PAIN-AGE, a Controlled Before/After Study Assessing an Audit and Feedback Perioperative Pain Management Intervention in Older Patients with Hip Fracture.

PAIN-AGE, a Controlled Before/After Study Assessing an Audit and Feedback Perioperative Pain Management Intervention in Older Patients with Hip Fracture. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article PAIN-AGE, a Controlled Before/After Study Assessing an Audit and Feedback Perioperative Pain Management Intervention in Older Patients with Hip Fracture. Sabine Drevet, Bastien Boussat, Armance Grevy, Audrey Brevet, and 13 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3978284/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Sep, 2024 Read the published version in BMC Geriatrics → Version 1 posted 12 You are reading this latest preprint version Abstract Background Pain in older adults is historically neglected. The study assessed the ability of an audit and feedback (A&F) intervention built with nurses to improve the quality of perioperative pain management in older patients hospitalized for hip fracture. Methods Controlled before/after study in an orthogeriatric unit (experimental group); a conventional orthopedic unit served as control (no intervention). Quality of perioperative pain management was evaluated based on acetaminophen distribution and prescription adherence. The primary endpoint was the evolution of the percentage of patients who received 3g/day of acetaminophen during the three postoperative days. Secondary endpoints included nurses’ adherence to medical prescriptions and factors associated with intervention. The significative level was set at 0.05 for statistical analysis. Results We studied data from 398 patients (mean age, 89 years). During the postoperative period, 16% of patients from the experimental group received 3g/day of acetaminophen before the A&F intervention; the percentage reached 60% after the intervention. The likelihood of receiving 3g/day of acetaminophen during the postoperative period and adhering to the medical prescription of acetaminophen were significantly increased in the experimental group as compared with the control group. The patient’s functional status at discharge (assessed by Activities of Daily Living scores) was significantly better and the length of hospital stay significantly reduced after the A&F intervention. Conclusion Our controlled before/after study showed that an A&F intervention significantly improved perioperative pain management in older adults hospitalized for hip fracture. Involving teams in continuous education programs appears crucial to improve the quality of pain management and ensure nurses’ adherence to medical prescriptions. Acetaminophen Adherence Hip fractures Nurses Pain Perioperative period Education Intervention Program Figures Figure 1 Figure 2 Figure 3 Background Thanks to better prevention, the risk of hip fractures is decreasing; however, the number of hip fractures continues to increase with the aging of the population and the increasing number of people over 60 years of age [1]. Postoperative pain has been identified as an unfavorable prognostic factor [2],[3]. Pain delays ambulation, extends hospital stay, reduces the probability of recovery, and finally increases risk of long-term functional impairment [4]. Pre- and postoperative (perioperative) pain management is based on multimodal analgesia that consists of the use of several analgesic medications and techniques combined with non-pharmacological interventions [5],[6],[7]. Multimodal analgesia improves perioperative pain management and reduces analgesic doses leading to a reduction in the incidence of adverse events [8],[9]. Acetaminophen is an effective analgesic for musculoskeletal pain and represents the front-line therapy for the management of pain in the geriatric population, especially during perioperative periods [10],[11]. Acetaminophen is safe despite old age and associated polypharmacy and polymorbidity [12]. Acetaminophen is recommended as part of the multimodal analgesia [13],[5]. It is the only analgesic that brings a morphine-sparing effect compared to other analgesics such as non-steroidal anti-inflammatory drugs [8],[14]. Acetaminophen increases the efficacy of oxycodone in adults confronted with acute moderate to severe perioperative pain [14]. Its systematic administration following a preestablished protocol is preferred to administration on demand [15]. Learned societies recommend assessment, prevention, and management of perioperative pain. Nurses play a crucial role in this perioperative pain management. By providing care to patients, they serve as the essential link between patients and physicians, ensuring the proper implementation of prescribed treatments. Several barriers to optimal pain management have been described. The lack of knowledge and inadequate pain assessment have been clearly identified [16],[17]. The atypical presentation of pain in older adults is one of the limits leading to underdiagnosed and undertreated pain [18],[19]. Managing pain poses a challenge to the healthcare teams. However, in 2017, only 14% of hip fracture clinical trials took pain into consideration [20]. Pain in older adults is historically neglected [21]. In the new era of modernization of analgesic techniques, the adherence to basic analgesic prescription remains unknown, particularly for older patients hospitalized for a hip fracture. According to a local pilot study, less than 30% of older patients receive the optimum dose of acetaminophen during the perioperative period. We hypothesize that patients aged 75 years or more (75+) hospitalized for a hip fracture do not receive optimal management of pain in the perioperative period, in particular do not receive optimal acetaminophen treatment. Our multimodal Audit & Feedback (A&F) intervention was to improve the quality of hip fracture pain management in 75+. Our study (PAIN-AGE) was to evaluate the impact of our A&F intervention. The primary endpoint was the change in the percentage of patients who received 3g/day of acetaminophen during the three postoperative days. Our secondary objectives evaluated clinical practices of perioperative pain management and the impact of the A&F intervention on patient outcomes. Methods We performed a controlled before/after study (quasi-experimental study) to evaluate the impact of an A&F intervention carried out with nurses (Figure 1). We evaluated acetaminophen distribution as well as nurses’ adherence to prescribed pain medications and complications occurring during hospital stay in a cohort of 75+ admitted for hip fracture to an orthogeriatric unit (experimental group). Results were compared with those of a cohort of patients with similar characteristics admitted to a conventional orthopedic unit (control group). The purpose of the control group was to ensure that the changes observed in the experimental group did not result from other organizational elements or from any events occurring between the two periods. The study took place in the Grenoble Alpes University Hospital (France): the orthogeriatric unit was located in the North hospital and the conventional orthopedic unit in the South hospital. The orthogeriatric unit (experimental group) belongs to the orthopedic and traumatological surgery department. It receives patients from the emergency department. There is a daily comanagement between orthopedic surgeons, anesthesiologists, and geriatricians for perioperative care. In this unit, a set of standard pain assessment and management protocols are employed. This set consists of the following: (1) pain assessment through a numerical scale or visual analog scale (VAS) performed systematically 3 times a day and then repeated as many times as necessary; (2) non-pharmacological pain management included during the preoperative period: the limitation of the movements of the traumatized limb by aligning it properly, blocking rotations by avoiding muscular contractions of the traumatized limb, mobilization by trained paramedical teams, and ice during perioperative period; (3) routine prescription of 1g of acetaminophen 3 times a day, and 5mg per os of oxycodone (or equivalent) systematically distributed in the morning, before the nursing and the mobilization procedures; (4) conditional prescription of strong opioids based on pain intensity during all day. A pain intensity level greater than 6 induces opioid use. Data tracking of the numerical scale of prescriptions and analgesics given was performed by nursing staff. In the conventional orthopedic unit, no analgesic prescription protocol was used. Based on a pilot study, the primary endpoint (percentage of patients who received 3g/day of acetaminophen each day during the perioperative period) was achieved in 30% of patients. To demonstrate a 20% improvement in this proportion, with a risk of statistical error of 0.05 in a two-sided situation and a power of 0.90, a sample of 248 patients (124 patients in each group) was required. The study consecutively included 75+ hospitalized with hip fracture. The recruitment period lasted from December 2018 to April 2020. Patients were excluded in case of death before the surgery, admission after the surgery, multiple concomitant fractures, metastatic fractures, or functional management of the fracture. Patients who stayed less than 48 hours in the unit or under any form of legal protection, or without collected data were also excluded from the study. Other reason such as acetaminophen allergy, early orthopedic complications (luxation within 48 hours) could lead to study exclusion. A multimodal intervention including A&F was built with nurses [22]. The A&F intervention which included a pre- and post-intervention audit was implemented in the orthogeriatric unit, starting on May 2019 (Figure 2). The postintervention audit was associated with feedback. Between the two audits, several practical actions were first implemented in the unit. Firstly, healthcare workers were trained on the theme of pain (two 1-hour collective sessions) by a medical doctor and the Pain Center nurse. The course included four parts entitled “knowledge about pain” (definition and pathophysiology), “pain assessment and tools”, “pain treatment”, and “specificity of pain in older patients”. The consequences of inadequate perioperative pain management were presented [17]. We used a positive approach of errors. Secondly, a pain assessment scale was distributed. Thirdly, the existing pain management protocol was updated with a specific mention: “give acetaminophen regardless of pain assessment”. Fourthly, the medicine staffing was reviewed in collaboration with the clinical pharmacy unit. Fifthly and finally, continuation of care was guaranteed by the implementation of standby night and weekend shift, and the implementation of a medical ward round on Saturday morning. No A&F intervention was implemented in the conventional orthopedic unit (control group). The following data collected from 01 January 2020 to 30 April 2021 were retrospectively gathered for the study: demographic characteristics (sex, age), fracture and surgery characteristics (type of fracture, type of surgery, type of anesthesia), preoperative delay (hours), medical history (comorbidities and treatments), standard geriatric measures such as scores to 6-point functional status according to the Katz’s Activities of Daily Living scale (ADL) and the 8-point Lawton’s Instrumental Activities of Daily Living scale (IADL), the 6-point American Society of Anesthesiologists score (ASA), the 56-point Cumulative Illness Rating Scale – Geriatric (CIRS-G), the 24-point Charlson index score. Pain was assessed using 10-point VAS or numerical rating scale (NRS). All complications occurring during the hospital stay were collected including pain, delirium, anemia, bleeding, infection, fibrillation, stroke, myocardial