title: Omitting pre-operative coagulation screening tests in hip fracture patients: stopping the financial cascade?
abstract: BACKGROUND
  Coagulation screening continues as a standard of care in many hip fracture pathways despite the 2011 guidelines from the Association of Anaesthetists of Great Britain and Ireland (AAGBI) which recommend that such screening be performed only if clinically indicated. This study aims to evaluate the use of pre-operative coagulation screening and explore its financial impact.
  
  
  METHODS
  Prospective data was collected in accordance with the "Standardised Audit of Hip Fractures in Europe" (SAHFE) protocol. All patients admitted to our hospital with hip fractures during a 12-month period from November 2011 to November 2012 were analysed. Data including coagulation results and the use of vitamin K or blood products were collected retrospectively from the hospital computer system. Patient subgroup analysis was performed for intraoperative blood loss, post-operative blood units transfused, haematoma formation and gastrointestinal haemorrhage.
  
  
  RESULTS
  814 hip fractures were analysed. 91.4% (n=744) had coagulation tests performed and 22.0% (n=164) had an abnormal result. Of these, 55 patients were taking warfarin leaving 109 patients who had abnormal results and were not taking warfarin. When this group (n=109) was compared to those who had normal test results (n=580) and to all other patients (n=705) there was no difference in intraoperative blood loss (p=0.79, 0.78), postoperative transfusion (p=0.38, 0.30), postoperative haematoma formation (p=0.79, 1.00), or gastrointestinal haemorrhage (p=0.45, 1.00), respectively. In those who were not taking warfarin, but had abnormal results, none had treatment to reverse their coagulopathy with either vitamin K or blood products. By omitting pre-operative coagulation tests in patients who are not taking warfarin, we estimate a financial saving of between £66,500 and £432,250 per annum.
  
  
  CONCLUSIONS
  This study supports the hypothesis that routine pre-operative coagulation screening is unnecessary in hip fracture patients unless they take warfarin or have a known coagulopathy. Moreover, its omission represents significant cost-saving potential.
authors.affiliation: Department of Orthopaedics and Trauma, Queens Medical Centre, Derby Road, Nottingham NG7 2UH, Nottinghamshire, UK. Electronic address: omer.salar@nhs.net.
authors.forename: O
authors.initials: O
authors.lastname: Salar
authors.affiliation: Department of Orthopaedics and Trauma, Queens Medical Centre, Derby Road, Nottingham NG7 2UH, Nottinghamshire, UK.
authors.forename: J
authors.initials: J
authors.lastname: Holley
authors.affiliation: Department of Orthopaedics and Trauma, Queens Medical Centre, Derby Road, Nottingham NG7 2UH, Nottinghamshire, UK.
authors.forename: B
authors.initials: B
authors.lastname: Baker
authors.affiliation: Department of Orthopaedics and Trauma, Queens Medical Centre, Derby Road, Nottingham NG7 2UH, Nottinghamshire, UK.
authors.forename: B J
authors.initials: BJ
authors.lastname: Ollivere
authors.affiliation: Department of Orthopaedics and Trauma, Queens Medical Centre, Derby Road, Nottingham NG7 2UH, Nottinghamshire, UK.
authors.forename: C G
authors.initials: CG
authors.lastname: Moran
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage; D001780:Blood Coagulation Tests / Q000191:economics*; D003362:Cost-Benefit Analysis; D005260:Female; D006620:Hip Fractures / Q000453:epidemiology / Q000628:therapy*; D006801:Humans; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D011300:Preoperative Care / Q000191:economics / Q000379:methods; D011446:Prospective Studies; D006113:United Kingdom / Q000453:epidemiology; D019564:Unnecessary Procedures / Q000191:economics*; D014812:Vitamin K / Q000008:administration & dosage; D014859:Warfarin / Q000008:administration & dosage
chemical_list: D000925:Anticoagulants; D014812:Vitamin K; D014859:Warfarin
keywords: AAGBI; Coagulation screening; Cost saving; Departmental protocols; Hip fractures; Peri-operative complications; Post-operative complications