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Evidence to Improve Care


Multimodal Analgesia

Patients with suspected hip fracture have their pain assessed within 30 minutes of arriving at hospital and managed using a multimodal approach, including consideration of non-opioid systemic analgesics and peripheral nerve blocks.

For patients who have experienced a hip fracture, pain is one of the main physiological and psychological stresses. A patient’s pre–hip fracture pain medications should be reviewed (as applicable) to assess the need for continuation or substitution while in hospital.

Opioids are effective at relieving acute pain; however, they are associated with side effects including confusion, vomiting, constipation, sedation, and respiratory depression. It is important to consider the use of multimodal analgesia to reduce dose-dependent opioid-related side effects. Nonnarcotic systemic analgesics, such as acetaminophen and nonsteroidal anti-inflammatory drugs (if not contraindicated), and peripheral nerve blocks, such as a fascia iliaca or femoral nerve block, can improve pain control, reduce postoperative delirium, and reduce overall opioid requirements. Peripheral nerve blockade should be performed by medical practitioners with appropriate training, with consideration of the benefits and risks of the procedure, and with an explanation of the procedure to the patient.

Choice of Anaesthesia

Patients undergoing hip fracture surgery receive either neuraxial or general anaesthesia. As current evidence suggests that the two modalities are equivalent for most outcomes, the choice of anaesthesia should be made based on patient characteristics and, where possible, in consultation with the patient and family or caregivers. Neuraxial anaesthesia may be contraindicated for patients on anticoagulation medication; surgery should not be delayed if general anaesthesia is an acceptable option.

For Patients

Your pain should be assessed and treated promptly upon arriving at the emergency department. Various pain relief treatments should be considered, including non-opioid treatments.

For Clinicians

If you suspect that a person has a hip fracture, ensure that their pain is immediately assessed and managed. If the patient needs opioids, consider augmentation with non-opioid systemic analgesics and/or a peripheral nerve block to reduce the opioid dosage needed to manage the patient’s pain.

For Health Services

Ensure that systems, processes, and resources are in place to assist clinicians with the rapid assessment of pain in the emergency department. Ensure that appropriate training and resources are available for clinicians such that all can become competent at inserting and initiating peripheral nerve blocks.

Process Indicators

Percentage of patients with suspected hip fracture whose pain is assessed within 30 minutes of arrival at hospital

  • Denominator: total number of patients presenting to hospital with suspected hip fracture

  • Numerator: number of people in the denominator whose pain is assessed within 30 minutes of arrival at hospital

  • Data source: local data collection

Percentage of hip fracture patients with an order for opioids who do not also receive non-opioid systemic analgesia or a nerve block

  • Denominator: total number of adults admitted to hospital with a primary diagnosis of fragility hip fracture with an order for opioids

  • Numerator: number of people in the denominator who do not receive non-opioid systemic analgesia or a nerve block

  • Data source: local data collection

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