ARLINGTON, Texas — Every year, some 300,000 older Americans are hospitalized with hip fractures and frequently treated with opioids. Nurses at two Texas Health Resources hospitals are making a difference by leading efforts to reduce opioid use in those cases, decreasing pain for patients at the same time.

Joni Belz, B.S.N., R.N., CEN, TCRN, at Texas Health Arlington Memorial Hospital, completed a project on the practice, which is in place now at the hospital.

"I asked, 'What can we do better for them in treating their pain that will also help minimize their risk?'" Belz said. The answer is a fascia iliaca compartment block, which is a nerve block in the hip area.

According to the literature she reviewed, the blocks decrease intensity of pain both before and after surgery; decrease the frequency of needing opioids; reduce post-operative delirium; and may improve post-operative cognitive function in older adults.

Good results

She took a multidisciplinary approach, meeting with nurses, physicians, orthopedic services, anesthesiology services and the pharmacy department to discuss the evidence. They developed guidelines, worked on education and collected data on pain from patients who received the blocks and those who didn't.

The results: The average pain rating before and after surgery dropped with use of the blocks, as did the frequency of prescribing opioids. "Some cases would require a dose of opiate, but when you looked at the big picture it was reduced compared to those that didn't get the block," Belz said. "Some patients didn't need it at all."

The project, which started in 2018, was adopted for hospital use in the third quarter of that year and presented at the Trauma Center Association of America's conference this year.

"This is just one example of how Texas Health is addressing the opioid crisis and finding better ways of delivering more reliable and safer care for the community while managing costs," said Glenn Hardesty, D.O., a physician on the medical staff at Texas Health Presbyterian Hospital Plano who works as an emergency room physician at Texas Health Prosper and is co-chairman of the Comprehensive Opioid Steering Committee. "One goal of the committee is to help promote best practices across the organization."

Texas Health Fort Worth

Texas Health Harris Methodist Hospital Fort Worth has been Joint Commission certified in hip fractures since 2010 and has been using fascia iliaca blocks since 2012, said Kindra McWilliams-Ross, M.S.N., APRN, ACNS-BC, an orthopedic clinical nurse specialist.

The practice began in the Post Anesthesia Care Unit.

"Through our performance improvement process, we began seeing a trend of patients who were receiving higher doses of narcotics based on their pain and the team was committed to changing practice to reduce narcotics," McWilliams-Ross said. "Older patients (defined as older than 60) must be treated differently than the younger patients. Higher doses of narcotics can leave patients sleepy and unable to participate in their care. It also can cause them to stay in the hospital longer with complications."

McWilliams-Ross estimated the hospital sees about 480 geriatric hip fracture patients a year, up from 250-300 in 2009.

Blocks in the Emergency Department

In 2015, a multidisciplinary performance improvement project was set up at Texas Health Fort Worth to look at 0-10 pain scales in the Emergency Department before and after blocks. Patients averaged 6.2 before the block and 2.8 after. Because of the project, the team decided to implement the block program in the ED as well as the PACU.

"The ED blocks, in addition to intravenous acetaminophen, have made the patients' pain manageable until they are in the operating room," McWilliams-Ross said. The block provided in the PACU uses a longer-lasting pain medication and can last up to 48 hours post-surgery.

"We continue to work with an increasing number of geriatric hip fractures," said Hugo Sanchez, M.D., medical director of the hip fracture program and a physician on the medical staff at Texas Health Fort Worth. As more older patients experience hip fractures their complete medical history needs to be taken into account when deciding on pain medication.

"We have implemented the use of regional blocks, intravenous anti-inflammatory medication and a multiple modal pain regimen in order to minimize sedation and decrease complications. The results of this best practice have been shared with other EDs in our system as well as at numerous national conferences."