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Journal of Clinical Orthopaedics and Trauma logoLink to Journal of Clinical Orthopaedics and Trauma
. 2020 Sep 28;14:45–51. doi: 10.1016/j.jcot.2020.09.027

Partial warfarin reversal prior to hip fracture surgical intervention in geriatric trauma patients effects on blood loss and transfusions☆

Richard Meinig a, David Cornutt b, Stephanie Jarvis c, Kristin Salottolo c, Michael Kelly a, Paul Harrison d, Michelle Nentwig d, Steven Morgan e, Nnamdi Nwafo e, Patrick McNair f, Rahul Banerjee g, Bradley Woods h, David Bar-Or c,∗
PMCID: PMC7920139  PMID: 33717896

Abstract

Background

Warfarin reversal is typically sought prior to surgery for geriatric hip fractures; however, patients often proceed to surgery with partial warfarin reversal. The effect of partial reversal (defined as having an international normalized ratio [INR] > 1.5) remains unclear.

Methods

This was a retrospective cohort study. Geriatric patients (≥65 y/o) admitted to six level I trauma centers from 01/2014-01/2018 with isolated hip fractures requiring surgery who were taking warfarin pre-injury were included. Warfarin reversal methods included: vitamin K, factor VIIa, (a)PCC, fresh frozen plasma (FFP), and the “wait and watch” method. An INR of ≤ 1.5 defined complete reversal. The primary outcome was the volume of blood loss during surgery; other outcomes included packed red blood cell (pRBC) and FFP transfusions, and time to surgery.

Results

There were 135 patients, 44% partially reversed and 56% completely reversed. The median volume of blood loss was 100 mL for both those completely and partially reversed, p = 0.72. There was no difference in the proportion of patients with blood loss by study arm, 95% vs. 95%, p > 0.99. Twenty-five percent of those completely reversed and 39% of those partially reversed had pRBCs transfused, p = 0.08. Of those completely reversed 5% received an FFP transfusion compared to 14% of those partially reversed, p = 0.09. There were no statistically significant differences observed for the volume of pRBC or FFP transfused, or for time to surgery.

Conclusions

Partial reversal may be safe for blood loss and blood product transfusions for geriatric patients with isolated hip fractures. Complete warfarin reversal may not be necessary prior to hip fracture surgery, especially for mildly elevated INRs.

Keywords: Warfarin, Reversal, Hip fracture, Trauma, Geriatric

Abbreviations: TQIP, Trauma Quality Improvement Program; AAOS, American Academy of Orthopedic Surgeons; IV, intravenous; DOAC, direct oral anticoagulants; INR, international normalized ratio; FFP, fresh frozen plasma; PCC, prothrombin complex concentrates; aPCC, activated prothrombin complex concentrates; ION, Injury Outcomes Network; HIPAA, health insurance accountability and assurance act; ICD, international classification of diseases; HLOS, hospital length of stay; ICU LOS, intensive care unit length of stay; pRBC, packed red blood cells; mL, milliliters; DVT, deep vein thrombosis; PE, pulmonary embolism; MI, myocardial infarction; CVA, cerebrovascular accident; SD, standard deviation; IQR, interquartile range; ANOVA, analysis of variance

1. Background

Surgical candidates who are geriatric and suffering from hip fractures are often treated with pre-injury warfarin, which is believed to increase the risk for blood loss and consequent blood product transfusions during surgery.1, 2, 3, 4, 5, 6, 7, 8 It is recommended to interrupt warfarin five days prior to surgery for elective hip surgeries.9,10 However, current guidelines for non-elective cases with fragility hip fractures from the American College of Surgeons Trauma Quality Improvement Program (TQIP) and American Academy of Orthopaedic Surgeons (AAOS) recommend surgery within 48 hours of admission.11,12 Therefore, physicians often attempt to reverse the effect of warfarin prior to surgery to prevent surgical delays.6,13,14 Recent publications suggest similar outcomes between patients whose anticoagulant was reversed and those whose anticoagulant was not reversed prior to hip fracture surgery.15,16

