Rapid Analgesia for Prehospital hip Disruption (RAPID): findings from a randomised feasibility study

Abstract

Background In managing hip fracture, effective pain relief before admission to hospital is difficult without risking side effects. Although emergency departments routinely use fascia iliaca compartment block (FICB), there has been little evaluation of its use by paramedics before hospital admission. We aimed to assess whether a multi-centre randomised trial to evaluate FICB was feasible. Methods Volunteer paramedics used scratchcards to allocate patients with hip fracture at random between FICB and pain relief as usual. Primary outcomes were mortality and quality of life. We also measured adverse events, costs, final diagnosis, length of stay in hospital, pain scores and quality of care and collected qualitative data about acceptability to patients in interviews, and paramedics in focus groups. We pre-specified criteria for deciding whether to progress to a fully powered trial based on the recruitment of paramedics and patients, delivery of FICB, retrieval of outcome data, safety, acceptability, and diagnostic accuracy of hip fracture. Results We effectively met all progression criteria: we recruited 19 paramedics who randomly allocated 71 patients between trial arms between 28 June 2016 and 31 July 2017; 57 (31 experimental arm, 26 usual care arm, 80% overall) retrospectively consented to follow-up. Just over half (17/31) of experimental participants received FICB; all others had contraindications, including nine taking anticoagulants. Four of the 31 participants assigned FICB and six of the 26 assigned usual care died within 6 months of hospital admission. Serious adverse events were also similar: 3/35 experimental versus 4/36 in usual care. Paramedics’ recognition of hip fracture had sensitivity of 49/64 (77%) with a positive predictive value of 46/57 (81%). We received quality of life questionnaires for 30 of 49 patients (61%) at 1 month and 12 of 17 (71%) at 6 months. Patient satisfaction was similar: experimental mean 3.4 ( n = 20) versus 3.5 ( n = 13) for usual care. Conclusions RAPID met all progression criteria within reasonable limits. As equipoise remains, we plan to undertake a fully powered multi-centre trial to test clinical and cost effectiveness of paramedic-administered FICB at the scene of hip fracture. Trial registration ISRCTN 60065373 sought 5 November 2015. Electronic supplementary material The online version of this article (10.1186/s40814-019-0454-1) contains supplementary material, which is available to authorized users.

Is fascia iliaca compartment block administered by paramedics for suspected hip fracture acceptable to patients? A qualitative study

“…FICB is a safe and effective pain management for hip fracture in hospital allowing reduced morphine administration and potentially fewer side effects 20 23 58 59. It can also be administered by paramedics at the scene of injury although evidence of effectiveness in this setting is lacking 19 29 30 58. The RAPID study has demonstrated that paramedics are willing and able to administer FICB to patients with suspected hip fracture before ambulance transport to hospital 60.…”

“…A participating emergency paramedic who attended a 999 call and identified a hip fracture in an eligible patient then used a scratchcard42 to randomly allocate the individual to receive FICB (if not contra-indicated) or usual care. Full RAPID results are available 19…”

“…Fascia iliaca compartment block (FICB)—a local anaesthetic injection directly into the groin region—is routinely used in the emergency department by medical and, increasingly, nurse practitioners. It has equal pain relief to opioids and fewer side effects, potentially improving patient outcomes and length of hospital stay 14 19–27. The Association of Anaesthetists of Great Britain and Ireland supports delivery of FICB by trained non-medical health professionals 28.…”

“…We convened a multidisciplinary team including paramedics, anaesthetists, patients, carers, ambulance service managers and methodologists who advised on the rigorous planning and conduct of this study. We conducted a study to assess the feasibility of undertaking a fully powered multi centre pragmatic randomised trial to test the clinical and cost effectiveness of paramedics providing FICB as early pain relief at the scene of their injuries for patients who have fractured their hip 19. Within this feasibility study, we explored patients’ experience of receiving FICB for suspected hip fracture.…”

Assessing the Time to Ward Transfer in Patients Presenting to the Emergency Department with an Acute Hip Fracture: A Closed-loop Audit

“…Subsequently, a policy change was implemented, stipulating that on-call orthopedic clinicians would review prospective hip fracture patients prior to definitive diagnosis once the hip fracture alert was initiated. It has been shown in one clinical trial that paramedics can diagnose hip fractures out of the hospital, with 77% sensitivity [11]. The reliability of paramedic diagnosis is further demonstrated by the successful implementation of the bypass system in the South-East of Ireland where suspected hip fracture patients are triaged at the scene and brought directly to an orthopedic trauma center, bypassing potentially closer EDs in which orthopedic services are not directly available on site [12].…”