By Stuart Grant, MB, ChB, FRCA, Gavin Martin, MB, ChB, FRCA, and Ellen Flanagan, MD – Oct 5, 2016
- Each year, at least 250,000 older people—those 65 years and older—are hospitalized for hip fractures.
- More than 95% of hip fractures are caused by falling, usually by falling sideways.
- Women experience three quarters of all hip fractures.
- Women more often have osteoporosis.
- Fall prevention programs are
important.
When developing a plan to care for elderly patients with hip fractures, amassing a multidisciplinary team is the first step. With all stakeholders present charting the patient’s journey from arrival to discharge, a discussion of all areas of care and opportunities to reduce unwanted variability and improve care can take place.
As anesthesiologists working on the care improvement team, we had heard discussion about the severe pain many of these patients have to endure from arrival in the emergency room (ER) to continuation in other areas such as the X-ray suite, which we do not normally consider. As acute pain specialists with interests in regional anesthesia, we felt we could offer a better quality patient experience if we placed peripheral nerve catheters in these patients as soon as they arrived in the ER. In a previous review, Riddell et al[1] examined the use of femoral nerve blocks in the ER. Both single-shot and catheter techniques have shown benefit by reducing pain scores and opioid consumption. Additionally, reductions in respiratory and cardiac side effects have been noted without any increase in any adverse events.
In collaboration with ER colleagues, we developed a plan to call anesthesiology as soon as a hip fracture was diagnosed. We used an electronic order set, which is triggered by the ER provider when the orthopedic surgeon is called.
The thought of taking on another off-service burden was something that was met with some resistance by a minority of colleagues. We all consider ourselves to be busy all the time, but when we analyzed the total number of patients with hip fractures who are admitted each year, we realized that this was not going to be an overwhelming burden for any individual provider and that it would be a huge benefit to individual patients. The calls would be taken by all providers who covered in-house calls within our institution. Colleagues not on the acute pain service expressed reservations about their ability to actually perform the blocks. To address this issue, we created an education program which was delivered repeatedly to colleagues through didactics and online education. Support was offered to ensure that everyone who might be called to provide this service could comfortably meet the expectations. One of the ways this was done was to provide direct clinical support during weekday calls for these catheters. An acute pain faculty member would accompany a generalist when he or she was placing femoral nerve catheters. In this way, the faculty member could answer questions and provide technical support for this procedure to improve the comfort level and expertise of all anesthesiologists in the department.
In addition, each day our anesthesia technicians ensured that all the equipment necessary was loaded into a bag stored beside the ultrasound machine. The bag contained our peripheral nerve catheter kits, ultrasound gel, consent form (for the nerve block and the surgery the next day), and a check list of all required equipment. Drugs cannot be stocked in the bag per regulations of the Centers for Medicare and Medicaid Services (CMS) and still have to be added from pharmacy before departure for the ER. The stocked bag and checklist minimized inconvenience to the patient as well as off-service providers who have to travel off-site and do not realize what equipment is missing until they arrive in the ER.