Vitamin K is administered to reverse the effects of warfarin with a recommended intravenous (IV) dose of 5 mg, however many patients need multiple doses of Vitamin K as the international normalized ratio (INR) does not always normalize with one dose of Vitamin K, resulting in partial warfarin reversal.13,17,18

As a result non-specific reversal agents such as fresh frozen plasma (FFP), prothrombin complex concentrates (PCC), activated PCC (aPCC), and recombinant activated factor VIIa, are often administered to accelerate the reversal process.5,6,13 Non-specific agents also may not completely reverse the effect of warfarin, leaving the patient partially reversed at the time of surgery.19,20

Another option is to wait and watch for the effect to dissipate naturally, during which the INR can be monitored to determine the anticoagulant status.1,8,21 The American College of Chest Physicians guidelines on perioperative management of antithrombotic therapy suggest an INR of <1.5 at the time of surgery.18 The American Heart Association and American College of Cardiology defines a normal INR as < 1.2 but does not propose any guidelines on an appropriate INR range for trauma patients needing surgery and instead recommends to lower the INR into a safe but not subtherapeutic range without causing resistance once warfarin is reinstated.22 The American Heart Association and American College of Cardiology also does not provide a specific target INR for surgery.22 The American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines recommends 2.5–5 mg of oral or IV vitamin K and to consider PCCs or FFP for immediate reversal prior to urgent surgery.10

Because non-specific agents and the wait and watch method are increasingly used as methods of warfarin reversal, it is important to know the clinical impact of partially reversed warfarin on outcomes in geriatric patients with hip fractures requiring surgery. Therefore, the purpose of this study was to compare outcomes, primarily the volume of blood loss, among patients whose pre-injury warfarin was partially reversed to patients whose pre-injury warfarin was completely reversed.

2. Materials and methods

This multicenter retrospective cohort study was conducted by the Injury Outcomes Network (ION), a collaboration of six level I trauma centers. This study was approved by all six center’s institutional review boards with HIPAA authorization and a waiver of informed consent. Geriatric patients (≥ 65 y/o) who sustained an isolated fragility hip fracture requiring surgery from January 2014 to January 2018 and were taking pre-injury warfarin were included. ICD 9 and ICD 10 codes were used to identify patients from the trauma registries. Poly-trauma patients, defined as having an Abbreviated Injury Scale of ≥ 2 in any anatomical body region other than the lower extremity were excluded from the study. Patients who were not reversed were excluded (defined as surgical repair within 24 h of admission without receiving a reversal agent). Comparisons between those reversed to those not reversed prior to hip fracture repair were previously reported and there were no differences among outcomes; this study represents a subset analysis of this previous report.16 No lab values indicative of the anticoagulant effect for direct oral anticoagulants (DOACs) were collected, therefore patients taking pre-injury DOACs were not included as we could not determine the coagulation status at the time of surgery.

The following were considered reversal strategies: Vitamin K, factor VIIa, PCC, aPCC, FFP, and the wait and watch method. Patients could be reversed using multiple reversal strategies. The “wait and watch” method was defined as surgery > 24 h after the time that the last dose of warfarin was taken. The pharmacological dosing regimen was used to estimate when the last dose was taken if the date and time of the last dose was not recorded. Patients were categorized into two groups “completely reversed” or “partially reversed”. A preoperative INR of less than or equal to 1.5 defined complete reversal; patients with a preoperative INR of greater than 1.5 were considered partially reversed.

