Joints

Background This quality improvement (QI) work was done at the South Edinburgh Parkinson’s clinic.

Introduction Idiopathic Parkinson’s disease (IPD) is a secondary risk factor for osteoporosis (Torsney KM et al. Journal Neurology Neurosurgery Psychiatry 2014; 85: 1159–1166). The 2022 UK Parkinson’s audit highlighted bone health as an area of QI for IPD (www.Parkinsons.org.uk).

Methods A Plan-Do-Study-Act (PDSA) structure was adopted and project charter created. Baseline data was collected from 20 patients attending the IPD clinic between June- September 2023, reviewing details of assessments in the last three years. The Parkinson’s Excellence network bone health form was used to assess osteoporosis risk (www.Parkinsons.org.uk). Patient records were prospectively assessed pre-annual clinic between June-July 2024. The assessment outcome was documented in the patient’s records to guide discussion. After clinic the form was updated and interventions actioned.

Results From baseline data, only 2 of 20 patients had a bone health assessment as part of recent annual reviews. Using the assessment form, 33 patient notes were reviewed. 22 patients were excluded based on the form’s screening criteria or lack of formal IPD diagnosis. 11 patients had a full assessment completed. Three patients were given lifestyle advice only. 7 patients (63.6%) had a FRAX score for a major osteoporotic fracture >10% and a DEXA scan was suggested for all. 3 of these patients were deemed high risk, ideally to be started on bone health treatment immediately. On average it took 3minutes and 47seconds to complete the form.

Conclusions The assessment forms were straightforward to complete and helped identify IPD patients at increased risk of osteoporosis. The Lothian Parkinson’s service is considering how best to implement this into the structure of annual reviews and will be undertaking further assessments with larger patient numbers. The impact on the service and clinical time needs to be better understood.

Background

Evidence suggests 30-40% of patients with a neck of femur fracture (NOF#) develop oropharyngeal dysphagia (OPD) during the perioperative period.1-2 Our data, collected over two months, shows our Speech and Language Therapy Team (SLT) identified only 12% of cases. Given the importance of nutrition and medication in the perioperative period, early identification of OPD is critical. We launched a new dysphagia screening tool for all patients admitted to our hospital with a NOF#.

Methods

A retrospective review of patient notes allowed collection of data regarding age, hip injury, frailty score, comorbidities, and staff compliance with tool. Patients with a completed screening tool had outcomes recorded (low, medium, high risk), timeliness of referral to SLT if appropriate, and if OPD was present on assessment. Balancing measures included length of time kept nil by mouth. We completed four PDSA cycles over 5 months.

Results

During this period, 157 patients were admitted with a NOF# and 58 had a completed screening tool. By producing a training pack and expanding into the emergency department, compliance improved by 33% over the 4 cycles. 19 of the 58 patients with a completed screening tool had OPD; 79% had mild, 14% moderate and 7% severe. The screen was adjusted during each cycle improving the suitability of SLT referrals from a 25% identification rate in cycle 1 to 100% in cycle 4. No patients were kept nil by mouth.

Conclusions

The screening tool has increased OPD identification by 21%. However, this requires staff training and high compliance rates to be effective. Next steps include adding the tool to the NOF# proforma, creating a training pack for the wider MDT, and improving the specificity of the tool.

References

1. Love et al. Age and Ageing, 2013. 42(6):782-5. 2. Mateos-Nozal J et al. Age and Ageing, 2021. 28;50(4):1416-1421.

Introduction

NICE guidelines state that fracture risk assessment should occur in all women aged ≥65 and all men aged ≥75. This includes assessing patients’ FRAX score, measuring serum vitamin D and calcium levels. Early detection and treatment can prevent complications like fragility fractures. We conducted a Quality Improvement Project to improve bone health assessments on Geriatric Wards.

Methods

A baseline audit assessed: admission reason, falls history, FRAX score, CFS, previous DEXA scans, whether vitamin D and calcium levels were checked during the admission, and if treatment was commenced (bone resorption medication and vitamin D/calcium supplements). Data was collected two further times following interventions over a 5-month period. The first intervention was an announcement at the morning departmental meeting reminding clinicians. The second intervention was an email reminder.

Results

There were 56, 51, and 58 patients per cycle. 19, 15, and 17 patients were admitted with falls. 23, 14, and 10 patients had a falls history. Average CFS was 5.4, 5.4, and 5.5. Average major osteoporotic fracture FRAX score was 15.8, 16.4, and 12.9. Checking serum calcium was 88%, 100%, and 100%. Checking vitamin D was 30%, 43%, and 60%. 28%, 43%, and 47% of patients were prescribed calcium and vitamin D supplements. Patients on bone resorptive treatment dropped from 7% to 3% to 2%. 8, 12, and 11 patients had a previous DEXA.

Discussion

Verbal announcement had the greatest impact. Visible reminders help sustainability. This QIP highlighted the lack of bone protection treatment with multiple contributing factors including some patients lacking the capacity to follow instructions to take weekly medications or patients requiring vitamin D being replaced initially, with initiation later. This QIP feeds into a larger trust project in developing a ‘Fracture Liaison Service’, which could improve adherence and provide a pathway in utilising annual and bi-annual treatments.

