Bone Health

Background Osteoporosis is a global health concern that is likely to increase with a rapidly ageing world population. It affects one in three women and one in five men over the age of 50. Although there is a large body of qualitative research exploring the experience of living with osteoporosis, far fewer studies have focused on men. We aim to explore the meaning making processes of men with osteoporosis. Methods We interviewed 13 White British men aged 63 to 94 with an osteoporotic vertebral fracture We used the six stages of reflexive thematic analysis: familiarisation with the data; coding ; generating initial themes; developing and reviewing themes through discussion; refining and naming themes; writing up. Results We developed six themes giving insight into the existential losses of men with osteoporosis: there has been a step changed coming; I am no longer what I once was; the change in me is de-meaning; I want to know where I am heading; I want to know why this happened to me; I want to know what’s wrong and how to fix it? We describe moral narratives used in defence of self. Conclusions Our findings highlight the challenge of deciphering the symptoms of osteoporosis and age-related changes. We also see the impact on self and a struggle to repair self. Healthcare providers are in a unique and privileged position to accompany their patients at points of Existential Crisis. As such, they attend to the repair of both identity and body. This comes with an ethical responsibility and has implications for clinical education. Health professionals should feel equipped to be alongside people facing existential losses. Qualitative Research and can give valuable insight into the phenomenology of illness and contribute to improvements in care pathways.

Introduction At Wrightington, Wigan and Leigh we admitted over 400 patients with hip fracture diagnosis in 2023. As part of ortho-geriatric review, denosumab treatment would be utilised in a cohort of patients where this is appropriate, in line with NOGG guidelines. Traditional model of delivering first dose after outpatient appointment led to delays in treatment initiation and did not address the significant risk of “imminent fracture” which was recognised in the latest NOGG guidelines. The aim of this project was to reduce delays in denosumab treatment initiation by introducing consenting process during hospital stay led by ortho-geriatric Advanced Clinical Practitioner.

Method Utilising hospital electronic records, a sample of patients was selected from patients admitted in 2022 (19 patients), 2023 (19 patients) and 2024 (6 patients). Time of decision to treat with denosumab to time of first dose administered was used as the outcome measure. Alongside this, analysis of time to outpatient appointment was completed which was where the pre-intervention consent was taken. Intervention of inpatient consent being taken was implemented in September 2023.

Results The average length of time from clinical decision being made to first dose of denosumab being administered was 187 days in 2022 sample, 76 days in 2023 sample and 27 days in 2024 sample. The governance around consent process was established and adopted by the whole ortho-geriatric team. Waiting times for outpatient bone health clinic were on average 240 days in 2022, 164 days in 2023 and unknown in 2024 cohort.

Conclusion(s). Introduction of ward-based consent process for patients who are suitable for denosumab led to significant decrease in delays in time to first dose. This ensures that patients benefit from bone protection in a timely manner, as their risk of refracture is greatest in the first 6 months post index fracture.

Objectives: Older adults hospitalized with a hip fracture are at risk for adverse health outcomes depending on their level of frailty. This study examined how frailty levels prior to admission impacted length of stay (LOS), requirement for alternative level of care (ALC), returning home post-discharge, and mortality.

Methods: A random sample was generated from all hip fracture patients aged 65 and older admitted to a Level One Trauma Centre in New Brunswick, Canada from 2015-2019. This sample had their frailty level determined retrospectively using the Pictorial Fit-Frail Scale and the patients’ hospital electronic health record.

Results: Our study included 189 patients (mean age: 83.2 ± 8.2, 73.0% female), representing 91 not frail to mildly frail (48.2%; NF-MF), 32 moderately frail (16.9%; ModF), and 66 severely frail (34.9%; SF) patients. The ModF patients had a longer LOS (median: 20.0 days, IQR=22.5) compared to NF-MF patients (median: 11.0 days, IQR=10.0, p=0.039, Kruskal-Wallis test) and SF patients (median: 8 days, IQR=5.5, p<0.0001, Kruskal-Wallis test). More ModF patients (56.3%) required an ALC stay in acute care compared to NF-MF (30.8%) and SF (28.8%) patients (p=0.016, Chi-square test). More SF patients (28.8%) died in hospital or within six months post-discharge compared to NF-MF (8.8%) patients (p=0.005, Chi-square test). Logistic regression revealed that both NF-MF (OR=8.11, 95% CI: [3.12-21.06], p<0.001) and ModF (OR=5.18, 95% CI: [0.85-0.95], p=0.007) patients had greater odds of returning home compared to SF patients when accounting for sex, age, and time to surgery.

