Abstract
Introduction
Approximately 70,000 hip fractures occur annually in the UK, costing the NHS over £2 billion each year. These injuries carry significant morbidity and up to 30% one-year mortality. One in five patients will sustain another further fragility fracture within five years - most commonly in the first year.
Zoledronic acid, a parenteral bisphosphonate, significantly reduces subsequent fracture risk and mortality. Although timely inpatient use is supported by National Osteoporosis Guideline Group (NOGG) guidance and a 2023 British Geriatrics Society Call To Action, uptake remains low across many hospitals due to lack of standardised protocols, unclear prescribing responsibilities, and limited clinician awareness.
Methods
We conducted a Quality Improvement Project at University College London Hospital (UCLH) to evaluate inpatient zoledronic acid use, identify barriers, and implement targeted interventions. An initial audit assessed prescribing rates, timeliness of required blood tests, and documentation of bone health in discharge summaries.
Two Plan-Do-Study-Act (PDSA) cycles were undertaken. The first focussed on education of the orthopaedic team. The second introduced visual prompts and a newly-developed local guideline. This guideline, which has now been submitted for publication in the hospital’s Medical Emergency Document Library (MEDL), provides a clear decision-making pathway and enables junior doctors to initiate zoledronic acid in straightforward cases.
Results
At baseline, 20% of eligible patients received inpatient zoledronic acid. This improved to 50% post-intervention. Documentation of bone health plans improved from 34% to 60%, although timely blood test completion remained unchanged.
Education and a structured guideline pathway improved inpatient zoledronic acid prescribing. While its long-term impact is pending re-audit, its accessibility and clarity offer a scaleable model for other trusts aiming to enhance secondary fracture prevention after hip fracture.
Comments
A well-designed and…
A well-designed and impactful QI project addressing an important gap in secondary fracture prevention. The structured PDSA approach, education, and introduction of a local guideline led to measurable improvement and sustainable change. Clear relevance, strong methodology, and good potential for wider adoption.
Hip fracture patients deserve bone health assessment
You have demonstrated well in adopting the NOGG update regarding zoledronic in hip fractures. When we developed that orthogeriatrics pathway for zoledronic we have the struggles as well i.e. rapid loading of vit D, pushbacks from primary care re bloods monitoring and pharmacy re local adoption, capacity of our day treatment units for the succeeding doses, denosumab for those not qualify, long waiting list from rheumatology colleagues, etc. Up to present we are still amending some of the processes and it feels like never-ending! We will get there and this is a good start in improving bone health of hip fracture patients. Well done!