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BackgroundRoutine pre-hospital pain management for hip fracture is inadequate, with risk of potentially fatal complications, particularly from morphine. Fascia Iliaca Compartment Block (FICB) is used in Emergency Department and orthopaedic wards. The RAPID trial tested feasibility of paramedics administering FICB to patients with suspected hip fracture at the scene of injury.ObjectiveTo explore paramedics’ experience of delivering FICB pre-hospitally.MethodsWe held three focus groups with 11 paramedics serving one district hospital, audio-recorded with participants’ consent. We conducted thematic analysis of interview transcripts. Two researchers, one paramedic and one lay member were in the analysis team.ResultsRespondents believed FICB was a suitable intervention for paramedics to deliver. It aligned with their routine practice and was within people’s capabilities to administer, they reported. They said it took up to 10 min longer than usual care to prepare and deliver, in part due to nervousness and unfamiliarity with a new procedure. They praised the training provided but said they were anxious about causing harm by injecting into the wrong location. Confidence increased after one paramedic team successfully treated a patient for toxic reaction. Reported challenges related to the emergency context: patients often waited many hours for ambulance arrival; they sometimes needed to be moved from awkward locations which exacerbated pain; family and neighbours were present as paramedics administered treatment. Most respondents treated few or just one patient with FICB. Although uncertain whether FICB reduced patients’ pain more effectively than other pain relief options, respondents believed it was safer for elderly people at risk of pneumonia.ConclusionsParamedics are willing and able to administer FICB to patients with suspected hip fracture before ambulance transport to hospital. Feasibility study findings will inform a research proposal for a definitive multi-centre trial of paramedic administered prehospital FICB.

BackgroundAdequate pain relief in prehospital care is a major challenge in all acute traumas, especially for those with hip fractures, whose injuries are difficult to immobilise and whose long term outcomes may be adversely affected by administration of opiate analgesics. Fascia Iliaca Compartment Block (FICB) is routinely undertaken by clinicians in the emergency department for patients with hip fracture, but has not been fully evaluated for use by paramedics in prehospital care.We aimed to test whether FICB for hip fracture pain relief carried out by paramedics in prehospital care was feasible, safe and acceptable, and whether trial Methods were viable, so that we could decide whether to proceed to a fully-powered RCT to evaluate clinical and cost effectiveness.MethodsNineteen paramedics were trained to administer FICB. They randomly allocated eligible patients to FICB or usual care using audited scratchcards. Patients were followed up to assess availability of key outcomes including quality of life, length of hospital stay, pain scores, and adverse events. Findings were analysed against pre-specified feasibility criteria to determine whether it was appropriate to progress to a fully-powered trial.ResultsSeventy-one patients were randomised by paramedics between 28/6/16 and 31/7/17; 57 of these patients consented to follow up. The only outcome which reached a statistically significant difference between groups was the proportion of participants who received morphine (38% difference between groups 95% CI −61.88 to −15.79). There was a difference of approximately nine days in the length of stay between trial arms (mean difference 9.12 (95% CI −20.51 to 2.27).ConclusionsRAPID met its pre-specified progression criteria; a funding application for a fully-powered RCT will therefore be submitted. We will consider the use of length of stay as the primary outcome measure, as feasibility study findings indicated that there was a difference between groups without reaching statistical significance.

