Bone Health

Introduction: Falls account for one of the most common and serious issues contributing to a disability, especially among elderly individuals. (1) Injuries resulting from a fall range from mild to severe, but they are all usually painful. (2) According to RCEM ‘Recognition and alleviation of pain should be a priority when treating the ill and injured’. (3) The aim of this project was to improve pain management in patients with falls being referred to the OPAL team. Studies have shown that patients whose primary pain is well managed and treated in the ED have a higher overall satisfaction with hospital services. (4)

Method: Two PDSA cycles have been completed. Initial data was collected retrospectively from 3/9/23 to 9/9/23 to gather baseline information on current practice. Data was collected from hospital patient’s electronic records. This was followed by teaching sessions and poster distribution to improve staff education highlighting ways to address pain and its management. Post intervention data was collected from 11/12/23 -17/12/23. Duplicate records and non-fallers were excluded.

Result: Initial data was collected on total 75 patients which showed nearly 50% of the patients were in pain when referred to OPAL team. Amongst the patients in pain, OPAL team advised for pain relief in only 1/3rd of them. Following intervention, data was collected on 57 patients following exclusion. It showed only 26.3% of the patients were in pain at the time of referral, a significant improvement from nearly half in the previous cycle. Also, OPAL team advised regarding pain relief in almost all patients in pain. As a result, 79% of the patient were pain free during OPAL assessment.

Conclusion: The QIP showed importance of staff education in improving pain management in elderly patients presenting with falls. Further PDSA cycles are planned to sustain the current improvement in practice.

Reference: (1) https://www.ncbi.nlm.nih.gov/books/NBK560761/

(2) https://www.ditomasolaw.com/blog/slip-and-fall-accident-should-be-sore/

(3) RCEM_BPC_Management_of_Pain_in_Adults_300621.pdf

(4) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6548151/

Introduction The aim of this study was to examine the prevalence of vitamin D deficiency in elderly patients with fragility fractures of the hip by estimating 25-hydroxyvitamin D levels, whether low levels of Vitamin D at the time of admission affects the functional outcomes and mortality at 28 day and one year. Methods A retrospective study of all the patients admitted with a fracture neck of femur from Jan 2018 to March 2021 was carried out. The data was obtained from NHFD (National Hip Fracture Database) and Medway software. A total of 1221 patients were admitted during this period. Patient demographics including age, sex, fracture pattern, Vitamin D levels at the time of admission, function at 120 days, mortality at one month and one year were calculated. Results Of the 1221 patients, 106 patients did not have the Vit D levels checked at the time of admission. The average age was 81.91 (range-60 to 108). There were 845(70%) females and 376(30%) males. The serum Vit D levels were low in 611(55.3%) patients. The mobility in patients with Vit D deficiency 261(40.9%) has dropped significantly in the 3 months after surgery for fractures of proximal femurs. The 28 day and one year mortality was 6.74% and 30.3% compared to 4.7% and 27.3% for those with low and normal levels of vitamin D respectively. Patients with low Vit D levels at the time of admission with proximal femur fractures has got higher 28 day and one year mortality rates compared to those with normal levels. Conclusion Our study showed that low levels of Vitamin D at the time of admission with proximal femur fractures are associated with poor functional mobility, higher perioperative and one year mortality

Introduction

In 2022, 293 hip fractures had been admitted to the Bristol Royal Infirmary. As recommended by National Osteoporosis Guideline Group ( NOGG ) intravenous zoledronate is the first line treatment option following a hip fracture.

Aims

We wanted to improve bone health summaries on discharge summaries for the benefit of the General practitioner ( GP ), Fracture liaison service and patient.

Results

We used our local National Hip Fracture database to identify the patients who had had a fractured hip in September 2023. We then introduced our changes as part of the PDSA cycle. The change was copying and pasting a blank bone health paragraph into every discharge summary on day 1 of the patient's admission to make it easier for the Trauma and Orthopaedic (T&O) junior doctor completing the discharge summary pre discharge. We then used an excel spreadsheet to collect results in September and October 2023 and analyse them and display them using pie charts. In September , 28.3% of discharge summaries did not have a bone health plan, compared to 25% in October. Not mentioning of Vitamin D levels in discharge summaries has increased from 57.1% to 59.4%. Mentioning of administration of inpatient zoledronic acid post fracture decreased from 32.1% to 25%.