infarction, thromboembolic event, stool impaction, urinary retention, pressure ulcer, dehydration, acute renal failure, and death. Functional status at discharge was assessed by ADL, and functional decline was calculated using the ADL score before the hip fracture (Day -15) and at discharge. For strong opioids, administered doses were calculated in mg/day of morphine equivalent using conversion factors [23]. For psychotropic drugs, distributed benzodiazepine (oxazepam) and hypnotic drugs were considered. Study data were collected through patient electronic records using Cristalnet and Easily software. Descriptive analysis was conducted on all collected variables, and on the total population collected. The main analysis investigated the first-order interaction between group (experimental versus control) and time (before versus after A&F intervention) on the outcome of the primary endpoint (percentage of patients who received routine acetaminophen treatment) by a logistic regression model. Then the crude interaction coefficient was adjusted for baseline patient characteristics in a multivariate model to account for potential confounders. The baseline characteristics introduced in the model were selected by comparing the two groups at the two times of the study by association tests (Kruskal Wallis test for continuous variables or Chi² test for nominal variables). The same analysis looking for an interaction between group and time was performed for each of the secondary criteria. Odds ratios (ORs) were adjusted on age, sex, and type of fracture. Qualitative parameters were expressed in numbers and percentages. Quantitative parameters were described by the median with the 25th and 75th percentiles. Analysis was performed using data processed in Excel 2019 for PC, and statistics were performed with Stata Version 14.0 software (Stata Corporation, College Station, TX, USA). The significative level was set at 0.05. The study followed CNIL (National Commission on Informatics and Liberty, France) and RGPD (General Data Protection Regulation) recommendations. Study registration within the internal register for processing activities of the Data Protection Officer controller was performed prior to Clinical Research and Innovation Delegation approval (MR 4914030220). Our hospital ethics committee approved this study and authorized waived informed consent since the study was observational. Patients and their families were informed about the study and could refuse to participate. Results A total of 745 patients were screened to be included in this controlled before/after study. Of these, 398 were included: 100 before A&F intervention and 100 after A&F intervention in the experimental group, and 100 before A&F intervention and 98 after the A&F intervention in the control group (Figure 3). The median age of the included patients was 89 in the experimental group and 85 in the control group. Patients were mainly women (from 67% to 76% according to the group and the period). Patients in the experimental group were multimorbid and dependent. Patients frequently presented with femoral neck fracture. Detailed characteristics are presented in Table 1. Table 1 Title : Characteristics of the population Legend: Qualitative parameters were expressed in numbers and percentages. Quantitative parameters were described by the median with the 25th and 75th percentiles (IQR). * In the experimental group, data were missing for 9 patients [BEFORE] and 15 patients [AFTER] for general anesthesia; 11 patients [BEFORE] and 14 patients [AFTER] for locoregional anesthesia; 31 patients [BEFORE] and 6 patients [AFTER] for the CIRS-G; 30 patients [BEFORE] and 7 patients [AFTER] for Charlson index score; 44 patients [BEFORE] and 9 patients [AFTER] for ASA; 6 patients [BEFORE] for ADL on Day -15; 9 patients [BEFORE] and 1 patient [AFTER] for IADL on Day -15. In the control group, data were missing for 5 patients [BEFORE] for general anesthesia; 5 patients [BEFORE] for locoregional anesthesia; 1 patient [AFTER] for acetaminophen; 79 patients [BEFORE] and 66 patients [AFTER] for ADL on Day -15; 82 patients [BEFORE] and 67 patients [AFTER] for IADL on Day -15. Moreover, CIRS-G and Charlson index score were not usually collected. Abbreviations: ADL: Activities of Daily Living scale; ASA: American Society of Anesthesiologists score; CIRS-G: Cumulative Illness Rating Scale – Geriatric; CO: conventional orthopedic unit; IADL: Instrumental Activities of Daily Living scale; IQR: interquartile range; ND: Not determined; OG: orthogeriatric unit During the preoperative period, 9% of patients from the experimental group received 3g/day of acetaminophen before the A&F intervention and 16% after the A&F intervention, without significant statistical difference (p=0.13) (Table 2). Table 2 Title: Impact of the intervention on clinical pain management Legend: Qualitative parameters were expressed in numbers and percentages. Quantitative parameters were described by the mean ± standard deviation, and by median with the 25th and 75th percentiles. * assessed through acetaminophen; † in morphine sulfate equivalent. Abbreviations: CO: conventional orthopedic unit; IQR: Interquartile; OG: orthogeriatric unit; OR: Odds ratio; Pre: Preoperative; Post: Postoperative; R: Regression coefficient; VAS: Visual analog scale During the postoperative period, 16% of patients from the experimental group received 3g/day of acetaminophen before the A&F intervention; the percentage reached 60% after the A&F intervention (OR=8.55 [4.29;17.03]; p<0.001). In the control group, no change in the distribution of acetaminophen was observed after the A&F intervention, neither in the preoperative (p=0.76) nor in the postoperative period (p=0.43). After the A&F intervention, the likelihood of receiving 3g/day of acetaminophen during the postoperative period was significantly increased in the experimental group as compared with the control group (OR=6.76 [2.7;16.9]; p<0.001). During the preoperative period, nurses’ adherence to the medical prescriptions of acetaminophen was 13% in the experimental group before the A&F intervention and 32% after the A&F intervention (p=0.001). During the postoperative period, it was 13% in the experimental group before the A&F intervention, but reached 52% after the A&F intervention (p<0.001). The likelihood of adhering to medical prescription of acetaminophen was significantly increased in the experimental group as compared with the control group (OR=20.34 [4.4;94.05], p<0.001). In the experimental group, the number of in-hospital VAS recorded slightly decreased after the A&F intervention (p=0.02). The strong opioid distribution during the pre and postoperative periods did not differ after the A&F intervention. In the preoperative period, the distribution of benzodiazepine significantly decreased after the A&F intervention (p=0.007); it was not significantly modified after the A&F intervention during the postoperative period (p=0.33). The complication rates were not different before and after the A&F intervention (Table 3). Table 3 Title: Impact of the intervention on the patient outcomes Legend: Qualitative parameters were expressed in numbers and percentages. Quantitative parameters were described using median and the 25th and 75th percentiles. * In the experimental group, data were missing for 30 patients [BEFORE] and 8 patients [AFTER] for ADL score at discharge; these data were missing for 87 patients [BEFORE] and 68 patients [AFTER] discharge in the control group Abbreviations: ADL: Activities of Daily Living scale; CO: conventional orthopedic unit; IQR: Interquartile; ND: not determined; OG: orthogeriatric unit; OR: Odds ratio; Pre.: Preoperative; Post: Postoperative; R: Regression coefficient; VAS: Visual analog scale The functional status at discharge according to ADL score was better after the A&F intervention (p =0.008) in the experimental group, and the length of stay significantly decreased by 2.5 days (p=0.002). Discussion Our controlled before/after study showed that an A&F intervention significantly improved perioperative pain management in older adults hospitalized for hip fracture. After the A&F intervention, the likelihood of receiving 3g/day of acetaminophen during the postoperative period was significantly increased and the nurses’ adherence to medical prescriptions based on acetaminophen prescription improved. In addition, the functional status at discharge according to ADL score was better after the A&F intervention and the length of stay in the orthogeriatric unit significantly shorter. Our study presented several limitations. Firstly, the control group experienced a high rate of missing data due to conventional care without specific geriatric management and data collection. Additionally, the perioperative complication rates did not decrease following the A&F intervention. However, it is important to note that the study was not designed to measure complication outcomes. A dedicated study should be conducted to assess the impact of the A&F intervention on complications. Finally, in contrast to other studies [24], we examined both prescription and medication distribution, thus considering the behaviors of both doctors and nurses. Pain management is one of the key elements in orthogeriatric comanagement [25]. Several barriers to optimal pain control have been described with four distinct areas: healthcare system; physicians; nurses; patients [26],[17],[27]. An analysis of the literature found that 72% of hip-fractured patients received no prehospital analgesia [28]. According to Herr & Titler [29], the most common barrier to manage pain in older adults with hip fracture admitted through the emergency department is the inability to offer analgesic drugs until a diagnosis is established by the physician. In their article, only 60% of patients had an analgesic ordered. Physicians could also be reluctant to prescribe opioids in traumatic older patients [4]. Finally, inadequate prescriptions or the lack of medical prescriptions of analgesics hinder optimal pain management at admission [29],[24]. Nurses play a critical role in pain management during the hospital stay, especially when analgesics are prescribed pro re nata (PRN; i.e., as needed or required by the patient) [30], rather than according to a regular schedule [31]. Acetaminophen is the most frequently administered analgesic (28% to 61%) in hip-fractured patients [32],[31]. However, undertreatment with acetaminophen is common [31]. In a PRN context, the quality of assessment is a determining factor for pain management. Pain assessment can be difficult in complex pain situations (e.g., individuals with neurological disorders such as dementia or delirium) [33]. In our study, both pain assessment and medical prescriptions were considered. Our study assessed the management of an acute and foreseeable pain, in an established traumatic context, in older adults, with routine medical prescription leaving no room for interpretation. The major finding of our study was the gap between analgesic prescription and drug distribution with a real lack of adherence to medical prescriptions. This gap has been known for a long time in the postoperative period in such context. Strong opioids distribution in patients aged over 65 years and hospitalized for a hip fracture is lower than the dose prescribed [34]. Concerning non-opioid administration, two thirds of patients received less than 50% of the prescribed analgesic [34]. Finally, a study which included day and night observation of nine nurses and in-depth interviews showed that nurses did not give the recommended combination of drugs (i.e., acetaminophen with opioids) [35]. Pain undertreatment usually affects the old-old and those with cognitive impairment [34]. In our study, acetaminophen distribution rate was extremely low