Abstract
Introduction
Falls are a common presentation comprising 17% of all ED attendances in older people and can result in harm including fragility fractures (FFs). FFs lead to pain, functional decline, deconditioning, and high mortality. Validated tools such as FRAX can increase prescribing of antiresorptive medications (ARM), reducing harm.
Comprehensive geriatric assessment (CGA) is the gold standard for assessing and managing geriatric syndromes including falls and can include fragility fracture risk assessment.
Method
An audit was conducted of all inpatients over one day on Colwell Ward at Isle of Wight NHS Trust. Patients were screened meeting NICE criteria for Bone Health Assessment (BHA).
Notes were reviewed for evidence of FRAX scores or BHAs. Bloods were reviewed for vitamin D and calcium. Drug charts, medicine reconciliations, and GP records were screened to see if vitamin D, calcium, and anti-resorptive medications were prescribed previously.
Following the audit FRAX scoring has been included in the CGA being piloted by the acute frailty team.
Results
Of 30 inpatients, 100% met NICE criteria for BHA. Mean and median age was 85 (72-96). 63.3% were female (19/30). 16.7% had a history of osteoporosis or osteopenia (5/30).
6.7% (2/30) had a note mentioning BHA in their medical notes, however zero patients had had a FRAX score calculated.
46.7% (14/30) had vitamin D checked and 93.3% (28/30) had had calcium checked. 6.7% (2/30) were already on ARM and the same percentage were started on ARM that admission. 56.7% (17/30) had vitamin D and calcium prescribed on their drug charts.
Conclusion
All patients met NICE criteria for BHA however few had FRAX scores completed. This may lead to avoidable fragility fractures. Reasons for few BHAs are likely multifactorial. Embedding FRAX within the CGA increases opportunities to identify at-risk patients. Re-audit is recommended after the CGA has been fully implemented locally.
Comments
Hi,
Thank you for your…
Hi,
Thank you for your poster. Were there any patterns among the few patients who did have bone health assessments — for instance, were they more likely to have known osteoporosis?
CGA documentation
I think it is really hard to get the CGA domains really clearly documented for all patients and also to remember that not 'all' of the domains needs addressing at the same time. Cear CGA documentation across the country with a usable templace seems to be the ward forward
Difficult area to improve
I did a similar QI project in a DGH which aimed to improve FRAX assessments in our ambulatory frailty unit. I share your difficulties in that we had huge proportion of patients eligible for BHA but really low consideration. A big point of fracture liaison is to reduce future fractures when one has been identified, but in our patients there are clearly opportunities to address increased fracture risk even before first fracture that aren't been taken. I'd be interested to hear how your department follows these patients up, as we struggled once identifying high FRAX risk, but didn't have a robust DXA pathway or route for parenteral treatment follow up apart from referral to endocrine services.
Difficult area to improve
I did a similar project in a DGH; our issue once identifying the large cohort of people identified by FRAX as high risk was that we struggled to get patients booked into early follow up for parenteral treatment or DXA scanning. I'd be interested in hearing how your hospital follows these patients up once identifying risk.