hip fractures primarily affect older people87.6% of hip fractures in canada occur among patients 65 years of age or older , and the rate of hip fractures increases exponentially with age , more than quadrupling from age 65 to 85 . the ontario bone and joint health network developed a model of care for hip fracture patients across the province to reduce post - operative complications and prevent prolonged lengths of stay . these recommendations included multidisciplinary care , ideally commencing upon the patients arrival to the emergency department . the key interventions include optimal pain management , timely surgery , and close attention to patients post - operative care , namely an interdisciplinary focus on interventions which shorten the acute care length of stay . not surprisingly , hip fracture patients are at increased risk for a range of complications during their hospital admission , including delirium , urinary tract infections , heart failure , and chest infections optimal pain management is a frequently overlooked aspect of hip fracture patient care that may contribute to improving patient outcomes . a recent systematic literature review and meta - analysis on the effectiveness of different pain management techniques for hip fractures concluded that there was moderate evidence that regional anaesthesia was effective for managing acute pain , and that perioperative use of regional anaesthesia independently reduces the severity and duration of delirium . despite this , optimal analgesia is seldom achieved . a number of factors may contribute to physicians tendency to limit strong opiate analgesics including a perception that patients may not tolerate these medications well or may have a reduced capacity to metabolize and eliminate these drugs , poly - pharmacy interactions , or concerns about opioid side effects such as delirium . unfortunately , this avoidance of , or administration of , suboptimal doses of opioids is also a predictor for the onset of delirium . similarly , patients have an increased occurrence of delirium when experiencing higher pain scores at rest , as well as experiencing moderate to severe pain in the immediate post - operative period . delirium in and of itself can increase risk for poor outcomes , which may include an increased mortality rate . an ideal solution is to provide the physician with an alternative to opioid - based analgesia , thereby effectively treating the pain and minimizing the risk of suboptimal analgesic dosing . hip fracture pain is amenable to nerve block analgesia , and both the femoral nerve block or fascia iliaca compartment block are effective . advantages over standard analgesic strategies include improved pain control , faster onset of analgesia , minimizing the use of opioid analgesics and their side effects , minimizing sedation , and reducing the rate , severity , and duration of delirium . however , with greater emphasis on early pain management and the availability of tools such as the portable ultrasound to improve block safety and success , there is renewed interest in the training of emergency department physicians to provide such care . before commencement of a multidisciplinary ( anaesthesia , orthopedics , emergency ) education program to train emergency physicians from academic toronto hospitals in the practice of nerve block analgesia for hip fracture patients , we undertook a survey to determine their current practices , level of training , and attitudes . we hypothesized that there was an underutilization of nerve block techniques in the analgesic management of hip fracture patients and when it is performed , there is an inconsistent approach that limits effectiveness . ethics approval was obtained from the sunnybrook health sciences centre research ethics board to undertake a survey of all ed staff and resident physicians from three teaching hospitals across toronto . amongst these hospitals , there are approximately 550 patients presenting with hip fracture per 12-month period . potential participants were identified from comprehensive lists of ed staff and residents physicians that were made available by department directors at each participating institution . potential participants were assigned a unique study number that was kept on a separate database to ensure duplicate surveys were not received from the same respondent . from the three participating hospitals , a total of 107 staff physicians and 47 resident physicians were identified as potential candidates for the survey . participants were aware that the information they provided individually would be held confidential . but that the pooled information would be analyzed and would undergo publication . an ed staff lead at each site , an orthopedic lead physician , and anaesthesia staff prepared questions for the survey . the survey questions were designed to determine the current practices and frequency of nerve block utilization for hip fracture patients . the paper survey was organized into five major sections : ( 1 ) demographics ( hospital , years of ed experience , work shifts per month , availability of a block area ) ; ( 2 ) nerve block experience ( how frequently blocks are performed , preferred techniques , confidence in block success , preferred timing of block during patient care ) ; ( 3 ) attitudes ( importance of nerve blocks , factors limiting more widespread nerve block utilization ) ; ( 4 ) block training ( satisfaction with current knowledge , training already undertaken , list key learning objectives ) ; and , ( 5 ) appreciation of scientific evidence for nerve block analgesia . surveys were distributed to ed staff physicians at their three departmental business meetings ( one held at each study site ) and to ed residents at their city - wide educational rounds . surveys were distributed by the study investigator ( l.h . ) at the start of these meetings and collected at the end of the meeting on the same day . a small number of surveys not received during the meeting were returned by mail ( four surveys ) . survey responses were entered into a database ( microsoft excel , microsoft corporation ) for analysis . the resultant data is summarized by proportion , percentages , and standard deviations , and rounded to the nearest whole number . of the potential 154 potential survey candidates , a total of 100 surveys were distributed amongst 71/107 ( 66% ) ed staff and 29/47 ( 62% ) ed resident physicians . of these , 74 were completed and returned ( 48 ed staff and 26 ed resident physicians ) for an overall response rate of 74% . ed staff physician respondents were evenly spread between the three surveyed institutions  with 17 , 13 , and 18 at site a , b , and c , respectively ( table 1 ) . site b had five fewer respondents , leading to a significant difference in the number of surveys collected between sites ( p = 0.04 ) . of the 48 ed staff physician respondents , the mean experience as a staff physician was 11 ( sd  9 ) years , and they work a mean of 11 ( sd  4 ) shifts per month . ed resident respondents ranged in experience ; three were postgraduate year 1 ( pgy1 ) , five pgy2 , nine pgy3 , four pgy4 , and five were pgy5 or fellow status . considering both staff and resident ed physicians , the total number of clinicians providing nerve block analgesia for hip fracture patients is 22/74 ( 30% ) . thirty - two out of 48 ( 67% ) staff ed physicians and 20/26 ( 77% ) resident physicians indicated that they the 16/48 ( 33% ) ed staff physicians that utilize nerve block analgesia in hip fracture patients were asked to estimate how many blocks they perform in an average month . eleven of sixteen ( 69% ) perform 12 blocks a month , and 2/16 ( 13% ) respondents indicated that they perform > 10 per month ; the remaining 3/16 ( 18% ) indicated they performed between 3 and 5 blocks per month . blocks used are either femoral nerve block , ultrasound guidance , or femoral nerve block technique , landmark guided . no respondents reported using the fascia iliaca compartment block ( ficb ) technique ( table 2 ) . when ultrasound is used , the most common needle - nerve orientation was an out - of - plane ( needle perpendicular to the ultrasound probe ) technique in 7/15 ( 47% ) , while 8/15 ( 53% ) used the in - plane ( needle parallel to the ultrasound probe ) technique . local anesthetic volumes used varied widely from 5 ml to 20 ml , with a median volume of 15 ml ( sd  6 ml ) . the mean duration of analgesia that respondents expected from their nerve blockade procedure was 7 hours ( sd  2 h ) . when respondents were asked to rate confidence in their  ability to provide safe and successful blockade overall , 66/74 ( 89% ) of respondents were  in favour of nerve blocks for hip fractures while 1/74 ( 1% ) was  not in favour ; 7/74 ( 9% ) did not respond to the question . respondents were then asked to rate the importance of nerve block analgesia in the management of hip fracture patient pain on a 5-point rating scale ( table 3 ) . respondents were also asked to rank the priority of nerve block analgesia alongside five other essential steps in the management of an ed patient with possible hip fracture . respondents were asked to identify with narrative what factors they felt limited more widespread use of nerve blocks in hip fracture patient management . common themes included  lack of familiarity with nerve block techniques ; identification that they felt the block  took an extended length of time to perform , and  lack of confidence or  in need of more training for improved success of nerve block techniques . overall 32/74 ( 43% ) of respondents indicated that they had received some training in nerve block analgesia techniques for hip fracture pain management . among these , the training method and individual satisfaction with this training was elucidated ( table 4 ) . when asked to identify with narrative the central learning objectives that would be valuable in a new nerve block in hip fracture training course , the majority of respondents stated they would like to review landmark and ultrasound techniques , and learn an effective technique which can be performed in a short timeframe . of the potential 154 potential survey candidates , a total of 100 surveys were distributed amongst 71/107 ( 66% ) ed staff and 29/47 ( 62% ) ed resident physicians . of these , 74 were completed and returned ( 48 ed staff and 26 ed resident physicians ) for an overall response rate of 74% . ed staff physician respondents were evenly spread between the three surveyed institutions  with 17 , 13 , and 18 at site a , b , and c , respectively ( table 1 ) . site b had five fewer respondents , leading to a significant difference in the number of surveys collected between sites ( p = 0.04 ) . of the 48 ed staff physician respondents , the mean experience as a staff physician was 11 ( sd  9 ) years , and they work a mean of 11 ( sd  4 ) shifts per month . ed resident respondents ranged in experience ; three were postgraduate year 1 ( pgy1 ) , five pgy2 , nine pgy3 , four pgy4 , and five were pgy5 or fellow status . considering both staff and resident ed physicians , the total number of clinicians providing nerve block analgesia for hip fracture patients is 22/74 ( 30% ) . thirty - two out of 48 ( 67% ) staff ed physicians and 20/26 ( 77% ) resident physicians indicated that they the 16/48 ( 33% ) ed staff physicians that utilize nerve block analgesia in hip fracture patients were asked to estimate how many blocks they perform in an average month . eleven of sixteen ( 69% ) perform 12 blocks a month , and 2/16 ( 13% ) respondents