and far from 100%. Nurses are responsible for treatment distribution and administration; their poor knowledge leads to their non-adherence to good clinical practices [17]. Comprehensive knowledge encompasses both pain assessment and pain management [27]. From nurses’ perspectives, pain assessment and management could be improved by improving nurse’s knowledge and attitudes [27],[36],[37]. A systematic review concluded that education programs may exert a positive impact on nurses’ attitude toward pain management [38]. Multidisciplinary geriatric fracture programs including early, multimodal pain management were associated with improved emergency department pain management of older patients with hip fracture: the use of acetaminophen increased from 10% to 51% (p<0.001) and the use of morphine decreased in the first 24 hours [39]. Our study directly measured the effect of our multimodal intervention on nurses’ attitudes and practices. The distribution of pain medication was greatly increased in the postoperative period thanks to our A&F intervention. Strong opioid distribution did not decrease following the A&F intervention, but our study did not aim to compare optimal pain management with non-optimal pain management. Furthermore, this could be a sign of the good quality of care in the unit. In a recent study [40], we demonstrated that 75+ with or without cognitive deficits or delirium hospitalized for a hip fracture in a orthogeriatric unit received the same daily average quantity of strong opioids during the preoperative period. The standard pain management in an orthogeriatric unit avoids the undertreatment of pain in patients with moderate to strong cognitive deficits. Our study pointed two crucial findings. Firstly, the rate of nurses’ adherence to medical prescriptions remained insufficient following the A&F intervention. Dihle reported that nurses did not always use their knowledge in clinical practice, which led to a huge gap between “what nurses say and what nurses do” [35]. This constitutes a barrier to an optimal postoperative pain management. Educational interventions succeed in improving knowledge and practices but their impact on health provider’s beliefs is controversial [36]. Subconscious barriers have been described [30], leading to a gap “between the nurses’ own perceptions about how they dealt with postoperative pain management and how they actually performed it in the clinical setting” [35]. Secondly, the A&F intervention failed in the preoperative period. Conclusions By demonstrating that less than one quarter of patients received the optimal dosage of acetaminophen despite routine medical prescription, this study is an opportunity to question ourselves about our practices from prescription to administration including medication circuit, and to raise awareness of healthcare providers about this alarming issue. The management of pain is still not up to the mark. Defining clinical practice guidelines or pain action plan is not sufficient. In contrast to the opioid crisis, our challenge is not excessive use, but rather the underuse of a front-line medication named acetaminophen. It might be referred to as an "acetaminophen crisis". Our A&F intervention could potentially be used by other healthcare team managers to develop practice assessment in their own unit and pain education program. Team involvement in continuous education seems to be a key determinant of pain management quality and more studies are needed to assess factors associated with an optimal pain management in traumatized older adults. Abbreviations A&F: Audit and Feedback Declarations Ethical approval and consent to participate The study followed CNIL (National Commission on Informatics and Liberty, France) and RGPD (General Data Protection Regulation) recommendations. Study registration within the internal register for processing activities of the Data Protection Officer controller was performed prior to Clinical Research and Innovation Delegation approval (MR 4914030220). Our hospital ethics committee approved this study and authorized waived informed consent since the study was observational. Patients and their families were informed about the study and could refuse to participate. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interest The authors declare that they have no competing interests. Funding The University Hospital Grenoble Alpes funded the study. Authors' contributions SD: Conceptualization (C), Funding Acquisition (FA), Project Administration (PA), Methodology (M), Supervision (S), Investigation (I), Formal analysis (Fa), Validation (Va) Visualization (V), Writing original Draft, Writing – Review-Editing (WRE); BB (M, Fa, Software (S), Data curation (DC), Va, M,V, WRE); AG (M, DC, S,V); AB (I, WRE) FO (I,V); MR (I, M,V); LM (I,V); AG (I, Fa,V); CM (M,V); RP (I, V); BRD (I, V); PB (C, I, V); JT (C, I, V); CB (I, V, R); GG (C, M, ID, M, V, WRE); PF (M, M, V); PG (M, I, M, V, WRE). Acknowledgements We thank the University Hospital Grenoble Alpes for the funding. We thank Fabienne Peretz for editorial assistance. References Briot K, Maravic M, Roux C. Changes in number and incidence of hip fractures over 12years in France. Bone. 2015;81:131–7. https://doi.org/10.1016/j.bone.2015.07.009 . Sanzone AG. Current Challenges in Pain Management in Hip Fracture Patients. J Orthop Trauma. 2016;30(5):S1–5. https://doi.org/10.1097/BOT.0000000000000562 . Mosk CA, Mus M, Vroemen JP, van der Ploeg T, Vos DI, Elmans LH, et al. Dementia and delirium, the outcomes in elderly hip fracture patients. Clin Interv Aging. 2017;12:421–30. https://doi.org/10.2147/CIA.S115945 . Morrison SR, Magaziner J, McLaughlin MA, Orosz G, Silberzweig SB, Koval KJ, et al. The impact of post-operative pain on outcomes following hip fracture. Pain. 2003;103(3):303–11. https://doi.org/10.1016/S0304-3959(02)00458-X . Chou R, Gordon DB, de Leon-Casasola OA. Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2015;17(2):131–57. https://doi.org/10.1016/j.jpain.2015.12.008 . Jones J, Southerland W, Catalani B. The Importance of Optimizing Acute Pain in the Orthopedic Trauma Patient. Orthop Clin North Am. 2017;48(4):445–65. https://doi.org/10.1016/j.ocl.2017.06.003 . Aubrun F, Baillard C, Beuscart JB, Billard V, Boddaert J, Boulanger É, et al. Recommandation sur l’anesthésie du sujet âgé: l’exemple de fracture de l’extrémité supérieure du fémur. Anesthésie Réanimation. 2019;5(2):122–38. https://doi.org/10.1016/j.anrea.2018.12.002 . Remy C, Marret E, Bonnet F. Effects of acetaminophen on morphine side-effects and consumption after major surgery: meta-analysis of randomized controlled trials. Br J Anaesth. 2005;94(4):505–13. https://doi.org/10.1093/bja/aei085 . Garlich JM, Pujari A, Moak Z, Debbi E, Yalamanchili R, Stephenson S, et al. Pain Management with Early Regional Anesthesia in Geriatric Hip Fracture Patients. J Am Geriatr Soc. 2020;68(9):2043–50. https://doi.org/10.1111/jgs.16547 . Ftouh S, Morga A, Swift C. Management of hip fracture in adults: summary of NICE guidance. BMJ. 2011;342:d3304. https://doi.org/10.1136/bmj.d3304 . The American Society of Anesthesiologists. Practice Guidelines for Acute Pain Management in the Perioperative Setting: An Updated Report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012;116(2):248–73. https://doi.org/10.1097/ALN.0b013e31823c1030 . Girard P, Sourdet S, Cantet C, De Souto Barreto P, Rolland Y, Acetaminophen Safety. Risk of Mortality and Cardiovascular Events in Nursing Home Residents, a Prospective Study. J Am Geriatr Soc. 2019;67(6):1240–7. https://doi.org/10.1111/jgs.15861 . Macario A, Royal MA. A literature review of randomized clinical trials of intravenous acetaminophen (paracetamol) for acute postoperative pain. Pain Pract. 2010;11(3):290–6. https://doi.org/10.1111/j.1533-2500.2010.00426.x . Gaskell H, Derry S, Moore RA, McQuay HJ. Single dose oral oxycodone and oxycodone plus paracetamol (acetaminophen) for acute postoperative pain in adults. Cochrane Database Syst Rev. 2009;3 https://doi.org/10.1002/14651858.CD002763.pub2 . Griffiths R, Alper J, Beckingsale A, Goldhill D, Heyburn G, Holloway J, et al. Management of proximal femoral fractures 2011: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia. 2011;67(1):85–98. https://doi.org/10.1111/j.1365-2044.2011.06957.x . Zhang CH, Hsu L, Zou BR, Li JF, Wang HY, Huang J. Effects of a pain education program on nurses' pain knowledge, attitudes and pain assessment practices in China. J Pain Symptom Manage. 2008;36(6):616–27. https://doi.org/10.1016/j.jpainsymman.2007.12.020 . Tomaszek L, Dębska G. Knowledge, compliance with good clinical practices and barriers to effective control of postoperative pain among nurses from hospitals with and without a Hospital without Pain certificate. J Clin Nurs. 2017;27(7–8):1641–52. https://doi.org/10.1111/jocn.14215 . Holloway H, Parker D, McCutcheon H. The complexity of pain in aged care. Contemp Nurse. 2018;54(2):121–5. https://doi.org/10.1080/10376178.2018.1480399 . Shier V, Edelen MO, McMullen TL, Dunbar MS, Bruckenthal P, Ahluwalia SC, et al. Standardized assessment of cognitive function, mood, and pain among patients who are unable to communicate. J Am Geriatr Soc. 2022;70(4):1012–22. https://doi.org/10.1111/jgs.17647 . Smith TO, Collier T, Sheehan KJ, Sherrington C. The uptake of the hip fracture core outcome set: analysis of 20 years of hip fracture trials. Age Ageing. 2019;48(4):595–8. https://doi.org/10.1093/ageing/afz018 . Knopp-Sihota JA, Patel P, Estabrooks CA. Interventions for the Treatment of Pain in Nursing Home Residents: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc. 2016;17(12):1163. https://doi.org/10.1016/j.jamda.2016.09.016 . .e19-1163.e28 . Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012;6 https://doi.org/10.1002/14651858.CD000259.pub3 . Von Korff M, Saunders K, Thomas Ray G, Boudreau D, Campbell C, Merrill J, et al. De facto long-term opioid therapy for noncancer pain. Clin J Pain. 2008;24(6):521–7. https://doi.org/10.1097/AJP.0b013e318169d03b . Bouri F, El Ansari W, Mahmoud S, Elhessy A, Al-Ansari A, Al-Dosari MAA. Orthopedic Professionals’ Recognition and Knowledge of Pain and Perceived Barriers to Optimal Pain Management at Five Hospitals. 2018;6(3):98. https://doi.org/10.3390/healthcare6030098 . Liem IS, Kammerlander C, Suhm N, Blauth M, Roth T, Gosch M, et al. Identifying a standard set of outcome parameters for the evaluation of orthogeriatric co-management for hip fractures. Injury. 2013;44(11):1403–12. https://doi.org/10.1016/j.injury.2013.06.018 . Coulling S. Nurses’ and doctors’ knowledge of pain after surgery. Nurs Stand. 2005;19(34):41–9. https://doi.org/10.7748/ns2005.05.19.34.41.c3859 . Rababa M, Al-Sabbah S, Hayajneh AA. Nurses' Perceived Barriers to and Facilitators of Pain Assessment and Management in Critical Care Patients: A Systematic Review. J Pain Res. 2021;14:3475–91. https://doi.org/10.2147/JPR.S332423 . Dixon J, Ashton F, Baker P, Charlton K, Bates C, Eardley W. Assessment and Early Management of Pain in Hip Fractures: The Impact of Paracetamol. Geriatr Orthop Surg Rehabil 2018;9():. https://doi.org/10.1177/2151459318806443 . Herr K, Titler M. Acute pain assessment and pharmacological management practices for the older adult with a hip fracture: review of ED trends. J Emerg Nurs. 2008;35(4):312–20. https://doi.org/10.1016/j.jen.2008.08.006 . Schafheutle EI, Cantrill JA, Noyce PR. Why is pain management suboptimal on surgical wards? J Adv Nurs. 2001;33(6):728–37. https://doi.org/10.1046/j.1365-2648.2001.01714.x . Eid T, Bucknall T. Documenting and implementing evidence-based post-operative pain management in older patients with hip fractures. J Orthop Nurs. 2008;12(2):90–8. https://doi.org/10.1016/j.joon.2008.07.003 . Titler MG, Herr K, Schilling ML, Marsh JL, Xie XJ, Ardery G, et al. Acute pain treatment for older adults hospitalized with hip fracture: current nursing practices and perceived barriers. Appl Nurs Res. 2003;16(4):211–27. https://doi.org/10.1016/s0897-1897(03)00051-x . Hadjistavropoulos T, Herr K, Prkachin KM, Craig KD, Gibson SJ, Lukas A, et al. Pain assessment in elderly adults with dementia. Lancet Neurol. 