1. 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 Dr D Neely, Dr M Kanagarathnam, Dr M Satisha Department of Anaesthetics, Darent Valley Hospital, Dartford

2. 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  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

3. NICE Analgesia Recommendations

4. NICE Analgesia Standards: Immediately upon presentation to hospital 100% Within 30 min of administering analgesia 100% Hourly till settled on the ward100% Regularly as part of Routine Nursing Observations 100% Pain should be assessed:

5. NICE Analgesia Standards: Immediate analgesia should be offered, incl. cognitively impaired 100% Analgesia should be sufficient to allow investigations, nursing and rehabilitation 100% Paracetamol should be offered q6h, unless contraindicated 100% Opioids should be offered if insufficient pain relief 100%

6. NICE Analgesia Standards: Adding nerve blocks should be considered if analgesia insufficient or to limit opioid dose 100% Nerve blocks should be administered by trained personnel 100% Nerve blocks must not be used as an alternative to early surgery 100%

7. NICE Analgesia Standards: Paracetamol should be offered q6h post-operatively 100% Opioids should be offered if Paracetamol insufficient post- operatively 100% NSAIDs should not be given100%

8. 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  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

9. Demographics at DVH (n=50)

11. Side Affected by Fracture

12. Assessment of Pain

13. Administration of Analgesia

14. Preoperative Analgesia

15. Preoperative Analgesia: Adequacy

16. 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  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

17. Postoperative Analgesia

19. Findings: What we do well  Prescription of regular Paracetamol, with opioids for breakthrough pain  Avoidance of administration of NSAIDs  Prescription of regular Paracetamol, with opioids for breakthrough pain  Avoidance of administration of NSAIDs

20. 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  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

21. 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?  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?

22. 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) http://www.nhfd.co.uk/003/hipfractureR.nsf/NHFDN ationalReport2011_Final.pdf  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) http://www.nice.org.uk/nicemedia/live/13489/54921/5 4921.pdf  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) http://www.nhfd.co.uk/003/hipfractureR.nsf/NHFDN ationalReport2011_Final.pdf  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) http://www.nice.org.uk/nicemedia/live/13489/54921/5 4921.pdf