Ultrasound-Guided Regional Anesthesia by Emergency Physicians for Hip Fractures and Delirium: A Randomized Clinical Trial

Abstract

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