Bone Health

Introduction

Fragility fractures are associated with significant morbidity and mortality. The National Osteoporosis Guideline Group advise that a FRAX assessment should be completed in all patients with falls. Despite this only 3% of patients admitted to a geriatric ward following a fall had a bone health assessment completed within 72 hours of admission. Our aim is for a bone health assessment to be completed in >90% of these patients.

Method

Our intervention focused on promoting bone health assessment with a ‘FRAX proforma’. This was aimed at junior doctors as the main cohort expected to perform the assessment. The proforma incorporated documentation of the FRAX score including outcome, vitamin D and calcium results, prescribed supplementation and antiresorptives, and a prompt for referral to the fracture liaison service or osteoporosis clinic. The main outcome measure was the percentage of completed bone health assessments using FRAX or Qfracture. Awareness of the proforma was raised through a presentation at a senior health department teaching session and sending an email to all members of the senior health team. Data was collected daily for a week approximately 3 weeks later.

Results

Following our intervention, the percentage of completed bone health assessments increased from 3% to 12%, consistent with a modest improvement. This should translate to a decreased risk of fragility fracture. However, there is ongoing scope to improve. We are planning a further intervention integrating bone health assessment into the ward admission proforma.

Conclusions

Although our intervention has demonstrated a modest improvement, there is scope for further improvement embedding bone health assessment as routine practice for older patients presenting with falls. Future interventions will increase this further by integrating bone health assessment into the existing documentation tools, embedding this as regular practice in the inpatient setting.

Introduction:

Inpatient falls are the most common adverse patient safety incidents in hospitals in the UK. The assessment and management following an inpatient fall is often the responsibility of the most junior doctor on call, particularly out of hours. Frequently, there are key omissions in the assessment of these patients, leading to missed diagnoses, poor management and avoidable patient harm. This study aimed to improve the knowledge and confidence of foundation doctors in the assessment and management of inpatient falls.

Method:

31 patients were identified who had suffered ‘severe harm’ following an inpatient fall and a retrospective review of their notes was performed. A preliminary survey on self-perceived confidence levels on different areas of the assessment and management of inpatient falls was distributed to all foundation doctors at Ipswich Hospital. The key themes of the simulation scenario were subsequently determined by the areas of weakness identified in both the survey and documentation review. A total of 9 foundation doctors at Ipswich Hospital participated in a high-fidelity inpatient fall simulation with a patient actor. Pre- and post-simulation knowledge and confidence surveys consisting of ten multiple choice questions and Likert scales respectively were distributed using QR codes.

Results:

Post-simulation confidence levels improved in all domains measured (p < 0.05) with an overall increase in average confidence levels from 3.3/5.0 to 4.3/5.0 (p=0.007). Average post-simulation knowledge score increased from 4.6/10 to 7.4/10 (p= 0.01). Domains in which the greatest improvements in knowledge and confidence were seen included: moving & handling, neurological observations, assessment of suspected hip fractures and escalating concerns.

Conclusion:

The use of simulated patients improves the knowledge and confidence of foundation doctors in the assessment and management of inpatient falls. The pilot project is due to be expanded with plans to incorporate this simulation scenario into the local foundation teaching programme.

Introduction: Concerns about falling (CaF) is a psychosocial concept, precipitating a spiral of increasing inactivity, social isolation and falls, and is common in those who have experienced, or are at risk of, a fall. One method of assessing CaF is the Falls Efficacy Scale International version (FES-I),with previous studies finding associations between higher FES-I scores and poor scoring on commonly used clinical assessments of functional mobility and balance (Gait speed (GS), Timed up and Go test (TUG), and Five time sit to stand (FTSS)). Using the FES-I to predict poor functional mobility and balance has the potential to identify those at risk before an initial fall, at which point an intervention may be provided.

Methods: A prospective study was carried out over 24 weeks, in which 119 participants were recruited from the North Tyneside Community Falls Prevention Service (NTCFPS). Participants completed questionnaires and underwent physical testing whilst attending the falls clinic (baseline) and at week 24, completing bi-weekly falls diaries throughout. Participants were users of the NTCFPS, and residents of North Tyneside.

