Development and implementation of an acute bone health assessment toolkit for patients presenting with falls to the medical take

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S. Browne1, I. Wood2, A. Pasyar1
1 Barnet Hospital; Royal Free London NHS Trust, 2 Royal Free Hospital; Royal Free London NHS Trust
Clinical Quality
CQ - Clinical Effectiveness
Bone Health

Abstract

Introduction

Falls, in older patients living with frailty, are a common presentation to the medical take. Assessment of bone health is a key component of the comprehensive geriatric assessment and a risk factor for fragility fracture. We collected baseline data highlighting that bone health in this cohort was commonly overlooked. In response, our quality improvement (QI) project led to the development and implementation of an acute bone health assessment toolkit with overall enhancement in assessment.

Methods

Using QI and Plan-Do-Study-Act (PDSA) methodology, baseline data was collected for patients presenting with fall to the medical take. By assimilating local and national guidance, a toolkit was created.  This constituted a five-point action plan focusing on relevant but easy to measure variables contributing to overall bone health including serum bone profile, vitamin D and FRAX score. We produced a poster and delivered educational sessions before re-auditing. Cycle 2 has incorporated the toolkit into a user-friendly proforma within our electronic patient record system and made readily available.

Results

Initial data analysis in April 2024 identified shortcomings in various parameters. During re-audit after cycle 1 there were 99 patients presenting with falls to the medical take (October-December 2024), of which 20% sustained at least one fracture. After intervention there was a 14% and 9% improvement in bone health related documentation in the medical clerking and post-take ward round respectively. There was a 6% increase in measured vitamin D levels, 5% increase in FRAX assessment calculation and 64% of patients had their bone profile checked.

Conclusions

In summary, the implementation of this toolkit has shown objective improvement in important bone health contributors and received positive feedback. We are planning another PDSA cycle following teaching to the wider multi-disciplinary team and future work could involve material to empower patients with increased awareness of the importance of optimal bone health

Comments

Hello. Thank you for presenting you work. as you identified, there was some improvement in the re-audit - what barriers were there to bone health being assessed and what do you plan to do to overcome these?

Submitted by alasdair.macrae on

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Hi there,

Many thanks for the comment and apologies for the delay in responding 

I think the main barriers were mainly:

1 - bone health appears to generally be overlooked in the acute setting, excluding of course dedicated ortho-geriatric liaison for neck of femur fractures 

2 - time pressures on a busy medical take 

3 - medical focus on those presenting with falls (rightly) taking priority in terms of initial assessment/management, but then less likely to be picked up later on unless proven fracture 

Submitted by stefan.browne… on

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Thank you for your poster, in terms of your next steps, we know that bone protection is a longer term intervention, has there been any consideration of liaison with community and primary care services to support this work further?

Submitted by samdavidolden_27620 on

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Hi there,

Many thanks for the comment and apologies for the delay in responding 

Of course direct liaison with primary care can be tricky but is also often under-utilised 

The majority of patients were found to be vitamin D deficient and modal loading regimes sat at 6 weeks, meaning initiation of bone protective agents would be done by our primary care colleagues in these circumstances. We tried to make things easier by already measuring a FRAX score and baseline DXA where possible, and communicating our feeling about appropriateness for these treatments through discharge summaries 

Hi there,

Many thanks for the comment and apologies for the delay in responding 

The main limitations included:

Rotation of resident doctors and losing some of the educational benefit that had been provided to their predecessors 

Extremely time consuming means of obtaining the data to select those that had fallen and presented to our acute medical take via our electronic patient record 

Fear/lack of confidence in use of bisphosphonates or alternatives 

 

The proforma is actually extremely easy to use and start to finish takes literally seconds (not including the time to actually calculate the FRAX). This is why this was selected as the next measure to improve adherence and utilisation 

Hi there,

Many thanks for the comment and apologies for the delay in responding 

Educational sessions included one of the following:
Dedicated FY1 core teaching - highlighting the importance of this cohort of resident doctors in this project as they are the mainstay of the post take ward round 

Weekly geriatric departmental teaching 

Adhoc on the shopfloor teaching - usually at medical ward board rounds

This is a very well-structured QI project addressing an important but often overlooked aspect of falls care. I appreciate how you’ve combined national guidance with local data to create a simple, actionable toolkit that is both measurable and sustainable. 


Given the positive impact you’ve demonstrated, what are your plans to ensure long-term sustainability and adoption of the toolkit across different teams, especially as staff rotate?

Submitted by muhammadrahib… on

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Hi there,

Many thanks for the comment and apologies for the delay in responding 

Agreed one of the barriers to sustainability is rotation of staff. The hope of involving the wider MDT, consultant body and regular flagging of bone health in key areas such as front door frailty or acute medical take would be our main plan to try and maintain the positive impact that was had.

I also do believe that we could look at producing patient materials in the near future. The aim of allowing them to be more informed and feel empowered to ask about treatments that may improve their bone health. 

Submitted by stefan.browne… on

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