indicated that they perform > 10 per month ; the remaining 3/16 ( 18% ) indicated they performed between 3 and 5 blocks per month . blocks used are either femoral nerve block , ultrasound guidance , or femoral nerve block technique , landmark guided . no respondents reported using the fascia iliaca compartment block ( ficb ) technique ( table 2 ) . when ultrasound is used , the most common needle - nerve orientation was an out - of - plane ( needle perpendicular to the ultrasound probe ) technique in 7/15 ( 47% ) , while 8/15 ( 53% ) used the in - plane ( needle parallel to the ultrasound probe ) technique . local anesthetic volumes used varied widely from 5 ml to 20 ml , with a median volume of 15 ml ( sd  6 ml ) . the mean duration of analgesia that respondents expected from their nerve blockade procedure was 7 hours ( sd  2 h ) . when respondents were asked to rate confidence in their  ability to provide safe and successful blockade overall , 66/74 ( 89% ) of respondents were  in favour of nerve blocks for hip fractures while 1/74 ( 1% ) was  not in favour ; 7/74 ( 9% ) did not respond to the question . respondents were then asked to rate the importance of nerve block analgesia in the management of hip fracture patient pain on a 5-point rating scale ( table 3 ) . respondents were also asked to rank the priority of nerve block analgesia alongside five other essential steps in the management of an ed patient with possible hip fracture . respondents were asked to identify with narrative what factors they felt limited more widespread use of nerve blocks in hip fracture patient management . common themes included  lack of familiarity with nerve block techniques ; identification that they felt the block  took an extended length of time to perform , and  lack of confidence or  in need of more training for improved success of nerve block techniques . overall 32/74 ( 43% ) of respondents indicated that they had received some training in nerve block analgesia techniques for hip fracture pain management . among these , the training method and individual satisfaction with this training was elucidated ( table 4 ) . when asked to identify with narrative the central learning objectives that would be valuable in a new nerve block in hip fracture training course , the majority of respondents stated they would like to review landmark and ultrasound techniques , and learn an effective technique which can be performed in a short timeframe . the utilization of nerve block analgesia with hip fracture patients has been demonstrated to significantly reduce pain levels and decrease the required quantity of oral analgesia , and may also minimize risks of complications such as delirium , particularly if initiated early in patient care . while the provision of nerve block analgesia has traditionally been the domain of anesthesiologists , with basic training the skill can be safely and successfully performed by other physicians , including ed staff . ed physician utilization of the fascia iliaca compartment block is ideal for this patient population as it is simple to learn , easy to use , and exhibits a fast onset . the nerve block is considered to be safe , as the site of injection is away from any nerves or blood vessels , thereby decreasing the possibility of intravascular or intraneural injection . our institution is seeking to write and implement an education and training program for ed physicians on nerve block analgesia in hip fracture patients to be led by regional anesthesiologists . prior to the educational intervention , this survey was distributed to ed staff physicians and residents across the greater toronto area to assess current experience with nerve block analgesia , attitudes , understanding of medication dosing and techniques , previous educational experiences , and to obtain feedback on perceived barriers to use of nerve block analgesia in the hip fracture population . when looking at historical rates of patient admission for hip fracture , ed physicians from these three sites had access to a sufficient number of patients to learn and maintain competency in the nerve block technique . within the last year , the three surveyed gta - lhin institutions treated more than 50% of the total hip fracture patients ( 550 patients of 968 gta - lhin admissions ) . although there was a significant difference noted in the response rates , we analyzed the results together as the hospitals are in similar urban regions , exposed to similar populations , have similar treatment protocols , as well as meeting the same length - of - stay benchmarks . the ed resident respondents work across any of the three sites during their education at the university of toronto . the most important finding from our survey is that as a primary pain management tool for hip fracture patients in the ed , nerve block analgesia is grossly underutilized . sixty - seven per cent of staff ed physicians and 77% of resident physicians indicated that they interestingly , of those physicians that do utilize nerve block analgesia , a large proportion perform more than 10 blocks per month , demonstrating that once nerve block skill and confidence is acquired , it becomes a common part of practice . respondents also noted that they perform the femoral nerve block using ultrasound guidance ; currently no respondents said that they use the fascia iliaca compartment block . the survey also provided information as to the anesthetic used , and ed physician s expectations for duration of action . a wide range of local anesthetic volumes are utilized ( median volume of 15 ml ) ; some respondents used such low volumes that block efficacy may be compromised . current evidence suggests that a fascia iliaca compartment block has an analgesic duration of 8 hours with a solution of 