NR 716 Week 2 PICOT Question Write-Up Example

A PICOT Question on Emergency Department Fascia Iliaca Blocks for Older Adults With Hip Fracture, Defended Element by Element

Student Name

College of Nursing, Chamberlain University

NR 716: Analytic Methods

Instructor Name

Month Day, Year

A PICOT Question on Emergency Department Fascia Iliaca Blocks for Older Adults With Hip Fracture, Defended Element by Element

The Problem Before the Question

Our emergency department sent 214 hip fracture patients aged 65 and over to the orthopedic floor in fiscal year 2026. The 4 A's Test, recorded by orthopedic unit nurses, was positive before surgery in 61 of them (28.5%). In the first twelve hours after arrival, patients received a median of 12 mg of intravenous morphine equivalents. No patient received a nerve block in the department; 37% received a fascia iliaca block from anesthesia immediately before surgery, a median of 26 hours after arrival. According to a Cochrane review, nerve blocks given for a broken hip lower pain on movement and the risk of acute confusional state (Guay & Kopp, 2020), and the department's practice council will decide in March 2027 whether to add an early block to the hip fracture pathway. The question below is written for that decision.

A Population a Query Could Find

P: adults aged 65 or older who arrive at our emergency department with a hip fracture confirmed on X-ray and are admitted for surgical repair. Each part of that definition can be found by a records query: age at arrival, a diagnosis code for fracture of the femoral neck, intertrochanteric or subtrochanteric region, an imaging result and an admission order to orthopedics. Patients transferred in from another hospital after a block, patients with a periprosthetic fracture and patients managed without surgery are excluded, because each would receive different care whatever the pathway says. Patients with dementia are included. Many trials excluded them, but they make up about a third of our population and are the group most likely to develop delirium, so leaving them out would answer a question nobody here is asking.

The Intervention, at Protocol Grain

I: an ultrasound-guided fascia iliaca compartment block placed in the department within 60 minutes of radiographic confirmation, by a credentialed emergency physician or advanced practice nurse, using a single injection of a long-acting local anesthetic at the weight-based dose in the pharmacy-approved order set, together with scheduled acetaminophen and intravenous opioid only for breakthrough pain. Stated at this grain, two clinicians would deliver it the same way. It deliberately excludes continuous catheters, which our department cannot manage, and the newer pericapsular block, which has been compared with the fascia iliaca block in a single emergency department trial (Di Pietro et al., 2025) and is not yet in our credentialing program.

The Comparison That Runs

C: our current practice, written out so that it can continue unchanged in any comparison period: scheduled acetaminophen 1 g every eight hours, intravenous morphine or hydromorphone as needed under the department's pain protocol, reassessment of pain every hour and no nerve block until anesthesia sees the patient before surgery. Calling this standard care would hide the detail that matters most, that about a third of patients already receive a block, only much later. Any comparison has to keep that preoperative block in both arms, so the question is about timing and placement, not about block against no block.

An Outcome Already Counted

O: preoperative delirium, defined as a positive 4 A's Test score of 4 or more recorded on any shift between admission to the orthopedic unit and the start of surgery, and, as a secondary outcome, total intravenous morphine milligram equivalents given in the first 12 hours after arrival. Both are already recorded: the 4 A's Test is a required field on the orthopedic unit's shift assessment, and opioid doses are in the medication administration record. Choosing outcomes the hospital already counts means the project measures from the first day instead of building a measurement system. Pain on movement would be the most direct outcome, but our department records pain at rest only, and changing that would be its own project.

Time Matched to the Outcome

T: from arrival in the department until the start of surgery, or 72 hours if surgery is delayed. The window follows the outcome. Preoperative delirium can only occur before surgery, and our median time to surgery is 26 hours, so a 72-hour ceiling captures nearly every patient. The opioid outcome uses its own fixed 12-hour window, because a single block lasts roughly that long.

The Question Type Declared

The question belongs to the intervention, or therapy, type: it asks if acting produces a better result than the present course, which points the search toward randomized trials and systematic reviews of them and, for the parts trials do not answer, such as who can safely place the block, toward cohort studies and practice guidelines. Declaring the type also tells the reader what kind of answer is possible. The national orthopedic guideline for older adults with hip fracture already recommends regional nerve blocks as part of pain management (O'Connor & Switzer, 2022), so the open question for this department is narrower than whether blocks help. It is whether placing one early, in the emergency department, by our own clinicians, adds enough to the later block anesthesia already gives to justify the training, the order set and the time each placement takes.

The Question in Full

In adults 65 and over whom our emergency department admits with a hip fracture seen on X-ray (P), would a fascia iliaca block under ultrasound guidance, given within 60 minutes of radiographic confirmation by a credentialed emergency clinician (I), compared with scheduled acetaminophen and as-needed intravenous opioid with any block deferred to anesthesia before surgery (C), reduce preoperative delirium on the 4 A's Test and intravenous morphine equivalents in the first 12 hours (O) between arrival and surgery or 72 hours (T)?

What the Question Leaves Out

Three things were considered and left out. Mortality was dropped as an outcome, because a pathway change in one department cannot detect a difference in deaths and the Cochrane review found the evidence on mortality uncertain even across many trials. Length of stay was dropped because it depends on surgical scheduling more than on analgesia. And patient satisfaction was dropped because the department's survey is sent weeks after discharge and returns too few responses for this group. Each could become its own question later; none belongs in the one the council will use in March, which needs outcomes the department can read within months of a change.

References

Di Pietro, S., Maffeis, R., Jannelli, E., Mascia, B., Resta, F., De Silvestri, A., Musella, V., Centurioni, C. E., Regeni, E., Grassi, F. A., Locatelli, A., & Perlini, S. (2025). Comparing the pericapsular nerve group block and fascia iliaca block for acute pain management in patients with hip fracture: A randomised clinical trial. Anaesthesia, 80(12), 1484-1492. https://doi.org/10.1111/anae.16695

Guay, J., & Kopp, S. (2020). Peripheral nerve blocks for hip fractures in adults. Cochrane Database of Systematic Reviews, 2020(11), Article CD001159. https://doi.org/10.1002/14651858.CD001159.pub3

O'Connor, M. I., & Switzer, J. A. (2022). AAOS clinical practice guideline summary: Management of hip fractures in older adults. Journal of the American Academy of Orthopaedic Surgeons, 30(20), e1291-e1296. https://doi.org/10.5435/JAAOS-D-22-00125