Title

The effect of an immediate preoperative haemoglobin blood test on hip fracture patient outcomes: A before and after cohort study

Date of Award

2021

Degree Type

Thesis

Degree Name

Masters in Nursing (by Research)

School

School of Nursing and Midwifery

First Advisor

Linda Coventry

Second Advisor

Beverley Ewens

Third Advisor

Nicholas Gibson

Fourth Advisor

Dale Currigan

Abstract

Introduction

An ageing population presents challenges to health care, such as the increasing prevalence of osteoporosis and associated low trauma hip fractures. These types of fractures are usually repaired surgically, which in turn presents risks. It is estimated that 35- 67% of patients with hip fractures have low haemoglobin levels on-admission, which is associated with increased length of hospital stay, morbidity and mortality.

Background

Patients who present with low trauma hip fracture at the study site have haemoglobin levels taken on-admission but not again prior to surgery. It is not known whether an additional haemoglobin level prior to surgery may reduce hospital length of stay and improve patient outcomes.

Aims

To investigate whether the implementation of a preoperative haemoglobin blood test immediately before surgery would improve patient outcomes. Primary aim: To reduce acute hospital length of stay. Secondary aims: To reduce post-anaesthetic care unit length of stay, complications and in-hospital mortality.

Methodology

Research design: A before and after cohort study. Participants were recruited into three groups: retrospective, interventional and observational. The retrospective group and observational groups received usual care. The observational group comprised prospective patients without capacity to make informed consent. The interventional group received an immediate preoperative HemoCue test to determine haemoglobin levels. Participants and setting: A large tertiary centre in metropolitan Western Australia. 150 participants >50 years, were recruited intro three groups of 50 each. Data analysis: The trend of haemoglobin taken across five timepoints in the interventional group was compared with a one-way repeated measures ANOVA. Hospital length of stay and post-anaesthetic care unit length of stay was compared using a generalised linear model negative binomial test with log link that adjusted for age, gender and other covariates.

Results

There was a statistically significant mean difference in haemoglobin between preoperative haemoglobin and on-admission haemoglobin in the interventional group. In the interventional group a preoperative drop in haemoglobin of -13.25g/L (95% CI: -21.25- - 5.25, p < 0.001) occurred. The preoperative drop in haemoglobin was more significant than the drop in haemoglobin observed intraoperatively or on any day postoperatively. An additional preoperative haemoglobin blood test taken immediately prior to surgery did not reduce hospital length of stay or post-anaesthetic care unit length of stay and was not associated with intraoperative use of tranexamic acid or packed red blood cells. Hospital length of stay was 30% shorter for participants who had a consultant perform the operation. Post anaesthetic care unit stay was 1.40 times longer if the patient was transfused with packed red blood cells intraoperatively; 1.23 times longer if the patient received a general anaesthetic; and 1.75 times longer if the patient experienced any complication in the post-anaesthetic care unit.

Conclusions

Patients with hip fractures experience significant drops in haemoglobin level prior to surgery, likely due to acute-fracture related blood loss. A haemoglobin blood test immediately prior to surgery did not improve patient outcomes. Larger studies are required to investigate if a preoperative haemoglobin test in hip fracture patients may identify preoperative blood loss and impact on patient outcomes.

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