Results: Findings showed (i) the FES-I had a limited ability to predict poor scores on GS, TUG and FTSS; (ii) attending referred Age UK strength and balance classes was significantly associated with improvements in FES-I score and FTSS; (iii) CaF at the outset of Age UK training was not significantly associated with clinically significant improvements in GS, FTSS and TUG.

Conclusions: Whilst the predictive capabilities of the FES-I were limited, the measure showed an ability to track improvements in participants CaF in the short to medium term. Further work is needed to explore the measures applications within the general population of community dwelling older adults, rather than a cohort of falls service users.

Introduction:

Osteoporosis is a known consequence of stroke, associated with an increased incidence of fractures and leading to further disability. The pattern of bone loss seen in stroke patients is different from that usually seen with postmenopausal osteoporosis. It depends on the degree of paresis, gait disability, and the duration of immobilisation.

Methods:

We retrospectively analyzed data from 20 patients admitted to the stroke ward. All patients with stroke aged more than 65 years were included in the data. Patients who were less than 65 years old, non-stroke patients, and patients who passed away during admission were excluded. Results: Fall risk assessment showed 25% of patients were low risk, 35% were medium risk, and 40% were high risk. Among them, 15% of the patients had a history of osteoporosis. Only 25% of patients had osteoporosis treatment before admission. 15% had a history of vertebral/femoral fracture in the past. We calculated the FRAX score for all patients (low risk in 44%, intermediate risk in 44%, and high risk in 12%). We compared the pre- and post-admission osteoporosis treatment (25% vs. 30%).

Proposed Plan:

Check vitamin D levels for all patients admitted to the stroke ward. Conduct falls risk assessments for all patients. Calculate FRAX scores for all patients under 90 years. Provide osteoporosis treatment if a previous vertebral fracture is found incidentally, unless contraindicated. If creatinine clearance is less than 30%, refer to the fracture liaison service or ask the GP to refer.

Conclusion:

This study highlights the high prevalence of osteoporosis and fall risk among stroke patients, emphasizing the need for routine osteoporosis screening and treatment in this population. Implementing systematic assessments and appropriate interventions can potentially reduce the risk of fractures and improve the overall quality of life for stroke patients.

 Introduction:

Maintaining good postural stability is considered important to prevent falls in the elderly. We evaluated factors associated with good postural stability.

Methods:

We evaluated 33 patients (6 males and 27 females) over 65 years old. The average age was 76.1 years old ranging 65 to 85. We measured Index of Postural Stability(IPS) using gravicoder GW-5000 manufactured by ANIMA. The IPS was advocated by Mochizuki in 2000. It was defined following this equation; IPS=log[(area of stability limit + area of postural sway)/area of postural sway). Larger IPS means better postural stability. The average IPS in each age was already known. IPS was calculated automatically through gravicoda. We divided these patients into two groups by the results of IPS. Group A with the patients whose IPS was larger, Group B with the patients whose IPS was smaller than the average in their age. We compared the following items between the two groups. Functional performance (gait speed, two-step test, one-leg standing test, five-repetition sit-to-stand test, grip strength), body composition (height, weight, BMI, limb circumference, skeletal muscle mass ), spino-pelvic parameters (Pelvic Incidence(PI), Lumbar Lordosis(LL), Pelvic Tilt(PT), Sagittal Vertical Axis (SVA)) using whole spine x-ray photograph.

Results:

Thirteen patients were classified into Group A and 20 patients were into Group B. Gait speed, two-step test, five-repetition sit-to-stand test, one-leg standing test, SVA were significantly different between the two groups. SVA was 6.39±31.0mm in Group A and 50.6±27.5 mm in Group B. SVA of less than 50 mm is known to be an important indicator of good posture.

Conclusion:

The results showed that SVA is related to postural stability as well as gait and balance ability. This suggests that good posture is likely one of the keys to fall prevention.

