Bone Health

University Hospital Plymouth (UHP) provides secondary care to 475,000 people with a wider population of almost 2,000,000 people who can access its specialist services.

COVID pandemic had a significant impact of the outpatient list within the UHP NHS Trust and demonstrated that previously well-established model of Falls clinic was no longer fit for purpose. This resulted in a significant delay in waiting times for patients awaiting a specialist review.

A new model was designed to address issues and reduce waiting times for patients with Falls in the catchment area. The Pilot Multidisciplinary Team (MDT) Falls Clinic was introduced in July 2022 where patients are seen by a Falls Specialist Nurse, Advanced Pharmacist and Advanced Physiotherapist on the same day. All patients then are discussed at weekly virtual MDT meeting with Consultant Geriatrician where a decision is made whether patient could be discharged back to the Primary Care.

117 out of 149 patients have been booked into clinic. Only 57 patients (47%) were referred forward to the 1st Medical clinic. Out of 57 patients 31 have been seen and 10 were discharged back to GP following clinic attendance.

60 patients (51%) were discharged following review at the Pilot MDT Falls Clinic. 7 patients were re-admitted within the next 6 months after been discharged from the Pilot MDT Falls clinic. However, none of the admissions were related to Falls.

The waiting times were reduced by 4 months.

Funding was secured to run the clinic for the 12 months and the next step is to expand the team by employing another Advanced Pharmacist and Physiotherapist. The Pilot MDT Falls clinic demonstrated that a new approach is beneficial to patients. It also supports development of the skills for all team members though sharing expertise, knowledge and skills, and building team rapport.

Introduction:

A scoping exercise in a residential dementia care home identified high numbers of falls occurring in residents’ bedrooms at night. Assessment and reduction of risk was often difficult since many falls were unwitnessed, and residents had poor recall. Collaborative working between Lewisham Community Falls Service (CFS); and Lewisham Linkline Service; involved the use of the ‘Just Checking’ monitoring system to enhance multifactorial falls assessment.

Method:

The Occupational Therapist (OT) in the CFS completed an initial multifactorial falls assessment. This helped to determine if data on night-time activity would be beneficial. This was discussed with care home staff and patient’s family prior to installation by the Telecare Specialist. The system was left insitu for four weeks with regular analysis of data by the OT and Telecare Specialist.

Results:

Resident A was a new admission with a recent dementia diagnosis and an injurious fall at home. 'Just Checking' was installed to monitor night time orientation and if he used his walking aid. He was refusing to keep a light on and was resistant to staff entering his room for checks. 'Just Checking' data guided intervention which included installation of motion centred lights. The resident started to use his walking aid at night without staff involvement. Resident B who had moderate to severe dementia, had demonstrated some challenging behaviours at night which increased his falls risk. 'Just Checking' data showed that he was restless throughout the night. This lack of quality sleep was identified as a key falls risk factor. Further exploration of his life story found that he had been a night worker for many years. Care home staff changed his day/sleep patterns. He experienced no further falls.

Conclusion:

Used as an adjunct to multifactorial falls assessment; ‘Just Checking’ can provide valuable data to understand falls risk and improve resident safety.

Introduction:

Inappropriate catheterisation poses a risk to orthogeriatric patients both in the pre-op and post-op phase. Introducing a foreign object increases the risk of infections, sepsis and seeding of infection to the newly implanted prosthetics for surgical neck of femur (NOF) fracture patients. Furthermore, catheterisation also increases the length of hospital stay and risks of bladder deconditioning and failed attempts at trial without catheter. Therefore, it is essential that nursing and medical staff are aware of the appropriate indications of catheterisation.

Method:

We retrospectively reviewed 40 patients within a one month period who were admitted to the orthogeriatric ward and underwent surgery for their NOF fracture. We examined whether catheterisation and indications were documented on the electronic patient records (EPR), we also reviewed where the catheterisation took place (e.g. on the ward or in the Emergency Department (ED)). Indications were compared to our hospital guidelines for catheterisation.

Results:

1 Patient had a long-term-catheter and was not used in the data analysis. Of the remaining 39 patients, 23 (60%) were catheterised. Majority of these cases (83%) were documented appropriately, with the most common indication being that of urinary retention (47%) especially in the post-op phase. However, 'NOF fracture/immobility' was the second most common documented indication (37%), majority of which (86%) were done in the ED prior to transfer to theatres/ward.

