Reducing delays to surgery and achieving best practice tariff for hip fracture patients on direct oral anticoagulants: a protocol for expediting surgery without increasing peri-operative complications

Background: Patients who sustain a hip fracture whilst taking direct oral anticoagulants (DOACs) experience delays to surgery, which can increase morbidity and mortality. Achievement of the prompt surgery aspect of the National Hip Fracture Database (NHFD) best practice tariff (BPT) stipulates surgery within 36 h, which these patients often fail to meet. Patients and methods: Our protocol for expedited hip fracture surgery in patients taking DOACs was implemented. We compared surgery within 36 h (primary outcome) and peri-operative blood transfusions, 30-day mortality, wound leakage, return to theatre and length of hospital stay (secondary outcomes) with standard care of 80 matched non-anticoagulated controls. Results: Median times to theatre were 26.0 h (IQR 16.2 h) in DOAC patients and 22.4 h (IQR 16.9 h) in controls: bootstrapped 95% CI for the difference (−0.935, 7.52). Bias-corrected related samples bootstrapped t-test revealed no evidence for a group difference on the primary outcome (p = 0.133) or any secondary outcome, including post-operative transfusions (χ ² ₍₁₎= 0.533; p = 0.465, 95% CI for the difference −18.3% to 8.37%); death within 30 days (χ ² ₍₁₎= 0.667; p = 0.414, 95% CI for the difference −3.48% to 8.48%); wound leakage (χ ² ₍₁₎= 0.571; p = 0.450, 95% CI −1.79% to 0.792%); return to theatre (χ ² ₍₁₎= 0.00; p = 1.00); and median length of hospital stay (p = 0.678, bias-corrected bootstrapped 95% CI for the difference −4.47 to 6.68). Discussion: Our protocol is simple, does not require plasma DOAC level testing and can be used to achieve the NHFD recommendation of surgery within 36 h without increasing peri-operative transfusions, wound leakage, return to theatre, length of stay or mortality.