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How are you managing hip fracture patients on DOACs?

In an attempt to end the dilemma surrounding the management of hip fracture patients on direct oral anticoagulants, Sheweidin Aziz, Krishan Almeida, and Grahame Taylor share the highlights of their recent publication.

Blog entry written on: How should we manage hip fracture patients on direct oral anticoagulants? (bmjebm-2019-111317)

Authors: Sheweidin Aziz, Krishnan Almeida, and Grahame Taylor.


Currently there are no national protocols in place for managing hip fracture patients on Direct Oral Anti-Coagulants (DOACs) hence various local management protocols exist.

What did we do?

This is the first study to comparing three different local protocols with a control group assessing blood loss and time delay to theatre.

What we propose and why?

Based on our comparison, we recommend operating in the window between 24 hours from last DOAC dose and within 36 hours of diagnosis of fracture. Most excess blood loss in DOAC patients had occurred prior to arrival to hospital; there was no significant difference in blood loss between the three protocol groups thereafter. Patients on DOACs required more blood transfusions than the control group, mostly pre-operatively. Therefore, we recommend blood transfusion should be made available promptly on admission. Our recommendations should prevent delay to theatre, prevent financial losses by achieving the Best Practice Tariff (PBT) time, of operating within 36 hours of diagnosis, and standardise the management of hip fracture patients on DOACs. There were considerable differences in delays to theatre between the three protocol groups, with no difference in blood loss; however, the delays did cause substantial financial losses.

How did we reach our recommendations?

We conducted an observational study, a power calculation was conducted based on 5g/L drop in Haemoglobin (Hb) being a considered clinically relevant difference between the groups, as it would represent on average ½ a unit of blood.1 However, the actual Hb drop between the three protocol groups and the control group was on average only 3g/L.

Who are we?

We are an Orthopaedic registrar in training (Sheweidin Aziz), a medical student (aspiring to become an Orthopaedic surgeon, Krishan Almeida), and an Orthopaedic surgeon (Grahame Taylor). We are dedicated to promoting patient care and improving outcomes through research. At the time of this project we were based at University hospitals of Leicester and Nottingham University Hospitals.

Competing Interests

The authors have no conflicts of interests to declare.


Sheweidin Aziz


  1. Trauma and Orthopaedics, Leicester General Hospital, Leicester, Leicester, UK
  2. Trauma and Orthopaedics departmentQueen’s Medical Centre Nottingham University Hospital NHS TrustNottinghamNottingham, UK

Krishan Almeida, Trauma and OrthopaedicsLeicester General HospitalLeicesterLeicester, UK

Grahame Taylor, Trauma and OrthopaedicsLeicester General HospitalLeicesterLeicester, UK



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