Transcript An Audit of Hip Fracture Analgesia at Darent Valley Hospital

An Audit of Hip Fracture
Analgesia at Darent Valley
Hospital
Dr D Neely, Dr M Kanagarathnam, Dr M Satisha
Department of Anaesthetics, Darent Valley Hospital, Dartford
The Problem
 Est. 70,000 - 75,000 per year in UK
 Pain
 Loss of Mobility
 Loss of Independence
 Hospital Stay
 Mortality: 1/12: 10%; 12/12: 33%
 £2 BILLION per year
NICE Analgesia Recommendations
NICE Analgesia Standards:
Pain should be assessed:
Immediately upon presentation to
hospital
100%
Within 30 min of administering
analgesia
100%
Hourly till settled on the ward
100%
Regularly as part of Routine
Nursing Observations
100%
NICE Analgesia Standards:
Immediate analgesia should be
offered, incl. cognitively impaired
100%
Analgesia should be sufficient to
allow investigations, nursing and
rehabilitation
Paracetamol should be offered q6h,
unless contraindicated
100%
Opioids should be offered if
insufficient pain relief
100%
100%
NICE Analgesia Standards:
Adding nerve blocks should be
considered if analgesia insufficient
or to limit opioid dose
Nerve blocks should be
administered by trained personnel
100%
Nerve blocks must not be used as
an alternative to early surgery
100%
100%
NICE Analgesia Standards:
Paracetamol should be offered q6h
post-operatively
100%
Opioids should be offered if
Paracetamol insufficient postoperatively
NSAIDs should not be given
100%
100%
Audit Method
 Data for all patients admitted to DVH with
fractured NOF (01/09/11 - 23/10/11)
 Review 1-3 days post-op of:
Medical Notes
Hip Fracture Proforma
Nursing notes
Physiotherapy notes
Observation charts
Drug charts
 Collated anonymised data using Excel
Demographics at DVH (n=50)
Male
Female
Cognition Intact
Cognitive Impairment
0
Age (years)
91-95
86-90
81-85
76-80
71-75
66-70
61-65
55-60
F r eq u en cy
Demographics at DVH (n=50)
16
14
12
10
8
6
4
2
Side Affected by Fracture
Left
Right
Assessment of Pain
Immediate Assessment 16%
30 min after Analgesia 2%
Hourly Assessment till
settled on ward 2%
Routine Pain Assessment as
part of Observations 2%
No Pain Assessment 78%
Administration of Analgesia
0-15min 10%
16-30min 18%
31-45min 2%
46-60min 22%
>60min or none 48%
Preoperative Analgesia
Paracetamol 100%
Opioids 100%
Preoperative Analgesia: Adequacy
Sufficient 64%
Insufficient 22%
Unknown 14%
Nerve Blocks
 In total, 12 nerve blocks were performed
(24%)
 All by an anaesthetist perioperatively
 Of the 11 patients known to be in pain,
only 3 received nerve blocks (27%)
 None of the notes suggested that nerve
blocks had been considered
 Nerve blocks were not used as a substitute
for early surgery
Postoperative Analgesia
Paracetamol 100%
Opioids 100%
Postoperative Analgesia
NSAIDs Prescribed 4%
NSAIDs not Prescribed 96%
Findings: What we do well
 Prescription of regular Paracetamol,
with opioids for breakthrough pain
 Avoidance of administration of NSAIDs
Findings: What needs Improvement
 Pain Assessment
 Administration of analgesia on admission
 Consideration of nerve blocks
 Early delivery of nerve blocks to patients
who have insufficient analgesia from
Paracetamol / Opioids
Recommendations
 Education re: need for regular pain
assessments (and incorporation into Hip
Fracture Proforma)
 Education re: need for early analgesia
 Education and Training re: Nerve
Blocks
 Designated Person:
 Acute Pain Service / Anaesthetic SHO
 Orthopaedic Team / Hip CNS
 A+E?
References
 British Geriatrics Society. 2011. The National Hip
Fracture Database.
http://www.nhfd.co.uk/003/hipfractureR.nsf/NHFDN
ationalReport2011_Final.pdf (Accessed 04/01/12)
 National Clinical Guideline Centre. 2011. NICE
Clinical Guideline 124: Hip Fracture: The
Management of Hip Fracture in Adults.
http://www.nice.org.uk/nicemedia/live/13489/54921/5
4921.pdf (Accessed 25/08/11)