Introduction: Inpatient falls are a common problem, and it is important that newly qualified doctors feel confident in conducting competent assessments of patients after they fall. This project seeks to assess the confidence levels of final year Manchester Medical School (MMS) students surrounding the topic of inpatient falls assessments, as well as to determine whether another resource from MMS regarding this topic would be beneficial.

Method: A survey was conducted and disseminated amongst final year students at MMS through email and social media, with questions designed to address the objectives set, as well as gain an understanding of students’ prior experience and knowledge of inpatient falls assessments.

Results: A total of 70 out of 545 students answered the survey, equivalent to a 13% response rate. The results demonstrated that 70% had observed and 27.1% of students had performed an inpatient post-fall assessment. The results showed students generally were not confident in conducting inpatient falls assessments, with 17% and 39% of students self-assessing as ‘Extremely not confident’ and ‘Somewhat not confident’ respectively. 100% of students believed an additional resource on the topic would be a beneficial addition to the MMS curriculum; with the majority (60%) opting for a simulation session as an appropriate option, followed by an informative summary document (21%), an interactive online case (9%), and a lecture (6%).

Conclusions: Despite certain limitations of the project, it can be said that students generally lack confidence and experience when performing inpatient falls assessments and believe that an additional resource from MMS would be beneficial.

Introduction: Inpatient falls present a significant safety concern in NHS hospitals, with approximately 247,000 inpatient falls per year in England alone (Healthcare Quality Improvement Partnership (2023), National Audit of Inpatient Falls 2022). The actions following an inpatient fall have potential to influence clinical outcomes and patient safety. This quality improvement project aimed to enhance patient safety by improving the accuracy of post-fall review documentation and increase awareness of the Trust's post-fall protocol.

Methods: Data collection involved reviewing electronic notes of patients across three Senior Health wards who experienced inpatient falls during two cycles: 01/06/23 – 31/10/23 (N=12) and 01/11/2023 - 29/02/2024 (N=25). Additionally, surveys were conducted among Senior Health medical staff to gauge awareness of post-fall protocols and documentation. Interventions, in the form of teaching sessions and a poster circulated within the department, aimed to improve awareness of post-fall protocol and documentation. Statistical analysis was conducted using unpaired t-test.

Results: Statistically significant improvement was observed in the use of post-fall review proformas between audit cycles, increasing from 33% to 70% (p<0.05). Although awareness of the post-fall proforma improved from 63% to 80%, this change was not statistically significant.

Conclusion: The intervention significantly enhanced the accuracy of inpatient post-fall documentation, evidenced by the increased use of post-fall review proformas. The circulation of the 'Inpatient Post-fall Review' poster contributed to this improvement by outlining recommended timeframes for review and steps for accessing post-fall review proformas. While awareness of the hospital's post-fall protocol did not significantly improve, the increased completion rate of post-fall proformas indicates a commitment to thorough assessment and documentation among Senior Health medical professionals. However, despite awareness of the existence of the post-fall proforma, some professionals may not utilize it for documentation, potentially explaining the lack of significant difference in awareness across cycles but an improvement in proforma usage post-intervention.

Introduction: Falls remain the leading reason for elderly people to attend emergency department (ED), which in 2023 led to 250,000 hospital admissions in the UK. A seemingly large number of geriatric patients undergo CT head as an initial workup in ED which might not be necessary, especially in minor head trauma. NICE (National Institute for Health and Care Excellence), recommended risk stratification to reduce unnecessary head scanning which may potentially reduce ED length of stay, hospitalisation and medical expense. Our study evaluated the current practice of adherence to NICE guidance on Head Injury: assessment and early management for performing CT head scans in elderly admitted to Basildon hospital.

Methods: Two cycles of retrospective data collection were undertaken across three elderly care wards. Elderly patients admitted with falls who had CT head scans were identified. Indication for scanning were evaluated to determine adherence with NICE guidelines for head injury. Between cycles, formal educational sessions were provided to Junior Doctors by departmental teaching and distributing leaflets/posters explaining NICE guidance for indication of CT head scans in head injury.

