Elizabeth Harper - St Vincent’s Hospital Sydney - Development of Fascia Iliaca Blocks and...
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Transcript of Elizabeth Harper - St Vincent’s Hospital Sydney - Development of Fascia Iliaca Blocks and...
Improving Pain Management in Elderly Patients With
Traumatic Injuries Including Neck of Femur Fracture
St Vincent’s Hospital, Sydney
Dr Elizabeth Harper
SVH Pain Team Members
Associate Professor Steven Faux (Chair, Working Party)
Dr Melinda Berry (Staff Specialist, Emergency Department)
Dr Jennifer Stevens (Visiting Anaesthetist)
Dr Elizabeth Harper (SS, Geriatric Medicine)
Julie Gawthorne (CNC, Emergency)
Jacqueline Jensen (CNC, Chronic Pain)
Karon McDonell (CNC, Trauma)
Susan Welch (Pharmacist)
Melissa O’Brien (Quality Manager, CPI)
Dr Julia Nelson (Orthogeriatric Reg, 2011) initiated the first Pain in the Elderly Clinical File Audit
Evidence that the problem is worth
solving
International
• #NOF patients : 50-70% very severe pain in the first 24 hrs1
• Under-treated pain can increase delirium2
NSW Health
• NSW Health Patient Satisfaction Surveys- Pain consistently rated as an area for
improvement
• ACI Aged Care and Pain Network
• NSW Pain Management plan 2012-2016
1 Orosz GM et al. JAMA 2004 2 Morrison et al. J Gerontol A Biol Sci Med Sci 2003
A Local problem
• 2011 Pain in the Elderly Audit (72hrs) by Dr Julia Nelson
• Found a wide variation of analgesia used
• Variation of analgesia given in the ambulance
• Poor adherence to pain guidelines
• Low rates of regular analgesia prescribing
• Poor documentation of pain and of response to analgesia
• Only small numbers received nerve blocks
• Patients who received Paracetamol and Oxycodone in Emergency were less
likely to suffer a delirium
• Patients who received Morphine in Emergency were more likely to
experience delirium.
• Delirious patients experienced less opioids during their stay, significant at 24
to 48 hours.
Page 4
A local problem
• Two Root Cause Analysis (2011) involving elderly patients who
suffered fractures with pain management recommendations.
• Case 1: an 83 year old residential care patient
• Morphine prescription was written without supervision or
consideration for patient’s age, weight and renal function.
• Large doses given in nursing home and ambulance not taken
into account
• Case 2: 91 year old from home
• Periods of no analgesia which increased the amount of
analgesia subsequently given
Page 5
Recommendations
• Develop and implement guidelines for pain assessment and
management of the elderly patient.
• Guidelines to address
• age-related pain assessment tools,
• age-related changes in drug sensitivity, efficacy, metabolism and
side effects
Page 6
Pain in the elderly
• Often poorly managed1,2
• Lack of assessments, polypharmacy, co-morbidities
• Fear of adverse effects of analgesia
• May have behavioural changes or confusion when in pain
• Different pain perceptions and response to analgesia
• Age induced physiological changes.
• Age related 2 to 4 fold decrease in opioid requirements with age3
• Percentage of PRN analgesic dose declines with age1
• Important that medications be prescribed regularly in older patients
Page 7
1 Morrison R et al. Journal of Pain and Sympt Mx. 2000;19 2 Mehta S et al. Pain Medicine:Pain and Aging ection 2010; 11 3 Macintyre P et al. Acute Pain Management: Scientific Evidence 2010
Hip Fractures Are Painful
• Patients who experience greater pain are at a higher risk of delirium1
• Slower to mobilise, longer hospital stay and poorer health related quality of
life2
• Pain increases the surgical stress response3
• Contributing to the morbidity and mortality in fragile patients
• Cognitively intact patients with untreated pain are more likely (9x) to develop
delirium than those whose pain is adequately treated4
• Undertreated pain is a risk factor for delirium in frail older adults4
Page 8
1 Abou-Setta AM. Annals of Internal Medicine 2011;155 2 Morrison RS. Pain 2003;103;303-11 3 Griffiths R et al . Acta Anaesthesiol Scand 2010; 54:661-62 4 Morrison RS et al. J Gerontol A Biol Sci Med Sci 2003
Establishing Best Practice
Guidelines pain assessment and
management elderly patients with fractures
