The fascia iliaca block (FIB) is an efficacious form of regional anaesthesia indicated for use in the management of neck of femur fractures (NOFFs) (Scottish Government, 2019).
Neck of femur fractures occur in a largely geriatric population (Brennan nee Saunders et al, 2003). There is a well-recognised 1-year mortality rate of 30% after sustaining a NOFF (Kearns et al, 2013). Largely, this is a result of the multimorbid status of these patients (Brennan nee Saunders et al, 2003). Because of this, these patients are vulnerable to the side effects of opiate-based analgesia (Mangram et al, 2015). Therefore, the FIB lends itself well for use in this cohort to provide opiate-sparing analgesia (Guay et al, 2017).
Further perceived benefits include the provision of long-lasting, higher-quality analgesia for patients with perioperative NOFFs (Chesters and Atkinson, 2014; Steenberg and Møller 2018; Tarekegn and Sisay, 2021). Alongside this, multiple literature reviews have reported low to negligible complications associated with the procedure (Chesters and Atkinson, 2014; Guay et al, 2017; Steenberg and Møller, 2018; O'Reilly et al, 2019; Zhang et al, 2019). Given these findings, it is nationally recognised that this procedure should be performed in patients presenting to the emergency department (ED) with a NOFF (Scottish Government, 2019).
The evidence focuses largely on in-hospital FIB delivery. However, because of its efficacy, this procedure is starting to be expanded into prehospital care. The most comprehensive resource examining the use of the FIB in a prehospital setting is the systematic review by Hards et al (2018). This review included seven studies, accounting for 254 FIBs. These studies collectively reported a success rate of 90%, with only one adverse event reported among all studies.
Other studies quote a higher success rate of 95% (Gozlan et al, 2005; Lopez et al, 2003). Despite this, neither of the current National Institute for Health and Care Excellence (NICE) (2016; 2017) guidelines on prehospital management of trauma and of NOFFs suggest the use of prehospital regional nerve blockade. Therefore, the use of the FIB in the prehospital setting remains limited.
This study sought to explore the potential growth of this procedure into the prehospital setting through administration by allied health professionals (AHPs). There is little evidence for the use of the FIB as a paramedic-based skill, even though paramedics are first on scene and are more numerous than advanced practitioners who can perform it.
The systematic review undertaken by Hards et al (2018) includes only 11 blocks performed by paramedics. All of these were in the feasibility study performed by McRae et al (2015). It concluded that this was a safe and suitable procedure for paramedics to perform.
There is one other feasibility study assessing paramedic-performed FIB that concluded that the protocol was suitable for use by paramedics, and the authors planned to undertake a full-scale randomised controlled trial (Jones et al, 2019). A qualitative study based on this trial then examined how paramedics felt about performing the block and noted they found it to be an acceptable procedure within their capabilities (Evans et al, 2019).
The literature discussed above demonstrates the potential for paramedics to become skilled in providing FIBs, as well as the lack of current research on the topic.
In contrast, there is a reasonable body of evidence that advanced practitioners can safely and easily perform FIBs. The term ‘advanced practitioners’ encompasses health professionals, largely from a nursing background but who may have a background in paramedicine, who have undertaken a master's degree in advanced practice (Hards et al, 2017). Of the 254 blocks in the systematic review by Hards et al (2018), 100 were performed by advanced nurse specialists. These were all from a single feasibility study, which quoted a success rate of 96% and no reported complications (Dochez et al, 2014).
Multiple studies have confirmed the safety and efficacy of nurse-performed FIBs in hospital-based studies (Obideyi et al, 2008; Randall et al, 2008; Williams et al, 2018; Gawthorne et al, 2021).
No current literature was identified exploring the views of advanced practitioners on the procedure or their confidence in carrying it out.
Overall, there is a notable body of evidence examining the efficacy of FIBs but considerably less exploring their role in the prehospital setting. There is thus a gap in the literature on the role and opinions of AHPs with regards to prehospital FIB. This study sought to provide a foundation from which to conduct further research and promote FIB as a recognised prehospital procedure that can be undertaken by AHPs in Scotland.