The primary aim of the study was to evaluate the effect of partial warfarin reversal on the volume of blood loss recorded. Secondary outcomes were the: proportion of patients with blood loss, proportion of patients with blood transfusions, volume of blood transfusions, complications, hospital length of stay (HLOS), intensive care unit (ICU) LOS, and discharge disposition. Blood transfusions included packed red blood cells (pRBC), cryoprecipitate, FFP, and platelets. All blood loss and transfusion volumes were reported in milliliters (mL). Any blood loss or transfusions occurring before the operation were excluded as the reversal methods were also provided before the operation. Therefore, warfarin reversal likely had no effect on blood loss or transfusions that occurred before the operation. Only actual volumes of blood loss during the operation and postoperatively were included, estimated blood loss was not excluded from the analysis. Complications reported from the trauma registry included: unplanned return to the ICU, pneumonia, deep vein thrombosis (DVT) or pulmonary embolism (PE), myocardial infarction (MI), stroke or cerebrovascular accident (CVA). The presence of a wound hematoma was obtained from the patient’s medical charts. Additionally, we compared the rate of having any complication between the two groups.

2.1. Statistical analysis

Categorical and dichotomous data were expressed as proportions (counts) and continuous data were expressed as means (standard deviation, SD) or medians (interquartile range, IQR) when appropriate. Data were compared using Fisher’s exact, chi-squared, Kruskal-Wallis or analysis of variance (ANOVA) when appropriate. All hypothesis tests were two-tailed; alpha = 0.05.

3. Results

There were 135 patients included, 56% were completely reversed and 44% were partially reversed. Overall, 66% were female and the median age was 85 years old, Table 1. There were no differences observed between groups for any comorbidity or the comorbidity count. All other patient demographics and clinical characteristics were also statistically similar between groups. Overall, 48% of patients had an intertrochanteric fracture, 46% had a femoral neck fracture, and 10% had a subtrochanteric fracture. There were no significant differences observed between groups for the type of hip fracture or procedure. Intramedullary fixation was the most common procedure for both groups. Eight percent of patients had a total hip arthroplasty. Across all patients, the median INR value was 1.5. As expected, and based on our definition, the median preoperative INR was significantly lower among patients completely reversed compared to those partially reversed, 1.3 vs. 1.8, p < 0.001. Among those partially reversed 22% of patients had an INR > 2 and the highest INR value was 4.25.

Indications for warfarin use were also similar between groups, except that there were more patients completely reversed who were taking warfarin to prevent DVT or PE than those partially reversed, 21% vs. 8%, p = 0.05, Table 2. The most common method of warfarin reversal for both groups was Vitamin K. A lower proportion of patients who were completely reversed received FFP for reversal than those who were partially reversed, 21% vs 37%, p = 0.04. Only 1% of completely reversed patients were given aPCC prior to hip fracture intervention, and 4% of completely reversed patients were given Factor VIIa. No partially reversed patients received aPCC or Factor VIIa. There was a higher proportion of patients who were completely reversed who received Vitamin K along with another reversal method than those partially reversed, 12% vs. 10%, but this was not statistically different, p = 0.76; whereas a lower proportion of completely reversed patients received FFP along with another reversal method than those partially reversed, 11% vs. 14%, but again this was not statistically significant, p = 0.59.

There was no difference in the volume of blood loss recorded between groups; those completely reversed had a median (IQR) of 100 mL (50, 150) and those partially reversed had a median (IQR) or 100 mL (50, 200), p = 0.72, Table 3. There was also no statistical difference in the proportion of completely reversed patients who had blood loss when compared to the proportion of partially reversed patients with blood loss, 95% vs. 95%, p > 0.99. Overall, 31% of patients received a pRBC transfusion, 25% of patients who were completely reversed had a pRBC transfusion and 39% of those partially reversed, this difference was not statistically significant, p = 0.08. There was also not a significant difference in the median volume of pRBCs transfused between groups, p = 0.09. Overall, only 9% received an FFP transfusion, 5% of those completely reversed and 14% of those partially reversed received an FFP transfusion, again this was not statistically significant, p = 0.09. No patients were given cryoprecipitate or platelet transfusions.