Background
An important modifiable risk factor associated with falling is the use of falls-risk inducing drugs (FRIDs). The World Falls Guidelines identified this as a key domain and recommended that a validated tool should be used in medication reviews targeted to falls prevention in older adults (1).
A proforma was created based on the STOPPFall Tool (2) to aid doctors in performing structured medication reviews in patients with falls. The research question was ‘in older adult inpatients with falls, does use of the STOPPFall screening tool increase deprescribing of FRIDs?’

Methods
The project was carried out on Geriatric Medicine wards. Patients were included if they were inpatients and had been admitted with a fall, had a history of recurrent falls and/or had an inpatient fall. FRID classes were identified using STOPPFall, and FRIDs prescribed on admission and discharge were determined using discharge letters. The primary outcome was the number of FRIDs stopped or dose reduced on discharge. An online survey assessed HCOP doctors’ confidence in deprescribing.

Results
102 patients were reviewed at baseline. The percentage of patients prescribed at least 1 FRID was reduced from 84.3% on admission to 65.7% on discharge. A total of 162 FRIDs were prescribed on admission; 73 (45.1%) of these were stopped and 12 (7.4%) were dose reduced.
19 prescribers responded to the online survey, and self-assessment of confidence in deprescribing averaged at 7.74 (1-10 - ‘not confident at all’ to ‘very confident’). Confidence increased with seniority; average confidence ranged from 6.5 in foundation doctors to 9.0 in consultants. 

Conclusion
52.5% of FRIDs prescribed in older adult inpatients with falls were stopped or reduced. Introduction of a STOPPFall proforma shows potential in encouraging deprescribing of FRIDs.

Falls and fall related injury are a common problem within our older adult population and are associated with an impact on quality of life and functional independence. The first phase for reducing adverse effects from falls is to identify risk factors that can cause or exacerbate the risk of falling and then act to minimise these risk factors.

Method

A retrospective audit was undertaken to review how falls are assessed in a front door frailty service within the emergency department (ED) and acute medical units (AMU). The notes of each patient who had attended following a fall and was assessed by the OPAL team were reviewed. There are NICE guidelines on how to assess falls in older adults and the risk factors identified were used as a benchmark for the audit.

Results

The audit identified that there is a multidisciplinary approach to falls assessments and that the majority of the risk factors were identified on assessment. There were two domains that were not frequently identified on review - footwear and completion of lying and standing blood pressure measurements. Following completion of the audit, teaching was undertaken to the team and the results distributed with production of a crib sheet for staff to aid future falls assessments to ensure all domains are assessed.

Conclusion

Front door frailty teams often review patients who have presented to ED or AMU following a fall. A standardised approach to identification of risk factors across a multi-disciplinary team ensures patients are receiving appropriate management on risk factors to assist in reducing further falls in line with NICE guidance.

Introduction Predicting outcomes after hip fracture is important for identifying high-risk patients who may benefit from additional care and rehabilitation. Pre-operative scores based on patient characteristics are commonly used to predict hip fracture outcomes. Mobility, an indicator of pre-operative function, has been neglected as a potential predictor. We assessed the ability of pre-fracture mobility to predict post-operative outcomes following hip fracture surgery.

Methods We analysed prospectively collected data from hip fracture surgery patients at a large-volume trauma unit. Mobility was classified into four groups. Post-operative outcomes studied were mortality and residence at 30-days, medical complications within 30- or 60-days post-operatively, and prolonged length of stay (LOS, ≥28 days). We performed multivariate regression analyses adjusting for age and sex to assess the discriminative ability of the Nottingham Hip Fracture Score (NHFS), with and without mobility, for predicting outcomes using the area under the receiver operating characteristic curve (AUROC).

Results 1919 patients were included, mean age 82.6 (SD 8.2); 1357 (70.7%) were women. Multivariate analysis demonstrated patients with worse mobility had a 1.7-5.5-fold higher 30-day mortality (p≤0.001), and 1.9-3.2-fold higher likelihood of prolonged LOS (p≤0.001). Worse mobility was associated with a 2.3-3.8-fold higher likelihood of living in a care home at 30-days post-operatively (p<.001) and a 1.3-2.0-fold higher likelihood of complications within 30-days (p≤0.001). addition mobility improved nhfs discrimination for discharge location, auroc 0.755 [0.733-0.777] to nhfs+mobility 0.808 [0.789–0.828], los, 0.584 [0.557-0.611] 0.616 [0.590–0.643].

Conclusions incorporating assessment into risk scores may improve casemix adjustment, prognostication following hip fracture, identify high-risk groups requiring enhanced pre, peri post-operative care at admission. this implies that information available admission could facilitate prognostication, planning, bed management aversion, as well informing discussions between clinical teams patients about recovery.

Topic

We identified a deficiency in the identification and treatment of bone health in the Day Rehabilitation Unit. DRU is an Out-patient clinic where older people with falls or reduced mobility receive comprehensive geriatric assessment. We aimed to improve early screening for osteoporosis, prompting targeted investigation and intervention to improve patient outcomes.