Aims
The primary aim of this study was to determine factors affecting AHPs' confidence in administering FIBs in patients with a suspected neck of femur fracture in a prehospital setting.
The secondary aim was to explore the concerns of two groups of AHPs about fascia iliaca block: trained paramedics (who do not currently perform the procedure); and prehospital advanced practitioners (who perform the procedure under medical supervision).
Methods
This was a single-centre, qualitative study. Data were gathered via in-person, individual, semi-structured interviews. The study focused on two groups, both of whom were NHS staff: paramedics and advanced practitioners. Table 1 shows inclusion and exclusion criteria. The study aimed to recruit 5–20 members of staff across both groups.
| Inclusion criteria | Exclusion criteria |
|---|---|
| Trained paramedics or prehospital advanced practitioners | Allied health professionals who are not paramedics or advanced practitioners |
| Participants should have either performed OR have seen a fascia iliaca block administered | Professionals who have neither seen nor performed a fascia iliaca block |
| Participants should be able to give informed consent | Inability to provide informed consent |
| Participants should have an adequate understanding of English to be able to take part in the interview | Participants who would be unable to take part in the interview in English |
Recruitment was bimodal. A flyer detailing the study was sent out by email to all eligible people in NHS Highland (NHSH) via the prehospital team they work for. Secondary recruitment was through information leaflets left in the local ambulance bay and in the emergency department ambulance entrance where all paramedics should have an opportunity to see them. Participants who contacted the researcher expressing interest were then given time to read the information sheet and ask questions before consenting to take part in the study. Consent was taken in written format directly before the interview, and interviews were conducted face-to-face in line with NHS Highland COVID-19 guidance.
With regard to the format of the interview, topic questions were generated to provide a semi-structured format while leaving scope to explore participants' opinions (Adeoye-Olatunde and Olenik, 2021). The interviews were audio-recorded on a voice recorder; the recordings were transcribed verbatim into anonymised Microsoft Word documents. Following full anonymisation of the dataset, the transcripts were then analysed using Delve Qualitative Analysis software; this was undertaken according to the grounded theory paradigm (Guest et al, 2017; Urquhart, 2017).
Concerning ethical considerations, the study protocol and associated documents were submitted to the academic and central office for research and development at the NHSH research institute. The project was approved to proceed under NHSH's research and development team guidance. NHSH reviewed and approved the project locally. The NHSH research and development team deemed that this study did not require review under a full ethics board. As this was a non-interventional, staff-based study, risk to participants was perceived to be negligible. Participants were expressly informed that they were free to withdraw at any time.
Results
A total of 12 semi-structured interviews were conducted, six with advanced practitioners and six with paramedics. The advanced practitioners had backgrounds in both nursing and paramedicine, but all were working under the title advanced practitioner with the health board's prehospital care team. Four women and eight men took part in the study.
Figures 1 and 2 give an overview of the major themes and subthemes identified for each outcome. The quotes in the upcoming sections are followed by the letters ‘AP’ to indicate an advanced practitioner or ‘P’ for a paramedic.
Primary aim. Factors affecting procedural confidence
Graduated exposure
Graduated exposure was a key theme, contributing to AHPs' procedural confidence. Participants noted that they learned procedural skills best when teaching was undertaken in a stepwise manner. They reported this allowed them to feel comfortable and confident with each progression and this therefore promoted overall procedural confidence.
APs discussed their procedural learning for the FIB (Figure 3). Paramedics were also in favour of learning in a graduated manner. They perceived this to be the gold standard way to learn:
‘I think going right through the board from theory lectures right up to prehospital with someone like PICT [prehospital immediate care and trauma scheme] would be the biggest benefit to get us comfortable doing it.’
‘I wouldn't say I was comfortable to begin with – so we did a lot in the emergency department and then we did a lot when we were prehospital with senior clinicians.’
‘We had a good exposure to it over a sustained, and safe period of time.’
Procedural frequency
Procedural frequency was identified as a core concept relating to procedural confidence. It was felt to be multifactorial.