The median time to surgery was similar between those completely reversed and those partially reversed, 34 h versus 27 h respectively, p = 0.08. The median length of procedure was trending towards significantly significance, 56 min for those completely reversed compared to 69 min for those partially reversed, p = 0.06. The median (IQR) HLOS was 6 days (4, 8) for those completely reversed and was 6 days (6, 9) for those partially reversed, p = 0.97. ICU LOS and in-hospital complication rates were comparable between groups. Mortality rates and those discharged to hospice or home/home health were also similar between groups. However, there was a significantly lower proportion of completely reversed patients discharged to rehabilitation than those partially reversed, 14% vs. 41%, p = 0.001; whereas there was a significantly higher proportion of completely reversed patients discharged to a skilled nursing facility when compared to those partially reversed, 71% vs. 44%, p = 0.002.

4. Discussion

To our knowledge, this is the first study to compare outcomes among patients who had complete warfarin reversal to those with partial warfarin reversal prior to geriatric hip fracture surgery. Previous studies have alluded to partial reversal as a potential issue for blood loss and blood transfusions.19,20,23, 24, 25, 26, 27, 28, 29 The findings of this study show that partial reversal prior to hip fracture surgery in this population did not result in a greater proportion of patients experiencing blood loss, receiving blood transfusions, or a greater volume in blood loss or blood transfusions.

It is anticipated that the number of patients prescribed warfarin will further decrease due to the benefits of DOACs; however warfarin currently remains the most frequently prescribed anticoagulant.5,6,28,30 We previously conducted an analysis comparing those reversed to those not reversed among geriatric hip fracture patients on anticoagulants and found that 66% of patients were taking warfarin.16 In the event of trauma for patients on warfarin the risk of bleeding remains a substantial concern leading to warfarin reversal; however reversal is not always complete at the time of surgery, and the effect of partial reversal is not fully elucidated.13,17,31 In this study partial reversal, defined as having an INR of > 1.5 before surgery, was not associated with an increased risk for blood loss or transfusions.

Although the median preoperative INR was significantly higher among those partially reversed compared to those completely reversed (1.8 vs. 1.3), the preoperative INR for those partially reversed was still relatively low, with only 22% having an INR greater than 2. The maximum INR value among those partially reversed was 4.25. This may be part of the reason why there was no statistically significant differences observed for blood loss between groups. Curtis et al. defined an INR of 1.8 as mildly elevated and said it is not predictive of bleeding in surgical procedures.9 One systemic review found that an INR of 2–3 was the safest in terms of hemorrhage and thromboembolic complications.32 Khatib et al. conducted a meta-analysis on warfarin reversal and found that there is very low evidence to suggest there is any benefit in reversal of an elevated INR between 4.5 and 10 for patients who are not bleeding.33 The American Heart Association and American College of Cardiology also state that when the INR is above the therapeutic range but less than 5 with an absence of bleeding not to reverse the effect of warfarin.33 Similar to the results of this study, Cohn et al. concluded that an INR of above 1.5 may not be a contraindication for hip fracture surgery for patients otherwise medically safe for surgery; however their study included both patients reversed and those not reversed prior to surgery in their assessment, whereas the current study focused solely on patients whose warfarin was reversed in some capacity.34 One study identified other variables that were significant predictors of the need for transfusions for geriatric patients with hip fractures: age, gender, hemoglobin levels, time from admission to surgery, and the type of procedure conducted.35

Major orthopaedic bone surgery is commonly associated with a higher risk of bleeding.36 In this study a majority of patients were treated with intramedullary fixation, internal fixation, or screw fixation which are typically less invasive than a hemiarthroplasty or total hip arthroplasty.1,37,38 Foss et al. found that patients treated with arthroplasty lost a median of 200 ml of blood compared to 50 ml for patients treated with a screw or pin, p < 0.001.39 Another study found a significantly higher volume of mean blood loss among patients treated with bipolar hemiarthroplasty or a dynamic hip screw than patients treated with a proximal femoral nail.40 Alternatively, one study found that the odds for receiving a blood transfusion were five times higher among patients treated with a cephalomedullary nail, and two times higher for those treated with a dynamic hip screw, when compared to those treated with hemiarthroplasty.35 There were no statistically significant differences observed in the type of procedure conducted, or the type of fracture between groups in this study.