Conclusions: A patient’s level of frailty prior to hospital admission impacts various health outcomes following a hip fracture and may provide helpful information for guiding treatment as well as discussions about health care.  

Introduction: Hip fractures, predominantly affecting older adults, represent a significant health concern due to high morbidity, mortality, and healthcare resource utilisation. This ongoing Quality Improvement Project within Forth Valley Royal Hospital aims to enhance adherence to recommendations from the 2023 and 2024 Scottish Hip Fracture Audit. It specifically focusses on the timely administration of Vitamin D and IV Zoledronic Acid to frail patients with hip fractures.

Method: A retrospective and prospective cohort study design was employed, analysing the records of 165 inpatients under orthogeriatric care from November 2023 to May 2024. Initial data analysis indicated low rates of IV zoledronic acid and vitamin D administration, primarily due to clinician unfamiliarity and process inefficiencies. Subsequent interventions included staff education sessions, process standardisation, and the introduction of tracking tools such as Bone Health stickers and whiteboards. Formal referral pathways and decision-making protocols were implemented to ensure comprehensive and timely patient care.

Results: The interventions led to substantial improvements in adherence rates. Between November 2023 and March 2024 vitamin D administration rates increased from 14.71% to 100%, and IV Zoledronic Acid administration rose from 12.12% to 95.45%. These improvements were achieved through systematic tracking, enhanced clinician education, and standardised care processes. Despite these gains, challenges remain in achieving 100% adherence to IV Zoledronic Acid administration and addressing initial data capture inaccuracies due to inconsistent use of referral systems.

Conclusion: The project demonstrates that targeted interventions and standardized care pathways substantially improve adherence to national guidelines for hip fracture patients. Sustained efforts in education, process refinement, and collaboration with the Hip Fracture Audit Team are essential to maintain these improvements. Future proposals include integrating Vitamin D and Adcal-D3 doses into an electronic prescribing protocol and conducting detailed statistical analyses to identify further areas for improvement.  

Introduction

Fall-related injuries such as fractures are on the rise as the older adult population grows in New Brunswick, Canada. These injuries can lead to hospitalization and transitions in care that are complicated for patients and families. The objective was to investigate the impact of patient navigators (PNs) working alongside the healthcare team on patient and family experiences, as compared to the usual standard of care (SOC), for adults aged 65 and older admitted with a fracture to an Orthopedic Unit at one hospital in New Brunswick.

Methods

A concurrent embedded mixed methods design, in which the quantitative randomized control trial had an embedded qualitative component. The results for the family caregiver qualitative component, which used an interpretive description approach, are presented.

Results

Semi-structured interviews were conducted and thematically analyzed for 15 family caregivers (8 PN group, 7 SOC group). The SOC caregivers, six women and one man, had a mean age of 64.6 years (SD=6.9 years). The mean age of the 8 women in the PN group was 61.3 years (SD=10.1). All participants in both SOC and PN groups self reported their ethnicity as white. Thematic analysis found that SOC group caregivers discussed patients relying on support from family and friends throughout their care journey, whereas caregivers in the PN group predominantly discussed finding PNs supportive and helpful. Both groups discussed the ongoing stress that they felt throughout the care journey of the patient for which they cared for; however, for the PN group this topic was less prevalent.

Conclusions

This study provides an understanding of the positive impacts a patient navigator can have on older adult inpatient care and transitions in care. Patient Navigators were shown to be helpful to families, particularly those of patients with higher care needs and fewer family supports.

