Evaluating and Improving Postoperative Pain Management in Hip Fracture Patients: A Multidisciplinary Quality Improvement Project

Introduction 

Early mobilisation following hip fracture surgery is a key determinant of better health outcomes and reduced mortality. However, high levels of postoperative pain and inconsistent analgesia administration were noted as barriers to mobilisation on our dedicated femoral fracture unit. This quality improvement project aimed to understand pain and analgesia on the unit, and in doing so, target better pain relief to improve outcomes through optimised engagement with therapy. 

Methods 

Baseline data were collected on 26 post-operative patients to assess subjective pain scores (or Abbey Pain Scale where appropriate), pre-operative prescribing bundle adherence, and administration of PRN analgesia. Semi-structured interviews with ward nurses and therapy staff explored barriers to effective pain management and access to PRN analgesia. Using Model for Improvement methodology multiple Plan-Do-Study-Act (PDSA) cycles were undertaken, including a test of change to trial use of a buprenorphine patch, staff education to target prescribing behaviours and nursing workflow optimisation. 

Results 

Initial data showed 30% of patients reported pain ≥8/10 on day one, with poor correlation between pain scores and PRN analgesia administered. Qualitative data revealed key barriers included staff workload, controlled drug (CD) access delays, poor interprofessional communication, and hesitancy around use of stronger opioids. Introduction of a one-off buprenorphine patch resulted in a 20% reduction in day one pain and a 23% reduction on day two. The highest reported pain was 7/10 (vs 10/10 pre-intervention). No significant increase in postoperative delirium was noted. However, PRN administration remained inconsistent despite improvements in pre-op analgesia bundle prescribing and communication strategies. 

Conclusion

 This multifaceted, multidisciplinary quality improvement project has provided valuable insight into understanding pain and analgesia on the hip fracture unit. The project has highlighted focus areas for strategies to reduce postoperative pain. However further work is required to address persistent barriers to PRN analgesia administration and promote sustained prescribing behaviours.