Additionally, surgery was performed within the AAOS and TQIP recommendations for both groups.11,12 Patients completely reversed had a median time to surgery of 34 h, which was statistically similar to patients partially reversed who went to surgery a median of 27 h after arrival. The prompt time to surgery seen for both groups may have contributed to the lack of difference in blood loss among the groups. There is a perception that time to surgery may increase the risk for complications and poor outcomes. However results from studies on effect of time to surgery on outcomes are inconsistent, and some have found that time to surgery is a marker of underlying conditions suggesting that these factors may be the real driver of outcomes.41, 42, 43, 44, 45, 46, 47, 48

It has been reported that the sensitivity to warfarin is affected by the patients age which is suspected to be due to the pharmacokinetics and pharmacodynamics of the drug.49 Additionally per the FDA drug label, increased age while on warfarin is associated with an increased risk for bleeding.49 Patients in this study were comparable in age. Partially reversed patients had a median age of 85 and completely reversed had a median age of 86, p = 0.85. Several studies have assessed age as a risk factor for bleeding in geriatric hip fractures. Age was identified a significant predictor of the need for blood transfusions within 72 h of admission and 10 days from admission by Kadar et al.35 Desai et al. found older patients were at an increased odds of blood transfusions when analyzing by age univariately, but on a multivariable analyses, age was not a significant predictor of the need for blood transfusion.48 Another study found that age over 75 years old was a significant predictor of blood loss.50 In all of these studies, hemoglobin was significantly associated with the need for transfusions.35,48,50 No difference was observed for the preoperative hemoglobin value between groups in this study. The only demographic and clinical characteristic that was significantly different between the two groups was the preoperative INR.

5. Limitations

The sample size was relatively small, which limited our ability to conduct adjusted analyses; however, the groups were statistically similar for every demographic and clinical characteristic other than the variable distinguishing the reversal status, preoperative INR. The date and time that the last warfarin dose was taken, and the warfarin dosing regimen may not have been known. For those patients it was unknown if a patient was reversed using the wait and watch method. Indications for warfarin reversal and reversal methods were not consistent across all hospitals. Blood volumes recorded may have been estimated blood loss during procedures, which can be subjective.

6. Conclusions

There were no differences in the volume of blood loss or blood products transfusions among geriatric patients with isolated hip fractures who had partial warfarin reversal compared to those with complete warfarin reversal. Given the lack of difference in outcomes, the findings of this study provide some evidence that it may be safe, in terms of blood loss and complications, for geriatric patients with hip fractures to proceed to surgery with partial warfarin reversal. Partial warfarin reversal may not be an issue in these patients, especially for those with a mildly elevated INR.

Author contributions

DC, RM, MK, PH, MN, SM, NN, PM, RB, BW, and DBO contributed to the conception and design of the study, the revising of the manuscript, and provided final approval for submission. SJ and KS contributed to study design, analysis, and interpretation of the data, drafting of the manuscript, and provided final approval for submission. MN also contributed to acquisition of the study data.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

None.

Acknowledgements

We would like to thank our program manager, Diane Redmond, IRB coordinator, Tina Thompson, and Clinical Research Coordinators: Jennifer Pekarek, Jamie Shaddix, Kathy Rodkey, Shenequa Deas, Brenda Kuipoff, and Carolyn Blue for their assistance on this project.

Footnotes

☆

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Appendix. Tables.

Table 1.

Demographic and Clinical Characteristics.