Results: Following the interventions implemented, patient compliance to the NICE guidance for undergoing CT head with a history of falls, rose from 77.33% to 93.99%. No significant difference in abnormal CT head findings were demonstrated between cycles. In addition, mortality observed between cycles was near equivalent, 12% and 11.67% respectively. The mean time for CT head scans performed also improved, from 13 hours to 4 hours.

Conclusion: We demonstrated education regarding the indication for CT head scans in elderly with falls improved the appropriateness of scans performed in accordance with NICE guidance. CT head scans performed which more robustly met NICE guidance demonstrated no difference in adverse findings or patient mortality and may have contributed to reduced mean scan time, thus improving resource allocation.

Objective: To identify good practices and highlight areas for improvement in the prevention and management of inpatient falls.

Method Fifteen patients had serious inpatient falls between April and September 2023 within the hospital. Electronic notes and fall panel meeting minutes were used to provide an analysis of the "pre-fall" and "post-fall" assessments. Data was collected and analysed using AMaT and then compared to the standards set by RCP National Audit of Inpatient Falls (NAIF) – from KPI overview, 25% of patients had good quality Multi Factorial Risk Assessment (MFRA) in our Trust compared to National average of 33%.

Results 70% of patients had been identified as high risk of falls at admission. Patients were prescribed a median of 10 medications, with a median of 3 falls-risk increasing drugs (FRID). Before the inpatient fall: the majority of patients received an ECG and mobility assessment early in admission. Only 40% of patients had a lying/standing blood pressure (LSBP) 100% of those that showed a deficit were acted on appropriately. Only 20% had a documented medication review. Following the inpatient fall: A LSBP was done in only 33% of patients. A medication review was completed in 53% yet the average patient was discharged with 3 more medications. 73% of patients suffered fragility fractures due to the fall however bone protection was only considered in 40%.

Conclusion This audit highlights that there are areas of MFRA that require improvement, specifically LSBP, and a medication review. 33% of falls occurred in "medically-optimised" patients - resulting in at least 60 additional inpatient days. The results have been discussed with the multi-disciplinary team – intervention to improve performance will be piloted in two areas with the highest incidence of inpatient falls, with continuous learning and sharing of lessons embedded into our Falls Collaborative Initiative.

 Background: Patients who experience a hip fracture have a high re-fracture risk. Prompt initiation of anti-osteoporosis treatment is therefore vital. Oral bisphosphonates are less well tolerated in some older people resulting in poor adherence. A single dose of IV zoledronate however, can be effective for up to 3 years and is shown to reduce fracture rate by 35% (Gregson, Age and Ageing, Vol 51, 2022).

Aim: To increase use of IV zoledronate post hip fracture in Salford Royal Hospital

Local barriers: a trust guideline advising a 7 week vitamin D loading regime means inpatient IV zoledronate post hip fracture is limited. Waiting time for outpatient parental therapy is > 6 months.

Intervention: • A new trust wide guideline was written, approving rapid vitamin D loading over 10 days post fragility fracture to promote IV zoledronate use.

Methods: Retrospective analysis of case notes for 100 patients admitted with hip fracture at baseline (August 2021). Repeat data collection performed post intervention in August 2023 (100 patients) and March 2024 (30 patients). We recorded FRAX recommendation, adherence to new vitamin D regime, bone health plan on discharge, and osteoporosis treatment implemented.

Results: There was an increase in inpatient zoledronate use to 30 % (5% at baseline). Oral bisphosphonate use reduced to 10% (28%). There was 98% adherence to the new rapid vitamin D loading regime.

In cycle 2, 6% of patients did not receive planned IV zoledronate as discharged before vitamin D loading completion. 2% did not receive planned IV zoledronate despite vitamin D loading complete

Conclusions: Rapid vitamin D loading allowed more patients to receive inpatient IV zoledronate post hip fracture. There is scope to increase this further. Future plans include adding ‘date for IV zoledronate’ to the electronic notes template and including bone health in the pre-weekend check list to avoid delay in IV zoledronate administration.