Fracture in the Elderly Multidisciplinary Rehabilitation (FEMuR): study protocol for a phase II randomised feasibility study of a multidisciplinary rehabilitation package following hip fracture

Objective: To conduct a rigorous feasibility study for a future definitive parallel-group randomised controlled trial (RCT) and economic evaluation of an enhanced rehabilitation package for hip fracture.Setting: Recruitment from 3 acute hospitals in North Wales. Intervention delivery in the community.Participants: Older adults (aged ≥65) who received surgical treatment for hip fracture, lived independently prior to fracture, had mental capacity (assessed by clinical team) and received rehabilitation in the North Wales area.Intervention: Remote randomisation to usual care (control) or usual care+enhanced rehabilitation package (intervention), including six additional home-based physiotherapy sessions delivered by a physiotherapist or technical instructor, novel information workbook and goal-setting diary.Primary and secondary outcome measures: Primary: Barthel Activities of Daily Living (BADL). Secondary measures included Nottingham Extended Activities of Daily Living scale (NEADL), EQ-5D, ICECAP capability, a suite of self-efficacy, psychosocial and service-use measures and costs. Outcome measures were assessed at baseline and 3-month follow-up by blinded researchers.Results: 62 participants were recruited, 61 randomised (control 32; intervention 29) and 49 (79%) completed 3-month follow-up. Minimal differences occurred between the 2 groups for most outcomes, including BADL (adjusted mean difference 0.5). The intervention group showed a medium-sized improvement in the NEADL relative to the control group, with an adjusted mean difference between groups of 3.0 (Cohen's d 0.63), and a trend for greater improvement in self-efficacy and mental health, but with small effect sizes. The mean cost of delivering the intervention was £231 per patient. There was a small relative improvement in quality-adjusted life year in the intervention group. No serious adverse events relating to the intervention were reported.Conclusions: The trial methods were feasible in terms of eligibility, recruitment and retention. The effectiveness and cost-effectiveness of the rehabilitation package should be tested in a phase III RCT

Can emergency nurses safely and effectively insert fascia iliaca blocks in patients with a fractured neck of femur? A prospective cohort study in an Australian emergency department

Aims and objectives To compare the effectiveness and safety of ultrasound-guided fascia iliaca block (FIB) insertion in patients with fractured neck of femur by trained emergency nurses with insertion by doctors. Background The FIB is an effective and safe form of analgesia for patients with hip fracture presenting to the emergency department (ED). While it has traditionally been inserted by medical doctors, no evidence exists comparing the effectiveness and safety of FIB insertion by nurses compared with doctors. Design A prospective cohort study. Methods The study was conducted in an Australian metropolitan ED. Patients admitted to the ED with suspected or confirmed fractured neck of femur had a FIB inserted under ultrasound guidance by either a trained emergency nurse or doctor. A retrospective medical record audit was undertaken of consecutive ED patients presenting between January 2013–December 2017. Reporting of this study followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for cohort studies. Results Of the 472 patients eligible for a FIB, 322 (68%) had one inserted. A majority were inserted by doctors (n = 207, 64.3%) with 22.4% (n = 72) by nurses and in 13.3% (n = 43) of patients the clinician was not documented. There were no differences between the nurse-inserted and doctor-inserted groups for mean pain scores 1 hr post-FIB insertion; clinically significant reduction (≥30%) in pain score 1 hr post-FIB insertion; pain score 4 hr post-FIB insertion; delirium incidence; opioid use post-FIB insertion; or time to FIB insertion. No adverse events were identified in either group. Conclusion Insertion of FIBs by trained emergency nurses is as effective and safe as insertion by doctors in patients with fractured neck of femur in the ED. Senior emergency nurses should routinely be inserting FIB as a form of analgesia for patients with hip fracture. Relevance to clinical practice Our study showed trained emergency nurses can safely and effectively insert fascia iliaca blocks in patients with hip fractures. Pain was significantly reduced in a majority of patients with no reported complications. Emergency nurses should be trained to insert fascia iliaca blocks in patients with hip fractures