Establish referrals pathways
Clinical Education Package
Developed
Ongoing Pain Assessment
documentation tools
Clinical Audit Process
established
Patient Outcomes/ pain
monitored
Patient education Package
developed
Within 12 months
100% of elderly
patients (>70 years)
with fractures will have
best practice pain
assessment and
management
Best Practice
• Use multimodal analgesia1
• Paracetamol administration every 6 hours1,3
• NSAIDS not recommended1,3
• If Paracetamol does not provide sufficient, additional opioids
recommended1
• No benefit for use of preoperative traction5
• Nerve blocks to reduce preoperative pain2,6
Page 10
1 NSW ACI. Minimum Standards for Management of Hip Fracture in Older persons 2014 2 Abou-Setta AM et al. Annals of Int Med 2011;155 3 Mak JCS et al. MJA 2010; 192 4 NCGC. The Management of Hip Fracture in Adults, London 2011. 5 Handoll HHG et al. Cochrane Database 2011. 6 Parker, M.J et al. Cochrane Database 2009.er
Procedure: SVH Pain Assessment &
Management for Elderly Patients with Traumatic
Injuries
Safe and effective best practice preoperative pain assessment and management
• Elderly over 75 years
• Development of a flow chart
• Review and consider analgesia prior to hospital
• Pain assessment documented
• On admission, post administration of pain relief and according to nursing care
plan
• More frequently if poorly controlled pain or treatment interventions changed
• Pain scales
• Verbal Numerical Rating Scale
• Abbey Pain Scale in patients with dementia
Page 11
Footnote to go here Page 12
Page 13
Key points
• Attend physical assessment ie Vital signs
• Regular assessments of pain and sedation scores
• Fascia Iliac Blocks as part of the pathway for fractured neck of femur
patients
• Regular Paracetamol
• Regular analgesia
• Regular Coloxyl and Senna
• Referral to acute pain team if any concerns
Page 14
Procedure: SVH FIB for Perioperative Pain
Management in Adults with Fractured Neck of
Femur
Safe and effective best practice pre-operative pain relief through administration
of Fascia Iliac Blocks for suspected or confirmed Fracture Neck of Femur.
• Consider in proximal to mid shaft fractured femurs
• Initiated as soon as suspected
• Exclusion
• Anticoagulants (warfarin with INR>1.4), Clopidogrel, Low Molecular
Weight Heparin <12 hrs, Heparin <6 hours or clotting disorders.
• Meet any of the Ropivacaine contraindications (allergy, infection at site,
pregnant or lactating, severe hepatic disease, Amiodarone therapy,
second or third degrees heart block on ECG
• Previous sensitivity to local anaesthetics
• Previous vascular surgery of effected limb
• Unable to identify femoral artery
Page 15
Who can perform?
• Anaesthetists
• Supervised Anaesthetic and Pain
Fellows who have demonstrated
competency
• Emergency Staff Specialist and
Supervised ED Registrars who have
demonstrated competency
• Emergency Department Clinical Nurse
Specialist 2 (CNS2) and Clinical
Initiatives Nurses (CINS)who have
demonstrated competency are permitted
to initiate without a medical officers
order.
Page 16
Fascia Iliac Blocks (FIB)
Page 17
• 2 operator procedure to ensure safe patient
care.
• Monitoring- ecg, blood pressure monitor,
pulse oximeter
• Ultrasound guided (held in non-dominant
hand)
• Provide patient education
• Regular pain assessment
• Failed block= pain score not decreased by
30% within 40 min
• Re administer block when no longer
effective (approx 6-8 hours)
Nerve Blocks
• Superior for the relief of acute pain of hip fracture compared to standard care1, 4
• Pre and postoperative pain reduced2
• Reduce need for systemic analgesics1
• Shortened hospital length of stay1
• Accelerated patient rehabilitation and recovery3
• Reduced Incidence of Delirium1,4
• Especially in high risk3
Page 18
1 Abou-Setta et al. Annals of Internal Med 2011;155 2 Fujihara et al. J Orthop Sci 2013;18 3 Halaszynski . Current Opinion in Anaesthesiology 2009; 22 4 Rashiq et al. Canadian J Amesth 2013; 60
Fascia Iliac Blocks (FIB)
• Relatively newer block
• Has been found to give superior or equal pain relief to old blocks1,2
• Multiple audits and trials show safe in Emergency1,3
• Even when given by junior doctors that are taught well4.
