risk score; factors contributing to the score; options to order routine or stat ECG, or electrolyte replacement protocols if indicated; and an ability to cancel the medication being ordered or existing medications known to have a risk of TdP. Over 8 months, nearly 8,000 risk advisories were displayed, most often because of antibiotics. From these, at least one action was taken 34.6 percent of the time, most commonly an order for a routine ECG. Mortality rates were lower in the post-implementation group compared to the pre-implementation group.

Education programs were conducted in person at 11 acute care facilities within the healthcare system across three States. Assessments showed that participants improved their ability to identify and measure QTc intervals and to manage patients with prolonged QTc interval. Education materials were made available online and used by over 2,000 people.

A satisfaction survey showed that clinicians agreed that the information in the advisory was correct, potential next actions were clearly specified, and the advisory was placed in a good place in their workflow. Nearly half, however, felt that the advisory appeared too often, and one third indicated the advisory had not applied to their patient.

This research showed that decision support tools placed appropriately within a provider’s workflow is accepted by clinicians and acted upon. Targeted education programs do improve comfort with identification management of prologue QTc intervals. Addition research will need to be done to address issues of over alerting and applicability.