Falls

Introduction:

Parkinson's disease (PD) is associated with an increased risk of osteoporosis and fractures to factors like falls resulting from postural instability, polypharmacy, and muscle weakness. Reduced bone mineral density (BMD), often caused by vitamin D deficiency, disease severity, and low BMI, further elevates fracture risk in PD patients. This project aims to improve awareness and bone health testing in PD patients by focusing on vitamin D, bone profile assessments, DEXA scans, and FRAX scores for fracture risk evaluation and management.

Methodology:

This QIP involved two cycles focused on managing Parkinson’s disease (PD) patients. The first cycle interventions focused on educating doctors through sessions and a poster, while the second cycle introduced personalized treatment plans for PD patients, recorded in their clinical notes. A comparative analysis of post-intervention data was conducted to evaluate the effectiveness of both interventions.

Results:

Bone profile testing was successfully completed in 100% of patients after both interventions. In cycle 1, 63.3% of patients required vitamin D testing, compared to 25% in cycle 2. Of these, 14.3% received testing after the first intervention, and 100% after the second. However, none of the patients had their FRAX scores calculated or DEXA scans scheduled. The teaching session increased overall confidance amongst junior doctors in diagnosing osteoporosis from 60% to 70%, and managing osteoporosis from 10% to 80%. It also improved the overall awareness on how to use the FRAX tool from around 50% to 90%. 

Conclusion:

Personalized treatment plans and targeted interventions led to significant improvements in vitamin D testing. However, notable gaps remain in adherence to FRAX calculation and organizing DEXA scans. Future efforts should focus on these limitations and ensuring complete bone health assessments for PD patients. The teaching sessions proved to be highly effective, significantly enhancing participants' understanding of bone health issues in Parkinson's disease.

Introduction

National guidance suggests that all patients with neck of femur fractures (NOFF) should be mobilised day one post-operatively (NICE, 2023, QS16). This reduces rates of delirium, pneumonia and length of stay (Sallehuddin & Ong, Age and Ageing, 2021, 50, 356-357). Hypotension is a leading cause of immobilisation post-operatively. National guidance advises appropriate fluid resuscitation and review of polypharmacy when indicated (British Orthopaedic Association, 2007). This quality improvement project aimed to reduce post-operative hypotension and improve day one post-operative mobilisation in NOFF patients.

Method

Three months of NOFF patients were retrospectively reviewed pre-intervention. Those who did not receive surgical intervention were excluded. The proportion of NOFF patients that were unable to mobilise due to post-operative hypotension on day one was identified. We reviewed if intravenous fluids were given pre-operatively and if anti-hypertensives were held. An intervention was then implemented including educational posters and teaching sessions for doctors and nurses to encourage prescription of fluids on admission, holding of antihypertensives pre-operatively and detection and escalation of oliguria or hypotension post-operatively. Data were then re-collected in a three-month period post-intervention to ascertain if there was any change in practice.

Results

70 patients underwent NOFF repair pre-intervention compared to 54 patients post-intervention. There was a decrease in the proportion of patients unable to mobilise day one post-operatively due to hypotension from 15.7% pre-intervention to 9.3% post-intervention. There was an increase in the proportion of patients who received pre-operative intravenous fluids from 64.3% pre-intervention to 77.8% post-intervention. Of those patients who took anti-hypertensive medication, a higher proportion had this suspended pre-operatively, increasing from 82.9% pre-intervention to 88.2% post-intervention.

Conclusion

Simple educational interventions can reduce post-operative hypotension in NOFF patients. Developing local guidelines may facilitate persistent clinical change, as improvements following poster distribution and teaching sessions may be transient.

Introduction

• Preoperative systemic inflammation has been shown to worsen postoperative outcome in emergency surgical patients.
• C-reactive protein (mg/L)/Albumin (g/L) ratio is a well validated inflammation marker.
• Studies have shown an inverse relationship between 25-hydroxyvitamin D level and markers of inflammation. Vitamin D deficiency has been previously shown to be associated with inflammation.

Aims and Objectives

• To determine the relationship between 25-hydroxyvitamin D level and CRP/Albumin ratio in older acute hip fracture patients.
• To explore the impact of gender on this relationship.

Methods

• A retrospective review of electronic notes from the hip fracture database was carried out on hip fracture patients attending a single trauma centre from January to December 2022.
• Anonymised data were extracted from the database. Patients aged 60 years and older who sustained an acute hip fracture were included. Patients with incomplete data were excluded. The IBM SPSS 29 software was used for statistical analysis.
• Descriptive statistics was used for baseline characteristics. Linear regression was used to determine correlation.