All patients n = 135 Partial n = 59 Complete n = 76 p
Age Median (IQR) 85 (79, 89) 85 (81, 90) 86 (79, 90) 0.85
Sex % Female 66% (89) 59% (35) 71% (54) 0.15
Race % White (n) 93% (126) 95% (56) 92% (70) 0.89
Comorbidities % (n)
 Diabetes 24% (32) 24% (14) 24% (18) >0.99
 Hypertension 64% (86) 66% (39) 62% (47) 0.61
 Congestive Heart Failure 21% (28) 15% (9) 25% (19) 0.17
 COPD 13% (18) 12% (7) 14% (11) 0.66
 Comorbidity Count Median (IQR) 2 (1, 4) 2 (1, 4) 2 (1, 4) 0.92
Prior Hip Fracture % (n) 10% (13) 8% (5) 11% (8) 0.68
SBP Median (IQR) 147 (128, 163) 143 (128, 156) 153 (133, 168) 0.74
HR Median (IQR) 78 (68, 89) 81 (74, 96) 78 (66, 91) 0.37
Preop Hemoglobin Mean (SD) 11.0 (1.8) 11.0 (1.8) 10.9 (1.9) 0.93
Postop Hemoglobin Median (IQR) 10.2 (9.1, 11.9) 9.4 (8.9, 10.8) 9.7 (8.4, 12.4) 0.48
Preop INR Median (IQR) 1.5 (1.2, 1.8) 1.8 (1.6, 2.0) 1.3 (1.2, 1.4) <0.0001
Type of Hip Fracture∗ % (n)
 Intertrochanteric 48% (66) 44% (26) 53% (40) 0.32
 Femoral Neck 46% (62) 49% (29) 43% (33) 0.51
 Subtrochanteric 10% (14) 10% (6) 11% (8) 0.95
Hip Fracture Procedure∗ % (n)
 Screw Fixation 7% (9) 10% (6) 4% (3) 0.18
 Total Hip Arthroplasty 8% (11) 8% (5) 8% (6) >0.99
 Hemiarthroplasty 24% (32) 25% (15) 22% (17) 0.68
 Intramedullary Fixation 57% (77) 54% (32) 59% (45) 0.56
 Internal fixation 22% (30) 17% (10) 26% (20) 0.22
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IQR: interquartile range, SD: standard deviation, COPD: chronic obstructive pulmonary disease, SBP: systolic blood pressure, HR: heart rate, preop: preoperative, postop: postoperative, INR: international normalized ratio. ∗Patients could have multiple fracture types and multiple procedure types.

Table 2.

Warfarin Indications and Warfarin Reversal.

All patients n = 135 Partial n = 59 Complete n = 76 p
Indication % (n) a
 A-fib 67% (91) 73% (43) 63% (48) 0.23
 DVT or PE 16% (21) 8% (5) 21% (16) 0.05
 Unknown 4% (6) 3% (2) 5% (4) 0.70
 Valve Replacement 6% (8) 7% (4) 5% (4) 0.73
 Stroke or CVA 4% (6) 7% (4) 5% (4) 0.40
 CAD 8% (11) 7% (4) 9% (7) 0.76
Bridging % (n)
 Heparin Bridge 3% (4) 2% (1) 4% (3) 0.63
 Enoxaparin Bridge 15% (20) 10% (6) 18% (14) 0.18
 Preop Bridgeb 13% (3) 0% (0) 18% (3) 0.53
 Postop Bridgeb 88% (21) 100% (7) 82% (14) 0.53
Warfarin Reversal Informationc
 FFP % (n) 28% (38) 37% (22) 21% (16) 0.04
 FFP Volume (mL) Median (IQR) 516 (384, 622) 508 (500, 819) 532 (255, 575) 0.77
 Factor VIIa % (n) 2% (3) 0% (0) 4% (3) 0.50
 Factor VIIa Dose (mL) Median (IQR) 51 (20, 80) N/A 51 (20, 80) N/A
 Vitamin K % (n) 59% (79) 54% (32) 62% (47) 0.37
 Vitamin K Dose (mL) Median (IQR) 5 (4, 10) 5 (3, 10) 5 (5, 10) 0.08
 Wait and Watch % (n) 27% (36) 22% (13) 30% (23) 0.28
 aPCC % (n) 1% (1) 0% (0) 1% (1) >0.99
 aPCC Dose (mL) 80 N/A 80c N/A
 FFP with any other reversal method 12% (16) 14% (8) 11% (8) 0.59
 Vitamin K with any other reversal method 11% (15) 10% (6) 12% (9) 0.76
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a = Some patients had multiple indications for warfarin, b = proportions presented among patients who were given a bridge, c = Some patients had multiple anticoagulation reversal methods, c = only one patient given aPCC, IQR: interquartile range, A-fib: atrial fibrillation, DVT: deep vein thrombosis, PE: pulmonary embolus, CVA: cerebrovascular accident, CAD: coronary artery disease, Preop: preoperative, FFP: fresh frozen plasma, aPCC: activated prothrombin complex concentrate, mL: milliliters.