0.3 ml / kg of 0.25% bupivacaine , with the possibility of longer duration as demonstrated by a continued tolerance to hip flexion . the majority of respondents indicated that the nerve block would be carried out only after x - ray confirmation of a fracture . since clinical diagnosis of hip fracture can be made with a high degree of certainty in the majority of patients , there is a strong argument for increasing the priority of nerve block analgesia in ed management of these patients . research has demonstrated the benefit of the fascia iliaca block as a part of pre - hospital care . frequently , patients can experience delay waiting for x - rays , and the nerve block will improve patient comfort during positioning for these procedures . even without data available on the rates of the clinically suspected hip fractures that go on to have negative x - rays , a recently published comprehensive hip fracture program suggests immediate implementation of a nerve block in those patients presenting with clinical signs of hip fracture , prior to hip x - ray . a small number of physicians rated nerve block analgesia as having little or no importance in the management of the hip fracture patient . the majority of respondents did not report a high degree of confidence in their ability to provide safe and effective nerve block analgesia . a  moderate level of confidence predominates amongst surveyed ed physicians and this suggests that further training and education is required . ideally , further education and hands - on training would greatly improve confidence levels and ultimately lead to an increase in nerve block utilization . a number of barriers to utilization of nerve blocks were listed by the respondents that indicate the blocks take too long to perform , or similarly , that physicians do nt have the time to focus on a nerve block insertion , highlighting the need for an efficient and effective technique for the nerve block procedure in ed . overall , we believe the lack of a consistent approach for safe , simple , and efficacious nerve block technique may be due to a lack of knowledge , confidence , and education . it has been found in our three selected sites that nerve block analgesia in the ed for this patient population is underutilized and performed with varying degrees of confidence . regional anaesthesia via nerve blockade has been recognized as an optimal way to provide analgesia for these elderly patients . early implementation of an optimal analgesic plan , inclusive of utilization of a fascia iliaca block at time of admission , when combined with a comprehensive pain protocol , can aid in early patient mobilization and decrease the acute length of stay . the ficb was poorly appreciated and underutilized by our study population even though it is safe , effective , and simple to learn . we believe that a simple skill set , the speed and ease of insertion , and low risk of complications makes ficb the most viable option for ed physicians seeking training in nerve block analgesia for the treatment of pain associated with hip fractures . the ed physicians are increasingly utilizing ultrasound and have identified an interest in improving their skills and confidence in utilization of this type of block . it is hoped that this improved understanding of current practice and attitudes will assist in the development of an effective multidisciplinary training program in these techniques , through collaboration with regional anaesthetists at the department of anaesthesia , sunnybrook hospital . a training program , designed with the input from anesthesia and ed staff physicians , can provide clinical pearls , and effective and efficient methods to increase confidence , ensure standardization of doses , and serve to enhance interprofessional communication between specialties . this will result in an effective perioperative pain management plan and  ultimately  better patient outcomes .
backgroundin 201011 approximately 968 hip fracture patients presented to emergency departments in the greater toronto local health integration network ( gta - lhin ) . 
 optimal pain management is a frequently overlooked aspect of hip fracture patient care , which may contribute to patient outcomes.although recommendations have been published , there is currently not a standardized approach to the analgesic management of pain in the hip fracture patient . 
 nerve blocks , including the fascia iliaca compartment block ( ficb ) , are more effective than traditional opioid analgesics in reducing pain after hip fracture . 
 research suggests that analgesia via nerve blockade is best initiated early , upon arrival to the emergency department.emergency physicians are trained in ultrasound , and do utilize regional anaesthesia ; however , the frequency of block utilization and techniques used for block insertion are unknown . 
 we sought to undertake the first survey of emergency department ( ed ) staff and resident physicians across the gta - lhin , looking at the current ed practice of nerve block analgesia in hip fracture patients.purposethe primary aim was to determine the prevalence and range of techniques utilized . 
 the secondary aims were to determine the extent of training in nerve block insertion techniques , to gauge opinion on the most important objectives for future training courses , and to seek an understanding of the barriers to establishing a standardized approach for nerve block utilization in hip fracture patients.conclusionsthis data will be used to develop a multidisciplinary training program specifically for use by ed physicians . 
 ed physicians and anesthesiologists will collaborate to standardize nerve block insertion techniques and develop an optimal analgesic management plan of hip fracture patients at sunnybrook hospital .