Improving the rate of use of fascia iliaca compartment blocks in patients presenting with hip fractures.

backgroundPatients presenting to the emergency department (ED) with hip fractures are typically treated with opioids, which are associated with adverse events such as delirium and respiratory depression. The fascia iliaca compartment block (hereafter fascia iliaca block) is a regional analgesia technique which avoids these negative outcomes. We sought to increase the rate of use of this technique to 50% of all patients with hip fractures who presented to our EDs within an 18-month period.

methodsWe held three Plan-Do-Study-Act cycles designed in accordance with surveys sent to our physician group. The first cycle consisted of the dissemination of educational materials and standardization of equipment carts. Next, we held educational sessions for staff and trainee physicians. The third cycle consisted of additional education, Audit and Feedback methodology and incentives. Our outcome measure was the rate of fascia iliaca blocks performed. We tracked the number of unique physicians performing the fascia iliaca block as well as physician-reported comfort with the procedure for our process measures. Our balancing measure was the rate of adverse events.

resultsWe went from a baseline rate of 2.0% to 22.6% of patients receiving fascia iliaca blocks. The number of physicians doing this increased from 6 pre-project to 35. Only one adverse event occurred (arterial puncture), which did not cause any significant patient harm. Our statistical process control chart revealed special cause variation in the form of a shift.

conclusionAlthough we did not meet our goal, we were able to significantly improve the rate of fascia iliaca blocks performed at our center. This was largely achieved through educational interventions. Our approach can be adapted by other centers looking to pursue a similar project.