Number of procedures
The number of procedures performed during learning was proportional to confidence:
‘You would have to be supervised until you were signed off for a certain amount of attempts at trying it – until it seemed like you were satisfactory at doing it.’
Gaps between performing the procedure
Long gaps were felt to reduce confidence. Almost universally, participants said that when they experienced a prolonged period where they did not use a skill, they had to cognitively revise the procedural steps. The loss of skill intuition correlated to a loss in procedural confidence:
‘There was a long period of a couple of months where I didn't do any, and then I was trying to do them in theatre, and I was getting mixed up between the femoral block, the fascia iliaca block and the indications for them. So, I did struggle with that.’
‘Because we're not doing it all the time when we do go to do one, I do think “oh!” I do have to think about it for a minute and I think I would be slicker if we were doing them more frequently.’
‘What makes it difficult is the lack of practice, and that's what affects my confidence.’
Environmental factors
Procedural frequency was felt to be related to environmental factors. These included the number of shifts worked, shift location (ED versus prehospital) and the number of patients presenting with NOFFs. These factors were largely out of the control of the practitioners but were recognised as having an impact on procedural confidence:
‘I haven't done one for probably 3 months, and that's been a mixture of we just haven't had them and annual leave and there haven't been any in the department.’
Senior supervision
Senior supervision during training was also a key contributor to confidence. Participants described gaining confidence through being supervised by experienced colleagues. They trusted these colleagues to provide guidance and step in to correct issues as they arose. They also trusted them to teach them the correct way to perform the procedure. This gave them confidence to perform it going forwards:
‘We would get exposure with the [senior doctors] in the environment of the ED and we were guided through it, which was about as good as it could get, I think.’
‘[I would want to] spend some time with somebody who does that a lot—I think I would find that quite helpful in my training.’
Conversely, confidence was felt to decrease where teaching was poor or where it was thought that teachers themselves were clearly not experienced in the procedure:
‘It depends very much who is running the training as to the quality of the training we get. It can be a bit of a shambles and sometimes we are not being taught by somebody who knows or is using those skills, which doesn't help, certainly.’
Procedural consistency
Procedural consistency was the fourth key theme identified as contributing to procedural confidence. Participants felt that being taught the procedure by the same supervisor, using the same equipment and the same technique increased confidence.
‘So what makes me confident is the setup of it and using your landmarks and how we do it. The kit that we use is always the same and that's really helpful.’
Researcher: ‘What do you think could be improved on?’
Respondent: ‘Just the continuity of what's getting taught.’
Despite this, procedural consistency impacted confidence less as experience was gained—i.e. more experienced professionals could tolerate a higher degree of variation in the procedure without it affecting their confidence.
Secondary aim. Concerns related to administration of FIB
The secondary aim of the study was to explore concerns related to the FIB. From the data, three major themes and 10 subthemes emerged.
Notably, concerns around the provision of adequate training and governance of the procedure were raised as barriers to procedural expansion. However, participants suggested potential solutions to these (Figure 4).
Major theme 1. Risk of doing harm
Procedural complications
Common concerns highlighted by both groups included local anaesthetic toxicity, giving a large volume injection, haemorrhage and the possibility of injecting into a vascular space:
‘I was very worried about getting the artery—the femoral artery—and not being able to stop the bleeding’.
Researcher: ‘When you first started doing fascia iliaca blocks, what concerns did you have about performing them?’
Interviewee: ‘Just injecting that volume of local anaesthetic into a person.’
Sterility in the prehospital environment
Both paramedics and advanced practitioners raised concerns about the sterility of the prehospital environment and the potential for infection. Some stated they would not perform the block if there were concerns over sterility:
‘Any procedure that involves puncturing the skin has a risk of infection.’
‘I probably wouldn't do a block because you're not going to get it clean, and I don't want to introduce infection into that area.’
Prehospital care providing alternative challenges
It was noted that there are additional pressures in prehospital medicine and that these might affect the safety and efficacy of the procedure, particularly in relation to the use of tools such as ultrasound:
‘They are never on a trolley, so they will often be quite difficult to get to places and it's difficult to keep things clean, and you can feel a time pressure – even if there isn't necessarily a time pressure, it can feel quite time dependent.’