Conclusion:

NOF or immobility is not an automatic indication for catheterisation and catheterisation in these patients is not considered a routine pre-op measure for hip fracture surgery. More education needs to be done with the medical and nursing staff especially in the emergency department regarding this, including encouragement of use of other methods such as pads and bed-pans in the pre-op phase.

Introduction: In the current European guidelines, sarcopenia is diagnosed on the basis of low muscle strength, with low muscle mass used to confirm diagnosis. The added value of measuring muscle mass is unclear. We performed a systematic review to assess whether muscle mass was independently associated with adverse outcomes in patients with hip fracture.

Method: The systematic review protocol was registered on the PROSPERO database (CRD42021274981). Electronic databases (MEDLINE, EMBASE, CENTRAL, CINAHL, Clinicaltrials.gov) were searched for observational studies of patients with hip fracture aged ≥60 who had muscle mass or strength assessment perioperatively. Two reviewers independently screened titles/abstracts for inclusion. The association of muscle mass or strength with postoperative outcomes (mortality, Barthel Index, mobility, physical performance measures, length of stay, complications) was recorded. Risk-of-bias was assessed using the AXIS or ROBINS-I tool as appropriate. Due to the degree of study heterogeneity, data were analysed by narrative synthesis.

Results: The search strategy identified 3,007 records. Ten studies were included (n=2281 participants), containing 27 associations between muscle mass assessment and hip fracture postoperative outcomes. Four studies had intermediate risk of bias; 6 studies had high risk of bias. Lower muscle mass was associated with higher mortality and worse physical performance measures in univariate analyses but there was no significant association between muscle mass and mobility, length of stay and postoperative complication scores in any included study. Six studies assessed both muscle mass and strength. Muscle mass was not a significant independent predictor of any adverse outcome in any included study after adjustment for muscle strength and other predictor variables.

Conclusion: Data on the clinical utility of muscle mass measurement in patients with hip fracture are limited in volume and quality, but available studies suggest muscle mass does not offer additional prognostic benefit to muscle strength measures.

Introduction:
Risk prediction tools help guide prognostic conversations and benchmarking in hip fracture care. The Nottingham Hip Fracture Score (NHFS) shows only moderate predictive ability for 30-day mortality. We assessed whether routine markers of inflammation could improve the discriminant ability of the NHFS to predict 30-day mortality following hip fracture surgery.

Methods:
We studied consecutive patients admitted with hip fractures at a large-volume trauma unit between 2015 and 2020. Baseline NHFS and postoperative outcome data were extracted from a local registry and linked to routine laboratory data from patients’ electronic clinical records. We selected measurements taken closest to admission pre-operatively. The biomarkers studied were albumin (negative acute-phase reactant), C-reactive protein (CRP), neutrophil-lymphocyte ratio (NLR) and monocyte-lymphocyte ratio (MLR). Univariate and multivariate logistic regression analyses were performed separately for each combination of NHFS and inflammatory marker. C-statistics were calculated to assess the discriminant ability of the NHFS with and without each inflammatory marker for 30-day mortality.

Results:
We included 1710 patients, mean age 82.5 years (SD 8.2). 1199 (70.1%) were women. 104 (6.1%) patients died within 30 days of admission. In univariate analysis, admission NHFS, albumin, CRP and NLR were significantly different between those alive and dead at 30 days. Higher admission albumin was an independent predictor of 30-day mortality in multivariate analysis (OR=0.86 [95%CI 0.81-0.91], p≤0.001) as was higher CRP (OR=1.93 [95%CI 1.04-1.44], p=0.013). The addition of albumin significantly improved the discriminant ability of the NHFS for 30-day mortality (p≤0.001) (c-statistic 0.742 [95%CI 0.683-0.800] vs 0.681 [95%CI 0.617-0.745] for the NHFS alone). Other inflammatory biomarkers did not significantly improve discrimination of 30-day mortality when added to the NHFS.

Conclusions:
Admission albumin improves the discrimination of 30-day mortality in patients undergoing hip fracture surgery when combined with the NHFS, whereas other markers of inflammation including CRP, MLR and NLR did not.

