Increasing Compliance Rates with a Hip Fracture Analgesia Protocol in a Trauma and Orthopaedic Centre

Sir,

The use of appropriate and adequate analgesia agents in the acute management of hip fractures contributes to reduced patient distress, less incidence of delirium, and aids return to independence and mobility. A local analgesia protocol was introduced to Galway University Hospital (GUH) Trauma & Orthopaedic Department for the management of hip fractures, largely based on the NICE guidelines in conjunction with the acute pain team1.

Outlined are principles for suitable opioids based on patient age and use of nerve blocks where possible, which has been shown to control pain management optimally in the acute setting2. Laxatives along with regular review of analgesia are strongly encouraged and analgesia should be titrated down after 3 days where possible. All patients admitted to GUH with a hip fracture were audited over a 4-week period. Data from the audit was collected, presented at the weekly Orthopaedic Trauma meeting & a review of the protocol was carried out with all Orthopaedic NCHDs present. Physical copies of the protocol were provided on the wards & ED, and also emailed to all Orthopaedic NCHDs to have on their smartphones. Re-audit was commenced for a further period of 4 weeks.

The initial audit included 18 patients in the cohort and 12 in the re-audit. Initially nerve blocks were used in 39% of cases, all performed by the ED Physicians. This improved to 75% after implementing the interventions, with over half of nerve blocks carried out by the anaesthetic physicians. Compliance with the strict dosing regime outlined in the protocol also improved noticeably, reaching 92% in the regular opioids charted and 83% of the ‘as required’ opioids from 33% and 58% respectively. Age-based compliance with opioids in the initial audit was 72% and 54% for regular and as required opioids respectively improving to 83% and 100% respectively after our intervention. Titration of analgesia occurred in 17% of cases initially, improving to 70% in the re-audit. Laxative prescribed simultaneous with opioids was improved to 93% from a figure of 22% at initial audit.

Our objectives of assessing and improving compliance with the protocol have been met, and we will continue to drive this initiative to contribute to greater patient comfort and reduced levels of distress around their admission.

In an ever-advancing technological world, we have proved that creative use of available resources can be quite effective in implementing change to benefit a vulnerable cohort of patients. Simple measures were taken with minimal effort or time cost to both heighten our colleagues’ awareness and ensure easier access to this important pain protocol. These can easily be replicated for other commonly-used medical or surgical protocols, and we encourage other centres to adopt some of these measures with the aim of reducing patient distress and aiding return to independence and mobility. The lack of funding and resources in our Health Service is a regular topic of discussion throughout our country. It is hoped that our study will stimulate new ideas on utilising available resources to ensure optimal treatment of our patients.

K Clesham1, RP. Piggot1, CG. Murphy1, O. Finnerty2,

 

1Department of Trauma and Orthopaedic Surgery, Galway University Hospital

2Department of Anaesthesia, Galway University Hospital

Correspondence:

Kevin Clesham, Annefield, Hollymount, Co Mayo

Email: kevinclesham@gmail.com

Phone 0861296081

References

  1. National institute for health and care excellence. 1. Hip fracture: management. [Online]. Available from: https://www.nice.org.uk/guidance/cg124/ [Accessed 1 August 2016].
  2. Au foss, N.B, Kristensen, B.B, Bundgaard, M, Bak, M, Heiring, C. Fascia iliaca compartment blockade for acute pain control in hip fracture patients: a randomized, placebo-controlled trial. Anesthesiology. 2007;106: 773.