Joints

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. 

Introduction:

Parkinson’s disease (PD) patients with or without psychosis are at higher risk of recurrent falls and fracture and as a consequence higher mortality and morbidity NICE (13) Henderson et al. (2019). We conducted a qualitative study to understand barriers and facilitators of introducing ‘bone health assessment’ for PD patients.

Method

We conducted a pilot study to identify and implement a bone health assessment tool to communicate falls and fracture risks to GPs. • SWOT and Stakeholder analysis was conducted to identify an appropriate bone health assessment tool . • PDSA cycles were completed to assess barriers and facilitators of bone health assessment in all PD clinical areas. • 4 Participants were identified from all possible PD clinical settings and trained on how to use the FRAX assessment tool. • Semi structured interviews were conducted to explore themes from 6 week pilot study.

Results

Bone health assessments were not conducted routinely in PD clinical settings in our Trust Literature review/ SWOT and Stake holder analysis identified ‘FRAX’ score as an appropriate bone health assessment tool for PD patients. Interviews with participants identified time constraints during the clinical consultation as a major barrier to conducting bone health assessment using the FRAX assessment tool. All participants agreed that this improved communication with patients and GPs in understanding bone health and risk of falls and fractures. Face to face PD Nurse Clinics were deemed the most appropriate clinical settings for these assessments.

Conclusion

As a result of this service improvement project bone health is now assessed in all PD Nurse clinics. This has enabled GPs to start the most appropriate bone protection treatment for PD patients

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.