Abstract
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.
Comments
Congratulations
I was impressed you were able to undertake 4 PDSA cycles in this non-HOF fracture risk group, this is a lot of work and you are to congratulated on your perseverance and dedication to this topic.
The hugely important improvements you made to the monitoring of bone health are extremely impressive and I have no doubt these will be important for patient care.
The challenge for the future will, as you correctly identified, be continuing this improvement as you leave Foundation training. I hope that your Consultant colleague is able to encourage continuation.
The poster is really well written and portrays the information clearly and the video presentation by both of you is well done with great visual displays of the data.
Thank you Professor Shore for reading and for your very kind words!
We learned a lot through 4 PDSA cycles, particularly the importance of considering barriers to overcome such as junior doctor rotation, and involving and utilising the multidisciplinary team consistently on the ward.
We hope that having handed this project to colleagues following our departure, this work will serve as a foundation for sustained change and patients will benefit from our efforts today and in the future.
Question
Hello. Thank you for your poster on bone health assessment. What were the reasons for the decline in bone health related bloods and the discharge documentation after the 4th PDSA cycle intervention?
Hello Dr MacRae,
Thank you very much for reading our poster and for your question.
It has been hard to fully account for the reduction in bone health bloods and discharge documentation between PDSA cycle 3 and 4.
We suspect that junior doctor changeover in April may partially account for this, however it has been difficult to know for sure given we are not currently working in the team. We have since tried to focus on consistent stakeholder recruitment and engagement to ensure they are invested in this project.
Additionally, it may be spurious given improvement in QI is not always linear. We hope that the results from our next data collection next month will show an upward trend.