2014;13(12):1216–27. https://doi.org/10.1016/S1474-4422(14)70103-6 . Feldt KS, Ryden MB, Miles S. Treatment of Pain in Cognitively Impaired Compared with Cognitively Intact Older Patients with Hip-Fracture. J Am Geriatr Soc. 1998;46(9):1079–85. https://doi.org/10.1111/j.1532-5415.1998.tb06644.x . Dihle A, Bjølseth G, Helseth S. The gap between saying and doing in postoperative pain management. J Clin Nurs. 2006;15(4):469–79. https://doi.org/10.1111/j.1365-2702.2006.01272.x . Abdalrahim MS, Majali SA, Stomberg MW, Bergbom I. The effect of postoperative pain management program on improving nurses’ knowledge and attitudes toward pain. Nurse Educ Pract. 2011;11(4):250–5. https://doi.org/10.1016/j.nepr.2010.11.016 . Brunkert T, Simon M, Ruppen W, Zúñiga F. Pain Management in Nursing Home Residents: Findings from a Pilot Effectiveness-Implementation Study. J Am Geriatr Soc. 2019;67(12):2574–80. https://doi.org/10.1111/jgs.16148 . AlReshidi N, Long T, Darvill A. A Systematic Review of the Impact of Educational Programs on Factors That Affect Nurses’ Post-Operative Pain Management for Children. Compr Child Adolesc Nurs. 2018;41(1):9–24. https://doi.org/10.1080/24694193.2017.1319432 . Casey SD, Stevenson DE, Mumma BE, Slee C, Wolinsky PR, Tyler K et al. Emergency Department Pain Management Following Implementation of a Geriatric Hip Fracture Program. 2017;18(4):. https://doi.org/10.5811/westjem.2017.3.32853 . Ruel M, Boussat B, Boudissa M, Garnier V, Bioteau C, Tonetti J, et al. Management of preoperative pain in elderly patients with moderate to severe cognitive deficits and hip fracture: a retrospective, monocentric study in an orthogeriatric unit. BMC Geriatr. 2021;21(1):575. https://doi.org/10.1186/s12877-021-02500-7 . Tables Tables 1-3 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.docx Table2.docx Table3.docx Cite Share Download PDF Status: Published Journal Publication published 05 Sep, 2024 Read the published version in BMC Geriatrics → Version 1 posted Editorial decision: Revision requested 25 Apr, 2024 Reviews received at journal 22 Apr, 2024 Reviews received at journal 06 Apr, 2024 Reviews received at journal 02 Apr, 2024 Reviewers agreed at journal 31 Mar, 2024 Reviewers agreed at journal 31 Mar, 2024 Reviewers agreed at journal 27 Mar, 2024 Reviewers invited by journal 26 Mar, 2024 Editor assigned by journal 26 Mar, 2024 Editor invited by journal 08 Mar, 2024 Submission checks completed at journal 08 Mar, 2024 First submitted to journal 22 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3978284","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":277512554,"identity":"c115d1d2-2939-4e9c-a36a-062d957a1d9f","order_by":0,"name":"Sabine Drevet","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAElEQVRIiWNgGAWjYFCCBDApxyABE5BgbmBgsCGoxcAYSQsjUEsaYS2JDURrkW/PffiYp+JPev/sHgPGr3ts8vilGxsfMCTcw6nF4MxzY2OeMwa5M+6cMWCWeZZWLDnnYLMBQ0Ixbi0SaWySM9sMcjdI5Jj/ljhwOHHDjcQ2CcYfCbgdNiON/efMfwbpBhI5BswSB/6DtLT/YEjArYXhRhobw8cGgwSQFsYPBw6AbWHAp8XgzDNmiQ/HjA1n3EgrYGY4kJw4E+gXiQQ8WuTb0xg/JNTIyfPPSN7A+OOAXWK/dPPBDx/wOQwZMPPAWERqYGBg/EGsylEwCkbBKBhRAADrZ1Zc7kOILQAAAABJRU5ErkJggg==","orcid":"","institution":"Grenoble Alpes University","correspondingAuthor":true,"prefix":"","firstName":"Sabine","middleName":"","lastName":"Drevet","suffix":""},{"id":277512555,"identity":"0ca9ffe3-f996-4471-845a-4aa5dab919f6","order_by":1,"name":"Bastien Boussat","email":"","orcid":"","institution":"Grenoble Alpes University","correspondingAuthor":false,"prefix":"","firstName":"Bastien","middleName":"","lastName":"Boussat","suffix":""},{"id":277512556,"identity":"644e5bdb-ca7f-4799-b18f-a980acb7fe94","order_by":2,"name":"Armance Grevy","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Grenoble","correspondingAuthor":false,"prefix":"","firstName":"Armance","middleName":"","lastName":"Grevy","suffix":""},{"id":277512557,"identity":"5a99df67-f0c3-49fe-a628-cebe316a0aee","order_by":3,"name":"Audrey Brevet","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Grenoble","correspondingAuthor":false,"prefix":"","firstName":"Audrey","middleName":"","lastName":"Brevet","suffix":""},{"id":277512558,"identity":"b57244c0-21c5-44f0-bf36-ca9f3a2f4955","order_by":4,"name":"Frederic Olive","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Grenoble","correspondingAuthor":false,"prefix":"","firstName":"Frederic","middleName":"","lastName":"Olive","suffix":""},{"id":277512559,"identity":"4c88c5c2-d5d6-48d7-a82f-5aea1b0cb710","order_by":5,"name":"Marion Richard","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Grenoble","correspondingAuthor":false,"prefix":"","firstName":"Marion","middleName":"","lastName":"Richard","suffix":""},{"id":277512560,"identity":"9ef3efbe-d7ce-43b5-a7b0-6a9f255d1390","order_by":6,"name":"Laura Marchesi","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Grenoble","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"","lastName":"Marchesi","suffix":""},{"id":277512561,"identity":"fcf6c483-c96a-433a-a8a0-d6111552f316","order_by":7,"name":"Alize Guyomard","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Grenoble","correspondingAuthor":false,"prefix":"","firstName":"Alize","middleName":"","lastName":"Guyomard","suffix":""},{"id":277512562,"identity":"2f12abbc-cb22-44b8-a00c-90c474263958","order_by":8,"name":"Caroline Maindet","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Grenoble","correspondingAuthor":false,"prefix":"","firstName":"Caroline","middleName":"","lastName":"Maindet","suffix":""},{"id":277512563,"identity":"fae4ac4e-ec9f-4aa0-9bfa-3b834996d777","order_by":9,"name":"Regis Pailhe","email":"","orcid":"","institution":"Grenoble Alpes University","correspondingAuthor":false,"prefix":"","firstName":"Regis","middleName":"","lastName":"Pailhe","suffix":""},{"id":277512564,"identity":"2fb1713e-4ddd-41ae-8dee-25e2bb08106b","order_by":10,"name":"Brice Rubens Duval","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Grenoble","correspondingAuthor":false,"prefix":"","firstName":"Brice","middleName":"Rubens","lastName":"Duval","suffix":""},{"id":277512565,"identity":"e4aa65b4-545c-42fc-a474-f95a8ef9ee59","order_by":11,"name":"Pierre Bouzat","email":"","orcid":"","institution":"Grenoble Alpes University","correspondingAuthor":false,"prefix":"","firstName":"Pierre","middleName":"","lastName":"Bouzat","suffix":""},{"id":277512566,"identity":"4bba61f8-d8cd-4b84-8217-ccad73f4f52a","order_by":12,"name":"Jérôme Tonetti","email":"","orcid":"","institution":"Grenoble Alpes University","correspondingAuthor":false,"prefix":"","firstName":"Jérôme","middleName":"","lastName":"Tonetti","suffix":""},{"id":277512567,"identity":"6b23e3c6-dafb-4dea-8dbd-fdbe44147e3b","order_by":13,"name":"Catherine Bioteau","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Grenoble","correspondingAuthor":false,"prefix":"","firstName":"Catherine","middleName":"","lastName":"Bioteau","suffix":""},{"id":277512568,"identity":"1812654e-efff-499f-9d36-c9e192ae4236","order_by":14,"name":"Gaetan Gavazzi","email":"","orcid":"","institution":"Grenoble Alpes University","correspondingAuthor":false,"prefix":"","firstName":"Gaetan","middleName":"","lastName":"Gavazzi","suffix":""},{"id":277512569,"identity":"531288ec-255a-46a4-8110-4faa1260f1f1","order_by":15,"name":"Patrice Francois","email":"","orcid":"","institution":"Grenoble Alpes University","correspondingAuthor":false,"prefix":"","firstName":"Patrice","middleName":"","lastName":"Francois","suffix":""},{"id":277512570,"identity":"21a7edf8-3c54-411e-83d6-bb934419d240","order_by":16,"name":"Prudence Gibert","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Grenoble","correspondingAuthor":false,"prefix":"","firstName":"Prudence","middleName":"","lastName":"Gibert","suffix":""}],"badges":[],"createdAt":"2024-02-22 10:19:49","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3978284/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3978284/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12877-024-05282-w","type":"published","date":"2024-09-05T16:04:54+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":52543217,"identity":"856689fc-e8d5-4e5c-9e1b-f16a312ee244","added_by":"auto","created_at":"2024-03-12 17:49:04","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":709767,"visible":true,"origin":"","legend":"\u003cp\u003eStudy design\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e We performed a controlled before/after study (quasi-experimental study) to evaluate the impact of an A\u0026amp;F intervention carried out with nurses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003eOG: orthogeriatric unit; CO: conventional orthopedic unit.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3978284/v1/61d488e4644b9f12a09ebd74.jpg"},{"id":52541603,"identity":"a14231c0-488b-4e38-969f-5593405bf87d","added_by":"auto","created_at":"2024-03-12 17:33:04","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":392775,"visible":true,"origin":"","legend":"\u003cp\u003eAudit \u0026amp; Feedback intervention\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e A multimodal intervention including A\u0026amp;F was built with nurses. The A\u0026amp;F intervention which included a pre- and post-intervention audit was implemented in the orthogeriatric unit.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3978284/v1/dd56cf6b20b954e36900b26c.jpg"},{"id":52542314,"identity":"57e283de-35e6-4f56-91e8-eb59c408803c","added_by":"auto","created_at":"2024-03-12 17:41:04","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":363485,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of the study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations: \u003c/strong\u003eOG: orthogeriatric unit; CO: conventional orthopedic unit.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3978284/v1/017b975b7e48ae5553b3110e.jpg"},{"id":64185641,"identity":"e8f963bd-8711-4bd9-8ebc-2a99a7a9de83","added_by":"auto","created_at":"2024-09-09 16:19:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1921689,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3978284/v1/e14a77e1-5717-4682-9b0b-cd03a7e0cdff.pdf"},{"id":52542313,"identity":"cfed9728-57b8-472f-a60d-6333804c9837","added_by":"auto","created_at":"2024-03-12 17:41:04","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":55983,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-3978284/v1/e0f0254311eb865fdfef0c06.docx"},{"id":52542312,"identity":"066307f2-86a0-4dc9-b523-48016be398c6","added_by":"auto","created_at":"2024-03-12 17:41:04","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":59455,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-3978284/v1/25f73a5dcfb3845d94e051cb.docx"},{"id":52541600,"identity":"ff6adb62-a333-4d8d-b3d5-c2fbaef9fc69","added_by":"auto","created_at":"2024-03-12 17:33:04","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":56124,"visible":true,"origin":"","legend":"","description":"","filename":"Table3.docx","url":"https://assets-eu.researchsquare.com/files/rs-3978284/v1/631ddf56446c52ebe6e78314.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"PAIN-AGE, a Controlled Before/After Study Assessing an Audit and Feedback Perioperative Pain Management Intervention in Older Patients with Hip Fracture.","fulltext":[{"header":"Background","content":"\u003cp\u003eThanks to better prevention, the risk of hip fractures is decreasing; however, the number of hip fractures continues to increase with the aging of the population and the increasing number of people over 60 years of age [1].