Results

• A total of 293 patients were analysed: 82 males and 211 females with a mean age of 81.6(SD 8.28) and 83.2(SD 7.85) years respectively.
• Mean 25-hydroxyvitamin D levels were 39.1 (SD 25.0) and 49.7 (SD 29.01) nmols/L respectively.
• Mean CRP/Albumin ratio was 0.94 (SD 1.51) and 0.71 (SD 1.34).
• There was a negative, statistically significant correlation between 25-hydroxyvitaminD and CRP/Albumin ratio in male patients but not in the females (r = -.274; p = .013 & r = - .035; p = .61) respectively.

Conclusion

• In this study, 25-hydroxyvitamin D levels are inversely correlated with markers of inflammation (CRP/Albumin ratio) in older male hip fracture patients but not older female hip fracture patients. More studies are needed to clarify whether vit D lowers inflammation or inflammation lowers 25-hydroxyvitamin D concentrations and to investigate the gender difference.

Introduction At Wrightington, Wigan and Leigh we admitted over 400 patients with hip fracture diagnosis in 2023. As part of ortho-geriatric review, denosumab treatment would be utilised in a cohort of patients where this is appropriate, in line with NOGG guidelines. Traditional model of delivering first dose after outpatient appointment led to delays in treatment initiation and did not address the significant risk of “imminent fracture” which was recognised in the latest NOGG guidelines. The aim of this project was to reduce delays in denosumab treatment initiation by introducing consenting process during hospital stay led by ortho-geriatric Advanced Clinical Practitioner.

Method Utilising hospital electronic records, a sample of patients was selected from patients admitted in 2022 (19 patients), 2023 (19 patients) and 2024 (6 patients). Time of decision to treat with denosumab to time of first dose administered was used as the outcome measure. Alongside this, analysis of time to outpatient appointment was completed which was where the pre-intervention consent was taken. Intervention of inpatient consent being taken was implemented in September 2023.

Results The average length of time from clinical decision being made to first dose of denosumab being administered was 187 days in 2022 sample, 76 days in 2023 sample and 27 days in 2024 sample. The governance around consent process was established and adopted by the whole ortho-geriatric team. Waiting times for outpatient bone health clinic were on average 240 days in 2022, 164 days in 2023 and unknown in 2024 cohort.

Conclusion(s). Introduction of ward-based consent process for patients who are suitable for denosumab led to significant decrease in delays in time to first dose. This ensures that patients benefit from bone protection in a timely manner, as their risk of refracture is greatest in the first 6 months post index fracture.

Introduction:

The local issue tackled was the suboptimal compliance with the Patient Fall Management Assessment (PFMA) on the Electronic Patient Record (EPR) due to assessments being completed on alternative electronic documents.The goal was to emphasize on this to improve patient safety.

Methods:

Audit data was collected by reviewing incident reports of inpatient falls across various complex care wards over a 12-month period each, with 109 notes reviewed in the first cycle and 204 in the second.

Interventions:

The approach involved conducting repeated training sessions for all grades of training doctors within the trust.

Results:

The first audit cycle revealed fair compliance with the PFMA document (87%), documenting events (94%), examinations (87-96%), further investigations and management (80-86%). However, these were lacking for past medical history (61%), medications, especially anticoagulation/antiplatelets (58%), although antihypertensives/sedative reviews were better (75%).

The interventions led to a small (2%) increase in the use of the PFMA document but a 100% compliance in recording fall events and a 13% improvement in documenting histories. Review of blood thinners and other medications improved by 17% and 8% respectively. Significant improvements were also seen in examinations and developing management plans. Despite these advancements, 14% of patients experienced recurrent falls, indicating a need for ongoing efforts.

Conclusions:

The audit highlighted the effectiveness of continuous training to ensure regular understanding of the importance of completing the PFMA. Given the frequent rotation of junior doctors as well as the increasing variety of allied health care professionals reviewing patients, especially out of hours, this presents a particular challenge. Future efforts will focus on more sustainable methods of increasing awareness of the PFMA such as discussion at multi-disciplinary staff inductions and welcome packs. Sustaining these improvements will involve regular audits and feedback loops as well as feedback on the document itself to assess for future improvements.