Introduction:

The local issue tackled was the suboptimal compliance with the Patient Fall Management Assessment (PFMA) on the Electronic Patient Record (EPR) due to assessments being completed on alternative electronic documents.The goal was to emphasize on this to improve patient safety.

Methods:

Audit data was collected by reviewing incident reports of inpatient falls across various complex care wards over a 12-month period each, with 109 notes reviewed in the first cycle and 204 in the second.

Interventions:

The approach involved conducting repeated training sessions for all grades of training doctors within the trust.

Results:

The first audit cycle revealed fair compliance with the PFMA document (87%), documenting events (94%), examinations (87-96%), further investigations and management (80-86%). However, these were lacking for past medical history (61%), medications, especially anticoagulation/antiplatelets (58%), although antihypertensives/sedative reviews were better (75%).

The interventions led to a small (2%) increase in the use of the PFMA document but a 100% compliance in recording fall events and a 13% improvement in documenting histories. Review of blood thinners and other medications improved by 17% and 8% respectively. Significant improvements were also seen in examinations and developing management plans. Despite these advancements, 14% of patients experienced recurrent falls, indicating a need for ongoing efforts.

Conclusions:

The audit highlighted the effectiveness of continuous training to ensure regular understanding of the importance of completing the PFMA. Given the frequent rotation of junior doctors as well as the increasing variety of allied health care professionals reviewing patients, especially out of hours, this presents a particular challenge. Future efforts will focus on more sustainable methods of increasing awareness of the PFMA such as discussion at multi-disciplinary staff inductions and welcome packs. Sustaining these improvements will involve regular audits and feedback loops as well as feedback on the document itself to assess for future improvements.

Introduction

• Preoperative systemic inflammation has been shown to worsen postoperative outcome in emergency surgical patients.
• C-reactive protein (mg/L)/Albumin (g/L) ratio is a well validated inflammation marker.
• Studies have shown an inverse relationship between 25-hydroxyvitamin D level and markers of inflammation. Vitamin D deficiency has been previously shown to be associated with inflammation.

Aims and Objectives

• To determine the relationship between 25-hydroxyvitamin D level and CRP/Albumin ratio in older acute hip fracture patients.
• To explore the impact of gender on this relationship.

Methods

• A retrospective review of electronic notes from the hip fracture database was carried out on hip fracture patients attending a single trauma centre from January to December 2022.
• Anonymised data were extracted from the database. Patients aged 60 years and older who sustained an acute hip fracture were included. Patients with incomplete data were excluded. The IBM SPSS 29 software was used for statistical analysis.
• Descriptive statistics was used for baseline characteristics. Linear regression was used to determine correlation.

Results

• A total of 293 patients were analysed: 82 males and 211 females with a mean age of 81.6(SD 8.28) and 83.2(SD 7.85) years respectively.
• Mean 25-hydroxyvitamin D levels were 39.1 (SD 25.0) and 49.7 (SD 29.01) nmols/L respectively.
• Mean CRP/Albumin ratio was 0.94 (SD 1.51) and 0.71 (SD 1.34).
• There was a negative, statistically significant correlation between 25-hydroxyvitaminD and CRP/Albumin ratio in male patients but not in the females (r = -.274; p = .013 & r = - .035; p = .61) respectively.

Conclusion

• In this study, 25-hydroxyvitamin D levels are inversely correlated with markers of inflammation (CRP/Albumin ratio) in older male hip fracture patients but not older female hip fracture patients. More studies are needed to clarify whether vit D lowers inflammation or inflammation lowers 25-hydroxyvitamin D concentrations and to investigate the gender difference.

Introduction: Orthostatic Hypotension is a significant cause of falls leading to injury and morbidity in elderly population. In an online survey by Royal College of Physicians (RCP) 271 out of 316 clinicians routinely performed these measurements and there were significant variations in how lying and standing BP is performed. This could have adverse effects on detection rates and accuracy of the procedure resulting in misdiagnosis. As a result, RCP has released guidance on L/S BP2 measurements in view of standardising practice and improving accuracy. The purpose of this QIP is to improve how L/S BP is measured and documented, by introducing poster on wards and re-audit the improvement in the correct method of measuring L/S BP.

