Improving bone health assessment and primary prevention of fragility fractures in patients presenting with falls

Introduction:

Fragility fractures are common: 1 in 2 women and 1 in 5 men will sustain a fragility fracture in their lifetime. The majority occur in older adults age >65. They are costly for the patient and for the NHS - estimated £4.7 billion per year. 

Guidelines for primary prevention of fragility fractures recommend use of risk assessment tools like FRAX to direct need for pharmacological treatment, alongside optimisation of vitamin deficiencies and lifestyle factors.

The aim of this project was to improve the proportion of patients presenting to the geriatric ward with a fall without an acute fracture who had a bone health assessment performed, comprising vitamin D level and FRAX score.

Method:

Baseline data for 25 patients was collected and analysed.

Two PDSA cycles performed, with a further 25 patients per cycle:

• Cycle 1 intervention: Email to doctors, introduction of proforma in medical notes
• Cycle 2 intervention: 6 teaching sessions

Results: 

At baseline, vitamin D levels were checked 40% of the time and FRAX risk assessments performed only 12% of the time.

Following cycle 1, even fewer patients had a bone health assessment completed: vitamin D 36%, FRAX 4%.

Following cycle 2 there was improvement in both areas: vitamin D 56% (non-significant), FRAX 36% (significant, P<0.05).

Most patients who had vitamin D checked were found to be severely deficient (<30nmol/L).

Conclusions:

Bone health assessments were not being carried out routinely in patients admitted with falls. Modest improvements were demonstrated in this project but still leave room for better practice. 

Improvements in practice were only seen following in-person delivery of teaching, suggesting that initial barriers included awareness and confidence knowing what to do on a practical level.

Future recommendations include exploring other barriers to address and prioritising teaching such as by including bone health in the geriatric departmental induction.