BACKGROUND

Theatre-listed trauma patients routinely require two ‘group and save’ blood-bank samples, in case they need perioperative transfusion. The Welsh Blood Service (WBS) need patients to have one recorded sample from any time in the last 10 years. A second sample, to permit cross-matching and blood issuing, must be within 7 days of transfusion (or within 48 hours if the patient is pregnant, or has been transfused within the last 3 months). The approximate cost of processing a sample is £15.00.

Patients with hip fracture are at high risk of venous thromboembolism (VTE). Chemical thromboprophylaxis with low molecular weight heparin (LMWH) is associated with a risk of major bleeding in certain patient groups, such as those with renal failure. In these patients, unfractionated heparin should be used. Our aim was to determine the practice of VTE risk assessment in patients admitted with hip fracture against the national guidance, which states that all should have VTE risk assessment on admission. We also assessed the impact of introducing the VTE risk assessment form on prescribing practice of chemical thromboprophylaxis in patients with renal failure.

Prospective audit of patients of 50 patients admitted with hip fracture from 4/8/10 with re-audit of 50 patients admitted from 17/2/2011 after introducing the VTE risk assessment form into the hip fracture admissions proforma. Retrospective analysis was undertaken to determine chemical thromboprophylaxis prescribing in patients with eGFR <30ml/min/1.73m².

Patient demographics were comparable in both audit loops, with the mean age being equal (84 years) and an equal majority of female patients (76%). There were similar numbers of patients with eGFR <30ml/min/1.73m² in both audit loops with 8% (n=4) in the initial audit, and 10% (n=5) in the re-audit. Frequency of VTE risk assessment significantly increased from 16% to 86% after including the VTE risk assessment form in the hip fracture proforma (p<0.0001). Despite this, there was no significant reduction in prescribing of LMWH in patients with renal failure with eGFR <30ml/min/1.73m², (P=0.52).

Documentation of VTE risk assessment in patients admitted with hip fracture can be improved by simple measures such as inclusion of the VTE risk assessment form in the admissions proforma. However, this did not result in a reduction of LMWH prescribed in patients with significant renal failure and risk of major bleeding.

Cognitive impairment is common in patients with hip fracture both on admission and may develop later on. Reduced cognitive function is a risk factor for development of delirium, correlates with poor rehabilitation, and is an independent predictor of increased mortality. Despite its commonplace and potential for serious morbidity, cognitive dysfunction is often poorly assessed & diagnosed.

Our aims were to 1) assess the practice of cognitive assessment on admission for hip fracture patients according to local guidelines and 2) ascertain whether it can be improved by the formal introduction of Abbreviated Mental Test Score (AMTS) & Clock Drawing Test (CDT) in the hip fracture admission proforma.

A prospective audit was undertaken of cognitive assessment by either AMTS or CDT for 50 consecutive patients admitted with hip fracture from 4/8/2010. Subsequently, the hip fracture admission proforma was amended to include both the AMTS & CDT. A re-audit was performed on 50 consecutive patients admitted from 17/2/2011 to determine the change in practice.

Patient demographics were comparable in both audit loops, with the mean age being equal (84 years) and an equal majority of female patients (76%). Cognitive assessment by either AMTS or CDT significant increased from 28% (n=14) to 86% (n=43) in the re-audit (p<0.0001). All AMTS were completed in accordance with instructions, whereas almost half of CDTs were incompletely or incorrectly filled out (45%).

The assessment of cognitive function can be greatly improved by inclusion of both the AMTS & CDT to the hip fracture admission proforma, allowing the most appropriate multi-disciplinary care to be planned for the patient. Whilst both CDT and AMTS are good screening tools for cognitive impairment, many are unfamiliar with CDT & more training is needed.