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePostoperative pain has been identified as an unfavorable prognostic factor [2],[3]. Pain delays ambulation, extends hospital stay, reduces the probability of recovery, and finally increases risk of long-term functional impairment [4]. Pre- and postoperative (perioperative) pain management is based on multimodal analgesia that consists of the use of several analgesic medications and techniques combined with non-pharmacological interventions [5],[6],[7]. Multimodal analgesia improves perioperative pain management and reduces analgesic doses leading to a reduction in the incidence of adverse events [8],[9].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcetaminophen is an effective analgesic for musculoskeletal pain and represents the front-line therapy for the management of pain in the geriatric population, especially during perioperative periods [10],[11]. Acetaminophen is safe despite old age and associated polypharmacy and polymorbidity [12]. Acetaminophen is recommended as part of the multimodal analgesia [13],[5]. It is the only analgesic that brings a morphine-sparing effect compared to other analgesics such as non-steroidal anti-inflammatory drugs [8],[14]. Acetaminophen increases the efficacy of oxycodone in adults confronted with acute moderate to severe perioperative pain [14]. Its systematic administration following a preestablished protocol is preferred to administration on demand [15].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLearned societies recommend assessment, prevention, and management of perioperative pain. Nurses play a crucial role in this perioperative pain management. By providing care to patients, they serve as the essential link between patients and physicians, ensuring the proper implementation of prescribed treatments.\u003c/p\u003e\n\u003cp\u003eSeveral barriers to optimal pain management have been described. The lack of knowledge and inadequate pain assessment have been clearly identified [16],[17]. The atypical presentation of pain in older adults is one of the limits leading to underdiagnosed and undertreated pain [18],[19]. Managing pain poses a challenge to the healthcare teams. However, in 2017, only 14% of hip fracture clinical trials took pain into consideration [20]. Pain in older adults is historically neglected [21]. In the new era of modernization of analgesic techniques, the adherence to basic analgesic prescription remains unknown, particularly for older patients hospitalized for a hip fracture. According to a local pilot study, less than 30% of older patients receive the optimum dose of acetaminophen during the perioperative period.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe hypothesize that patients aged 75 years or more (75+) hospitalized for a hip fracture do not receive optimal management of pain in the perioperative period, in particular do not receive optimal acetaminophen treatment. Our multimodal Audit \u0026amp; Feedback (A\u0026amp;F) intervention was to improve the quality of hip fracture pain management in 75+. Our study (PAIN-AGE) was to evaluate the impact of our A\u0026amp;F intervention. The primary endpoint was the change in the percentage of patients who received 3g/day of acetaminophen during the three postoperative days. Our secondary objectives evaluated clinical practices of perioperative pain management and the impact of the A\u0026amp;F intervention on patient outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe performed a controlled before/after study (quasi-experimental study) to evaluate the impact of an A\u0026amp;F intervention carried out with nurses (Figure 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe evaluated acetaminophen distribution as well as nurses\u0026rsquo; adherence to prescribed pain medications and complications occurring during hospital stay in a cohort of 75+ admitted for hip fracture to an orthogeriatric unit (experimental group). Results were compared with those of a cohort of patients with similar characteristics admitted to a conventional orthopedic unit (control group). The purpose of the control group was to ensure that the changes observed in the experimental group did not result from other organizational elements or from any events occurring between the two periods.\u003c/p\u003e\n\u003cp\u003eThe study took place in the Grenoble Alpes University Hospital (France): the orthogeriatric unit was located in the North hospital and the conventional orthopedic unit in the South hospital. The orthogeriatric unit (experimental group) belongs to the orthopedic and traumatological surgery department. It receives patients from the emergency department. There is a daily comanagement between orthopedic surgeons, anesthesiologists, and geriatricians for perioperative care. In this unit, a set of standard pain assessment and management protocols are employed. This set consists of the following: (1) pain assessment through a numerical scale or visual analog scale (VAS) performed systematically 3 times a day and then repeated as many times as necessary; (2) non-pharmacological pain management included during the preoperative period: the limitation of the movements of the traumatized limb by aligning it properly, blocking rotations by avoiding muscular contractions of the traumatized limb, mobilization by trained paramedical teams, and ice during perioperative period; (3) routine prescription of 1g of acetaminophen 3 times a day, and 5mg per os of oxycodone (or equivalent) systematically distributed in the morning, before the nursing and the mobilization procedures; (4) conditional prescription of strong opioids based on pain intensity during all day. A pain intensity level greater than 6 induces opioid use. Data tracking of the numerical scale of prescriptions and analgesics given was performed by nursing staff. In the conventional orthopedic unit, no analgesic prescription protocol was used.\u003c/p\u003e\n\u003cp\u003eBased on a pilot study, the primary endpoint (percentage of patients who received 3g/day of acetaminophen each day during the perioperative period) was achieved in 30% of patients. To demonstrate a 20% improvement in this proportion, with a risk of statistical error of 0.05 in a two-sided situation and a power of 0.90, a sample of 248 patients (124 patients in each group) was required.\u003c/p\u003e\n\u003cp\u003eThe study consecutively included 75+ hospitalized with hip fracture. The recruitment period lasted from December 2018 to April 2020. Patients were excluded in case of death before the surgery, admission after the surgery, multiple concomitant fractures, metastatic fractures, or functional management of the fracture. Patients who stayed less than 48 hours in the unit or under any form of legal protection, or without collected data were also excluded from the study. Other reason such as acetaminophen allergy, early orthopedic complications (luxation within 48 hours) could lead to study exclusion.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA multimodal intervention including A\u0026amp;F was built with nurses [22]. The A\u0026amp;F intervention which included a pre- and post-intervention audit was implemented in the orthogeriatric unit, starting on May 2019 (Figure 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe postintervention audit was associated with feedback. Between the two audits, several practical actions were first implemented in the unit. Firstly, healthcare workers were trained on the theme of pain (two 1-hour collective sessions) by a medical doctor and the Pain Center nurse. The course included four parts entitled \u0026ldquo;knowledge about pain\u0026rdquo; (definition and pathophysiology), \u0026ldquo;pain assessment and tools\u0026rdquo;, \u0026ldquo;pain treatment\u0026rdquo;, and \u0026ldquo;specificity of pain in older patients\u0026rdquo;. The consequences of inadequate perioperative pain management were presented [17]. We used a positive approach of errors. Secondly, a pain assessment scale was distributed. Thirdly, the existing pain management protocol was updated with a specific mention: \u0026ldquo;give acetaminophen regardless of pain assessment\u0026rdquo;. Fourthly, the medicine staffing was reviewed in collaboration with the clinical pharmacy unit. Fifthly and finally, continuation of care was guaranteed by the implementation of standby night and weekend shift, and the implementation of a medical ward round on Saturday morning. No A\u0026amp;F intervention was implemented in the conventional orthopedic unit (control group).\u003c/p\u003e\n\u003cp\u003eThe following data collected from 01 January 2020 to 30 April 2021 were retrospectively gathered for the study: demographic characteristics (sex, age), fracture and surgery characteristics (type of fracture, type of surgery, type of anesthesia), preoperative delay (hours), medical history (comorbidities and treatments), standard geriatric measures such as scores to 6-point functional status according to the Katz\u0026rsquo;s Activities of Daily Living scale (ADL) and the 8-point Lawton\u0026rsquo;s Instrumental Activities of Daily Living scale (IADL), the 6-point American Society of Anesthesiologists score (ASA), the 56-point Cumulative Illness Rating Scale \u0026ndash; Geriatric (CIRS-G), the 24-point Charlson index score. Pain was assessed using 10-point VAS or numerical rating scale (NRS). All complications occurring during the hospital stay were collected including pain, delirium, anemia, bleeding, infection, fibrillation, stroke, myocardial infarction, thromboembolic event, stool impaction, urinary retention, pressure ulcer, dehydration, acute renal failure, and death. Functional status at discharge was assessed by ADL, and functional decline was calculated using the ADL score before the hip fracture (Day -15) and at discharge. For strong opioids, administered doses were calculated in mg/day of morphine equivalent using conversion factors [23]. For psychotropic drugs, distributed benzodiazepine (oxazepam) and hypnotic drugs were considered.\u003c/p\u003e\n\u003cp\u003eStudy data were collected through patient electronic records using Cristalnet and Easily software. Descriptive analysis was conducted on all collected variables, and on the total population collected. The main analysis investigated the first-order interaction between group (experimental versus control) and time (before versus after A\u0026amp;F intervention) on the outcome of the primary endpoint (percentage of patients who received routine acetaminophen treatment) by a logistic regression model. Then the crude interaction coefficient was adjusted for baseline patient characteristics in a multivariate model to account for potential confounders. The baseline characteristics introduced in the model were selected by comparing the two groups at the two times of the study by association tests (Kruskal Wallis test for continuous variables or Chi\u0026sup2; test for nominal variables). The same analysis looking for an interaction between group and time was performed for each of the secondary criteria. Odds ratios (ORs) were adjusted on age, sex, and type of fracture. Qualitative parameters were expressed in numbers and percentages. Quantitative parameters were described by the median with the 25th and 75th percentiles. Analysis was performed using data processed in Excel 2019 for PC, and statistics were performed with Stata Version 14.0 software (Stata Corporation, College Station, TX, USA). The significative level was set at 0.05.\u003c/p\u003e\n\u003cp\u003eThe study followed CNIL (National Commission on Informatics and Liberty, France) and RGPD (General Data Protection Regulation) recommendations. Study registration within the internal register for processing activities of the Data Protection Officer controller was performed prior to Clinical Research and Innovation Delegation approval (MR 4914030220). Our hospital ethics committee approved this study and authorized waived informed consent since the study was observational. Patients and their families were informed about the study and could refuse to participate.