Title: Bone health assessment audit cycle at Queen Alexandra Hospital, Portsmouth (Audit ID 5474)

Background: Conducted in the Department of General Internal Medicine. Our focus group was elderly patients, especially women aged 65 and above and men 75 years and above as per NICE guidelines since these patients should have their bone health assessment done ideally.

Local problems: Osteoporosis is very common affecting approximately 3 million people. Over 5,00,000 fragility fracture occurs in the UK each year. Our audit aimed to find the percentage of patients who underwent bone health assessment and got bone protection treatment appropriately, thus checking our compliance with NICE guidelines. Hence keeping in line with patient safety.

Methods: A total of 45 patients’ data was collected from the medical wards in both the audit and re-audit. Data was collected from the patient’s case notes, previous clinical documents and medication charts. A questionnaire was used which entailed patient details, risk factors for osteoporosis and whether or not a bone health assessment had been done.

Interventions: We identified patients at risk of osteoporosis. Performed BHA with FRAX score calculation. Started them on appropriate treatment based on NOGG 2021 guidelines. Additionally, a teaching session was held after each audit to implement changes in the department and raise awareness about the importance of bone health assessment.

Results: The first audit showed that only 29 out of 45 patients (64%) had their assessment done. 41 patients (91%) had their assessment done in the re-audit showing a significant improvement of 26%.

Conclusions- Bone health is often overlooked and affects millions of people across the UK with a high risk of mortality and morbidity, affecting patients’ quality of life. Based on the comparative analysis, 26% more patients benefitted from the completed audit cycle.

Introduction: Older patients are vulnerable to falls after discharge as hospitalization could induce declines in physical function, mobility, and muscle strength. Falls may cause readmissions and subsequent healthcare burden. However, such incidence rates and costs have not been studied. This study aimed to investigate the incidence and costs of fall-related readmissions in older patients.

Method: A population-based retrospective cohort study was conducted among patients aged 65 or over and discharged from public hospitals in Hong Kong from 2007 to 2017. The administrative data for inpatient admission were obtained from the Hospital Authority Data Collaboration Lab. The fall-related readmissions within 12 months following discharge were identified by the International Classification of Diseases code of diagnosis. The incidence rates were calculated in terms of person-years. The costs were computed based on the public ward maintenance fees adopted since 2007.

Results: In total, 611,349 older patients with a mean (SD) age of 75.3(7.6) were analyzed. Within 12 months after discharge, 18,608 patients (3.0%) had 20,666 fall-related readmissions, giving an incidence rate of 35.2 per 1000 person-years. Meanwhile, such rates (per 1000 person-years) were 44.7 for women, 25.5 for men, 20.5 for patients aged 65-74, 41.0 for patients aged 75-84, and 76.2 for patients aged ≥85. The annual cost exceeded HKD 145.6 million (USD PPP 23.9 million in 2018) for older patients, and the mean cost per fall-related readmission was HKD 7,048 (USD PPP 1,158).

Conclusion: The fall-related hospital readmissions were important adverse events during the transitional period and caused a considerable healthcare burden to the patients, family caregivers, and the health system. Health professionals are suggested to implement interventions during hospitalizations or at the early stage after discharge to reduce falls, particularly for women and patients aged ≥75. For instance, increasing physical activity during the hospital stay can be considered for fall prevention.

Introduction: Frailty is a state of increased vulnerability to physiological stressors, which is associated with increased risk of adverse outcomes such as falls and delirium in older adults. For this patient group, healthcare decisions (as in whether to undergo elective surgery or continue a burdensome outpatient treatment) often have far-reaching consequences. Despite broad consensus that healthcare decision making should be a collaborative process, studies have shown frail older adults struggle to make healthcare choices and often do not feel fully involved in the decision-making process. We wanted to understand more about how frail older adults experience healthcare decision making, specifically whether they feel empowered to exercise autonomy. We also wanted to gather suggestions on how to improve the experience of healthcare decision making for this patient group.

Methods: We developed a questionnaire to assess frailty in older adults and gather data on healthcare decision making experiences. A pilot-study was undertaken to test questionnaire efficacy and accessibility. The questionnaire was distributed UK-wide to community groups. Participants completed the questionnaire independently and anonymously. Frailty was accessed based on responses to activities of daily living questions.