‘Finding enough hands to have your ultrasound machine on while you're getting everything else done can be a challenge as well. So it's definitely one of these things that is more of a challenge prehospital.’
Providing an ineffectual block
Both AHPs and paramedics described anxiety over the potential to provide an ineffective block and the impact this might have on patients. They also raised concerns about inadequate provision of analgesia if the FIB were unsuccessful:
‘So, I would have wondered that you are doing something that doesn't actually work… not with the catastrophe of being in a vascular space, but clinically actually just having an ineffective block and waiting for some time and nothing actually happening.’
‘You wouldn't want to think that you've got everything in place and then go to extricate and be half-way down the stairs when you realise that you've not got the outcome you were looking for.’
Major theme 2. Adequate training
Indications for use
Participants expressed concerns about the lack of diagnostic tools in a prehospital setting and therefore the potential to misdiagnose a patient. Anxiety was expressed over the potential ramifications of this:
‘You fit these criteria and you get this treatment, every time—and it's partly to protect paramedics as well. If somebody didn't have a neck of femur but you've just numbed their whole leg, they are going to end up spending the whole night in hospital because of you, and paramedics, I think, would be very fearful of making that sort of mistake.’
Competition for training
Concerns were raised about reduced exposure to the procedure during learning time because of the high number of trainees. This was felt to reduce overall exposure to the procedure during teaching:
‘You are in theatre, but there is a pecking order and everybody is fighting over not a lot of patients.’
‘We are all in a teaching environment and whether you're on placement in [the ED] or on placement in theatre, there are lots of people wanting to learn the same skill, so sometimes just everybody, everybody will miss out.’
Impact of COVID-19 on training
COVID-19 meant access to theatres was restricted so trainees were unable to experience this environment. In both groups, theatre time was understood to be a vital component of learning an advanced procedure and the loss of this was noted by practitioners:
‘I would have maybe been slightly more confident before if I'd had a bit more time in the hospital to practise on the trauma list [in theatre] but, because of COVID, we couldn't go there.’
‘Particularly during COVID, access to theatres was pretty much non-existent.’
Getting adequate time and support to attend training
It was consistently raised that the paramedics have very little training time and therefore gaining enough exposure to the procedure to feel confident about doing it was a great concern. Participants felt this could potentially be a barrier to promoting the FIB in prehospital care:
‘There is only a small team of us [advanced practitioners] versus a large number of paramedics who have very little, like two, dedicated training days out of the whole entire year. That's already pre-programmed by the training board of what you are going to do on those days, so to get folks trained is probably one of the hardest barriers.’
‘We don't actually get training days, we don't get training time, we don't get a training budget.’
Major theme 3. Governance and governing body support
Skill retention
Procedural governance was a concern. Paramedics work independently and the FIB may be a low-frequency skill. They were uncertain how skills governance could be achieved in a prehospital setting and, again, highlighted this as a barrier:
‘I'm not sure how you would supervise that afterwards because, obviously, it's just a paramedic and a technician you have on a crew.’
‘For [paramedics], it could be 3 months or 4 months between blocks.’
Perceived lack of support from governing body
Overall, paramedic practitioners had a negative view of the Scottish Ambulance Service (SAS) and their governing body. It was perceived that it would be unlikely to facilitate skills progression, and this linked back to the idea that it would also be unlikely that adequate governance would be put in place to facilitate FIB as a prehospital skill for paramedics:
‘I don't know whether they would fund it.’
‘I'm not sure how the service would be agreeable to all that and with the regards to overtime.’
‘Your time off is quite important to a lot of people so, if the ambulance service actually honoured it with either time off in lieu, or that there is some kind of gesture towards that they are supporting our learning’
SAS is the only NHS Scotland body responsible for the provision of emergency paramedic-led prehospital care.
Discussion
Procedural confidence (primary outcome)
This study found procedural confidence to be high among AHPs. There is a paucity of studies directly comparable to this one.
