Training requirements for higher specialist trainees in geriatric medicine in orthogeriatrics and bone health

Authors:
BGS Education and Training Committee
British Geriatrics Society
Date Published:
15 December 2021
Last updated: 
15 December 2021

This page clarifies the training standards for higher specialist trainees in geriatric medicine in orthogeriatrics in the context of the new training curriculum and syllabus. 

It is important to distinguish the basic training requirements for all higher specialist trainees in geriatric medicine who need to be able to assess and manage older patients presenting with the common geriatric problems from the smaller number of trainees seeking to demonstrate additional competencies in Orthogeriatrics and Bone health by completing the optional higher level training.

Reference should also be made to other areas of the curriculum such as falls, delirium, continence, tissue viability and palliative/end of life care which are relevant to this group of patients.
 
Specialist Major Trauma competences are not part of the Geriatric Medicine Training Curriculum but we recommend that they be considered as an Optional Higher Level Competence for future iterations, or as a post CCT credential.
How to assess acutely ill orthopaedic patients; to manage acute presentations and peri-operative care of patients with fragility fractures; to manage older orthopaedic patients and fragility fracture patients at all stages of their journey including rehabilitation.
Knowledge
  • Acute presentation and care, including Initial emergency department care and pathways
  • Surgical and anaesthetic issues including optimal timing of surgery and management of perioperative issue such as fasting, medicines management and analgesia.
  • Hip fracture: common types and their management including operative and non-operative.
  • Understanding of postoperative care, common problems and complications.
  • Different models of orthogeriatric care including role of intermediate care and community services in rehabilitation and in prevention.
  • Causes and management of falls as per other curriculum competences.
  • Causes and management of osteoporosis and role of fracture liaison services.
  • Awareness of relevant National Publications and Guidelines including NICE and SIGN guidance, BOA and AAGBI.
  • Understanding of National Audit Programmes National Hip Fracture Database/Falls and Fragility Fracture Audit Programme (England, Wales and Northern Ireland), Scottish Hip Fracture Audit ( Scotland)
Skills
  • Diagnostic skills to include assessment of comorbidities and any acute/subacute illness.
  • Able to do a comprehensive medication review and have specific knowledge regarding
  • interventions for analgesia, bowel care, anticoagulants, blood products and osteoporosis treatment.
  • Nutritional assessment using recognised score and appropriate interventions.
  • Assessment of frailty using a recognised score .
  • Communication, team and leadership skills.
  • Proactive Discharge Planning and planning transfers of care for Advance care Planning and Palliative Care.
  • The trainee should be able to assess which patients are likely to make a good recovery and return home, those who have ongoing rehabilitation needs and those who have a high likelihood of dying while in hospital and recognise that the expected outcome may change and requires regular review.
Behaviours
  • An approach to the management of elderly people with fracture that seeks to maximize early recovery/independence.
  • Enabling patient involvement and choice.
  • Close collaboration with theatre team, orthopaedic surgeons, anaesthetists and other professionals to optimisation for early surgery.
  • Effective engagement with and education of non-specialist teams caring for when fragility fracture patients who are not on orthopaedic wards.
  • Work with team, across whole pathway from admission to discharge to meet Quality Standards and best care.
  • Close collaboration with the MDT to effect discharge.
To gain experience in this topic trainees should be placed in units designated either as Trauma Units (TU) or Major Trauma Centres (MTC). A minimum attachment of 12 weeks over the five year training programme is recommended. Trainees should see a minimum of 30 patients, at least 15 seen initially on their own, then seen with a consultant orthogeriatrician (for some aspects other appropriately experienced consultants could include surgeon, anaesthetists, consultant/ specialist nurse/practitioner).
 
Trainees should spend time on orthopaedic wards where older patient with fragility fractures are admitted for operation/management, orthogeriatric wards, and rehabilitation facilities. They should work within specialist team which should include consultant orthogeriatrician. it would be good practice to also work alongside specialist/advanced practitioners where they are in post.
 
For the Bone Health component it is required to spend time with relevant specialist services in clinics or ward rounds (e.g fracture liaison service, osteoporosis specialist practitioner, falls clinic), and a WPBA / reflection / feedback completed afterwards. For Core Curriculum Competence a minimum of 6 falls and/or bone health sessions should be attended (at least 2 in each).
 
