Bone Health

Introduction: In Scotland, more than 18,000 older people are admitted to hospital after a fall each year. One in three people over the age of 65 experience a fall at least once each year (1). Neurological examination is an essential part of the initial assessment of these patients in hospital and can determine the cause of falls such as stroke, peripheral neuropathies and Parkinson’s disease. Local anecdotal evidence suggested that this was often not carried out, with the potential for delayed diagnosis and treatment.

Method: Baseline data was collected from clinical notes of admissions to the care of the elderly (COTE) wards at University Hospital Hairmyres (UHH) over a 1-month period. Multiple departmental education sessions were arranged to highlight to medical staff the importance of neurological examination in patients presenting to hospital following a fall. Following these sessions the data collection cycle was repeated. A poster has now been designed highlighting common causes of falls and in particular emphasising the importance of performing a neurological examination, with a further cycle of data collection planned.

Results: 36.8% of patients admitted to COTE wards in August 2022 were admitted with falls, with only 23% of patients having a neurological exam documented on admission. Following the initial intervention, 30 patients’ notes were reviewed in January 2023. 56.7% of patients were admitted with falls and frequency of documented neurological examination had increased to 58.8%.

Conclusion: Educational sessions resulted in a 156% increase in documented neurological examinations for patients admitted with falls. We hope this improvement will lead to earlier identification of causes of patients’ falls, allowing prompt management. Our project is ongoing, with planned implementation of posters as a secondary intervention, with further data collection in due course.

References: 1. NHS Inform. Why Falls Matter. Available from: https://www.nhsinform.scot/healthyliving/preventing-falls/why-falls-mat… (accessed 27 November 2022)

Introduction: At Warrington hospital, a small district general, the orthogeriatric team adheres to national guidelines by conducting bone health assessments for inpatients with neck-of- femur (NOF) fractures and commencing suitable secondary prevention measures. However, there is a noticeable gap in secondary prevention for patients with non-NOF fractures requiring admission (such as tibial or humeral fractures). This predisposes patients to a future increased risk of disability, morbidity and mortality following discharge.

Method: A Quality Improvement initiative was launched, introducing various interventions such as educational sessions for doctors and pharmacists, E-learning modules and a flow chart poster guiding bone health assessment. Bone health teaching and all interventions were shared and at each doctors changeover inductions, to reinforce and sustain change.

Results: Preliminary data in January 2023 identified that 0% of patients with non-NOF fractures received secondary prevention and only 7% had bone health mentioned in the discharge summary. The results of teaching alone from May 2023, indicated improved clinician knowledge and confidence, but only modest clinical improvement. However, by December 2023, the combined interventions demonstrated significant progress; 92% of patients had bone health bloods performed, 57% of patients were identified as requiring treatment and 70% of those received appropriate management. Additionally, 82% of patients had bone health mentioned on their discharge summary.

Conclusion: The interventions enhanced the identification of patients requiring further investigation and management, underscoring the importance of a multimodal approach for tangible change. To further solidify these improvements, a checklist was created for medically fit patients and is utilised by the ward manager to guide the daily multidisciplinary board round. Furthermore, an order set within our ICE system was created to streamline requesting bone health blood tests. Whilst the outcomes of these interventions are outstanding and to be collected in May 2024, we anticipate greater improvements in outcomes.

Background: Foot pain in older adults may reduce physical activity, resulting in impaired mobility and an increased risk of falls. Orthotics, both with and without a metatarsal pad, may provide foot pain relief and improved stability. Objective: Compare the use of Aetrex orthotics with and without a metatarsal pad in decreasing pain and fear of falling in older adults. Methods: 206 participants over 60 years old were randomised into the intervention group, who received Aetrex L2305 Orthotics with a metatarsal pad, or the control group, who received Aetrex L2300 Orthotics with no metatarsal pad. At baseline and 6-week follow-up, musculoskeletal pain was reported via Numerical Rating Scales (NRS), foot pain and functionality via the Foot Health Status Questionnaire (FHSQ), and fear of falling via the Short Falls Efficacy Scale International. Results: Both groups reported significant improvements in pain in the back, hips, knees, ankles, and feet using the NRS (P < 0.001). Using the FHSQ, foot pain significantly improved in both the intervention (x̄= 18.47 ±20.58, P < 0.001) and control group (x̄= 17.21 ±18.74, P < 0.001). Function also improved significantly in both groups (x̄= 18.35 ±20.67, P < 0.001 and x̄ = 15.07 ±20.15, P < 0.001, respectively), as did fear of falling (x̄= 1.55 ±3.79, P < 0.001 and x̄= 1.23 ±3.53, P < 0.001, respectively). No statistically significant difference was observed between groups for any outcome (P > 0.05). Conclusion: Aetrex orthotics, with and without metatarsal pads, decrease pain and fear of falling in older adults.