BackgroundUp to 40% of patients with suspected hip fracture report inadequate or no pre-hospital pain management. Morphine may raise risk of complications and may be avoided by paramedics. Fascia Iliaca Compartment Block (FICB) is used in Emergency Department and orthopaedic wards. The RAPID trial tested feasibility of paramedics administering FICB to patients with suspected hip fracture.ObjectiveTo explore patients’ views and experience of care received for suspected hip fracture and in particular FICB before ambulance transport to hospital.MethodWe interviewed six patients and the daughter of a patient who received FICB to manage their suspected hip fracture. Interviews, by telephone or face-to-face, were audio-recorded with consent. We conducted thematic analysis of transcripts. Two researchers, one paramedic and one lay member were in the analysis teamResultsRespondents’ memory of prehospital care was dominated by their experience of extreme pain. While they recalled events before falling, they only had partial memory of care prior to hip surgery. Although they recalled paramedics’ arrival, which they reported was up to six hours after their injury, respondents said they remembered little else. Just one recalled consenting to receiving FICB and could describe the process. Other respondents said they were in too much pain to comprehend what occurred or respond coherently. They explained their priority was to receive pain management and they expected the paramedics to treat them safely and effectively. Respondents appeared to be a stoical and trusting group who accepted the treatment they were offered. They did recall high quality of care and praised paramedics for their reassuring and calm manner.ConclusionsHip fracture patients’ overwhelming memory of injury and treatment was of pain and their priority was to receive pain relief. The quality of care, reassurance and administration of pain management was more important to patients than the mechanism of delivering the intervention.

Background Adequate pain relief at the scene of injury and during transport to hospital is a major challenge in all acute traumas, especially for those with hip fractures, whose injuries are difficult to immobilise and whose long-term outcomes may be adversely affected by administration of opiate analgesics. Fascia Iliaca Compartment Block (FICB) is a procedure routinely undertaken by clinicians in emergency departments for hip fracture patients, but use by paramedics at the scene of emergency calls, is not yet evaluated. We report on study progress following six months of patient recruitment. Methods We undertook a randomised controlled feasibility trial using novel audited scratchcard randomisation to allocate eligible patients to FICB or usual care. FICB is only administered to patients without contraindications. The primary measureable outcome is health related quality of life, measured using SF-12 at 1 and 6 months. Secondary outcome measures include mobility scores at 6 months (using Rivermead Mobility Index); patient satisfaction; pain scores; patient safety and length of hospital stay. Interviews and focus groups will be used to understand acceptability of FICB to patients and paramedics. We will also assess the accuracy of paramedic hip fracture recognition (using sensitivity and positive predictive value as indicators). Results We have developed paramedic pathway to assess patients for hip fracture and FICB paramedic training package, delivered by Consultant Anaesthetist randomisation scratchcards To date we have recruited 19 paramedics; 10 are fully trained and recruiting patients, the remainder are being trained. Twenty-two patients have been randomised and 16 have consented to follow-up. Discussion This study will enable us to recommend whether to undertake a definitive multi-centre randomised controlled trial of FICB by paramedics for hip fracture and the procedure is effective for patients and worthwhile for the NHS.

Objective To identify and estimate the effectiveness of interventions to provide analgesia for patients with femoral fracture in the emergency pre-hospital setting. Methods We searched the Cochrane Library, CINAHL, HMIC, Medline, PubMed, Scopus, Web of Science, grey literature and citations of included studies. We included randomised trials and observational studies that included pain score measurements. We carried out a meta-analysis using Review Manager. Results We identified 858 studies and assessed 36 full articles for eligibility. Ten studies met the inclusion criteria, including 478 patients. Five studies were randomised controlled trials, comparing outcomes between: fascia iliaca compartment block (FICB) with standard care; femoral nerve block with standard care; Transcutaneous Electrical Nerve Stimulation (TENS) with placebo; auricular acupressure with sham acupressure; and simple splints with traction splints. Two cohort studies included comparisons of pain scores with and without FICB. Three uncontrolled observational studies reported effects of FICB. Meta-analysis of four randomised studies with 227 patients showed that, compared with control, proactive interventions reduced pain scores by 1.9 standard deviations (95% CI from 1.1 to 2.7; p Conclusions Current published research suggests that interventions to enhance the provision of analgesia for femoral fracture in emergency pre-hospital care reduce pain scores significantly more than standard care. However, as only five randomised studies are available with a range of diverse interventions, further research is warranted.