• Ropivacaine safe and effective with minimal side effects or
complications5
• Ultrasound guidance improves efficacy of FIB6
Page 19
1 Chesters A et al. Emerg Med J .2014; 31 2 Reavley P et al. Emerg Med J 2015;32 3 Beaudoin FL et al. Academic Emergency Medicine 2013; 155 4 Hanna L et al. ISRN Orthop. 2014; 2014 5 Bleckner LL et al Regional Anaesthesia 2010; 110. 6 Dolan J et al. Regional Anesth and Pain Medicine 2008; 33
• Provided education and training on wards and emergency
• Development
• Documentation tools
• Established and implemented FIB education and credentialing package
• Procedure video
• FIB insertion sticker
• Patient information brochure
• Conducted a Clinical Audit
Page 20
Pain in the Elderly Working Party
Clinical Audit Results 2011 - 2014
Page 21
Elderly
Patients #
NOF
2011 2013 2014
Average
Age
72 years 82 years
(median 83 years)
87 years
(median of 86 years)
Females 79% (n=30) 59% (n=22) 70% (n=21)
Orthogeri 100% (n=38) 86% (n=32) 83% (n=25)
ALOS Ranged 2 - 30 days
Median of 12 days
Ranged 0 – 45 days
Median of 10 days
Ranged 1 – 37 days
Median of 10 days
Confusion /
delirium
45% (n=17) Not measured 33% (n=10)
Analgesia Prior to ED
Page 22
Emergency Department
Page 23
Fascia Iliaca Blocks
Page 24
2013 2014
Met FIB
criteria didn’t
receive FIB
90% (n=9) 64% (n=7)
Staff
Specialist
5% (n=1) ↑ 22% (n=4)
FIB inserted 73% (n=27) ↓ 60% (n=18)
Time to FIB 259 mins ↑ 313 mins
2nd FIB 7% (n=5) ↑ 28% (n=5)
Post Operative Analgesia
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Pain Assessments
Page 26
• Improvement in pain assessments post operatively on return
to the ward from only 29% (n=8) in 2013 to 84% (n=21) in
2014
• 40% (n=12) of patients were recognised as having dementia,
however only 2 patients were assessed using APS in 2014.
Where to from here?
• Reaudit July – Oct 2015
• monitoring average pain of patients who receive FIB
• Increase FIB rate (85% of appropriate #NOF patients) through:
• Regular 6 monthly FIB training
• Highlighting no need to wait for X-ray confirmation
• Increase number of pre and post analgesia pain assessments
• Use of Abbey pain scale for confused patients
• Conduct Surgical registrar training on pain assessment and management
• Investigate 2nd FIB issues including improving ED referral to Acute Pain
Service
• Development of pathways for the management of neuropathic pain in the
elderly
Footnote to go here
Page 27
Ongoing Success
• Improvements in a Vital signs audit report
• Significant increase in respiratory rate observations from 92% to 99% and pain
assessments from 69% to 86% over 6 months.
• NSW ambulance reviewed their pain management protocol
• In patients > 65 years age, analgesics must be halved
• Medicine administered and response on record and communicated in clinical
handover
• Use of ABBEY pain scale
• Development of NSW ACI Implementation Toolkit for Fascia Iliaca Blocks in
Acute Hip Fracture in the Older Person
• Implementation guide and Explanatory notes
• Video material of how to conduct procedures
• Competency and training materials. Audit tool
Page 28
Page 29
NSW Agency For Clinical Innovation Minimum
Standards for the Management of Hip Fracture in
the Older Person (2014)
• Pain assessment
• Upon presentation
• Within 30 minutes of initial analgesia
• Hourly until settled on ward
• Regularly as part of routine nursing observations
• Patient self reporting pain is gold standard
• Cognitively impaired patients use non verbal cues
Page 30
NSW ACI Minimum Standards for the
Management of Hip Fracture in the Older Person
(2014)
• Pain regime
• Multimodal pharmacological pain management
• Should commence in Emergency department
• Be regular
• Sufficient to allow movement for preoperative investigation (passive
external rotation of leg)
• Paracetamol every 6 hours preoperatively
• Additional opioids if required
• Femoral Nerve blocks if analgesia not providing sufficient relief
• NSAIDS and traction not recommended
Page 31
Recommendations
• The National Clinical Guidelines Centre (2011 London) recommends
the use of nerve blocks preoperatively
• The National Health and Medical Research Council (NHMRC)
Guidelines recognise that a nerve block is an effective method of
pain relief for hip fractures in the emergency department and is
useful for post operative care.
Page 32