Training requirements for higher specialist trainees in geriatric medicine in orthogeriatrics and bone health

All higher specialist trainees in geriatric medicine need to be able to assess and manage older patients presenting with the common geriatric problems, including hip fracture. Some trainees may seek to demonstrate additional competencies in Orthogeriatrics and Bone health by completing the additional theme for service.

Reference should also be made to other areas of the curriculum such as falls, delirium, continence, tissue viability and palliative/end of life care which are relevant to this group of patients.

Geriatric Medicine Curriculum 2022

The new geriatric medicine curriculum details a number of high level curriculum outcomes known as Capabilities in Practice (CiPs). The capabilities in practice (CiPs) describe the professional tasks or work within the scope of Geriatric Medicine. These are articulated in six generic CiPs, eight IM clinical CiPs and seven Geriatric Medicine specialty CiPs which have been mapped to the relevant GPC domains and subsections to reflect the professional generic capabilities required. Each CiP has a set of descriptors associated with that activity or task. Descriptors are intended to help trainees and trainers recognise the minimum level of knowledge, skills and attitudes which should be demonstrated for an entrustment decision to be made.

Orthogeriatrics is a key component of five of the geriatric medicine specialty CiPs: CiPs 1-4 and 6. These are detailed below along with the key descriptors pertaining to orthogeriatrics. Evidence to inform the entrustment decision might take the form of CbD, Mini-CEX, ACAT, SCE, and reflection on clinical cases. Trainees must be able to provide evidence of all capabilities in a community setting as well as a hospital setting. In addition, NHS services require trainees to have capabilities in selected areas of specialist practice at the time of appointment to a consultant post, and trainees will therefore undertake one module for an additional time period of 3 months – designed to ensure the output of geriatricians with the appropriate skills to meet service needs. Additional ‘themes for service’ capabilities will be integrated into the final 3 years of geriatric medicine training. Orthogeriatrics is an additional theme.

Geriatric Medicine Specialty CiP 1

Performing a comprehensive assessment of an older person, including mood and cognition, gait, nutrition and fitness for surgery in an in-patient, out-patient and community setting.

Geriatric Medicine Specialty CiP 2

Managing complex common presentations in older people, including falls, delirium, dementia, movement disorders, incontinence, immobility, tissue viability, and stroke in an in-patient, out-patient and community setting.

Geriatric Medicine Specialty CiP 3

Managing older people living with frailty in a hyper-acute (front door), in-patient, out-patient and community setting.

Geriatric Medicine Specialty CiP 4

Managing and leading rehabilitation services for older people, including stroke

Geriatric Medicine Specialty CiP 6

Managing liaison with other specialties, such as surgery, orthopaedics, critical care, oncology and old age psychiatry

Geriatric Medicine Syllabus 2022

Core competencies

To know how to assess acutely ill orthopaedic patients; to manage acute presentations and peri-operative care of patients with fragility fractures; to manage older orthopaedic patients and fragility fracture patients at all stages of their journey including rehabilitation.

Knowledge

• Acute presentation and care, including initial emergency department care and pathways

• Knowledge of appropriate assessment tools to inform clinical management decisions
• Surgical and anaesthetic issues including optimal timing of surgery and management of perioperative issue such as fasting, medicines management and analgesia
• Hip fracture: common types and their management including operative and non-operative
• Understanding of postoperative care, common problems and complications
• Knowledge of possible post-operative trajectories and outcomes
• Awareness of the factors that may impact rehabilitation e.g. fear of falling, continence, pain, fatigue, fixation failure etc.
• Different models of orthogeriatric care including role of intermediate care and community services in rehabilitation and in prevention
• Causes and management of falls
  
  • Able to recognise when falls are ‘unexplained’ and possibly syncopal including orthostatic hypotension, vasovagal syndrome, carotid sinus hypersensitivity.
• Causes and management of osteoporosis and role of fracture liaison services
• Awareness of relevant National Publications and Guidelines including NICE and SIGN guidance, BOA and AAGBI
• Understanding of National Audit Programmes National Hip Fracture Database/Falls and Fragility Fracture Audit Programme ( England, Wales and Northern Ireland), Scottish Hip Fracture Audit ( Scotland)