Introduction

During 2022, non-femoral fractures that didn’t require operative management had 30 days median inpatient length of stay (LOS) at SBUHB. Femoral fracture patients >65 years had LOS 36 days (GIRFT average 19 days), with 720 admissions. High local incidence is believed to be contributed by historical failures to identify and treat non-femoral fragility fractures. A new service was created from a collective effort to do better for our patients and prevent avoidable harm by breaking down barriers between services and promoting effective collaborative working.

Methods

A collaboration between the following key services was formed :- 1. Older Persons Assessment Service (OPAS) -identify fragility fractures presenting to ED 2. Orthogeriatrics -identify suitable femoral fracture patients 3. Physiotherapy -early assessment and transfer to reablement into the community. 4. Virtual Wards –ongoing CGA and reablement in the community Additional resource was secured to provide short-term bridging of care and community therapy input. Data was prospectively collected and included demographics, site of fracture, referrer and LOS.

Results

From March 2023, the service identified 457 patients, 312(68.7%) Female, median age 86 years. 157(34.6%) patients had a femoral fracture and 300(65.4%) were non-femoral fragility fractures, majority identified by OPAS, with 206(68.7%) being discharged same day. Overall, admission was avoided in 207(45.3%) patients and 247(54.6%) had an early discharge/reduced LOS with 3(0.1%) re-admissions avoided. The mean LOS on discharge is 6.6 days with a calculated monthly bed saving of 13.9 days across the service.

Conclusion

Collaborative working has created an early supported discharge pathway. Femoral fracture patients are discharged earlier, some 3 days post-op, with the necessary support to continue reablement at home. Fragility fractures are identified at the front door and offered same-day discharge with ongoing comprehensive geriatric assessment and reablement within the virtual wards with positive feedback from patients and their families.

Introduction

Reduction in outpatient appointments during the COVID-19 pandemic and patient concern surrounding risk of contracting COVID-19 by attending day-case settings, resulted in delayed or cancelled medical treatments including Zoledronic Acid infusions as management for Osteoporosis. This, alongside recent research concluding that these treatments can be given safely as early as 1-2 weeks post-fracture, lead to the adaptation of protocol at Hull University Teaching Hospitals Trust in 2021, to provide rapid loading of Cholecalciferol over 6 days, prior to administration of Zoledronic Acid on day 7. However, some concerns remain surrounding the potential interference with bone remodelling and healing. This completed audit cycle evaluates the logistics and safety of this new protocol.

Methods

All patients over 60, admitted with neck of femur fracture who received Zoledronic Acid infusion as inpatient or outpatient in 2019 and 2021 were included in the initial and repeat audit respectively. Electronic records for the following 12 months were analysed evaluating for further fragility fracture and mortality rate.

Results

There was an increase in patients receiving Zoledronic Acid as an inpatient treatment from 21% in the initial audit to 97% in the repeat audit. There was a slight increase in mortality rate at one year from 14% to 19%. The percentage of a further fragility fracture within one year, remained stable at 7%.

Conclusion

The increase in inpatient infusions suggests more patients with significant frailty who would otherwise not have been able to attend outpatient settings, have been able to receive treatment. The mortality results reflect this frailer audit population. The absence of a substantial increase in the rate of further fragility fracture at one year; supports the earlier administration of Zoledronic Acid as a management protocol.

Introduction
Older people are the fastest growing group of hospitalised trauma patients, most commonly due to falls from standing height. The Scottish Trauma Audit Group (STAG) collect extensive national data, but this does not currently include frailty and longer-term dependency.