Table 3.

Outcomes and Complications.

All patients n = 135 Partial n = 59 Complete n = 76 p
Blood Loss, Volume (ml), median (IQR) 100 (50, 150) 100 (50, 200) 100 (50, 150) 0.72
Any Blood Loss, % (n) 95% (128) 95% (56) 95% (72) >0.99
Blood Transfusions
pRBC Volume (ml), Median (IQR) 660 (350, 770) 660 (350, 700) 660 (350, 1050) 0.09
Any pRBC Transfusion, % (n) 31% (42) 39% (23) 25% (19) 0.08
FFP Volume (ml), Median (IQR) 318 (299, 620) 318 (301, 620) 411 (285, 671) 0.73
Any FFP Transfusion, % (n) 9% (12) 14% (8) 5% (4) 0.09
Time to Surgery, h, median (IQR) 26 (18, 41) 27 (21, 40) 34 (25, 50) 0.08
Length of Procedure, mins, median (IQR) 68 (40, 96) 69 (42, 103) 56 (32, 83) 0.06
Complications % (n)
Unplanned return to the ICU 1% (2) 0% (0) 3% (2) 0.50
Pneumonia 2% (3) 3% (2) 1% (1) 0.58
DVT or PE 2% (3) 2% (1) 3% (2) >0.99
MI 2% (3) 2% (1) 3% (2) >0.99
Stroke or CVA 1% (1) 2% (1) 0% (0) 0.44
Wound Hematoma 1% (2) 2% (1) 1% (1) >0.99
Any Complication 10% (13) 8% (5) 11% (8) 0.69
Discharge Disposition % (n)
Home or Home Health 7% (10) 5% (3) 9% (7) 0.51
Mortality 4% (6) 5% (3) 4% (3) >0.99
Hospice 3% (4) 5% (3) 1% (1) 0.32
Rehabilitation 26% (35) 41% (24) 14% (11) 0.001
Skilled Nursing Facility 59% (80) 44% (26) 71% (54) 0.002
HLOS, days, Median (IQR) 5 (4, 7) 6 (6, 9) 6 (4, 8) 0.97
ICU LOS∗, days, Median (IQR) 4 (2, 8) 6 (3, 9) 3 (2, 7) 0.18
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∗The median ICU LOS was calculated only for patients who went to the ICU. No patients were given cryoprecipitate or platelet transfusions. IQR: interquartile range, pRBC: packed red blood cells, FFP: fresh frozen plasma, h: hours, ICU: intensive care unit, DVT: deep vein thrombosis, PE: pulmonary embolus, MI: myocardial infarction, CVA: cerebrovascular accident, Home health: home with health care services, HLOS: hospital length of stay, ICU LOS: intensive care unit length of stay.

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