None listed
Conditions
Brief summary
Fractured neck of femur (#NOF) is a common, painful condition in the elderly for which regional nerve block (RNB) techniques provide effective and safe analgesia. Presently, RNBs are administered by doctors, usually later in the patient journey. RNB via Fascia Iliaca Nerve Block (FIB) has been demonstrated to be safe and effective when administered by trained nurses. We hypothesise that early, nurse-initiated FIB (ENI FIB) can be successfully introduced and sustained within a tertiary level Emergency Department (ED) and can be generalised to a regional ED. We aim to demonstrate that ENI FIB can be delivered to a higher proportion of eligible patients than current practice, is at least equi-analgesic and equivalently safe with standard medical RNB, and can be delivered significantly earlier than medically-initiated RNB. In the preparatory phase, data will be collected regarding current RNB/analgesic therapy whilst a core nurse FIB operator group is trained at RNSH. Subsequently the implementation phase will begin in early 2017 where ENI FIB will be introduced as the preferred RNB for #NOF. Data will be collected regarding enrollment rates, safety, pain levels and times to analgesia. Gosford ED will follow the protocol six months behind RNSH with implementation taking place in May 2017. After twelve months, ENI FIB will be re-evaluated at both sites with respect to embeddedness, safety and effective practice. The Implementation Package will be refined as indicated. Potential benefits are that significantly more patients with #NOF will have access to effective, safe and early pain relief. We aim to demonstrate that this model of care is generalisable to another ED whilst yielding similar positive clinical outcomes. Assuming adoption and sustainability of ENI FIB at both sites, there is potential to roll out a standardised, proven ENI FIB program across a large number of the State’s EDs in an economical fashion, utilising a ‘train the trainer’ model and our refined Implementation Package.
Interventions
Implementation study examining nurse-led and nurse administered Fascia Iliaca (femoral nerve) Blocks for pain management of #NOF among elderly patients in the Emergency Department. Importantly, this is purely observing the efficacy of nurse lead Fascia Iiliaca Blocks, which is being implemented into Royal North Shore Hospital, regardless of this study.
Trained senior nurses will administer 80 mg of Ropivacaine as soon as practicably possible after a patient is triaged and deemed likely to have a
Implementation study examining nurse-led and nurse administered Fascia Iliaca (femoral nerve) Blocks for pain management of #NOF among elderly patients in the Emergency Department. Importantly, this is purely observing the efficacy of nurse lead Fascia Iiliaca Blocks, which is being implemented into Royal North Shore Hospital, regardless of this study. Trained senior nurses will administer 80 mg of Ropivacaine as soon as practicably possible after a patient is triaged and deemed likely to have a #NOF, ideally within one hour of presentation. Nurse training will be a) one full day didactic and practical session at the Medical Simulation Centre in the Kolling Institute b) a minimum of four quarter-yearly three-hour didactic and practical sessions in the Emergency Department. Following the minimum attendance, further quarter yearly practical sessions will continue to be held for new Nurses wishing to partake in the study, as well as any Nurses who feel as though they need more practical sessions before performing a supervised block on a real patient. c) all nurses need to perform a minimum of three procedures under the direct supervision of an ultra-sound qualified Senior Staff Specialist d) the training will be co-ordinated by an ultra-sound qualified Senior Staff Specialist When a nurse operator has been credentialed to perform ENI-FIB autonomously and have done a minimum of ten successful procedures, they will be credentialed to train other nurses who have undergone the didactic/practical sessions listed above. The anticipated start date for the Gosford ENI-FIB session will be May 10 2017. Strategies used to monitor the adherence to the intervention include continuous logging of all procedures and continuous scrutiny of the effectiveness of the blocks and of any implementation issues, safety issues, or other issues as part of the bi-weekly steering group meeting. Evaluating the sustainability of the implementation is a core focus of the study and will be undertaken at the end of the study by comparing data on rates of ENI-FIB at the commencement and at the end of the study term. Small-scale follow-up will enquire into recovery rates after surgical repair and discharge to home.
Sponsors
Royal North Shore Hospital
Eligibility
Sex/Gender
All
Age
65 Years to No maximum
Healthy volunteers
No
Inclusion criteria
Patients over the age of 65 years who have a suspected #NOF and who consent to a nurse-initiated Fascia Iliaca Block
Exclusion criteria
Absolute Contraindications • Inability to cooperate with procedure • Medical or behavioural reasons (agitation, dementia, etc) • Known allergy to local anaesthetics • Any Ropivacaine contraindications • Adult that weighs less than 40kg • Localised injection site infections • Inability to identify the femoral artery with ultrasound Relative Contraindications • Documented hepatic disease • Known bleeding problems • Documented evidence of second or third-degree heart block on ECG (unless patient has a personal pacemaker) • On anticoagulants
Outcome results
None listed