Title : Improving uptake of fascia iliaca block in neck of femur fracture patients - a local centre service improvement project
Abstract:
Background: 75,000 neck of femur (NOF) fractures occur each year in England and Wales. Prompt adequate analgesia is a major priority in hip fracture management as per blue book. This not only improves patients’ wellbeing but also reduces the risk of delirium and facilitates earlier return to mobility and independence. Commonly, paracetamol, non-steroidal anti-inflammatory agents and opioids are routinely used over regional nerve blocks for analgesia management in hip fracture patients. However, there are numerous significant side effects such as constipation, respiratory depression, upper gastrointestinal bleeding and delirium. These side effects can delay surgery and increase morbidity. NICE guidelines for hip fracture management recommends consideration of fascia iliaca blocks (FIB). Few studies have investigated the use of FIB for NOF fracture patients however it is still a relatively new component of analgesia management for NOF fracture patients in the pre-operative period. Objectives: Our study aimed to review our pre-operative analgesia management of NOF patients in our centre. Our primary endpoint was to improve uptake of regional blocks in NOF patients. Design and Methods: We performed a prospective review of all patients with NOF fractures admitted via the emergency department at our local district general hospital. This was conducted over a 1 month period September – October 2018. We recorded patient demographics, time and date of admission, grade of physician performing block, VAS scores pre and post block. We excluded patients with significant cognitive impairment. Following review, we developed a multidisciplinary led short interventional training program of FIB administration. This was delivered to all relevant staff, pain management and pain scores were recorded in a second prospective cycle. Results: All fracture NOF patients (n=25 ) were managed according to the NICE guidelines for analgesia in hip fracture. 44% (n=11) of total patients received FIB and 56% (n=14) did not receive FIB pre-operatively. Patients that did not receive FIB had a mean initial pain score of 9.3. After oral analgesia mean pain score reduced to 7.3. Of the patients that received FIB, initial pain score was 9.7 and pain score after FIB was 4.5. There was a 53.2% reduction in pain score in the group that received FIB compared to 26.7% in patients who received oral analgesia only. This was a statistically significant percentage reduction (p value = 0.0046). An educational training day improved number of FIB given and pre-operative pain score. Conclusion: Poorly managed pain causes significant mortality in NOF patients. FIB is a safe, cheap and effective form of pain relief for patients with NOF fractures. A single shot in the emergency department can significantly decrease pain from 30 minutes to 8 hours post-block compared to opioids. Our study confirms that FIB is significantly better than oral based analgesia alone. Currently there is not a 100% rate of FIB administration for fracture NOF patients; reasons include poor pain assessment due to cognitive impairment, lack of confidence and training in FIB administration, patient refusal and increased staff workload. Our intervention improved the uptake of block in our cohort and this has been maintained in further cycles. We show that FIB can be safely administered by junior doctors, emergency department doctors, emergency nurse practitioners.
