Background: Warfarin reversal is typically sought prior to surgery for geriatric hip fractures; however, patients often proceed to surgery with partial warfarin reversal. The effect of partial reversal (defined as having an international normalized ratio [INR] > 1.5) remains unclear. Methods: This was a retrospective cohort study. Geriatric patients (65 y/o) admitted to six level I trauma centers from 01/2014-01/2018 with isolated hip fractures requiring surgery who were taking warfarin pre-injury were included. Warfarin reversal methods included: vitamin K, factor VIIa, (a)PCC, fresh frozen plasma (FFP), and the "wait and watch" method. An INR of 1.5 defined complete reversal. The primary outcome was the volume of blood loss during surgery; other outcomes included packed red blood cell (pRBC) and FFP transfusions, and time to surgery. Results: There were 135 patients, 44% partially reversed and 56% completely reversed. The median volume of blood loss was 100 mL for both those completely and partially reversed, p ¼ 0.72. There was no difference in the proportion of patients with blood loss by study arm, 95% vs. 95%, p > 0.99. Twenty-five percent of those completely reversed and 39% of those partially reversed had pRBCs transfused, p ¼ 0.08. Of those completely reversed 5% received an FFP transfusion compared to 14% of those partially reversed, p ¼ 0.09. There were no statistically significant differences observed for the volume of pRBC or FFP transfused, or for time to surgery.

Background: Studies have demonstrated that the risk of warfarin-related complications is highest in the first 90 days of treatment, while quality audits suggest that warfarin initiation protocols are not always adhered to. Aim: To improve the quality of anticoagulation for hospital patients initiated on warfarin. Method: A warfarin drug chart, incorporating the hospital's warfarin initiation protocol, was implemented on four target medical and cardiothoracic wards. The chart was used to record international normalised ratios (INRs) and prescribe warfarin, and was faxed to the patient's GP on discharge. Warfarin initiations on the target wards immediately postintroduction of the warfarin drug chart were reviewed and compared to the pre-intervention data collected over a 17-month period. Results: The pre-intervention and post-intervention groups included 271 and 183 patients initiated on warfarin, respectively. The intervention was associated with fewer warfarin-related complications (thromboembolism, major bleeding) occurring within a 90-day follow-up period (2.1% vs 11%; adjusted OR 0.24; 95%CI 0.07-0.85; p = 0.03), largely driven by a reduction in the incidence of major bleeding (0.7% vs 7.1%; adjusted OR 0.17; 95%CI 0.02-1.45; p = 0.05). Adherence to the warfarin initiation protocol improved significantly from 36% to 71% (p < 0.01) in the pre-and post-intervention data collection periods, respectively. Post-intervention, the proportion of patients with an INR > 4 and the proportion of patients who required a warfarin dose to be withheld was reduced from 8.5% and 13%, to 3.8% (p < 0.05) and 6.6% (p = 0.02), respectively. Conclusion: Adherence to an age and disease based warfarin initiation protocol, and improving the quality of discharge information for patients initiated on warfarin, significantly improved patient outcomes. J Pharm Pract Res 2007; 37: 295-7, 300-2.

Background Reversal of direct oral anticoagulants (DOACs) is currently recommended prior to emergent surgery, such as surgical intervention for traumatic geriatric hip fractures. However, reversal methods are expensive and timely, often delaying surgical intervention, which is a predictor of outcomes. The study objective was to examine the effect of DOAC reversal on blood loss and transfusions among geriatric patients with hip fractures. Methods This retrospective propensity-matched study across six level I trauma centers included geriatric patients on DOACs with isolated fragility hip fractures requiring surgical intervention (2014–2017). Outcomes included: intraoperative blood loss, intraoperative pRBCs, and hospital length of stay (HLOS). Results After matching there were 62 patients (31 reversed, 31 not reversed), 29 patients were not matched. The only reversal method utilized was passive reversal (waiting ≥ 24 hours for elimination). Passively reversed patients had a longer time to surgery (mean, 43 vs. 18 hours, p < 0.01). Most patients (92%) had blood loss (90% passively reversed, 94% not reversed); the median volume of blood loss was 100 mL for both those groups, p = 0.97. Thirteen percent had pRBCs transfused (13% passively reversed and 13% not reversed); the median volume of pRBCs transfused was 525 mL for those passively reversed and 314 mL for those not reversed, p = 0.52. The mean HLOS was significantly longer for those passively reversed (7 vs. 5 days, p = 0.001). Conclusions Passive DOAC reversal for geriatric patients with isolated hip fracture requiring surgery may be contributing to delayed surgery and an increased HLOS without having a significant effect on blood loss or transfusions. These data suggest that passive DOAC reversal may not be necessary prior to surgical repair of isolated hip fracture.