The single comparable study available is that undertaken by Evans et al (2019). This qualitative study used focus groups to ascertain paramedics' experience of carrying out the procedure in a feasibility study looking at the potential for paramedic-performed FIBs. It concluded that paramedics felt confident in recognising NOFFs but were anxious about performing the FIB given the unfamiliarity of the technique. The study also found anxiety related to prolonged gaps between training and skill use in real life (Evans et al, 2019). These findings are in line with this study, with the themes of confidence related to procedural frequency and graduated exposure. Aside from this, there is an overall lack of data on procedural learning and confidence for AHPs.
In contrast, there is a considerable body of evidence exploring medical students' procedural confidence (Stewart et al, 2007; Dehmer et al, 2013; Barr and Graffeo, 2016). These studies reiterate that low procedural confidence was related to a lack of clinical exposure and therefore recommended intensive procedural courses to increase confidence. Therefore, despite the difference in discipline, evidence suggests that the same basic principles affect procedural confidence—i.e. it is predominantly related to clinical exposure. Confidence can be increased if training is undertaken in a structured, supervised environment, where skills can be practised frequently.
Going forward, these concepts could be used to structure training programmes for FIB in future feasibility studies. Alternatively, these findings might be employed to improve AHP education. Although this study focused on the FIB, the core concepts of graduated exposure to a technique, repeated exposure to a technique (high procedural frequency), senior supervision and consistency during learning can be applied to training in other procedures.
Concerns related to fascia iliaca block administration (secondary aim)
Risk of harm (major theme 1)
Paramedics and advanced practitioners raised similar concerns about complications arising from a FIB. They were particularly concerned about arterial injection (and haemorrhage), local anaesthetic toxicity and injection site infections.
As noted above, the complication rates associated with the FIB are negligible (Chesters and Atkinson, 2014; Guay et al, 2017; Steenberg and Møller, 2018). On review of multiple systematic analyses of the FIB, no cases of site infection were noted so concerns regarding site infections are not supported by the literature.
Interviewees were also worried about the potential for providing an ineffectual block. The systematic reviews available noted that there was a lack of standardisation in determining the success of a block, but overall success rates were high (Steenberg and Møller, 2018; Desmet et al, 2019; Hong and Ma, 2019; Jones et al, 2019; Tarekegn and Sisay, 2021). Again, this denotes that concerns expressed were largely not supported by the evidence in the current literature.
A means of reducing initial anxiety might be to provide evidenced-based teaching on the risks and success rates.
Prehospital care and its associated challenges (major theme 1)
Several participants raised the issue of difficulties associated with prehospital working, stating that environmental conditions were often suboptimal.
It has been well recognised across the literature that prehospital medicine provides additional challenges in terms of environment and lack of resources (Atack and Maher, 2010; Hagiwara et al, 2013). It has also been acknowledged that in-hospital procedures are not directly applicable to prehospital scenarios (Bigham and Welsford, 2015).
This clearly underlines the importance of the development of prehospital-specific procedures and ongoing audit evaluating their effectiveness (Bigham and Welsford, 2015; Perona et al, 2019).
Training for allied health professionals (major theme 2)
Universally, study participants were concerned about the lack of provision for training in prehospital specialties. This was found to be particularly prevalent among the paramedics. They stated they had little annual provision for training and felt strongly that this would be a barrier to learning.
This was compounded by the concerns related to training competition ratios and less access to learning because of the COVID-19 pandemic. All these factors were viewed as components restricting access to training and resulted in paramedics feeling pessimistic about their continued professional development.
Several studies support the idea that the quality of training in paramedicine varies (Cooper and Grant, 2009; Wallin et al, 2013). The participants of this study proposed several solutions (Figure 4), including having dedicated trainers and designated training days. They also felt that having a protocol was important, as was the ability be able to refresh skills.
The literature indicates that protocolisation reduces clinical variation and allows for audit while promoting a higher standard of care (Heymann, 1994; Hewitt-Taylor, 2004; Rycroft-Malone et al, 2009; Hill et al, 2014). Equally, there are suggestions that protocols can be based on inadequate evidence and enforce rigidity in clinical practice (Woolf et al, 1999) so protocols might best be implemented with care and consideration.