Intervention

Our first intervention was consultant teaching specifically to the junior doctors working in clinic. This was followed up by the introduction of a Medical Assessment Proforma to include osteoporosis risk assessment. Finally we had departmental wide teaching on bone health assessment.

We hypothesised that a combination of clinical education and prompts in the proforma would improve our practice.

A total of 205 patients where audited across an 18 month period from Sept 20 to Feb 22. We reviewed the electronic care record of patients seen in clinic to determine if bone health had been considered. A spreadsheet was designed in accordance with the NICE⁽¹⁾ guidelines to record data. This included what supplements were prescribed, if a FRAX score had been recorded and the outcome of this.

Improvement

We noted an improvement in supplements prescribed (from 27% to 83%), FRAX score recorded (from 0% to 100%). Routine bloods including serum calcium remained unchanged (100%). Recording of Rockwood score also saw an improvement (from 0% to 49%).

Discussion

Increased use of a structured screening tool, supported by targeted education improves recognition and intervention of bone health. 54% of people who had a FRAX score done required a DEXA as per guidelines, of these 26% have osteoporosis. This early intervention helps to prevent osteoporotic fractures, therefore improving the quality of life of our elderly population.

References

1. Nice.org.uk. (2017). Osteoporosis: assessing the risk of fragility fracture | Guidelines| NICE. [Online] Available at: https://www.nice.org.uk/guidance/cg146

Introduction

Sarcopenia is common in patients with hip fracture, but few studies have examined whether assessment of sarcopenia improves prediction of adverse post-operative outcomes. We examined whether sarcopenia, diagnosed using handgrip strength (HGS), could predict outcomes after hip fracture.

Methods

Routinely collected data from the National Hip Fracture Database were combined with locally collected HGS data from a high-volume orthopaedic trauma unit. Patients aged ≥65years with surgically managed, non-pathological hip fracture with grip strength measured on admission were included. The European Working Group on Sarcopenia in Older People (EWGSOP2) thresholds were used to identify patients with or without sarcopenia; those unable to complete grip strength testing were also included in analyses. Outcomes examined were 30-day and 120-day mortality, residential status and mobility, prolonged length of stay (>15 days) and post-operative delirium. Binary logistic regression models were used to examine prognostic value of HGS, and discriminant ability for the Nottingham Hip Fracture Score (NHFS) alone and on adding sarcopenia status were compared using c-statistics.

Results

We analysed data from 282 individuals; mean age 83.2 (SD 9.2) years; 200 (70.9%) were female. 99 (35.1%) patients had sarcopenia and 109 (38.7%) were unable to complete testing. Sarcopenia predicted higher 120-day mortality (OR 13.0, 95%CI 1.7-101.1, p=0.014), but not 30-day mortality (OR 1.5, 95%CI 0.1-16.9, p=0.74). Patients unable to complete HGS testing had higher 30-day mortality (OR 13.5, 95%CI 1.8-103.8, p=0.012) and 120-day mortality (OR 34.5, 95%CI 4.6-258.7, p<0.001). Sarcopenia status did not significantly improve discrimination for mobility but improved prediction of 120-day residential status (c-statistic 0.89 [95%CI 0.85-0.94] for NHFS+sarcopenia vs 0.82 [95%CI 0.76-0.87] for NHFS alone) and post-operative delirium (c-statistic 0.91 [95%CI 0.87-0.94] vs 0.78 [95%CI 0.73-0.84]).

Conclusion

Sarcopenia assessment via HGS testing may provide additional prognostic information to existing risk scores in older patients with hip fracture.

Introduction:

Traumatic Brain Injury (TBI) is the most common fall-related injury among adults 65 and older, despite the high incidence there is a paucity of research to guide management of older adult TBI . Simple passive remote home monitoring systems can be used to unobtrusively track markers of health and function in older adults and enhance clinical decision making in community-based care models, such as ‘hospital at home’. There are few studies to-date examining healthcare practitioners (HCPs) views on this technology. We aimed to explore HCPs insights on how to best develop the technology and examined barriers and facilitators to the adoption of passive remote monitoring in the community to track health and function in older adults following TBI.

Method:

This was a multi-center mixed methodology qualitative study. HCPs opinions were explored during and online focus group and individual interviews. Purposive sampling was used to provide balanced representation of healthcare professionals (physicians, nurses and therapists) from both community and acute multidisciplinary teams. Data were analysed using the framework approach.

Results:

The perspectives of 6 HCPs were analysed. Potential barriers to adoption were HCPs lack of familiarity with technology, skepticism over the reliability of technology, the potential for nefarious use of patient’s data and concerns over how data will be managed and interpreted for clinical use. Facilitators were the promotion of safety and independence at home, reduced workload for HCPS, the potential to target appropriate healthcare interventions and flag issues early in cognitively impaired older adults.

Conclusion(s):

HCPs felt that passive remote monitoring holds potential to improve care for older adults following TBI. However, its implementation demands thoughtful planning and clear guidelines for its use and interpretation of data. Iterative development of these systems, incorporating HCPs insights will be key to successful and sustained use in research and clinical practice.

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.