Results: 116 older adults completed the study, with 18 judged to be frail. 27.8% of frail adults felt never or usually not listened to by doctors, compared to 8.7% of non-frail adults. 94% of frail adults definitely or probably wanted to be involved in their treatment plans. 61.5% of frail adults wanted to see changes in how they were involved in healthcare decision making.

Conclusion: Most frail older adults want make healthcare choices, yet a significant minority do not feel listened to. Suggestions to improve healthcare decision making for frail older adults arising from this work include addressing concerns across repeated patient-doctor consultations and providing literature in appropriate language to read and digest between consultations.

Introduction Alcohol excess is a risk factor for falls in all ages. However, it is important to establish the relationship in older patients, who are at a greater risk of falling, to allow for appropriate risk management. Methods The Older Persons Assessment Service (OPAS) is an Emergency Department service which, accepting patients on the basis of the presence of frailty syndromes in patients aged >70 years (falls, confusion, care dependence, polypharmacy and poor mobility).The OPAS databank was retrospectively analysed for people with alcohol excess admitted with a fall between June 2020-December 2022. We examined clinical outcomes relating to medication, age, Charlson Co-morbidity index (CCI) and clinical frailty score (CFS). Alcohol Excess was defined by regularly exceeding government guidelines (>14 units a week). We applied the POSAMINO (Potentially Serious Alcohol–Medication Interactions in Older adults) criteria to our database to identify potentially inappropriate medications (PIMS). Results 1067 consecutive patients presenting with falls with 55 (0.05%) having a history of chronic alcohol excess; 3 with acute intoxication at the time of presentation on a background of chronic misuse. Those who presented with alcohol excess were younger (76.5 years (±9.5) vs 84.5 (±7.5) p<0.001) and less frail as per CFS (4.9 (±1.1) vs 5.3 (±1.3) p<0.05). There was a trend towards greater CCI (5.9 (±2.4) vs 5.6 (±1.9) p=0.13) in those who drink more alcohol. There was no significant difference in gender or mortality between the groups. When applying the POSAMINO criteria, the overall number of PIMS identified was 1.7 (±1.4), with those PIMS contributing to increased falls of 1.2 (±1.2). Conclusion Alcohol consumption is associated with an increased risk of falls in older adults. Increased awareness of the POSAMINO criteria can aid clinician de-prescribing decisions, especially in this cohort who are more vulnerable for recurrent falls.

Introduction The Fracture Liaison Service (FLS) is a multidisciplinary service for individuals over 50 presenting with fragility fractures. It is designed to assess future fracture risk, and appropriately diagnose and manage patients with osteoporosis.1 At Wrightington, Wigan and Leigh Teaching Hospitals (WWL), concerns were raised that access to this service was poor, meaning some patients presenting with fragility fractures were not receiving appropriate management to reduce risk of recurrent fracture. This project was designed to increase referrals to the service. Methods A cohort was identified of patients over 50 presenting to WWL with a fractured proximal humerus or distal radius/ulna over a three-month period from January to March 2021. These presentations were reviewed to identify the proportion of these patients who had been appropriately referred to the FLS. Following the initial audit, the FLS referral pathway was reviewed, and discussions were held with multidisciplinary teams (MDTs) in radiology and orthopaedic surgery to highlight the importance of appropriate bone health risk assessment. The number of patients referred each week by radiology were assessed before and after these discussions to assess whether access to the FLS had improved. Results In the initial audit 4.2% of patients with humeral fractures (n=24) and 0% of patients with radial/ulnar fractures (n=29) were appropriately referred to the FLS. Mean weekly referrals from radiology to the FLS significantly increased following the MDT discussions (mean 6.14, SD 4.40 vs mean 22, SD 6.38; t=6.71 p001 conclusions pre-existing referral pathways to the fls were found be resulting in many patients not receiving appropriate care for their bone health. a simple review of pathways, and discussion with mdts other departments was way improving access therefore hopefully reducing risk fracture recurrence. references 1. https: />/theros.org.uk/media/1eubz33w/ros-clinical-standards-for-fracture-liaison-services-august-2019.pdf [Accessed 18.05.2022]