There is evidence that specialist trainers and skills refreshment courses result in higher-quality practice (Woollard et al, 2006; Lombarts et al, 2010; Shahsavari et al, 2017; Schwid et al, 2019).
The feasibility of these suggestions is uncertain.
Prehospital procedural governance (major theme 3)
Participants were uncertain about the support they would receive from their governing body and how procedural governance could be achieved.
The qualitative study by Evans et al (2019) also found that, while paramedics were happy with their initial training, there were concerns about skill fade between uses of the FIB.
As the FIB is not currently a skill performed by paramedics, evidence on governance was examined with respect to endotracheal intubation. This was selected as it is a similarly advanced skill with a low frequency of application. There are two reviews of the evidence (Deakin et al, 2010; Pilbery, 2018). These concluded there were no clear standards at which a paramedic was deemed to be competent in performing endotracheal intubation. They also highlighted skill fade because of a lack of routine use and no established means of reassessing learning as a significant problem (Deakin et al, 2010; Pilbery, 2018).
Several further studies examining the standardisation of the advanced practitioner role reported that there was a lack of national homogeneity in clinical governance provided for practitioners. They also reported that there was no standardisation between advanced practitioner roles (Melby et al, 2011; Nutbeam, 2011; Hill et al, 2014; Crouch and Brown, 2018). This is strongly in line with the concerns raised by the participants in this study.
An earlier study published in 2001 set out suggestions for improving prehospital procedural governance (Robertson-Steel et al, 2001). However, more recent papers note that, despite these suggestions, few changes have been made to implement prehospital clinical governance (Halligan and Donaldson, 2001; Grant and Wheatley, 2014). In turn, these studies proposed annual competency reviews, adverse incident reporting, the creation of national guidelines, new electronic records and improving initial education as alternative means by which governance could be achieved (Halligan and Donaldson, 2001; Grant and Wheatley, 2014).
These suggestions align with those provided by participants in this study. However, implementation of these suggestions is likely to take time, particularly in instances where additional skills, such as FIB administration, are being introduced concurrently.
Limitations
This study is a single-centre, non-interventional study based in the Scottish Highlands. It has several perceived limitations.
Primarily, because of NHSH is a large, sparsely populated area, the results of this study are unlikely to be directly applicable to the rest of Britain. Therefore, the transferability of the results is affected (Anderson, 2010). However, these results might be more applicable to other remote and rural regions.
A further limitation is the nature of the study. In qualitative analysis, there are arguments both for and against the use of multiple reviewers. Arguments in favour suggest that multiple reviewers reduce confirmation bias when interpreting the data (Pope et al, 2000). However, as this study was conducted in fulfilment of the requirements of a master's degree, there was no scope to include a second researcher. This should be considered when interpreting the results, as it may have contributed an element of confirmation bias (Pannucci and Wilkins, 2010).
Future research
Multiple strong clinical trials are needed to assess the feasibility of prehospital paramedic-performed FIB. Following the feasibility study undertaken in Wales, Jones et al (2019) were planning a further larger-scale study, which should currently be underway (Jones et al, 2019).
There is a notable lack of evidence surrounding education and governance in paramedicine and for advanced practitioners. Since these were consistently highlighted as concerns, gaining a fuller understanding of teaching and governance for these specialties is essential.
Conclusion
Overall procedural confidence with regards to the fascia iliaca block was high. All advanced practitioners stated they felt confident to perform FIBs, and all paramedics felt they would be confident given the correct training.
Four major themes were found to contribute to procedural confidence: graduated exposure; procedural frequency; senior supervision; and procedural consistency. These themes were in keeping with the literature.
With respect to the secondary aim of identifying concerns related to the FIB, three major themes emerged through the interviews: risk of doing harm; receiving adequate training; and governance and governing body support. Participants highlighted training and governance as potential barriers to expanding the procedure into prehospital care. Current literature also shows the lack of standardisation in training and governance of these specialties.
Further research is required in the form of randomised control trials to assess the feasibility of paramedics routinely performing the FIB. Research is also required to assess and increase the quality of training for AHPs.