Conclusion

Despite the intervention,The bone health plans are poorly communicated to the GP and the Fracture Liaison service, which leads to delay in administering bone health medication in a timely manner to prevent a second fracture.

Next step

Teaching Session with the T&O juniors to find out if they think it’s a good idea and discuss why they have not found the current standardised paragraph helpful. Then we can work together to make a further change (s) and start another PDSA cycle.

References

National Osteoporosis Guideline Group.UK ( NOGG ),2021

Background

Fragility fractures, defined as fractures resulting from low energy trauma (1), are consistent with a diagnosis of osteoporosis. When a patient is discharged from hospital, guidelines recommend principal and additional diagnoses, relevant co-morbidities contributing to primary diagnosis, medications and relevant investigations are recorded (2).

Methods

This audit reviewed discharge summaries of all patients discharged from a rehabilitation unit over two months, in accordance with the Health Information and Quality Authority’s (HIQA) National Standard for Patient Discharge Summary Information (2). Patients with fragility fractures were identified through medical record review. Principal and additional diagnoses were reviewed, with cause and mechanism of falls considered relevant co-morbidities. Discharge prescriptions for anti-resorptive medications were noted. Dual-energy x-ray absorptiometry (DXA) was recorded as a relevant investigation (3).

Results

33 discharge summaries met inclusion criteria. 12 patients were admitted with fragility fractures with a mean age of 81 years (69-90). 83.3% (n=10) were female. Osteoporosis was mentioned in 50% (n=6) of discharge summaries of patients with fragility fractures. On review of relevant co-morbidities, likely cause of the fall was documented in 58.3% (n=7) and mechanism in 75.0% (n=9). Bone protection was planned in 83.3% (n=10). Plan for DXA was documented in 8.3% (n=1)

Conclusion

This audit demonstrates suboptimal communication between hospital and community teams, despite chronic disease being predominantly managed in the community. In Europe, Ireland has one of the largest disease burdens relating to osteoporosis and the largest increase predicted in the next ten years (4) . It is of utmost importance we improve communication to minimise disease burden.

References

1. International Osteoporosis Foundation (2023) Fragility Fractures. https://www.osteoporosis.foundation/health-professionals/fragility-frac… (Accessed on 30 August 2023).

2. Health Information and Quality Authority (2013) ‘National Standard for Patient Discharge Summary Information’. Dublin: Health Information and Quality Authority. https://www.hiqa.ie/reports-and-publications/health-information/nationa…- patient-discharge-summary-information (Accessed on 30 August 2023).

3. Irish Osteoporosis Society (2023) About Osteoporosis. https://www.irishosteoporosis.ie/information-support/about- osteoporosis/#accordion-0-10 (Accessed 30 August 2023).

4.Carey, J.J., Erjiang, E., Wang, T., Yang, L., Dempsey, M., Brennan, A., Yu, M., Chan, W.P., Whelan, B., Silke, C., O'Sullivan, M., Rooney, B., McPartland, A. and O'Malley, G. (2023), Prevalence of Low Bone Mass and Osteoporosis in Ireland: the Dual-Energy X-Ray Absorptiometry (DXA) Health Informatics Prediction (HIP) Project. JBMR Plus, pp. 1-10.

Introduction

Falls are a common cause of morbidity and mortality in frail patients, with visual impairment doubling the risk of falls. NICE advises a multifactorial approach to identify risk factors to be treated, improved and managed. This includes sensory/visual assessment, which is poorly done in practice. The aim is for 50% of relevant patients admitted with fractures following falls to have a vision assessment within 5 days of admission.

Methods

A modified RCP ‘Look out! Bedside vision check for falls prevention’ aid for healthcare professionals was utilised. Patients excluded were those with significant delirium/dementia or medically unwell. We regularly collected data on how many patients had a vision assessment performed whilst implementing interventions such as Teaching Sessions, Posters and including visual assessments in the Comprehensive Geriatric Assessment(CGA).

Results

Initial results demonstrated poor rate of visual assessments in patients. With implementation of the modified tool, rates of visual assessments improved from 11%(n=1) to an average of 22%(n=4). Further interventions increased the overall average to 80%(n=36). The most effective intervention was including a visual assessment checkbox in the CGA. This improved rates of visual assessment in a subgroup of patients considered to have had falls due to visual impairment, from 33% to consistent rates of 100%. Additionally, the average days to assessment greatly reduced from 10.2 days to consistently under 5 days.