Trainees should undertake falls and bone health assessments acutely as part of their routine assessment of orthogeriatric patients in line with the NHFD. This assessment should be reviewed by an appropriate senior healthcare professional (e.g. consultant, specialist or advanced practitioner/nurse) as part of a WPBA and will require their ES to sign then off as competent in this capability.
 
It is expected that most of the work will be on orthopaedic or orthogeriatric wards. It would be good practice to be released to experience some time in other settings.
 
Trainees should be aware of, and where practicable, experience, the whole patient journey including pre-hospital / ambulance services, ED, wards pre and post-op, operation/anaesthesia/recovery (including WHO) and rehabilitation in acute or community settings. As a minimum they should have opportunities to see patients in every setting in the acute hospital from ED to discharge, including in theatre.
 
Trainees should be actively involved with peri-operative discussions with anaesthetists and surgeons on medical optimisation and have the opportunity to lead these discussions. It is expected that a trainee would attend at least one hip fracture operation to observe the whole theatre process from induction of anaesthesia to recovery. This should include WHO meeting.
 
Trainees should work closely with MDTs on trauma/orthogeriatric wards. They should have the opportunity to lead board rounds and family/patient discussions and work with the MDT to select patients for rehab beds. In order to develop an understanding of the different types of rehabilitation/discharge options it is good practice to visit these (e.g. a community rehabilitation bedded unit, a care home, rehab at home service). In an orthogeriatric attachment trainees should see the full range of outcomes of hip fracture surgery.
 
It is recommended that trainees are observed undertaking discussions with patients and family at differing points in the patient journey e.g:
  • Pre-operatively-compassionately explanation to patients and families of the risk and benefits of surgery, potential outcomes and where appropriate initiating advanced care planning conversations
  • Post-operatively explaining (using information gained from collaboration with the MDT) the anticipated trajectory for the patient
 
Trainees are expected to gain experience in the prevention and management of a wide range of peri- operative complications, such as pneumonia, acute kidney injury, thromboembolism, pressure ulcer prevention, pain management, constipation, surgical complications , wound healing, dislocation/ failure/cut-out, extended VTE prophylaxis, when to restart anticoagulation/antiplatelets. It il be helpful to keep a log of case and problems seen.
 
Learning will also take place by using local and national audit data such as the National Hip Fracture Database, or Scottish Ip Fracture Audit, and reviewing other relevant data such as local incident data, surgical site infection surveillance data WHO meetings, Fragility fracture governance meetings, M&M and service/pathway meetings.
 
It is expected that trainees will also be exposed to formal teaching sessions covering a range of relevant topics (e.g. BGS National and regional Meetings, post-hip fracture care, osteoporosis and falls, during their five year training programme (local, regional and national training and CPD meetings).
 
It is recommended that trainees receive supervision from a variety of professionals that reflect the multidisciplinary nature of orthogeriatric care. These supervisors must be able to assess a trainees competence using a combination of direct observation and supervised learning events (e.g. CbD, mini-CEX, ACAT and MSF) in order for the ES to be able to complete curriculum sign off.
 
To have advanced knowledge and skills in managing older patient who have sustained a femoral fracture
 
To have advanced knowledge and skills to assess and manage bone health and fracture risk in all groups of patients.
 
