Fascia Iliaca Block (FIB) - Why Develop a Competency Programme for Nurses?
Background
Dr A Blackburn – Pain Nurse Specialist, Dr MK Varma – Consultant Anaesthetist
Dr H Dawson – Consultant Anaesthetist
Royal Victoria Infirmary, Newcastle upon Tyne
Approximately 550 patients are admitted per year to our hospital with
#NOF; the incidence is expected to rise along with the attendant costs to
acute and on-going care. Unrelieved pain not only has physiological
consequences with significant effects on mortality and morbidity but is
unacceptable due to humanitarian reasons.
Patients admitted with # neck of femur (NOF) are typically elderly and frail
with multiple co-morbidities. There is usually a history of trauma, and
generally the fracture is displaced and unstable and can cause
considerable pain.
The Next Phase
Audit revealed that at best 50% of this patient group received the
desired block. Having identified the advantage of using FIC, it
became apparent that we needed to train additional practitioners
to perform a regional block. Registered anaesthetic / recovery
nurses and ODPs were chosen.
Baseline audits:
Review basic analgesia
Review administration
Introduce FIB
Why anaesthetic / recovery Teams?
Audit
FIB trials
Development of protocol
Still only targeting 50% of
potential patients
An audit in 2007 identified that patients admitted with #NOF experienced
severe pain pre-op and 6-12hrs post-op when the local anaesthetic block
given at the time of surgery wore off. Only half had morphine prescribed,
and less than a third received morphine post-op.
A further audit in 2009 revealed that severe pain was again experienced
pre-op and at 12 hours post-op. All analgesic groups were prescribed, but
again only one third of patients received morphine.
Our experience shows that #NOF causes significant pain which can be
difficult to manage in this group of patients. Opioid use and under-treated
pain have been shown to increase the incidence of delirium 1 and slow
postoperative mobilisation and recovery 2. The safety and utility of
regional nerve blocks for the relief of trauma and postoperative pain is
very well established and validated in medical practice. An appropriate,
safe and easily executed nerve block for #NOF is FIB. There is good
evidence that FIB results in fast, effective analgesia and significantly
reduces the cumulative doses of opioids in patients with #NOF 3,4,5,6.
Introduction of Fascia Iliaca Catheter (FIC)
Identify need for nursing
role development:
Competency assessment
agreed
PGDs approved
FIC was trialled Nov 2011 – Apr 2012, and demonstrated improved
comfort without impact on post-operative management. Opioid
consumption decreased. Nursing staff expressed greater ease with
performing cares.
However there was variability in offering the service due to the limited
number of clinicians who could perform the block. Audit identified that
despite intensive education, inclusion of FIC on the fast track pathway of
#NOF management, and an increased number of clinicians available to
perform the block we still only targeted 50% of patients admitted with
#NOF.
Nurses have been performing FIB for a number of years,
traditionally pain nurse specialists on wards. However we elected
to develop an alternative service using anaesthetic / recovery
teams because they are available 24/7 and can provide a service
to all patients admitted with #NOF. Importantly they can be
trained and supervised by experienced anaesthetists.
Selection of nurses
2 yrs post-reg experience
Working in
anaesthetic/recovery
minimum 6mth
5 per intake
Educational sessions
provided
10 supervised blocks
culminating in competency
A course of educational sessions was developed, culminating in a
practical session of ultrasound use and U/S guided block in fresh
cadavers.
The nurses/ODPs are expected to undertake 10 supervised
blocks, and after this time if competency is achieved they are
permitted to perform FIB unsupervised.
Revised #neck of
femur protocol
Fast-track from A&E
via block room
A comprehensive protocol standardises
management of this patient group.
the
expected
Re-audit analgesia use and pain
scores of patients admitted with #NOF
Outcomes
Successful introduction of
the programme
Growing pool of expertise
Improved pain scores
Standardised approach to FIB
Ultrasound guidance to increase efficacy of
FIB
Growing pool of competent staff to provide
24/7 cover, currently targeting more than
50% of #NOF population
The NOF fast-track from A&E to ward includes referral to the
block room for FIB ideally within 2 hours of admission.