Conclusion

Identification of visual impairment reduces recurrent falls and hospital admissions. The project demonstrated the clinical significance of vision assessments - aiding the diagnosis of PSP, prescribing eye drops, and optician follow-up. Utilisation of the modified ‘Look Out’ tool is a simple way to assess vision on the ward. Posters and teaching sessions improved clinicians’ confidence. However implementing sensory impairment in the CGA proforma proved the most sustainable effort. Next steps include implementation in other Geriatric wards and Falls clinics. 

Introduction

Inpatient fallers make up the minority of neck of femur fractures (NOF) in Morriston Hospital but it was observed that outcomes were less favourable than those in patients who sustained their fracture outside of hospital.

Method

Retrospective analysis was conducted of all NOF patients managed in Morriston Hospital whose injury was the result of an inpatient fall between January 2022 and December 2023. Outcomes were compared to those in all other NOF patients including pathological and occult fractures managed in the centre over the same two year period. Anonymised data were collected from departmental and electronic patient records.

Results

A total of 1383 NOF patients were analysed of whom 51 sustained their fracture whilst as inpatients across four hospital sites. Amongst inpatients 35% were identified as requiring supervision when mobilising, the majority required walking aids (73%) and fell on medical wards (65%). Median length of stay prior to falling was 25 days (range 1 – 171). Patients who sustained a NOF as an inpatient had a lower initial abbreviated mental test scores (p 0.001) and higher frailty scores (p 0.0001) compared to all others, they also had a longer length of stay post injury (Median 23 days vs 17 days p 0.002). Mortality was significantly higher amongst inpatient fallers Odds Ratio (OR) 4.0 and they were significantly less likely to be discharged to their own home OR 0.3. Post-operative delirium was also seen more frequently OR 2.1.

Conclusion

This data demonstrates that morbidity and mortality is significantly greater amongst those who fall and sustain a NOF fracture as an inpatient compared to all others. Further work, particularly the timing of inpatient falls in relation to staff handover, is being continued to investigate whether there are any modifiable factors to reduce inpatient falls and the burden of their consequences.

Introduction

A quarter of people with hip fractures sustain another fragility fracture within 5 years, but most receive no osteoporosis medication as secondary prevention. To coincide with the publication of ‘A call to action: a five nations consensus on the use of intravenous zoledronate after hip fracture" Age and Ageing, September 2023, we set out to explore clinicians’ reasons for not previously using zoledronate (IV Zol).

Methods

Prior to first presentation of the ‘Call to Action’ at the Global Fragility Fracture Network (FFN) and British Geriatrics Society conferences in autumn 2023, we used conference apps to run an online survey of 156 attendees (99 from UK, and 57 working in other countries).

Results

Licensing of IV Zol excludes people with creatinine clearance (CrCl) <35ml/min. Our surveys found that 27% of UK clinicians (9% of non-UK) already use a 30ml/min CrCl threshold. In addition, 13% (vs. 26%) use eGFR 30ml/min, and 23% (vs. 51%) eGFR 35ml/min as their threshold. This suggests that 63% of UK (87% of non-UK) clinicians already administer IV Zol if CrCl <35ml/min. UK clinicians indicated fewer concerns over reduced effectiveness if IV Zol was given within 14 days of fracture (56% vs. 86%), and greater preparedness to consider 4mg, rather than more expensive 5mg, doses (42% vs. 18%) and single infusions without a subsequent dose (91% vs. 68%).

Conclusions

It is important to understand why people feel reluctant to use IV Zol, despite this being the first-line recommendation of the National Osteoporosis Guideline Group (NOGG).

In particular, our demonstration that many clinicians in the UK and around the world are already using IV Zol, off license, in people with CrCl of 30-35 ml/min will support the ‘Call to Action’ paper, helping many more hip fracture patients with renal function in this category to receive a medication of proven effectiveness.

Introduction Many patients admitted with fragility femoral fractures have established cognitive impairment but no formal diagnosis of dementia. This lack of pre-existing diagnosis impacts care, counselling and discharge planning. This audit assessed how many people aged >65 admitted with a fragility fracture had information, at the time of admission, suggesting a likely but unconfirmed diagnosis of dementia and how their length of stay (LOS) and discharge destination compared to patients with confirmed dementia.

Methods 47 consecutive patients aged >65, admitted with a fragility femoral fracture had their electronic care records reviewed to identify information suggesting the presence of cognitive impairment/dementia. 30-day mortality, LOS and discharge destination was compared for three groups, 1) dementia, 2) informal dementia diagnosis and 3) no evidence of cognitive impairment.