To have knowledge and skills in assessment and management of older patients presenting with fragility fractures and other fall- related injuries which commonly occur on general wards or present to DGHs, (including head, spine, ribs, pelvis and limbs), from presentation to discharge.
Knowledge
  • Detailed in depth knowledge of the effects and risks of injury, surgery and anaesthesia on older people.
  • Knowledge of common fracture types, their management and prognosis.
  • Knowledge of common injury patterns in older people and how to assess and initially manage them in general wards / non-specialist areas, liaising with or referring to specialist services including MTC as appropriate:
  • Knowledge of peri-operative complications both generic (e.g. wound infection, delirium, AKI, pain) and specific (e.g. increased blood loss with Subtrochanteric fractures, DHS cut out , avascular necrosis).
  • Knowledge of possible post-operative trajectories and outcomes.
  • Awareness of the factors that may impact rehabilitation e.g. fear of falling, continence, pain, fatigue, fixation failure etc.
  • Knowledge of appropriate assessment tools to inform clinical management decisions.
  • Ability to understand and evaluate different models of delivering orthogeriatric services ideally with exposure to different models of service during training.
  • Have a detailed knowledge of National Hip Fracture Audit Programmes (NHFD/Falls and Fragility Fracture Audit Programme (England ,Wales and Northern Ireland), Scottish Hip Fracture Audit (Scotland) and understand how they have influenced different models of orthogeriatric care.
  • Have knowledge of relevant national guidelines e.g. BOA, AAGBI and understand the evidence base used to inform them.
  • Be aware of and keep up to date on relevant evidence reviews that inform practice e.g. Cochrane reviews and relevant NICE Guidance e.g on TLOC, falls, Hip fracture, Technical guidance on treatment for osteoporosis.
  • Be aware of and able to contribute to local policies for this group of patients.
Causes and management of falls - as per Falls curriculum competence
  • Be able to do a falls assessment as required by Best Practice Tariff for Hip Fracture.
  • Be aware of multiple risk factors for falls and how to modulate them.
  • Able to recognise when falls are ‘unexplained’ and possibly syncopal including orthostatic hypotension, Vasovagal syndrome VS, Carotid Sinus hypersensitivity.
  • Be able to interpret ECGs and appropriately refer on for further testing e.g. tilt / cardiac - ILR
  • Falls programmes and the evidence base for their effectiveness.
Bone health and osteoporosis
  • Knowledge of the causes of osteoporosis and appropriate strategies for the prevention and treatment of osteoporosis.
  • Drug and non-drug treatments for osteoporosis.
  • The appropriate use and interpretation of bone densitometry and the WHO FRAX tool.
  • Ability to manage osteoporosis in special groups (eg men, younger adults, steroid-treated, Down syndrome).
  • Other relevant metabolic bone disorders (osteomalacia, Paget’s disease, etc.).
  • Understanding of medical and surgical management of common metabolic bone diseases eg. osteomalacia, Paget’s disease & primary hyperparathyroidism.
  • Awareness and recognition of atypical bisphosphonate related fractures.
  • Awareness of Pathological fractures (non-fragility).
  • Public health and ‘whole life’ strategies for bone health.
Skills
  • To be familiar with local fragility fracture data and be able to describe how this influences the way in which orthogeriatric care is delivered locally.
  • To be able to work with and influence other specialities and professions caring for this group of patients.
  • Able to critically appraise and benchmark current service against national standards/data e.g. NHFD and identify areas for improvement to use QI methodology to monitor and continuously improve it.
  • Clinical assessment of patients with fragility fractures including understanding risks of complications.
  • Discharge planning.
  • Assess patients for and medically optimise for surgery.
  • Leadership and membership of a multidisciplinary team.
  • Ability to assess falls risk and institute fall prevention measures including referral to appropriate services where appropriate e.g. exercise classes, tilt testing.
  • Health promotion.
Behaviours
  • Compassionately explains to patients and families the impact of recommended interventions for, and possible outcomes of fragility fractures.
  • Uses advanced communication skills to understand what matters to the patient and use this information to guide care.
  • Advocates for early operation and discuss risks / benefits of delay in a collaborative manner with anaesthetist and surgeons.
  • Recognises limitations of own knowledge and engages with other specialities for advice regarding complex cases e.g. cardiology, haematology
  • Visible inclusive leadership style working in a collaborative interdisciplinary and multi-agency manner.
Specific Learning Methods – higher level curriculum competencies
  • Experience - at least 6 months fulltime equivalent (although not necessarily consecutively) of working in a variety of orthogeriatric settings including preoperative assessment and management, acute postoperative care, post-surgical rehabilitation and discharge planning.
  • Assessment standards will be set higher than those expected for core curriculum orthogeriatrics grids commensurate with the knowledge, skills and behaviours required to provide a more specialist service to patients with fragility fractures and falls -related injuries that occur on general wards or present to district general hospitals.
  • Exposure to/experience in a Major Trauma Centre Unit is desirable (e.g. in a taster or brief secondment) but not mandatory to achieve the requirements.
  • For Higher Level Competence a minimum of 12 osteoporosis sessions is required (includes clinics and also other sessions such as time with fracture liaison service). This may include osteoporosis sessions which are also counted towards the core competence. Trainees should also be encouraged to attend clinics in other relevant specialties, such as rheumatology.
  • Evidence in portfolio of contribution to Audit of care against national standards/guidelines/protocols .
  • It is expected that in addition to the formal teaching for the core curriculum trainees completing the higher level competencies will have attended more advanced or specialised teaching e.g. conferences such as POPS, Age Anaesthesia, specialist session at BGS national meeting.
  • It is also expected that they will have taken and evidenced in their portfolio the opportunity to provide teaching and support to junior doctors and other professions in aspects of orthogeriatric care.

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