A restrictive policy for red blood cell transfusion in older hip fracture patients: experiences from a patient register.

BACKGROUND: Allogeneic red blood cell transfusions (ABT) are common in older hip fracture patients. Recent research supports a restrictive transfusion policy. The aim was to study variation in hemoglobin (Hb) concentration, and clinical outcomes in these patients. RESULTS: Cross-sectional study with one-year follow-up in an orthogeriatric unit. Data were obtained from a quality register with demographic and medical information collected by an interdisciplinary team. 106 (22 %) of the 491 patients admitted from September 2011 throughout September 2012 (76 % women, mean age 85 years) received ABT. When given ABT, 80 % had Hb <80 g/l and mean Hb was 78 g/l. Mean Hb, regardless ABT, showed variation from 125 g/l (±16) on admission to 106 g/l (±17), 101 g/l (±16) and 102 g/l (±14) on 1st, 3rd and 5th postoperative day respectively. Patients with per-/subtrochanteric fractures more often received ABT than those with femur neck fractures (p < 0.001), 70 % of the patients receiving ABT had a per-/subtrochanteric fracture. Patients who received ABT were older, had more chronic diseases and lower mean Hb throughout the hospital stay. Length of stay was longer (median 7 vs. 6 days, p = 0.01), and medical complications more common. In-hospital and 30-day mortalities were similar in patients given ABT and in those who were not, but 1-year mortality was higher among patients who were given ABT (p = 0.008). CONCLUSIONS: Hb had a tendency to fall during the three first days after surgery and seemed to be stabilized on day 5. Patients who received ABT had poorer health, but not significantly higher short-term mortality. This study demonstrates a restrictive transfusion policy.

Use of warfarin is associated with delay in surgery for hip fracture in older patients.

INTRODUCTION: Delay in surgery for hip fractures in older patients may affect mortality and the risk of delirium. Delay in surgery may occur as a result of several factors. It has not been established whether certain patient-related factors, such as a high international normalized ratio (INR) caused by warfarin treatment is associated with delay in surgery. The aim of this study was to explore the associations between warfarin treatment, INR, and time from admission to surgery. METHODS: This is an observational study based on data from a database of all hip fracture patients aged ≥ 65 years who were admitted to an orthogeriatric unit. The database included data from 1192 consecutive patients admitted from January 2007 to April 2010. Data were collected during routine work. Use of warfarin, patient characteristics, medical complications, length of stay, and time from admission to surgery were registered from the patients' records, and INR at admission in warfarin users. RESULTS: Warfarin was used by 117 (9.8%) patients at admission, which included more men (n = 42; 14.4%) than women (n = 75; 8.3%) (P = 0.003). The mean age was 85 years, with no difference between users and nonusers. Warfarin users had more comorbid diseases (mean, 2.1 vs 1.8; P = 0.003), poorer health status (American Society of Anesthesiologists score of 3-5 in 77.8% vs 51.0%), and longer waiting time for surgery compared with nonusers (mean, 23 vs 12 hours; P < 0.001). There was no difference in need for blood transfusions (28.2% of users compared with 25.3% of nonusers; P = 0.49). Length of stay was longer among warfarin users compared with nonusers (mean, 14.6 vs 11.7 days; P = 0.002). Warfarin users with an INR of ≥ 2 had a longer waiting time than those with an INR of < 2, but they had a longer waiting time than nonusers. CONCLUSION: Hip fracture patients who are using warfarin experience a longer waiting time for surgery, most likely due to more comorbidities. A more active approach to better management of comorbidities may reduce waiting time for surgery in warfarin users.

Predictors of mortality in older hip fracture inpatients admitted to an orthogeriatric unit in oslo, norway.

OBJECTIVES: To identify to which degree patient-related factors (age, gender, place of residence, general health condition, comorbidity) and hospital-related factors (waiting time for surgery, type of surgery, in-hospital complications, length of stay) may predict 1-year mortality in elderly hip fracture patients in an orthogeriatric unit, to optimize treatment and care. METHOD: In-hospital patient information was routinely collected by multidisciplinary staff and entered into a database. Information about mortality was obtained for 567 patients aged 65 and above. Multivariate logistic regression was performed. RESULTS: Overall mortality was 23.5%, but there was a large variation in mortality according to age, gender, comorbidity, and place of residence. Independent predictors of mortality were admittance from nursing home (risk ratio [RR] = 3.24, 95% confidence interval [CI] = 2.37-4.43 compared with home dwellers) and a higher American Society of Anesthesiologists (ASA) score (RR = 1.75 and 95% CI = 1.24-2.46, for ASA ≥ 3 compared with ASA ≤ 2). Male gender, increasing age, increasing number of comorbid conditions, and having fallen indoors were indicators, but not independent predictors, of higher mortality. DISCUSSION: Almost one fourth of older hip fracture patients in this unit died within a year. The most important predictor was admittance from nursing home, which was associated with comorbidity and frailty. More attention to patients from nursing homes is needed in the health care system.