Skills

• Assessment of comorbidities and any acute / subacute illness
• Comprehensive medication review and specific knowledge regarding interventions for analgesia, bowel care, anticoagulants, blood products and osteoporosis treatment
• Nutritional assessment using recognised score and appropriate interventions
• Assessment of frailty using a recognised score
• Communication, team and leadership skills
• Proactive Discharge Planning and planning transfers of care for Advance care Planning and Palliative Care
• Assessment of which patients are likely to make a good recovery and return home, those who have ongoing rehabilitation needs and those who have a high likelihood of dying while in hospital and recognise that the expected outcome may change and requires regular review

Behaviours

• An approach to the management of elderly people with fracture that seeks to maximize early recovery / independence

• Enabling patient involvement and choice
• Close collaboration with theatre team, orthopaedic surgeons, anaesthetists and other professionals to optimisation for early surgery
• Effective engagement with and education of, non-specialist teams caring for fragility fracture patients who are not on orthopaedic wards
• Close collaboration with the MDT

Specific learning methods

To gain experience in this topic trainees should be placed in units designated either as Trauma Units (TU) or Major Trauma Centres (MTC) and should spend time on orthopaedic wards where older patients with fragility fractures are admitted for operation/management, orthogeriatric wards, and rehabilitation facilities. They should work within specialist team which should include a consultant orthogeriatrician. An indicative attachment of 12 weeks over the four year training programme is recommended. Trainees should see a minimum of 30 patients, and should have opportunities to see patients in every setting in the acute hospital from ED to discharge, including in theatre. In addition, trainees should be aware of and, where practicable, experience the whole patient journey including pre-hospital / ambulance services, ED, wards pre and post-op, operation/anaesthesia/recovery and rehabilitation in acute or community settings.

Trainees should be actively involved with peri-operative discussions with anaesthetists and surgeons on medical optimisation and have the opportunity to lead these discussions. It is expected that a trainee would attend at least one hip fracture operation to observe the whole theatre process from induction of anaesthesia to recovery.

Trainees should work closely with MDTs on trauma/orthogeriatric wards. They should have the opportunity to lead board rounds and family/patient discussions and work with the MDT to select patients for rehab beds. In order to develop an understanding of the different types of rehabilitation/discharge options it is good practice to visit these (e.g. a community rehabilitation bedded unit, a care home, rehab at home service). In an orthogeriatric attachment trainees should see the full range of outcomes of hip fracture surgery.

It is recommended that trainees are observed undertaking discussions with patients and family at differing points in the patient journey e.g.

• pre-operatively-compassionately explanation to patients and families of the risk and benefits of surgery, potential outcomes and where appropriate initiating advanced care planning conversations
• post-operatively explaining (using information gained from collaboration with the MDT) the anticipated trajectory for the patient

Trainees are expected to gain experience in the prevention and management of a wide range of peri-operative complications, such as pneumonia, acute kidney injury, thromboembolism, pressure ulcer prevention, pain management, constipation, surgical complications, wound healing, dislocation/failure/cut-out, extended VTE prophylaxis, when to restart anticoagulation/antiplatelets. It may be helpful to keep a log of cases and problems seen.

Learning will also take place by using local and national audit data such as the National Hip Fracture Database, or Scottish Hip Fracture Audit, and reviewing other relevant data such as local incident data, surgical site infection surveillance data, WHO meetings, fragility fracture governance meetings, M&M and service/pathway meetings.

It is expected that trainees will also be exposed to formal teaching sessions covering a range of relevant topics (e.g. BGS National and regional Meetings, post-hip fracture care, osteoporosis and falls, during their four year training programme (local, regional and national training and CPD meetings).

It is recommended that trainees receive supervision from a variety of professionals that reflect the multidisciplinary nature of orthogeriatric care. These supervisors must be able to assess a trainees competence using a combination of direct observation and supervised learning events (e.g. CbD, mini-CEX, ACAT and MSF) in order to evidence capability.

For the Bone Health component it is required to spend time with relevant specialist services in clinics or ward rounds (e.g. fracture liaison service, osteoporosis specialist practitioner, falls clinic), and a WPBA / reflection / feedback completed afterwards. A minimum of 6 falls and/or bone health sessions should be attended (at least 2 in each).

