Hip Fractures Sustained Through Inpatient Falls Are Associated With Lower Rates of Fascia Iliaca Block Administration and Higher Opiate Requirements: A Single-Centre Experience

TL;DR

Hip fractures occurring during hospital stays are linked to less use of pain-blocking injections and higher opioid use compared to fractures from emergency admissions.

Contribution

This study identifies disparities in pain management and outcomes for hip fracture patients based on admission pathway.

Findings

Only 17% of inpatient hip fracture cases received fascia iliaca blocks compared to 86% of emergency admissions.

Inpatient hip fracture patients had higher opioid requirements and longer hospital stays.

Mortality rates did not differ significantly between the two groups.

Abstract

Background

Hip fractures, also known as neck of femur (NOF) fractures, are a major cause of morbidity in older adults. Effective pain control is essential to minimise opioid-related complications such as delirium. Fascia iliaca blocks (FIBs) provide regional anaesthesia that can reduce opioid requirements. While emergency department (ED) pathways routinely include FIBs for NOF patients, it is unclear whether those who sustain NOFs during inpatient admissions receive comparable care.

Methods

A retrospective case-control study was conducted at a single NHS major trauma centre between January 2019 and December 2020. Patients aged over 60 with radiologically confirmed NOFs sustained during an inpatient stay were compared with age-, sex-, American Society of Anesthesiologists (ASA) grade-, premorbid mobility-, and Abbreviated Mental Test Score (AMTS)-matched controls admitted via the ED, irrespective of FIB status. Primary outcomes were administration of a FIB and 24-hour opioid use (oral morphine equivalent dose). Secondary outcomes were postoperative delirium, postoperative length of stay, and all-cause mortality at 30 days and one year.

Results

Of 4026 inpatient falls, 36 resulted in NOFs (3% of all NOFs during the study period (36/1182)). Only 17% (6/36) of inpatients received a FIB compared with 86% (988/1146) of ED-admitted patients (P<0.001). Patients who received a FIB had significantly lower 24-hour opioid requirements (mean 17.3 mg vs. 35.4 mg oral morphine equivalent doses (OMED); P=0.037). Postoperative delirium occurred in 20% of non-FIB patients versus 11.9% in the FIB group (P=0.347). Mean postoperative length of stay was longer for inpatients than for matched ED controls (41.5 vs. 15.2 days; P=0.01). Mortality at 30 days and one year did not differ significantly between groups.

Conclusions

Inpatients sustaining NOFs were markedly less likely to receive a FIB than ED-admitted patients and had higher opioid requirements and longer hospital stays. These findings highlight a disparity in pain management between inpatient and ED pathways and support the development of hospital-wide protocols to ensure timely regional anaesthesia for all NOF patients.

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