title: Prehospital intravenous fentanyl to patients with hip fracture: an observational cohort study of risk factors for analgesic non-treatment.
abstract: BACKGROUND
  Patients with proximal femoral neck fracture have a high short-term mortality, a high risk of postoperative complications, and impaired quality of life. One of the challenges related to the prehospital treatment of these patients is to administer systemic opioids fast and properly. Effective analgesic prehospital treatment ought be initiated rapidly in order to alleviate the stress that follows acute pain, to facilitate transportation, and to improve quality of care. The objectives of this study were to explore the prevalence of prehospital administration of intravenous fentanyl to patients with proximal femoral neck fracture in the ambulances and to assess risk factors for analgesic non-treatment.
  
  
  METHODS
  This was a register-based observational cohort study of patients with proximal femoral neck fracture from the North Denmark Region transported by ambulance. The patients were identified via the Danish Interdisciplinary Hip Fracture Registry over a 3-year period from 1 July 2011 to 30 June 2014. This hospital registry contains data on several patient characteristics used for the risk factor analysis. Data on prehospital treatment (intravenous fentanyl) and patient monitoring were registered in an electronic prehospital patient record. A modified Poisson regression with robust standard errors was carried out with intravenous fentanyl as the primary binary outcome and the following explanatory variables: age, sex, Charlson Comorbidity Index score, housing, body mass index, type of fracture, fracture displacement, prior consultation with general practitioner, dispatch triage level, and time with ambulance personnel.
  
  
  RESULTS
  In total, 2,140 patients with proximal femoral neck fracture were transported by ambulance, of which 584 (27.3%, 95% CI: 25.4-29.2) were treated with intravenous fentanyl. Risk factors for non-treatment were: older age, male sex (RR 0.77, 95% CI: 0.64-0.91), institutional housing (RR 0.72, 95% CI: 0.56-0.92), medial fracture (RR 0.74, 95% CI: 0.60-0.92), short time with ambulance personnel, Charlson Comorbidity Index score > 1, year of fracture (2011), low levels of urgency at dispatch, and if seen by general practitioners prior to transport.
  
  
  CONCLUSIONS
  Education of ambulance personnel in assessing and treating patients with hip fracture seems to be required. Also, future studies should consider alternative or supportive pain treatment options with suitable analgesic effects and side effects.
  
  
  CONCLUSIONS
  Few patients with proximal femoral neck fracture were treated with intravenous fentanyl, and several risk factors were associated with prehospital analgesic non-treatment. Future prospective studies should explore covariates of socioeconomic, cultural, and psychological origin to provide further insight into the multifactorial causes of non-treatment of acute pain.
authors.affiliation: Research Department, Prehospital Emergency Medical Service, Central Denmark Region, Olof Palmes Allé 34, 8200, Aarhus N, Denmark. k.friesgaard@clin.au.dk.|Department of Anesthesiology, Regional Hospital of Horsens, Horsens, Denmark. k.friesgaard@clin.au.dk.
authors.forename: Kristian D
authors.initials: KD
authors.lastname: Friesgaard
authors.affiliation: Department of Clinical Medicine, Pre-hospital and Emergency Research, Aalborg University, Aalborg, Denmark.|Department of Anesthesiology and Intensive Care, Emergency Clinic Aalborg University Hospital, Aalborg, Denmark.
authors.forename: Erika F
authors.initials: EF
authors.lastname: Christensen
authors.affiliation: Research Department, Prehospital Emergency Medical Service, Central Denmark Region, Olof Palmes Allé 34, 8200, Aarhus N, Denmark.
authors.forename: Hans
authors.initials: H
authors.lastname: Kirkegaard
authors.affiliation: Department of Clinical Medicine, Pre-hospital and Emergency Research, Aalborg University, Aalborg, Denmark.|Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark.
authors.forename: Mette D
authors.initials: MD
authors.lastname: Bendtsen
authors.affiliation: Prehospital Emergency Medical Services, North Denmark Region, Aalborg, Denmark.
authors.forename: Flemming B
authors.initials: FB
authors.lastname: Jensen
authors.affiliation: Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.|Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark.
authors.forename: Lone
authors.initials: L
authors.lastname: Nikolajsen
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000552:Ambulances; D000701:Analgesics, Opioid / Q000008:administration & dosage*; D003718:Denmark; D004638:Emergency Treatment / Q000379:methods*; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage*; D006620:Hip Fractures; D006801:Humans; D007275:Injections, Intravenous; D008297:Male; D059408:Pain Management / Q000379:methods*; D012307:Risk Factors
chemical_list: D000701:Analgesics, Opioid; D005283:Fentanyl
keywords: Acute pain; Hip fracture; Prehospital