Geriatric Medicine Specialty CiP (theme for service)

• • Demonstrates the ability to manage older people with fractures, including hip fractures, other fractures, polytrauma
  • Demonstrates the ability to manage the effects and risks of surgery and anaesthesia in older people, including the use of tools to risk assess for perioperative morbidity and mortality
  • Demonstrates the ability to clinically assess and manage older people with fractures and multi-morbidity peri-operatively, including e.g. anticoagulation, diabetes, COPD
  • Demonstrates awareness of different anaesthetic options for patients with complex co-morbidity
  • Demonstrates greater knowledge and ability to manage surgical complications, e.g. wound management (including options and timings for intervention), indications for repeat X-ray, non-union
  • Demonstrates ability to manage patients with osteoporosis treatment failure
  • Demonstrates greater ability to manage patients requiring parenteral osteoporosis therapy
  • Demonstrates an understanding of osteoporosis including special groups (e.g. men, younger adults, steroid treated, Down syndrome), and of patients presenting with metabolic bone disease
  • Demonstrates better understanding of the role for national audit to improve quality of care
  • Demonstrates an understanding of the knowledge and skills required to develop an orthogeriatric and bone health service for older people

Geriatric Medicine Syllabus 2022: Additional theme for service

Knowledge

• In depth knowledge of the effects and risks of injury, surgery and anaesthesia on older people
• Knowledge of common fracture types, their management and prognosis
• Knowledge of common injury patterns in older people and how to assess and initially manage them in general wards / non-specialist areas, liaising with or referring to specialist services
• Knowledge of peri-operative complications both generic (e.g. wound infection, delirium, AKI, pain) and specific (e.g. increased blood loss with subtrochanteric fractures, DHS cut out , avascular necrosis)
• Ability to understand and evaluate different models of delivering orthogeriatric services ideally with exposure to different models of service during training
• Have a detailed knowledge of National Hip Fracture Audit Programmes and understand how they have influenced different models of orthogeriatric care
• Be aware of and keep up to date on relevant evidence reviews that inform practice e.g. Cochrane reviews and relevant NICE Guidance e.g. on TLOC, falls, Hip fracture, Technical guidance on treatment for osteoporosis.
• Be aware of and able to contribute to local policies for this group of patients.
• Falls programmes and the evidence base for their effectiveness.
• Knowledge of the causes of osteoporosis and appropriate strategies for the prevention and treatment of osteoporosis.
• Drug and non-drug treatments for osteoporosis.
• The appropriate use and interpretation of bone densitometry and the WHO FRAX tool.
• Ability to manage osteoporosis in special groups (eg men, younger adults, steroid-treated, Down syndrome).
• Understanding of medical and surgical management of common metabolic bone diseases eg. osteomalacia, Paget’s disease & primary hyperparathyroidism.
• Awareness and recognition of atypical bisphosphonate related fractures.
• Awareness of Pathological fractures (non-fragility).

• Public health and ‘whole life’ strategies for bone health

Skills

• To be able to work with and influence other specialities and professions caring for this group of patients
• Able to critically appraise and benchmark current service against national standards/data and identify areas for improvement to use QI methodology to monitor and continuously improve it
• Clinical assessment of patients with fragility fractures including understanding risks of complications
• Discharge planning
• Assess patients for, and medically optimise for, surgery
• Leadership and membership of a multidisciplinary team
• Ability to assess falls risk and institute fall prevention measures including referral to appropriate services where appropriate e.g. exercise classes, tilt testing
• Health promotion

Behaviours

• Compassionately explains to patients and families the impact of recommended interventions for, and possible outcomes of fragility fractures
• Uses advanced communication skills to understand what matters to the patient and use this information to guide care
• Advocates for early operation and discuss risks / benefits of delay in a collaborative manner with anaesthetist and surgeons
• Recognises limitations of own knowledge and engages with other specialities for advice regarding complex cases e.g. cardiology, haematology
• Visible inclusive leadership style working in a collaborative interdisciplinary and multi-agency manner

Specific Learning Methods

• Experience – indicative additional 3 months fulltime equivalent (although not necessarily consecutively) of working in a variety of orthogeriatric settings including preoperative assessment and management, acute postoperative care, post-surgical rehabilitation and discharge planning
• Assessment standards will be set higher than those expected for core capabilities in orthogeriatrics commensurate with the knowledge, skills and behaviours required to provide a more specialist service to patients with fragility fractures and falls -related injuries that occur on general wards or present to district general hospitals
• A minimum of 12 osteoporosis sessions is recommended (includes clinics and also other sessions such as time with fracture liaison service). Trainees should also be encouraged to attend clinics in other relevant specialties, such as rheumatology
• Contribution to an audit of care against national standards/guidelines/protocols
• Attendance at more advanced or specialised teaching e.g. conferences such as POPS, Age Anaesthesia, Specialist session at BGS National Conference
• Provision of teaching and support to junior doctors and other professions in aspects of orthogeriatric care