Pain Management in Geriatric Hip Fracture Patients - Are There Barriers to Performing Ultrasound Guided Femoral Nerve Blocks?

Abstract

Ultrasound-guided femoral nerve blocks (UGfNB) are an effective alternative to opiates for hip fractures, yet few are performed in the Emergency Department (ED). To augment implementation of UGfNB at our institution, we used convergent, parallel mixed-methods approach to explore barriers to closing this evidence-to-practice gap. Considering all the stakeholders for UGfNB, we started by recruiting emergency medicine physicians and residents practicing in a large academic medical center to discuss barriers and facilitators to UGfNB adoption. Guided by the Consolidated Framework for Implementation Research, we developed an interview guide for our qualitative (focus group) and quantitative approach (survey). To develop comprehensive understanding, we distributed the quantitative survey to focus group participants regarding current practice, knowledge, and attitudes regarding UGfNB. This data was entered into Redcap®, anonymized, and collated for thematic analysis to supplement our focus group data. Twenty-two physicians participated in the quantitative survey. All participants reported weekly or monthly exposure to geriatric hip fractures yet only 27% (N=6) ever performed UGfNB. The most difficult aspect of controlling pain in geriatric hip fractures was that "typical IV/PO medicines have a lot of negative side effects" and that "the effects of pain control methods do not last long enough" thus requiring "frequent reassessments". Strong influencers of UGfNB included supportive hospital policy and multi-specialty agreement. Most (64%) reported that UGfNB offers "superior pain control, are safe, and have fewer side effects". Respondents were least comfortable with ultrasound anatomy, including identifying the femoral nerve and fascia iliaca. The most cited barriers to performing UGfNB in the ED were "too much time to perform" and "lack of procedural comfort". Though advantages for UGfNB exist in the ED, only a minority of physicians perform them in geriatric hip fractures. We identified barriers and facilitators towards implementation that serve as context for more in-depth focus group discussion.