Patient blood management and hip fracture

Hip fracture care is a major activity in the majority of NHS acute hospitals. Almost all patients undergo surgery and around 3600 acute NHS hospital beds are occupied every day by hip fracture patients. Anaemia is a common finding in these patients. In a recent report, 44% were anaemic on admission to hospital and 87% were anaemic after surgery [1]. Reviews suggest that anaemia in this population is associated with increased mortality [2] and peri-operative blood transfusion is common. Uncorrected anaemia after hip fracture may impede functional recovery in this group of patients [3, 4] and this appears to have a lasting effect on recovery and quality of life [5]. Recent publications [6, 7] have assessed the use of interventions such as intravenous iron to minimise anaemia and exposure to blood products in other surgical groups, however there is a paucity of evidence to guide treatment in the hip fracture population. We undertook a survey to assess current clinician practice and attitudes to patient blood management in this group. We surveyed UK peri-operative clinicians regarding practice and attitudes to patient blood management using an anonymous online survey (Smartsurvey.co.uk) during February and March 2020. The survey was circulated using the website and mailing lists of the Perioperative Medicine Clinical Trials Network and other professional societies, social media and direct contact with anaesthetic departments. All respondents were asked to assist with further onward dissemination of the survey to colleagues and local networks. Unfortunately, the survey was closed prematurely due to the onset of the COVID-19 pandemic. We received responses from 277 clinicians from more than 81 UK hospital sites. Respondents were anaesthetists (n = 134, 66%), elderly care physicians (n = 41, 20%), orthopaedic surgeons (n = 13, 6.4%). Seventy-four (26.7%) did not state their speciality. Anaemia management around the time of hip fracture surgery was variable and only 74 (29%) respondents reported using guidelines. A total of 105 (41.5%) respondents reported there was no local guideline and 74 (29.2%) respondents did not know of any guidance. Forty-six (18.4%) reported using an enhanced recovery after surgery bundle to guide peri-operative management. The majority of guidelines were directed at the use of blood products postoperatively and < 8% reported that their local guidelines pertained to the use of other haemopoetic stimulating treatments. Eighty-eight (36.8%) respondents reported using intravenous iron, 77 (32.7%) vitamin B12, 85 (36.5%) folate and 18 (8%) erythropoietin. We asked respondents their rationale for intravenous iron use in the hip fracture population in order to explore knowledge, attitudes and beliefs regarding the use of this drug. Intravenous iron was rarely included as part of routine clinical practice (6.7%) reportedly due to a lack of evidence, local guidance or perceived efficacy (Table 1). The opinions expressed by peri-operative clinicians support the idea that there is insufficient evidence to guide use of intravenous iron postoperatively in this group of emergency patients. When questioned, most clinicians (92.5%) agreed that they would like more research into this clinical question and a selection of respondents left additional comments about methodology or research aims. A total of 91% of respondents agreed that they would be prepared to recruit patients into a study investigating the use of intravenous iron after hip fracture. This survey was designed to provide a snapshot of current UK practice in this area. Key findings are that, despite patients with this condition being a common highrisk surgical group, less than a third of respondents reported current usage of patient blood management guidelines. While guidance was most commonly available to optimise the use of red cell transfusion, interventions that could be used to treat anaemia were performed on an individualised basis. Use of both oral and intravenous preparations of iron was reported and, less frequently, erythropoietin (8% of respondents), in contrast with reported European use of this drug in studies of the hip fracture population. While there are limitations to the scope of this study, and it did not capture all departments treating hip fracture in the UK, we feel that this snapshot is a valuable piece of background work required to assist the development of research in this area. It supports the view that clinical practice in this area is variable, that equipoise exists and that many in the clinical community would support further research.