Use of Anticoagulants Remains a Significant Threat to Timely Hip Fracture Surgery

Abstract

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.

Platelet Aggregation Inhibitors and Anticoagulants Delay Surgery for Hip Fractures

“…Several other recent studies identified approximately 9-16.6% of hip fracture patients to be anticoagulated. However, the absolute number of DOACs cases was relatively low [17][18][19][20]. In our study 9.9% were anticoagulated.…”

“…Several studies found both vitamin K antagonists and DOACs delayed emergency surgery [17][18][19][20]. Patients on DOACs had similar perioperative hemoglobin change, transfusion rates and mortality compared to subjects without anticoagulants in both trochanteric -internal fixation and femoral neck -arthroplasty situations [19][20][21][22]. For DOACs surgery should therefore be reasonably delayed, until reversal agents become available [5,6].…”

Early Surgical Fixation for Hip Fractures in Patients Taking Direct Oral Anticoagulation: A Retrospective Cohort Study

“…Such findings have been reproduced multiple times within the literature. 9,20,21 Three recent retrospective studies have addressed preoperative DOAC use and early hip fracture surgery. Nineteen hip fracture patients taking DOACs and receiving surgery within 48 hours were compared to a non-DOAC case-matched control.…”

“…Average time to surgery for DOAC patients has been shown to vary from 35 hours to 66.9 hours. 9,20,21 Three recent studies have investigated the outcomes of hip fracture surgery within 48 hours in patients taking DOACs. [22][23][24] All found no difference in perioperative blood loss; however, Schuetze et al 23 found patients taking DOAC medication prior to surgery had a 3.4-fold increase in intraoperative transfusion.…”

“…Average time to surgery for DOAC patients has been shown to vary from 35 hours to 66.9 hours. 9 , 20 , 21 …”