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 745 patients were screened to be included in this controlled before/after study. Of these, 398 were included: 100 before A\u0026amp;F intervention and 100 after A\u0026amp;F intervention in the experimental group, and 100 before A\u0026amp;F intervention and 98 after the A\u0026amp;F intervention in the control group (Figure 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe median age of the included patients was 89 in the experimental group and 85 in the control group. Patients were mainly women (from 67% to 76% according to the group and the period). Patients in the experimental group were multimorbid and dependent. Patients frequently presented with femoral neck fracture. Detailed characteristics are presented in Table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTitle\u003c/strong\u003e: Characteristics of the population\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e Qualitative parameters were expressed in numbers and percentages. Quantitative parameters were described by the median with the 25th and 75th percentiles (IQR).\u003c/p\u003e\n\u003cp\u003e* In the experimental group, data were missing for 9 patients [BEFORE] and 15 patients [AFTER] for general anesthesia; 11 patients [BEFORE] and 14 patients [AFTER] for locoregional anesthesia; 31 patients [BEFORE] and 6 patients [AFTER] for the CIRS-G; 30 patients [BEFORE] and 7 patients [AFTER] for Charlson index score; 44 patients [BEFORE] and 9 patients [AFTER] for ASA; 6 patients [BEFORE] for ADL on Day -15; 9 patients [BEFORE] and 1 patient [AFTER] for IADL on Day -15. In the control group, data were missing for 5 patients [BEFORE] for general anesthesia; 5 patients [BEFORE] for locoregional anesthesia; 1 patient [AFTER] for acetaminophen; 79 patients [BEFORE] and 66 patients [AFTER] for ADL on Day -15; 82 patients [BEFORE] and 67 patients [AFTER] for IADL on Day -15. Moreover, CIRS-G and Charlson index score were not usually collected.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e ADL: Activities of Daily Living scale; ASA: American Society of Anesthesiologists score; CIRS-G: Cumulative Illness Rating Scale \u0026ndash; Geriatric; CO: conventional orthopedic unit; IADL: Instrumental Activities of Daily Living scale; IQR: interquartile range; ND: Not determined; OG: orthogeriatric unit\u003c/p\u003e\n\u003cp\u003eDuring the preoperative period, 9% of patients from the experimental group received 3g/day of acetaminophen before the A\u0026amp;F intervention and 16% after the A\u0026amp;F intervention, without significant statistical difference (p=0.13) (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTitle:\u003c/strong\u003e Impact of the intervention on clinical pain management\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e Qualitative parameters were expressed in numbers and percentages. Quantitative parameters were described by the mean \u0026plusmn; standard deviation, and by median with the 25th and 75th percentiles. * assessed through acetaminophen; \u0026dagger; in morphine sulfate equivalent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e CO: conventional orthopedic unit; IQR: Interquartile; OG: orthogeriatric unit; OR: Odds ratio; Pre: Preoperative; Post: Postoperative; R: Regression coefficient; VAS: Visual analog scale\u003c/p\u003e\n\u003cp\u003eDuring the postoperative period, 16% of patients from the experimental group received 3g/day of acetaminophen before the A\u0026amp;F intervention; the percentage reached 60% after the A\u0026amp;F intervention (OR=8.55 [4.29;17.03]; p\u0026lt;0.001). In the control group, no change in the distribution of acetaminophen was observed after the A\u0026amp;F intervention, neither in the preoperative (p=0.76) nor in the postoperative period (p=0.43). After the A\u0026amp;F intervention, the likelihood of receiving 3g/day of acetaminophen during the postoperative period was significantly increased in the experimental group as compared with the control group (OR=6.76 [2.7;16.9]; p\u0026lt;0.001). During the preoperative period, nurses\u0026rsquo; adherence to the medical prescriptions of acetaminophen was 13% in the experimental group before the A\u0026amp;F intervention and 32% after the A\u0026amp;F intervention (p=0.001). During the postoperative period, it was 13% in the experimental group before the A\u0026amp;F intervention, but reached 52% after the A\u0026amp;F intervention (p\u0026lt;0.001). The likelihood of adhering to medical prescription of acetaminophen was significantly increased in the experimental group as compared with the control group (OR=20.34 [4.4;94.05], p\u0026lt;0.001). In the experimental group, the number of in-hospital VAS recorded slightly decreased after the A\u0026amp;F intervention (p=0.02). The strong opioid distribution during the pre and postoperative periods did not differ after the A\u0026amp;F intervention. In the preoperative period, the distribution of benzodiazepine significantly decreased after the A\u0026amp;F intervention (p=0.007); it was not significantly modified after the A\u0026amp;F intervention during the postoperative period (p=0.33).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe complication rates were not different before and after the A\u0026amp;F intervention (Table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTitle:\u003c/strong\u003e Impact of the intervention on the patient outcomes\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u0026nbsp;\u003c/strong\u003eQualitative parameters were expressed in numbers and percentages. Quantitative parameters were described using median and the 25th and 75th percentiles.\u003c/p\u003e\n\u003cp\u003e* In the experimental group, data were missing for 30 patients [BEFORE] and 8 patients [AFTER] for ADL score at discharge; these data were missing for 87 patients [BEFORE] and 68 patients [AFTER] discharge in the control group\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u0026nbsp;\u003c/strong\u003eADL: Activities of Daily Living scale; CO: conventional orthopedic unit; IQR: Interquartile; ND: not determined; OG: orthogeriatric unit; OR: Odds ratio; Pre.: Preoperative; Post: Postoperative; R: Regression coefficient; VAS: Visual analog scale\u003c/p\u003e\n\u003cp\u003eThe functional status at discharge according to ADL score was better after the A\u0026amp;F intervention (p =0.008) in the experimental group, and the length of stay significantly decreased by 2.5 days (p=0.002).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur controlled before/after study showed that an A\u0026amp;F intervention significantly improved perioperative pain management in older adults hospitalized for hip fracture. After the A\u0026amp;F intervention, the likelihood of receiving 3g/day of acetaminophen during the postoperative period was significantly increased and the nurses\u0026rsquo; adherence to medical prescriptions based on acetaminophen prescription improved. In addition, the functional status at discharge according to ADL score was better after the A\u0026amp;F intervention and the length of stay in the orthogeriatric unit significantly shorter.\u003c/p\u003e\n\u003cp\u003eOur study presented several limitations. Firstly, the control group experienced a high rate of missing data due to conventional care without specific geriatric management and data collection. Additionally, the perioperative complication rates did not decrease following the A\u0026amp;F intervention. However, it is important to note that the study was not designed to measure complication outcomes. A dedicated study should be conducted to assess the impact of the A\u0026amp;F intervention on complications. Finally, in contrast to other studies [24], we examined both prescription and medication distribution, thus considering the behaviors of both doctors and nurses.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePain management is one of the key elements in orthogeriatric comanagement [25]. Several barriers to optimal pain control have been described with four distinct areas: healthcare system; physicians; nurses; patients [26],[17],[27]. An analysis of the literature found that 72% of hip-fractured patients received no prehospital analgesia [28]. According to Herr \u0026amp; Titler [29], the most common barrier to manage pain in older adults with hip fracture admitted through the emergency department is the inability to offer analgesic drugs until a diagnosis is established by the physician. In their article, only 60% of patients had an analgesic ordered. Physicians could also be reluctant to prescribe opioids in traumatic older patients [4]. Finally, inadequate prescriptions or the lack of medical prescriptions of analgesics hinder optimal pain management at admission [29],[24].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNurses play a critical role in pain management during the hospital stay, especially when analgesics are prescribed pro re nata (PRN; i.e., as needed or required by the patient) [30], rather than according to a regular schedule [31]. Acetaminophen is the most frequently administered analgesic (28% to 61%) in hip-fractured patients [32],[31]. However, undertreatment with acetaminophen is common [31]. In a PRN context, the quality of assessment is a determining factor for pain management. Pain assessment can be difficult in complex pain situations (e.g., individuals with neurological disorders such as dementia or delirium) [33]. In our study, both pain assessment and medical prescriptions were considered.\u003c/p\u003e\n\u003cp\u003eOur study assessed the management of an acute and foreseeable pain, in an established traumatic context, in older adults, with routine medical prescription leaving no room for interpretation. The major finding of our study was the gap between analgesic prescription and drug distribution with a real lack of adherence to medical prescriptions. This gap has been known for a long time in the postoperative period in such context. Strong opioids distribution in patients aged over 65 years and hospitalized for a hip fracture is lower than the dose prescribed [34]. Concerning non-opioid administration, two thirds of patients received less than 50% of the prescribed analgesic [34]. Finally, a study which included day and night observation of nine nurses and in-depth interviews showed that nurses did not give the recommended combination of drugs (i.e., acetaminophen with opioids) [35]. Pain undertreatment usually affects the old-old and those with cognitive impairment [34]. In our study, acetaminophen distribution rate was extremely low and far from 100%. Nurses are responsible for treatment distribution and administration; their poor knowledge leads to their non-adherence to good clinical practices [17]. Comprehensive knowledge encompasses both pain assessment and pain management [27]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFrom nurses\u0026rsquo; perspectives, pain assessment and management could be improved by \u0026nbsp;improving nurse\u0026rsquo;s knowledge and attitudes [27],[36],[37]. A systematic review concluded that education programs may exert a positive impact on nurses\u0026rsquo; attitude toward pain management [38]. Multidisciplinary geriatric fracture programs including early, multimodal pain management were associated with improved emergency department pain management of older patients with hip fracture: the use of acetaminophen increased from 10% to 51% (p\u0026lt;0.001) and the use of morphine decreased in the first 24 hours [39]. Our study directly measured the effect of our multimodal intervention on nurses\u0026rsquo; attitudes and practices. The distribution of pain medication was greatly increased in the postoperative period thanks to our A\u0026amp;F intervention. Strong opioid distribution did not decrease following the A\u0026amp;F intervention, but our study did not aim to compare optimal pain management with non-optimal pain management. Furthermore, this could be a sign of the good quality of care in the unit. In a recent study [40], we demonstrated that 75+ with or without cognitive deficits or delirium hospitalized for a hip fracture in a orthogeriatric unit received the same daily average quantity of strong opioids during the preoperative period. The standard pain management in an orthogeriatric unit avoids the undertreatment of pain in patients with moderate to strong cognitive deficits.