Methods: Ward staff are audited to find out whether LS BP is measured as per RCP guidelines. Afterwards a poster of RCP recommended method of measuring LS BP are placed on ward and given to participants. The procedure of L/S BP measurement is re-audited after the intervention to find out changes in performing L/S BP (as per RCP guidelines).

Results: • 20% staff were aware of RCP guidelines on L/S BP procedure (90% after intervention). • 0-15% staff had formal training on how to measure L/S BP. • Over three times improvement in the method of procedure (20% to 65% after intervention). • 25% staff were documenting symptoms (improved to 85% after intervention). • 10% of staff knew how to interpret a positive result, improved to 60% after intervention.

Conclusion: • Staff education improves L/S BP Procedure, documentation and interpretation, it also helped raise staff awareness of the RCP guidelines and how to access them.

Background:

- Falls and associated injuries are a significant area of concern for older adults. Approximately 30% of those aged over 65 and 50% of those aged over 80 experience at least one fall each year.

- NICE guidelines state, “Older people who present for medical attention because of a fall, should be offered a multifactorial falls risk assessment”, which includes review of visual impairment.

Aims:

- To identify if visual impairment was documented on the orthopaedic clerking document for patients admitted following fall.

- To raise awareness of visual impairment as being a significant risk factor for falls in the elderly population.

Methods:

- Data collection was carried out retrospectively for patients presenting following a fall at Tunbridge Wells Hospital, via the orthopaedic admission list.

- Initially, data was collected from April to May 2024 and then from July to August 2024 following the first teaching intervention.

Results:

- 6% of patients (n = 50) admitted following a fall had visual status documented in the orthopaedic clerking document.

- Following the first intervention, 20% of documentation noted visual impairment.

Conclusion:

- Visual impairment was not routinely documented on orthopaedic clerking.

- The first intervention involved delivering a teaching session to the orthopaedic department, highlighting the significance of visual impairment contributing to falls.

- Data collection from July to August 2024 has shown an improvement in documentation, whereby 20% of documentation noted visual impairment.

- The second intervention will involve including these findings in the departmental induction and designing a poster to raise awareness.

Introduction:

Parkinson's disease (PD) is associated with an increased risk of osteoporosis and fractures to factors like falls resulting from postural instability, polypharmacy, and muscle weakness. Reduced bone mineral density (BMD), often caused by vitamin D deficiency, disease severity, and low BMI, further elevates fracture risk in PD patients. This project aims to improve awareness and bone health testing in PD patients by focusing on vitamin D, bone profile assessments, DEXA scans, and FRAX scores for fracture risk evaluation and management.

Methodology:

This QIP involved two cycles focused on managing Parkinson’s disease (PD) patients. The first cycle interventions focused on educating doctors through sessions and a poster, while the second cycle introduced personalized treatment plans for PD patients, recorded in their clinical notes. A comparative analysis of post-intervention data was conducted to evaluate the effectiveness of both interventions.

Results:

Bone profile testing was successfully completed in 100% of patients after both interventions. In cycle 1, 63.3% of patients required vitamin D testing, compared to 25% in cycle 2. Of these, 14.3% received testing after the first intervention, and 100% after the second. However, none of the patients had their FRAX scores calculated or DEXA scans scheduled. The teaching session increased overall confidance amongst junior doctors in diagnosing osteoporosis from 60% to 70%, and managing osteoporosis from 10% to 80%. It also improved the overall awareness on how to use the FRAX tool from around 50% to 90%. 

Conclusion:

Personalized treatment plans and targeted interventions led to significant improvements in vitamin D testing. However, notable gaps remain in adherence to FRAX calculation and organizing DEXA scans. Future efforts should focus on these limitations and ensuring complete bone health assessments for PD patients. The teaching sessions proved to be highly effective, significantly enhancing participants' understanding of bone health issues in Parkinson's disease.