IMPORTANCE: Delirium complicates 20% to 62% of the estimated 1.5 million hip fractures annually. Meta-analyses suggest that point-of-care ultrasound-guided regional anesthesia (POCUS-GRA) may reduce delirium, but uptake by emergency department (ED) physicians is highly variable.
OBJECTIVES: To measure the impact of a knowledge-to-practice intervention on uptake of POCUS-GRA by ED physicians, incidence and number of days of delirium, analgesic effectiveness, safety, and procedure time.
DESIGN, SETTING, AND PARTICIPANTS: This stepped-wedge cluster randomized clinical trial was conducted at 7 academic EDs from 4 provinces in Canada. The order in which ED physicians were trained at each site was randomized. ED physicians working at least 1 shift per week who did not regularly perform POCUS-GRA and patients aged 65 years and older with a hip fracture who were not delirious on arrival were included. Data were analyzed in August 2025.
INTERVENTION: A 2-hour structured training session on fascia iliaca blocks was followed by competency assessment, with a procedure bundle and email reminders provided.
MAIN OUTCOME AND MEASURES: Incidence of delirium within 7 days of ED presentation was measured using the Confusion Assessment Method, and duration of delirium was measured in days.
RESULTS: A total of 208 of 213 ED physicians (97.7%) who assessed 694 eligible patients with hip fracture (median [IQR] age, 81.0 [74.0-88.0] years; 483 female [69.6%]) were trained. Among these patients, 248 individuals were analyzed prior to training per intention-to-treat analysis, including 6 with protocol violations (control group), and 446 individuals after training (intervention group). The intervention increased blocks from 6 of 264 patients (2.2%) to 236 of 446 patients (52.9%) after training, for a change of 51.7%. After adjustment for a priori confounders, time, and clustering by site, delirium risk in the intervention group was reduced (odds ratio, 0.72; 95% CI, 0.57-0.93). Mean days of delirium was not reduced. Among 186 nerve blocks with pain effectiveness data, most nerve blocks were effective (107 nerve blocks [57.5%]with =50% pain reduction), quick (median [IQR] time, 15 [12-20] minutes; 113 nerve blocks [90.0%] <25 minutes), and safe (1 minor hematoma).
CONCLUSION AND RELEVANCE: In this study, a knowledge-to-practice intervention improved nerve block uptake, and nerve blocks were quick, safe, and mostly effective. Despite suboptimal uptake, the study adds to the evidence that POCUS-GRA reduces delirium.
TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02892968.
| Discipline Area | Score |
|---|---|
| Physician |  |
Physician rater
The study definitely demonstrates that training of ED physicians to do these blocks is feasible and increases uptake in practice. Enthusiasm for the results as reported is dampened because although the OR for reduction of delirium looks impressive at face value, only 1 out 20 patients benefited and the total number of days of delirium was unchanged.
Physician rater
This study could be useful for ED physicians.
, McMaster University