Research (NIHR)

2020 - April 2021, showed only 49% of patients with a neck of femur fracture had their pain assessed within 15 minutes of arrival, 15% had appropriate analgesia within the first 15 minutes, and only 3% had a reevaluation within 30 minutes of the first dose of analgesia.

In addition, older adults with a hip fracture wait longer for analgesia, are treated with lower doses, and are less likely to receive opioids compared to younger adults. Outcomes in this group of patients are poorer with prolonged hospital stays, and higher rates of anxiety and delirium.

Older Adults

Pain is a significant feature of a hip fracture and good clinical outcomes are dependent on early diagnosis, surgery and effective pain control.

Pre-hospital services (GP and ambulance) and emergency departments (ED) are usually the first points of contact to provide analgesia and play an important role in the patient's pain journey.

However, despite pain being the most common cause of attendance in ED (accounting for 75% of patients), acute pain is often under-treated, resulting in 'oligoanalgesia'.

A national audit of 159 emergency departments, undertaken between October

Why is this happening?

It is known that barriers to effective pain relief exist in healthcare, but this has not been wellresearched within the NHS. Evidence suggests staff and organisational priorities, patient characteristics, and variations in staff knowledge are involved. However, a deeper understanding of such issues is an important step in improving outcomes and equality in hip fracture care.

Aims of my study

The aims of my study were:

(1) to determine if older adults receive suboptimal pain management and if this is impacted by certain patient characteristics (age, gender and cognition).

(2) to see if a disparity in pain knowledge exists among staff groups and work areas (ED and Tye Green Ward).

(3) to evaluate if staff perceive any barriers to effective pain management.

I used a mixed methodological approach, involving:

1. A retrospective analysis of patient data (April 2021 –March 2022)

Using data from the National Hip Fracture database (n=199) and patient records (n=38), I compared the analgesic management in younger (<75 years) and older adults (>90 years). This included the analgesia given in ED and dosage, if a nerve block was given, and if pain was assessed at defined points of the inpatient journey.

2. A questionnaire to assess staff knowledge of pain

Staff knowledge of pain was assessed using a standardised questionnaire: Knowledge and Attitude Regarding Pain (KASRP).

3. Interviews with staff Semi-structured interviews with staff working in ED (n=5) and Tye Green Ward (n=3) to discuss their experience and barriers to pain relief. Staff included nurses, an advanced clinical practitioner (ACP) and consultants.

Main findings

1. Older adults received suboptimal pain management y Fewer older adults received a nerve block compared to younger adults, (28% vs. 47%, respectively, p<0.01) y Age was as an “acceptable” predictor for receiving a nerve block (ROC: AUC 0.665) y Older adults stayed longer in hospital by 4.9 days (p<0.01) y Only 45.8% of older adults (n=24) were assessed for pain compared to 32.9% of younger adults (n=14)

2. Staff knowledge did not differ between doctors, nurses and an ACP working in ED/Tye Green Ward y No significant differences were found in KASRP scores between staff groups (p=0.710) and work areas (p=0.862) y Staff achieved 61% correct answers, rating their performance as “fair”