Objectives and Backgrounds Fractured neck of femur (NOF) is a common presentation to UK emergency departments (ED) with approximately 75 000 patients admitted annually. Pain control and time to admission are important in this vulnerable group, and yet this is where we repeatedly underperform. Fascia iliac compartment block (FICB) is a well-established and efficacious method of analgesia for fractured hips with fewer side effects than systemic opiates and a longer duration of action. They do, however, mandate 60 min post-block observation in ED to check for signs of local anaesthetic toxicity. Objectives of this study were to evaluate whether delivery of a nerve block prolonged the time patients spent in the department (primary outcome) and whether need for additional analgesia were reduced in those patients receiving nerve blocks (secondary outcomes).
Methods Ultrasound-guided FICBs were introduced into practice in Barnsley Hospital ED in July 2010. Training to enable ED nursing staff to deliver landmark-technique blocks commenced in February 2010 as well as a revision of the fractured NOF pathway to incorporate this new practice. An ST5 emergency medicine (EM) trainee and consultant delivered this training with input from the acute pain team. A retrospective review of case notes of all patients with fractured NOF from July 2010 to January 2011 was undertaken to evaluate outcome measures as above. Following introduction of the nurse training, a prospective service evaluation commenced on 01 February 2011 to evaluate outcome measures in patients receiving US guided or landmark technique FICB and standard analgesia. (This data collection is ongoing until 30 June 2011 and results given below are, therefore, preliminary findings).
Results Patients identified with fractured NOF n=121; of these, 101 received “standard analgesia” (SA) and 21 received a nerve block (NB). Mean “time to admission” for SA=167 min (SD 63.3) and NB= 169 min (SD 48.5) p=0.736* (95% CI −31.2 to 22.1). Mean time to x-ray for SA= 72.54 min (SD 46.4) and NB=49.95 min (SD 24.5) p=0.003* (95% CI 8.15 to 37.03). 71.4% NBs were performed between 08:00 and 18:00 h and 28.6% between 18:00 and 24:00 h. Percentage of patients requiring additional analgesia: SA=20.5%, NB=19%. *Independent t test calculated using SPSS software.
Conclusions Results suggest that patients receiving nerve blocks do not wait longer for admission than those receiving standard analgesia. In a time-target driven world, time to undertake a new intervention is of paramount importance when considering adopting new practice. Nerve blocks were carried out predominantly during the day when senior cover in the department was at a maximum. The mean length of time waiting for an x-ray is lower in the nerve block group suggesting that blocks are done when the department is less busy. As more staff become trained and experienced at nerve block delivery, it is expected that this trend will improve to a “round the clock” service and that block “success” will improve accordingly with reduced additional analgesia requirements.
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