Future Work
Comprehensive educational package
Improved analgesia for frail elderly group,
avoiding opioids
Role Development
A competency based assessment was developed by the
consultant anaesthetists and the acute pain service, incorporating
knowledge of consent, technique, the drugs used and PGDs, plus
professional approach.
Key Points
FIB included in #NOF fast-track
FIB as a single shot technique has been endorsed by the AAGBI 9
for delivery by non-medical healthcare practitioners. The
technique involves the introduction of a regional block needle in
the upper thigh under ultrasound guidance and subsequent
injection of local anaesthetic solution in the fascia iliaca plane to
anaesthetise the femoral and adjacent nerves which supply the
hip joint. Analgesic effect from a single injection usually lasts
between 8 to 12 hours, but may be present for up to 24 hours10.
FIB is simple, fast acting, reliable and safe as the position of the
injection site is at a distance from the femoral artery. Ultrasound
guidance improves the target and efficacy of FIB.
Approval was granted by the role development group within the
Trust.
References
1. Morrison et al, Relationship between pain and opioid analgesics on the development of delirium following
hip fracture. Journal of Gerontology, 2003, Vol. 58A, No. 1, 76-81.
2. Morrison et al, The impact of post-operative pain on outcomes following hip fracture. Pain, 2003, 103, 30311.
3. Finlayson & Underhill, Femoral nerve block for analgesia in fractures of the femoral neck. Archives of
Emergency Medicine, 1988, 5, 173-6.
4. Haddad & Williams, Femoral nerve block in extracapsular femoral neck fractures. The Journal of Bone and
Joint Surgery, Nov 1995, Vol. 77-B, No.6, 922-3.
5. Fletcher, Rigby & Heyes, Three-in-one femoral nerve block as analgesia for fractured neck of femur in the
emergency department: A randomized, controlled trial. Annals of Emergency Medicine, Feb 2003, 41:2, 22733.
6. Kullenberg et al, Femoral nerve block as pain relief in hip fracture. A good alternative in perioperative
treatment proved by a prospective study. Lakartidningen, June 2004, Vol. 101, No. 24, 2104-7.
7. AAGBI RA-UK Fascia iliaca blocks & non-physician practitioners position statement 2013.
8. British National Formulary (2014) BMJ Group, London
Successful introduction of competency
based assessment
Providing a nurse led service will deliver a high standard of care
to patients as expertise can be developed and accumulated. The
presence of a dedicated group of staff will be able to prioritise the
administration of FIBs – single shot technique not catheter
placement, and the net result will be more patients receiving
effective analgesia.
Why FIB?
A hip fracture fast-track proforma was developed which included initiation
of analgesia and referral for FIC whilst in A&E. National Hip fracture
Database report (2013)7 in response to NICE guidance (2011) 8 quality
standard 16 advocates prompt and effective pain management.
A protocol was developed advocating the pre-operative placement of a
catheter within a few hours of admission by the on-call anaesthetic team,
and 12hrly injection of levobupivacaine by the acute pain service/ on-call
team. This could be continued post-op if deemed appropriate by the
anaesthetist.
Traditionally nerve blocks are performed by doctors in
anaesthesia or A&E. The majority of patients with #NOF are
admitted out of hours. Trainee doctors who invariably would
perform this procedure are transient in the hospital, and the time
and resources required to train and monitor such a group is a
sizeable undertaking and not always feasible. The A&E doctors or
on-call anaesthetists have duties which take priority over what
can be a time consuming technique, and frequently are not
available at the time of admission.
Re-audit Jan 2015
One year after 1st cohort
Audit outcomes and satisfaction of
competency based programme
Continue to roll out programme, and
develop round the clock provision of
FIB, ultimately targeting 100% of #NOF
population
Review time from admission to block,
duration of FIB, and if further block
required. Consider the need to develop
the role further to include catheter
placement