Method
We retrospectively reviewed consecutive cases in the STAG database for the Royal Infirmary of Edinburgh between September 2018 and February 2019. Casenote review was used to calculate baseline Charleston Comorbidity Index (CCI) and frailty status using the Clinical Frailty Scale (CFS). Outcomes of residence and mortality were collected to 1 year.

Results
We included 442 patients (mean age 62±20 years old, 43% female), of whom 218 (49%) were ≥65 years old (mean 78±8 years, 57% female). CFS could be ascertained in 209 (96%) patients ≥65 years, of whom 73 (35%) were frail (CFS ≥5). Frail patients were older (82±8 years vs. 77±8 years,
p<0.001) and had more comorbidities (mean CCI 5.4±1.8 vs. 4.4±1.8, p<0.001) prior to trauma compared to non-frail patients >65 years old. Median Injury Severity Scores (ISS) did not vary by age (9 [5-12] ≥65 years vs. 9 [8-16] <65 years, p=0.07) or frailty status (9 [9-10] frail vs 9 [4-14] non-frail, p=0.59). Frail older patients were twice as likely to die within one year of trauma (32% vs 14%
in non-frail, p<0.001), and this was independent of age (adjusted odds ratio 2.4, 95% confidence intervals 1.2–4.9, p=0.02). In survivors to 1 year, 16% of frail older patients required increased care at home (vs. 8% of non-frail older patients, p<0.001) and 14% were newly admitted to a care home
(vs. 4% of non-frail, p<0.001).

Conclusion
A third of older patients with trauma are frail and this is an important predictor of patient outcomes beyond death. Frailty provides more prognostic information than age in this setting.

Introduction

Inpatient falls are a major cause of avoidable harm in patients on elderly care wards. Delays in identification of fall precipitants and recognition of sustained injuries increases morbidity, mortality and length of stay (Cameron et al, Cochrane Database Syst Rev. 2018 Sep; 2018(9)). Patients sustaining falls are often initially assessed by postgraduate year 1 and 2 doctors independently. We aimed to improve patient outcomes following inpatient falls through standardisation of the assessment and documentation following a fall in hospital.

Methods

Using PDSA methodology, incident reports and documentation of inpatient falls were reviewed retrospectively over three 28-bedded elderly care wards. A post-falls proforma was devised that covered various domains of the post-fall assessment and was distributed to doctors throughout the hospital. Following the intervention, a repeat PDSA cycle was performed prospectively over the same wards and the proportion of assessments fulfilling each domain was compared between the cycles.

Results

Medical assessment of 27 falls from November 2020 to January 2021 was compared to 31 falls occurring between February and May 2022. Use of the proforma in cycle 2 was limited to 8/31 falls following intervention. Post-intervention, the proportion of assessments fulfilling medication review (19% vs 35%, p=0.14) and anticoagulation status (41% vs 55%, p=0.28) was improved. The proportion fulfilling fall circumstances (89% vs 90%, p=0.85), medical precipitant (70% vs 61%, p=0.46) and ordering of appropriate imaging (93% vs 97%, p=0.47) remained high.

Conclusion

Standardisation of post-falls assessment and documentation can improve patient safety outcomes through reducing delay in recognition of medical precipitants of falls and identification and management of sustained injuries. Improved integration of a post-falls proforma into electronic systems is needed to maximise its clinical benefit and would be the target of a further PDSA cycle.

Introduction: 

Following the publication of ‘Call to action: A Five nations consensus on the use of intravenous zoledronate after hip fracture,’ Craigavon Area Hospital began offering IV Zoledronic acid (IV Zol) to patients with a fragility neck of femur (NOF) fracture. However, the administration of IV Zol is based on the bone health assessment, vitamin D level, and requires ongoing post-discharge care. An oral bisphosphonate should be started one year after IV Zol administration. This study aimed to analyse whether discharges from Craigavon Area hospital following a NOF fracture had clear instructions for post-discharge care.

