A New Local Guideline for Hip Fracture Patients Taking Direct Oral Anticoagulants (DOACs)

Mohammed As-Sultany, Janice Armour, Jennifer Bowden, Rosemary Finley, Nigel J Donnachie

Background: Deciding when to safely operate on hip fracture patients taking DOACs is a challenge. The aim of this unique audit was to assess the safety of a new local guideline implemented in a busy district general hospital.

Methods: A retrospective review of all hip fracture patients taking DOACs during 2016 (Group 1) was carried out. Following presentation of the results, the new local guideline was introduced in August 2017. The recommended timing of surgery for each patient was based on the type of DOAC taken, the time of the last dose and the creatinine clearance on admission. A prospective audit following the implementation of the guideline was carried out between August 2017 and May 2018 (Group 2). Statistical analysis comparing both groups was carried out using the Student’s t-test and Fisher’s exact test, with a p-value of <0.05 indicating statistical significance.

Results: There were 33 patients in Group 1 and 48 patients in Group 2. They shared similar demographic data with the commonest DOAC being Apixaban taken mainly for atrial fibrillation. Group 2 showed that there was an 82% increase (p = 0.02) in the number of patients having surgery within the recommended best-tariff practice (BTP) of 36hrs. There was no statistical difference found in the amount of post-operative haemoglobin concentration drop (p=0.34) or the number of post-operative RBC transfusions (p=0.16) between the two groups. There was no increase risk in the number of re-operations due to wound problems or infections. There was no increase in mortality at 30 days (p=0.64), 3 months (p=0.34) or 1 year (p=1). The average total length of inpatient stay was comparable between the two groups (p=0.42).

Conclusions: Early results of this new guideline have shown that hip fracture patients taking DOACs could safely have surgery within the recommended timeframe.