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.

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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

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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

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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

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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

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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

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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

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Footnote to go here Page 12

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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

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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

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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.

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Fascia Iliac Blocks (FIB)

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• 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

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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

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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

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Pain in the Elderly Working Party

Clinical Audit Results 2011 - 2014

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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

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Emergency Department

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Fascia Iliaca Blocks

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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

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• 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

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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

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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

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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

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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.

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