Abstract：
BACKGROUND: Approximately 20 % of femoral fragility fracture patients take anticoagulants, typically warfarin or Direct Oral AntiCoagulant (DOAC). These can impact timing of surgery affecting patient survival. Due to several possible approaches and numerous factors to consider in the preoperative workup of anticoagulated patients, potential for variations in clinical practice exist. Some hospitals employ dedicated anticoagulation management protocols to address this issue, and to improve time to surgery. This study aimed to determine the proportion of hospitals with such protocols, compare protocol guidance between hospitals, and evaluate the effectiveness of protocols in facilitating prompt surgery.
METHODS: Data was prospectively collected through a collaborative, multicentre approach involving hospitals across the UK. Femoral fragility fracture patients aged ≥60 years and admitted to hospital between 1st May to 31st July 2023 were included. Information from dedicated anticoagulation management protocols were collated on several domains relating to perioperative care including administration of reversal agents and instructions on timing of surgery as well as others. Logistic regression was used to evaluate effects of dedicated protocols on time to surgery.
RESULTS: Dedicated protocols for management of patients taking warfarin and DOACs were present at 41 (52.6 %) and 43 (55.1 %) hospitals respectively. For patients taking warfarin, 39/41 (95.1 %) protocols specified the dose of vitamin k and the most common was 5 milligrams intravenously (n=21). INR threshold values for proceeding to surgery varied between protocols; 1.5 (n=28), 1.8 (n=6), and 2 (n=6). For patients taking DOACs, 35/43 (81.4 %) and 8/43 (18.6 %) protocols advised timing of surgery based on renal function and absolute time from last dose respectively. Analysis of 10,197 patients from 78 hospitals showed fewer patients taking DOACs received surgery within 36 h of admission at hospitals with a dedicated protocol compared to those without (adjusted OR 0.73, 95% CI 0.54-0.99, p=0.040), while there were no differences among patients taking warfarin (adjusted OR 1.64, 95% CI 0.75-3.57, p=0.219).
CONCLUSIONS: Around half of hospitals employed a dedicated anticoagulation management protocol for femoral fragility fracture patients, and substantial variation was observed in guidance between protocols. Dedicated protocols currently being used at hospitals were ineffective at improving the defined targets for time to surgery.
METHODS: Data was prospectively collected through a collaborative, multicentre approach involving hospitals across the UK. Femoral fragility fracture patients aged ≥60 years and admitted to hospital between 1st May to 31st July 2023 were included. Information from dedicated anticoagulation management protocols were collated on several domains relating to perioperative care including administration of reversal agents and instructions on timing of surgery as well as others. Logistic regression was used to evaluate effects of dedicated protocols on time to surgery.
RESULTS: Dedicated protocols for management of patients taking warfarin and DOACs were present at 41 (52.6 %) and 43 (55.1 %) hospitals respectively. For patients taking warfarin, 39/41 (95.1 %) protocols specified the dose of vitamin k and the most common was 5 milligrams intravenously (n=21). INR threshold values for proceeding to surgery varied between protocols; 1.5 (n=28), 1.8 (n=6), and 2 (n=6). For patients taking DOACs, 35/43 (81.4 %) and 8/43 (18.6 %) protocols advised timing of surgery based on renal function and absolute time from last dose respectively. Analysis of 10,197 patients from 78 hospitals showed fewer patients taking DOACs received surgery within 36 h of admission at hospitals with a dedicated protocol compared to those without (adjusted OR 0.73, 95% CI 0.54-0.99, p=0.040), while there were no differences among patients taking warfarin (adjusted OR 1.64, 95% CI 0.75-3.57, p=0.219).
CONCLUSIONS: Around half of hospitals employed a dedicated anticoagulation management protocol for femoral fragility fracture patients, and substantial variation was observed in guidance between protocols. Dedicated protocols currently being used at hospitals were ineffective at improving the defined targets for time to surgery.
摘要：
背景：大约20%的股骨脆性骨折患者服用抗凝剂，通常是华法林或直接口服抗凝剂（DOAC）。这些可以影响影响患者生存的手术时机。由于在抗凝患者的术前检查中需要考虑几种可能的方法和众多因素，临床实践中存在潜在的变化。一些医院采用专门的抗凝管理方案来解决这个问题，并改善手术时间。本研究旨在确定采用此类协议的医院比例，比较医院之间的协议指导，并评估协议在促进及时手术中的有效性。
方法：数据是通过合作收集的，涉及英国各地医院的多中心方法。纳入年龄≥60岁并在2023年5月1日至7月31日期间入院的股骨脆性骨折患者。从专门的抗凝管理方案中收集了与围手术期护理相关的几个领域的信息，包括逆转剂的施用和手术时机的说明以及其他方面。使用Logistic回归评估专用方案对手术时间的影响。
结果：41家（52.6%）和43家（55.1%）医院分别采用了治疗服用华法林和DOAC的患者的专用方案。对于服用华法林的患者，39/41（95.1％）方案指定了维生素k的剂量，最常见的是静脉内5毫克（n=21）。进行手术的INR阈值在方案之间有所不同；1.5(n=28)，1.8（n=6），2（n=6）。对于服用DOAC的患者，35/43（81.4％）和8/43（18.6％）的方案分别根据肾功能和从最后一次给药的绝对时间建议手术时机。对来自78家医院的10,197名患者的分析显示，与没有接受DOAC的患者相比，在有专门方案的医院入院后36小时内接受手术的患者较少（调整后的OR0.73，95％CI0.54-0.99，p=0.040）。而服用华法林的患者之间没有差异（校正OR1.64，95％CI0.75-3.57，p=0.219）。
结论：大约一半的医院对股骨脆性骨折患者采用了专门的抗凝治疗方案，并且在协议之间的指导中观察到实质性差异。目前在医院使用的专用协议在改善手术时间的定义目标方面无效。
方法：数据是通过合作收集的，涉及英国各地医院的多中心方法。纳入年龄≥60岁并在2023年5月1日至7月31日期间入院的股骨脆性骨折患者。从专门的抗凝管理方案中收集了与围手术期护理相关的几个领域的信息，包括逆转剂的施用和手术时机的说明以及其他方面。使用Logistic回归评估专用方案对手术时间的影响。
结果：41家（52.6%）和43家（55.1%）医院分别采用了治疗服用华法林和DOAC的患者的专用方案。对于服用华法林的患者，39/41（95.1％）方案指定了维生素k的剂量，最常见的是静脉内5毫克（n=21）。进行手术的INR阈值在方案之间有所不同；1.5(n=28)，1.8（n=6），2（n=6）。对于服用DOAC的患者，35/43（81.4％）和8/43（18.6％）的方案分别根据肾功能和从最后一次给药的绝对时间建议手术时机。对来自78家医院的10,197名患者的分析显示，与没有接受DOAC的患者相比，在有专门方案的医院入院后36小时内接受手术的患者较少（调整后的OR0.73，95％CI0.54-0.99，p=0.040）。而服用华法林的患者之间没有差异（校正OR1.64，95％CI0.75-3.57，p=0.219）。
结论：大约一半的医院对股骨脆性骨折患者采用了专门的抗凝治疗方案，并且在协议之间的指导中观察到实质性差异。目前在医院使用的专用协议在改善手术时间的定义目标方面无效。