Results Of 47 patients reviewed, 35(74%) were female, mean age 80.6 years (range, 68-94). Of these, 7/47(15%) had an established dementia diagnosis (mean age 82.4 years), 9/47 (19%) had unconfirmed cognitive impairment/dementia but without a formal diagnosis (mean age 82.2years) and 31/47 (66%) had no evidence of cognitive impairment(mean age 79.7 years). In cases of confirmed dementia diagnosis, the mean LOS was 54.7 days (range, 16-114). One patient died 1/7 (14.3%) and 3/7 (42.9%) were discharged home. For patients with an informal dementia diagnosis, the mean LOS was 35 days (range, 7-74). Two patients (2/9) died (22.2%), and 3/9 (33.3%) were discharged home. For those with no cognitive impairment, the mean LOS was 36 days (range, 7-92). Three patients 3/31 (9.7%) died, and 22/31 (71.0%) were discharged home.

Conclusion A significant minority of patients had likely undiagnosed dementia, with mortality and discharge destinations similar to patients with recognised dementia. Services need to consider how best to identify and diagnose cognitive impairment/dementia at the time of admission for fragility fractures.

Introduction:

Inappropriate polypharmacy is recognised as a contributing factor towards adverse outcomes in frail patients. Current efforts at national level are centred around primary care initiatives in completing structured medication reviews (SMR) where shared decision making takes place with open discussion around risks and benefits of treatments. The aim of this review was to assess whether recommendations for discussion in SMR have been adopted for patients attending frailty bone health clinic led by Consultant Pharmacist, in hospital outpatient setting.

Method:

Retrospective analysis of notes was undertaken in a sample of 30 patients reviewed in clinic in the period 01.09.22 - 28.02.23 who were on at least five medications, were still alive six months post review and where suggestions with regards to actions to discuss during a structured medication review were made.

Results:

Average age of patients sampled was 79 years with average CFS of 5.75. Number of medicines documented at outpatient appointment was on average 10.6 which reduced to 9.95 at review six months after the appointment. Around a third of recommendations were adapted fully, with another third partially completed and a third not completed. Interventions included review of falls risk increasing drugs (FRIDs), reduction of anticholinergic load, identification of possible prescribing cascades, review of opioiod medication in chronic pain context and review of medicines where benefit may no longer be derived due to frailty progression. In cases where review of medication with high anticholinergic load was advised, an average reduction of -3 was achieved at six month review.

Conclusion(s):

Starting a structured medication review in outpatient clinic has the potential to reduce the risk of adverse events and improve outcomes for patients. Further work will be undertaken to ascertain reasons for not adopting the recommendations and continuous collaboration with primary care colleagues will continue to address problematic polypharmacy.

Introduction:

Assessment of lying and standing blood pressure is commonly undertaken in geriatric medicine to make a diagnosis of orthostatic or postural hypotension. We carried out the audit to review the clinical practice and assess its adherence to the Royal College of Physicians (RCP) guidance on how to accurately measure the lying and standing blood pressure (Falls and Fragility Fracture Audit Programme).

Method:

It was a prospective audit. The first audit cycle was conducted in July 2020 and the second cycle in April 2021

Results:

During the first data collection, the practice was reviewed in 69 patients. 35 were female (age range 63-92 years) and 34 male (age range 72-95 years). The lying and standing blood pressures were measured in 27 patients. Only 4 were performed as per the RCP guidance. 34 team members (including doctors, nurses, healthcare assistants, etc.) were randomly surveyed on how to correctly measure lying and standing blood pressure. None were aware of the RCP guidance in this context. We delivered local presentations of the results of the audit and RCP guidance flyers were displayed on the bulletin boards in the department. During the second cycle, the practice was reviewed in 58 patients. 30 were female (aged 67-94 years) and 28 male (aged 68-96 years). The lying and standing blood pressures were measured in 32 patients, of which 20 were recorded according to the RCP guidance. There was an increase of adherence to the guidance from 14.8% to 62.5% after undertaking the aforementioned interventions.

Conclusions:

Following dissemination of the RCP guidance on how to accurately measure the lying and standing blood pressures, we witnessed an improvement in the practice suggestive of an improved clinical effectiveness. Robustly evaluating a service followed by education of the staff can lead to enhanced clinical care and quality improvement.