Abstract
Introduction
Neck of femur (NOF) fractures in older adults result in significant morbidity, delayed mobilisation, and increased opioid exposure. Effective, early analgesia is essential for preoperative optimisation and enhanced recovery. Fascia Iliaca Block (FIB), especially when performed under ultrasound guidance (USS), offers targeted pain relief. This quality improvement project (QIP) aimed to increase adherence to RCEM guidelines on ultrasound use for FIB, thereby improving perioperative analgesia.
Methods
A closed-loop audit was conducted over two cycles (Cycle 1: November to December 2023, Cycle 2: February to March 2024) in the Emergency Department. Data was collected using FIB audit sheets, documenting the technique used (Landmark, USS infra-inguinal, or USS supra-inguinal), pain score changes using the Numeric Rating Scale (NRS), opioid usage before and within 24 hours post-FIB, and documentation completion. Interventions included structured teaching and visual prompts to promote USS-FIB.
Results
The overall FIB success rate improved from 76% in Cycle 1 to 82% in Cycle 2. Ultrasound-guided infra-inguinal FIB was the most commonly used technique and maintained the highest success rate (91%). Supra-inguinal FIB showed reduced success in Cycle 2 (71%), likely reflecting early-stage adoption. Landmark technique use declined substantially, with only four patients in Cycle 2, limiting meaningful comparison. Opioid use before FIB remained highest in Landmark cases and lowest in supra-inguinal. Post-FIB PRN opioid use was lowest in the USS supra-inguinal group across both cycles, suggesting sustained analgesia despite reduced success scores in Cycle 2. Exclusions due to missing documentation fell from 23% to 15%, reflecting improved data quality.
Conclusion
This initiative underscores the importance of proactive pain management strategies in the perioperative care of older surgical patients. Teaching interventions and environmental prompts increased USS-FIB adoption and improved clinical and documentation outcomes in patients with NOF fractures.