Introduction:Hip fracture remains the biggest single source of morbidity and mortality in the elderly trauma population, and any intervention focused on quality improvement and system efficiency is beneficial for both patients and clinicians. Two of the variables contributory to improving care and efficiency are time to theater and length of stay, with the overall goal being to improve care as reflected within the achievement of best practice tariff. One of the biggest barriers to optimizing these variables is preinjury anticoagulation.Method:Building on our previous work with warfarin in this population, we utilized a regional hip fracture collaborative network collecting prospective data through the National Hip Fracture Database with custom fields pertaining to all agents, including novel oral anticoagulants.Results:In all, 1965 hip fracture patients median age 83 years (1639 not anticoagulated) were admitted to the 5 centers over 12 months. Median length of stay was 20.71 days; time to theater 23.09 hours, and the populations (anticoagulated vs control) were evenly matched for injury. Anticoagulated patients were delayed to theater (P ≤ .001), were inpatients for longer (P ≤ .001) and gained less best practice tariff (P ≤ .05). All variables per agent were noted and the impact of each assessed.Conclusions:Despite the widespread use of newer anticoagulants, popular due to unmonitored reversal and administration, patients stay longer in hospital and wait longer for surgery than nonanticoagulated patients of the same age and injury. Contemporary perioperative practices impact negatively on the ability to perform timely surgery on hip fracture patients. We propose a guideline specific to the management of anticoagulation in the hip fracture population to aid the optimum preparation of patients for theater, achievement of timely surgery, and potentially reduce length of stay.

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Anticoagulation reversal is a common cause of operative delay. We sought to establish for the first time the impact this has on best practice tariff (BPT) for patients with hip fracture admitted on warfarin. All patients with hip fracture treated operatively over a 32-month period were reviewed. Basic demographics, time to theater, length of stay, and mortality were recorded for all patients. Independent samples t-tests were used to identify statistically significant differences between patients on warfarin and those not taking the drug. A total of 83 patients were admitted anticoagulated with a mean international normalized ratio of 2.65 and a median time to theater of 49.7 hours. Of these patients, 79% breached BPT, incurring significant financial loss. In the control group, 908 patients took a median 24.5 hours, a 28% breach of BPT (P < .01). Length of stay, Nottingham Hip Fracture Score, and predicted 30-day mortality were similar for both the groups. As well as affecting clinical outcome following hip fracture, delay due to anticoagulation causes considerable loss of BPT. Potential loss of revenue due to delays over the study period was £80 000, inspiring the establishment of an ''early trigger'' anticoagulation protocol. Although it is accepted that there are limitations to this work, it should raise awareness of the real impact of warfarin on patients with hip fracture both in terms of outcome and for the first time, loss of potential revenue.

Best practice tariff (BPT) was introduced as a financial incentive model to improve compliance with evidence-based care, such as operation for hip fracture within 36 hours of admission. We previously evaluated the impact of warfarin on patients with hip fracture, revealing significant delay to operation and subsequent loss of revenue. As a result of this, an “early trigger” intravenous vitamin K (IVK) pathway was introduced and the service reaudited a year later. The first cycle was a retrospective audit of all cases with hip fracture against BPT standards over a 32-month period. Subsequent protocol change resulted in all warfarinised cases being given 2 mg IVK in the emergency department prior to blood testing. This protocol was reaudited against the same BPT standards 12 months later. An intention-to-treat approach was used, despite breaches of protocol and other reasons for patients not progressing to theater. The data were analyzed with parametric tools to establish true clinical and statistical impact of the introduction of the protocol. In the first cycle, 80 patients were admitted on warfarin with a mean time to theater of 53.71 hours. Of these patients, 79% breached BPT due to anticoagulation. Twelve months following protocol introduction, 42 patients had a mean time to theater of 37.61 hours. Of these patients, 34% breached BPT due to anticoagulation. These data are both clinically and statistically significant (P < .001). No adverse events occurred. We have shown for the first time that “early-trigger” IVK can reduce delay to theater and maximize tariff payments in warfarinised patients with hip fracture. This is in addition to other established benefits associated with early surgery such as decreasing risk of pressure lesions and pneumonia. It affords high-quality patient-centered care while ensuring trauma units achieve maximal financial reimbursement through pay for improved performance and supports a culture of change behavior.

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