An audit of inpatient falls - are we adequately addressing bone health?

An audit of inpatient falls - are we adequately addressing bone health?

Background:

Falls in older adults frequently result in osteoporotic fractures, leading to longer stays, greater dependency, and long-term morbidity. Fragility fractures are estimated to cost the UK around £4.5 billion annually.  Despite these serious implications, tools like FRAX, and routine assessments such as calcium and vitamin D levels, are still underused in the inpatient setting, especially following a fall. The National Osteoporosis Guideline Group (NOGG) recommends using the FRAX tool to estimate 10-year fracture risk and guide bone protection.

Objective:

To evaluate:

• Was a FRAX score calculated for patients who fell while in hospital?

• Was bone protection initiated appropriately based on FRAX risk?

• Was a vitamin D level checked within one year of the fall?

Methodology:

A retrospective case review of 35 in-patients falls during April–May 2023 across the Trust was done. Patients identified via DATIX and then randomly selected. A custom-designed proforma was used to assess completion of post-fall assessment form, FRAX score, risk stratification and bone health management decisions.

Results:

Most falls occurred in patients aged 70–90, consistent with NICE data indicating that 30% of people over 65 and 50% over 80 fall annually. Falls assessment sheet was completed in over 80% of cases. FRAX score was calculated in only 33.3% of cases. Among those, 60% of the patients were at intermediate risk, 20% at high risk and 10% at very high risk of future fractures. Among high-risk patients only 50% received oral bisphosphonates. Among patients without a FRAX assessment retrospective calculation showed 60% were very high risk and missed the opportunity for bone protection.
 

Key Findings:

High compliance with Trust guidelines in completing post-fall assessments. Suboptimal FRAX score documentation, with more than half of fallers not being assessed for fracture risk. Retrospective FRAX scoring revealed many of these were at moderate or high risk and could have benefited from intervention. Calcium and vitamin D checks were performed more frequently than FRAX but still fell short of optimal levels. Concerns regarding bisphosphonate use in patients with renal impairment. Only 50% of intermediate-risk patients had safe creatinine clearance for bisphosphonates, and less than 10% of high-risk patients were eligible.

Recommendations:

“Falls Alert Stickers” were introduced in high-risk areas. These include checkboxes for Calcium, Vitamin D, FRAX, and Creatinine Clearance, and a QR code linking to guidance for easy access. Clinician education on bone health management should be enhanced through Grand Rounds and departmental meetings, especially given the high proportion of elderly admissions. Post falls proforma was updated with a separate bone health assessment section and a QR code linked to guidelines.

Conclusion:

Falls remain a major issue in older inpatients, often resulting in serious fractures and long-term disability. Improving adherence to NICE and NOGG guidelines, particularly through routine FRAX use and attention to renal safety when prescribing bone protection, can improve outcomes. The implementation of Falls Alert Stickers, clinician engagement and revised post falls proforma are important steps toward improving practice.