Methodology: 

Discharge letters of patients with a NOF fracture from the Trauma Ward between 4/11/24 and 22/12/24 were divided into three groups:

A (Bone health, IV Zoledronic acid and post discharge instructions), B (Bone health and IV Zoledronic acid mentioned but no post discharge instructions given)

C (Bone health, IV Zoledronic acid and post discharge instructions not mentioned). 

These groups were then analysed for potential interventions to improve future discharge letters. The second stage assessed the 4 week period between 14/1/25 and 18/2/25 with the same methodology.

Discussion: 

Only 38% (16) of the 42 discharge letters were included in group A and 37.5% of these contained ambiguous instructions. There were 13 discharge letters in group B and C of which 15% and 38% were discharged during outside of normal working hours respectively. Standardised wording and poster reminders were implemented and the impact reassessed. In the second stage 96% of discharge letters contained a full bone health assessment with follow up instructions.

Conclusion:

This study has highlighted the importance of adequate post discharge care for patients who have received IV Zoledronic acid. Unfortunately, many discharges did not mention the necessary information for GPs so proposals were made to improve ongoing care. The impact has been significant with 96% of letters containing the required information and so these changes will be introduced permanently.

Introduction

Substantial variations remain in hip fracture care delivery across the UK despite established standards and guidelines. We aimed to predict adverse patient outcomes following hip fracture from modifiable hospital-level organisational factors and develop implementation tools to improve national service delivery.

Method

We used a national record-linkage cohort of 178,757 patients (≥60 years) with a hip fracture in England and Wales (2016–19). We linked patient-level hospital admissions, National Hip Fracture Database and mortality data with 231 metrics from 18 hospital-level organisational-level audits and reports. Multilevel models identified organisational factors, independent of patient case-mix, associated with patient outcomes: length of hospital stay, emergency 30-day readmission, 120-day mobility recovery, days in hospital and health costs over 365-days, and mortality (30- and 365-day) in 172 hospitals across England and Wales.

Results

Over one-year patients with mean (SD) age 83 (8.6) years, spent 31.7 (32.1) days in hospital, costing £14,642 (£9,017), and 50,354 (28.2%) died. We identified 46 key organisational factors independently associated with one or more patient outcome, of which 14 were (a) associated with cost and/or bed-day savings over one year, (b) consistently associated with other positive patient outcomes, and (c) potentially modifiable. Factors included weekend physiotherapy provision (mean saving per patient/year: £676 [95%CI:£67-1285]), orthogeriatrician assessment (£529 [£148-910]), direct admission to a hip fracture ward (3.4 [-0.36-7.07]days), regular dissemination of audit data to staff (0.85 [0.30-1.39]days). These data have informed the development of a hospital-specific cost-benefit calculator, with a model business case for service improvement, specialty checklists, audit and ‘how to’ guides for complex care delivery.

Conclusion

All hospitals should try to provide the best available hip fracture care equally across England and Wales. We identified multiple, potentially modifiable, organisational factors associated with important patient outcomes following hip fracture. Our practical and freely-available toolkit should help reduce variation in service delivery.

Introduction:

Mortality after a hip fracture increases compared to the general population. The main objective of this study is to examine the incidence, trends, and factors associated with mortality in patients with osteoporotic hip fractures.

Methods:

This is a retrospective cohort study from a South American hospital. Patients older than 65 years with osteoporotic hip fracture between 2015 and 2018 were identified. Demographic data and comorbidities were obtained. The incidence rate, standardized mortality rate, trend (Poisson regression), and risk (hazard ratio) were calculated.

Results:

A total of 304 patients admitted for osteoporotic hip fracture were found, 240 (79%) were women with a mean age of 81.3 years (SD 8.45) and 64 (22.1%) were men with a mean age of 85. .42 years (SD 10.08). The cumulative incidence of mortality was 72.5%. The annual mortality rate was 75.6/1000 patients/year (54.8 in men and 20.8 in women). The 1-year mortality rate increased significantly by 2% per year (HR 1.05, 95% CI 1.002–1.08). Median overall survival was 854 days (95%CI 802-906). The mortality probability density was 18% for women and 27% for men (first 90 days).

Conclusions:

A more significant increase in mortality was observed in men than in women. Institutionalization combined with comorbidities are associated with higher mortality.