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study pointed two crucial findings. Firstly, the rate of nurses\u0026rsquo; adherence to medical prescriptions remained insufficient following the A\u0026amp;F intervention. Dihle reported that nurses did not always use their knowledge in clinical practice, which led to a huge gap between \u0026ldquo;what nurses say and what nurses do\u0026rdquo; [35]. This constitutes a barrier to an optimal postoperative pain management. Educational interventions succeed in improving knowledge and practices but their impact on health provider\u0026rsquo;s beliefs is controversial [36]. Subconscious barriers have been described [30], leading to a gap \u0026ldquo;between the nurses\u0026rsquo; own perceptions about how they dealt with postoperative pain management and how they actually performed it in the clinical setting\u0026rdquo; [35]. Secondly, the A\u0026amp;F intervention failed in the preoperative period.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eBy demonstrating that less than one quarter of patients received the optimal dosage of acetaminophen despite routine medical prescription, this study is an opportunity to question ourselves about our practices from prescription to administration including medication circuit, and to raise awareness of healthcare providers about this alarming issue. The management of pain is still not up to the mark. Defining clinical practice guidelines or pain action plan is not sufficient. In contrast to the opioid crisis, our challenge is not excessive use, but rather the underuse of a front-line medication named acetaminophen. It might be referred to as an \u0026quot;acetaminophen crisis\u0026quot;. Our A\u0026amp;F intervention could potentially be used by other healthcare team managers to develop practice assessment in their own unit and pain education program. Team involvement in continuous education seems to be a key determinant of pain management quality and more studies are needed to assess factors associated with an optimal pain management in traumatized older adults.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eA\u0026amp;F: Audit and Feedback\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study followed CNIL (National Commission on Informatics and Liberty, France) and RGPD (General Data Protection Regulation) recommendations. Study registration within the internal register for processing activities of the Data Protection Officer controller was performed prior to Clinical Research and Innovation Delegation approval (MR 4914030220). Our hospital ethics committee approved this study and authorized waived informed consent since the study was observational. Patients and their families were informed about the study and could refuse to participate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe University Hospital Grenoble Alpes funded the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSD: Conceptualization (C), Funding Acquisition (FA), Project Administration (PA), Methodology (M), Supervision (S), Investigation (I), Formal analysis (Fa), Validation (Va) Visualization (V), Writing original Draft, Writing \u0026ndash; Review-Editing (WRE); BB (M, Fa, Software (S), Data curation (DC), Va, M,V, WRE); AG (M, DC, S,V); AB (I, WRE) FO (I,V); MR (I, M,V); LM (I,V); AG (I, Fa,V); CM (M,V); RP (I, V); BRD (I, V); PB (C, I, V); JT (C, I, V); CB (I, V, R); GG (C, M, ID, M, V, WRE); PF (M, M, V); PG (M, I, M, V, WRE).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the University Hospital Grenoble Alpes for the funding. We thank Fabienne Peretz for editorial assistance.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBriot K, Maravic M, Roux C. Changes in number and incidence of hip fractures over 12years in France. Bone. 2015;81:131\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.bone.2015.07.009\u003c/span\u003e\u003cspan address=\"10.1016/j.bone.2015.07.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSanzone AG. Current Challenges in Pain Management in Hip Fracture Patients. J Orthop Trauma. 2016;30(5):S1\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/BOT.0000000000000562\u003c/span\u003e\u003cspan address=\"10.1097/BOT.0000000000000562\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMosk CA, Mus M, Vroemen JP, van der Ploeg T, Vos DI, Elmans LH, et al. Dementia and delirium, the outcomes in elderly hip fracture patients. Clin Interv Aging. 2017;12:421\u0026ndash;30. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2147/CIA.S115945\u003c/span\u003e\u003cspan address=\"10.2147/CIA.S115945\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorrison SR, Magaziner J, McLaughlin MA, Orosz G, Silberzweig SB, Koval KJ, et al. The impact of post-operative pain on outcomes following hip fracture. Pain. 2003;103(3):303\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0304-3959(02)00458-X\u003c/span\u003e\u003cspan address=\"10.1016/S0304-3959(02)00458-X\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChou R, Gordon DB, de Leon-Casasola OA. Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2015;17(2):131\u0026ndash;57. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jpain.2015.12.008\u003c/span\u003e\u003cspan address=\"10.1016/j.jpain.2015.12.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones J, Southerland W, Catalani B. The Importance of Optimizing Acute Pain in the Orthopedic Trauma Patient. Orthop Clin North Am. 2017;48(4):445\u0026ndash;65. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ocl.2017.06.003\u003c/span\u003e\u003cspan address=\"10.1016/j.ocl.2017.06.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAubrun F, Baillard C, Beuscart JB, Billard V, Boddaert J, Boulanger \u0026Eacute;, et al. Recommandation sur l\u0026rsquo;anesth\u0026eacute;sie du sujet \u0026acirc;g\u0026eacute;: l\u0026rsquo;exemple de fracture de l\u0026rsquo;extr\u0026eacute;mit\u0026eacute; sup\u0026eacute;rieure du f\u0026eacute;mur. Anesth\u0026eacute;sie R\u0026eacute;animation. 2019;5(2):122\u0026ndash;38. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.anrea.2018.12.002\u003c/span\u003e\u003cspan address=\"10.1016/j.anrea.2018.12.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRemy C, Marret E, Bonnet F. Effects of acetaminophen on morphine side-effects and consumption after major surgery: meta-analysis of randomized controlled trials. Br J Anaesth. 2005;94(4):505\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/bja/aei085\u003c/span\u003e\u003cspan address=\"10.1093/bja/aei085\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarlich JM, Pujari A, Moak Z, Debbi E, Yalamanchili R, Stephenson S, et al. Pain Management with Early Regional Anesthesia in Geriatric Hip Fracture Patients. J Am Geriatr Soc. 2020;68(9):2043\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jgs.16547\u003c/span\u003e\u003cspan address=\"10.1111/jgs.16547\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFtouh S, Morga A, Swift C. Management of hip fracture in adults: summary of NICE guidance. BMJ. 2011;342:d3304. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmj.d3304\u003c/span\u003e\u003cspan address=\"10.1136/bmj.d3304\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThe American Society of Anesthesiologists. Practice Guidelines for Acute Pain Management in the Perioperative Setting: An Updated Report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012;116(2):248\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/ALN.0b013e31823c1030\u003c/span\u003e\u003cspan address=\"10.1097/ALN.0b013e31823c1030\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGirard P, Sourdet S, Cantet C, De Souto Barreto P, Rolland Y, Acetaminophen Safety. Risk of Mortality and Cardiovascular Events in Nursing Home Residents, a Prospective Study. J Am Geriatr Soc. 2019;67(6):1240\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jgs.15861\u003c/span\u003e\u003cspan address=\"10.1111/jgs.15861\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacario A, Royal MA. A literature review of randomized clinical trials of intravenous acetaminophen (paracetamol) for acute postoperative pain. Pain Pract. 2010;11(3):290\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1533-2500.2010.00426.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1533-2500.2010.00426.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGaskell H, Derry S, Moore RA, McQuay HJ. Single dose oral oxycodone and oxycodone plus paracetamol (acetaminophen) for acute postoperative pain in adults. Cochrane Database Syst Rev. 2009;3\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/14651858.CD002763.pub2\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD002763.pub2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGriffiths R, Alper J, Beckingsale A, Goldhill D, Heyburn G, Holloway J, et al. Management of proximal femoral fractures 2011: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia. 2011;67(1):85\u0026ndash;98. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1365-2044.2011.06957.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1365-2044.2011.06957.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang CH, Hsu L, Zou BR, Li JF, Wang HY, Huang J. Effects of a pain education program on nurses' pain knowledge, attitudes and pain assessment practices in China. J Pain Symptom Manage. 2008;36(6):616\u0026ndash;27. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jpainsymman.2007.12.020\u003c/span\u003e\u003cspan address=\"10.1016/j.jpainsymman.2007.12.020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTomaszek L, Dębska G. Knowledge, compliance with good clinical practices and barriers to effective control of postoperative pain among nurses from hospitals with and without a Hospital without Pain certificate. J Clin Nurs. 2017;27(7\u0026ndash;8):1641\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jocn.14215\u003c/span\u003e\u003cspan address=\"10.1111/jocn.14215\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolloway H, Parker D, McCutcheon H. The complexity of pain in aged care. Contemp Nurse. 2018;54(2):121\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/10376178.2018.1480399\u003c/span\u003e\u003cspan address=\"10.1080/10376178.2018.1480399\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShier V, Edelen MO, McMullen TL, Dunbar MS, Bruckenthal P, Ahluwalia SC, et al. Standardized assessment of cognitive function, mood, and pain among patients who are unable to communicate. J Am Geriatr Soc. 2022;70(4):1012\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jgs.17647\u003c/span\u003e\u003cspan address=\"10.1111/jgs.17647\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith TO, Collier T, Sheehan KJ, Sherrington C. The uptake of the hip fracture core outcome set: analysis of 20 years of hip fracture trials. Age Ageing. 2019;48(4):595\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/ageing/afz018\u003c/span\u003e\u003cspan address=\"10.1093/ageing/afz018\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKnopp-Sihota JA, Patel P, Estabrooks CA. Interventions for the Treatment of Pain in Nursing Home Residents: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc. 2016;17(12):1163. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jamda.2016.09.016\u003c/span\u003e\u003cspan address=\"10.1016/j.jamda.2016.09.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e.e19-1163.e28\u003c/span\u003e\u003cspan address=\"http://.e19-1163.e28\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIvers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012;6\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/14651858.CD000259.pub3\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD000259.pub3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVon Korff M, Saunders K, Thomas Ray G, Boudreau D, Campbell C, Merrill J, et al. De facto long-term opioid therapy for noncancer pain. Clin J Pain. 2008;24(6):521\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/AJP.0b013e318169d03b\u003c/span\u003e\u003cspan address=\"10.1097/AJP.0b013e318169d03b\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBouri F, El Ansari W, Mahmoud S, Elhessy A, Al-Ansari A, Al-Dosari MAA. Orthopedic Professionals\u0026rsquo; Recognition and Knowledge of Pain and Perceived Barriers to Optimal Pain Management at Five Hospitals. 2018;6(3):98. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/healthcare6030098\u003c/span\u003e\u003cspan address=\"10.3390/healthcare6030098\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiem IS, Kammerlander C, Suhm N, Blauth M, Roth T, Gosch M, et al. Identifying a standard set of outcome parameters for the evaluation of orthogeriatric co-management for hip fractures. Injury. 2013;44(11):1403\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.injury.2013.06.018\u003c/span\u003e\u003cspan address=\"10.1016/j.injury.2013.06.018\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoulling S. Nurses\u0026rsquo; and doctors\u0026rsquo; knowledge of pain after surgery. Nurs Stand. 2005;19(34):41\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7748/ns2005.05.19.34.41.c3859\u003c/span\u003e\u003cspan address=\"10.7748/ns2005.05.19.34.41.c3859\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRababa M, Al-Sabbah S, Hayajneh AA. Nurses' Perceived Barriers to and Facilitators of Pain Assessment and Management in Critical Care Patients: A Systematic Review. J Pain Res. 2021;14:3475\u0026ndash;91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2147/JPR.S332423\u003c/span\u003e\u003cspan address=\"10.2147/JPR.S332423\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDixon J, Ashton F, Baker P, Charlton K, Bates C, Eardley W. Assessment and Early Management of Pain in Hip Fractures: The Impact of Paracetamol. Geriatr Orthop Surg Rehabil 2018;9():. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/2151459318806443\u003c/span\u003e\u003cspan address=\"10.1177/2151459318806443\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHerr K, Titler M. Acute pain assessment and pharmacological management practices for the older adult with a hip fracture: review of ED trends. J Emerg Nurs. 2008;35(4):312\u0026ndash;20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jen.2008.08.006\u003c/span\u003e\u003cspan address=\"10.1016/j.jen.2008.08.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchafheutle EI, Cantrill JA, Noyce PR. Why is pain management suboptimal on surgical wards? J Adv Nurs. 2001;33(6):728\u0026ndash;37. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1046/j.1365-2648.2001.01714.x\u003c/span\u003e\u003cspan address=\"10.1046/j.1365-2648.2001.01714.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEid T, Bucknall T. Documenting and implementing evidence-based post-operative pain management in older patients with hip fractures. J Orthop Nurs. 2008;12(2):90\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.joon.2008.07.003\u003c/span\u003e\u003cspan address=\"10.1016/j.joon.2008.07.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTitler MG, Herr K, Schilling ML, Marsh JL, Xie XJ, Ardery G, et al. Acute pain treatment for older adults hospitalized with hip fracture: current nursing practices and perceived barriers. Appl Nurs Res. 2003;16(4):211\u0026ndash;27. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s0897-1897(03)00051-x\u003c/span\u003e\u003cspan address=\"10.1016/s0897-1897(03)00051-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHadjistavropoulos T, Herr K, Prkachin KM, Craig KD, Gibson SJ, Lukas A, et al. Pain assessment in elderly adults with dementia. Lancet Neurol. 2014;13(12):1216\u0026ndash;27. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S1474-4422(14)70103-6\u003c/span\u003e\u003cspan address=\"10.1016/S1474-4422(14)70103-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeldt KS, Ryden MB, Miles S. Treatment of Pain in Cognitively Impaired Compared with Cognitively Intact Older Patients with Hip-Fracture. J Am Geriatr Soc. 1998;46(9):1079\u0026ndash;85. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1532-5415.1998.tb06644.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1532-5415.1998.tb06644.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDihle A, Bj\u0026oslash;lseth G, Helseth S. The gap between saying and doing in postoperative pain management. J Clin Nurs. 2006;15(4):469\u0026ndash;79. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1365-2702.2006.01272.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1365-2702.2006.01272.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbdalrahim MS, Majali SA, Stomberg MW, Bergbom I. The effect of postoperative pain management program on improving nurses\u0026rsquo; knowledge and attitudes toward pain. Nurse Educ Pract. 2011;11(4):250\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.nepr.2010.11.016\u003c/span\u003e\u003cspan address=\"10.1016/j.nepr.2010.11.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrunkert T, Simon M, Ruppen W, Z\u0026uacute;\u0026ntilde;iga F. Pain Management in Nursing Home Residents: Findings from a Pilot Effectiveness-Implementation Study. J Am Geriatr Soc. 2019;67(12):2574\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jgs.16148\u003c/span\u003e\u003cspan address=\"10.1111/jgs.16148\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlReshidi N, Long T, Darvill A. A Systematic Review of the Impact of Educational Programs on Factors That Affect Nurses\u0026rsquo; Post-Operative Pain Management for Children. Compr Child Adolesc Nurs. 2018;41(1):9\u0026ndash;24. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/24694193.2017.1319432\u003c/span\u003e\u003cspan address=\"10.1080/24694193.2017.1319432\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCasey SD, Stevenson DE, Mumma BE, Slee C, Wolinsky PR, Tyler K et al. Emergency Department Pain Management Following Implementation of a Geriatric Hip Fracture Program. 2017;18(4):. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5811/westjem.2017.3.32853\u003c/span\u003e\u003cspan address=\"10.5811/westjem.2017.3.32853\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRuel M, Boussat B, Boudissa M, Garnier V, Bioteau C, Tonetti J, et al. Management of preoperative pain in elderly patients with moderate to severe cognitive deficits and hip fracture: a retrospective, monocentric study in an orthogeriatric unit. BMC Geriatr. 2021;21(1):575. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12877-021-02500-7\u003c/span\u003e\u003cspan address=\"10.1186/s12877-021-02500-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1-3 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Acetaminophen, Adherence, Hip fractures, Nurses, Pain, Perioperative period, Education, Intervention, Program","lastPublishedDoi":"10.21203/rs.3.rs-3978284/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3978284/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePain in older adults is historically neglected. The study assessed the ability of an audit and feedback (A\u0026amp;F) intervention built with nurses to improve the quality of perioperative pain management in older patients hospitalized for hip fracture.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eControlled before/after study in an orthogeriatric unit (experimental group); a conventional orthopedic unit served as control (no intervention). Quality of perioperative pain management was evaluated based on acetaminophen distribution and prescription adherence. The primary endpoint was the evolution of the percentage of patients who received 3g/day of acetaminophen during the three postoperative days. Secondary endpoints included nurses\u0026rsquo; adherence to medical prescriptions and factors associated with intervention. The significative level was set at 0.05 for statistical analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe studied data from 398 patients (mean age, 89 years). During the postoperative period, 16% of patients from the experimental group received 3g/day of acetaminophen before the A\u0026amp;F intervention; the percentage reached 60% after the intervention. The likelihood of receiving 3g/day of acetaminophen during the postoperative period and adhering to the medical prescription of acetaminophen were significantly increased in the experimental group as compared with the control group. The patient\u0026rsquo;s functional status at discharge (assessed by Activities of Daily Living scores) was significantly better and the length of hospital stay significantly reduced after the A\u0026amp;F intervention.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur controlled before/after study showed that an A\u0026amp;F intervention significantly improved perioperative pain management in older adults hospitalized for hip fracture. Involving teams in continuous education programs appears crucial to improve the quality of pain management and ensure nurses\u0026rsquo; adherence to medical prescriptions.\u003c/p\u003e","manuscriptTitle":"PAIN-AGE, a Controlled Before/After Study Assessing an Audit and Feedback Perioperative Pain Management Intervention in Older Patients with Hip Fracture.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-12 17:32:59","doi":"10.21203/rs.3.rs-3978284/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-25T11:22:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-22T14:24:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-06T16:18:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-02T12:27:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"d91b59ee-eede-4357-ad48-61e9e4fb3dbd","date":"2024-03-31T12:31:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"28a6578a-d341-49f9-8ee2-9197cb169042","date":"2024-03-31T08:59:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8d59f628-0a46-41c2-947d-0f5629af7918","date":"2024-03-27T16:48:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-26T14:51:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-26T13:31:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-03-08T12:50:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-08T11:44:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2024-02-22T10:16:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6191dd86-4998-4cbb-b2df-6d89eec71d15","owner":[],"postedDate":"March 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-09T16:09:09+00:00","versionOfRecord":{"articleIdentity":"rs-3978284","link":"https://doi.org/10.1186/s12877-024-05282-w","journal":{"identity":"bmc-geriatrics","isVorOnly":false,"title":"BMC Geriatrics"},"publishedOn":"2024-09-05 16:04:54","publishedOnDateReadable":"September 5th, 2024"},"versionCreatedAt":"2024-03-12 17:32:59","video":"","vorDoi":"10.1186/s12877-024-05282-w","vorDoiUrl":"https://doi.org/10.1186/s12877-024-05282-w","workflowStages":[]},"version":"v1","identity":"rs-3978284","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3978284","identity":"rs-3978284","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}