Introduction: Musculoskeletal (MSK) injuries are a common factor in acute presentations to the emergency department (ED). Effective pain management is crucial for patient comfort and recovery, yet pain control for MSK injuries admitted under the medical team often falls short of optimal standards. This quality improvement project aims to evaluate and enhance the prescription practices for pain relief in elderly patients with MSK injuries at the Wrexham Maelor Hospital (WMH) ED. Methods:  A two cycle project was completed in which patients with MSK injuries were identified and reviewed regarding any pain relief they may have been prescribed (regular or PRN). Following cycle 1, interventions were put in place and prescribing practices were reassessed. Inclusion criteria: >60 years of age, MSK injury described in notes. Each cycle of data collection lasted a week, with a sample size of 17 and 14 patients respectively. Results: Cycle 1 No pain relief- 33% PRN Only- 6% Regular Only- 50% Both- 11% A significant number of patients were not receiving adequate pain relief, highlighting the need for improved pain management protocols. Interventions Educational posters were displayed around the emergency department and the frailty hub, and a presentation was given to the frailty team. Cycle 2 (post intervention) No pain relief- 14% PRN Only- 29% Regular Only- 21% Both- 36% Post-intervention results showed a marked improvement in pain management, with fewer patients receiving no pain relief and an increase in the combined use of PRN and regular pain relief. Conclusion: The quality improvement project highlights the necessity for targeted interventions to enhance pain management for elderly patients with MSK injuries in the ED. Preliminary results suggest that increased awareness and education among medical staff can potentially improve pain relief prescription rates.

Introduction: Fracture liaison services (FLS) aim to prevent secondary fractures by ensuring high-quality care to all patients with fragility fractures above 50 years. The standard recommendation by FLS Database (FLS-DB) is to identify 80% of the expected fragility fractures, commencing treatment for 50% and monitoring 80% at 16 weeks and 52 weeks.

Methods: FLS team noted that only 18.4% (n=92) patients were followed at one-year of the total 875 patients identified in the year 2021 (National benchmark=22.3%). Whilst FLS team identified 42.6% (n=1649) patients in the year 2022, an 88% increase as compared to the year 2021. But there was reduction in the one-year follow-up from 18.4% to 13.8% (n=149) in 2022. Quality improvement methodology based on the model of improvement; Plan-Do-Study-Act cycles, was used. Process mapping for the existing FLS showed that follow-up was only ad-hoc and not formalised. Our objective was to improve follow-up at one-year.

Results: Process mapping supported the development of a separate clinic code for annual review of patients, led by a geriatrics specialty trainee and supported by the FLS Clinical Lead. The patient lists were drawn from the FLS-DB and new patients booked for one-year follow-up clinic. FLS identified more fragility fracture patients (n=2181, 61.4%) in 2023, a further increase of 32.2% as compared to previous year. Clinical leadership and dedicated one-year follow-up clinic supported improved performance (21.4%, n=310) in the year 2023, which is comparable to the national benchmark (22.2%).

Conclusion: Several challenges were identified including lack of accurate telephone numbers for many patients; patients are transferred to primary care at one-year but there but the is osteoporosis knowledge gap in the community and need for dedicated time for follow-up clinic. This quality initiative has streamlined our follow-up clinics but need dedicated time to meet the service demand and increased capacity.

Introduction

People with Parkinson's disease are more likely to have osteoporosis and falls. They also have a higher risk of fractures, and their outcomes are poorer than in the general population. Despite this, only half of the patients seen in Parkinson's clinic have a bone health assessment. The aim of this project was to improve bone health assessments in the Parkinson's clinic at Mansfield Community Hospital.

Method

One plan - do-study-act cycle was completed with the implementation of a Parkinson's fracture risk assessment tool in the clinic. 19 clinic notes were evaluated over an 8-week period. The notes were scored on whether bone health was addressed using the assessment tool. Feedback was collected from the clinicians about utilising the assessment tool in clinic. The FRAX (Fracture risk assessment) tool was also used to calculate the risk of fractures in the patients selected.

Results

16/19 (84%) notes had used the risk assessment tool in clinic. There was an improvement in the bone health assessments in clinic from 5% (1/19) at baseline to 29% (5/17). The Parkinson's risk assessment tool's identification of individuals who were high risk of fractures, correlated with those identified as high risk using FRAX. The clinicians had positive reviews of the tool, but they highlighted the time constraints.

Conclusion

Whilst the use of the assessment tool has shown some improvement in the number of bone health assessments happening in clinic; it hasn't resulted in all patients having an assessment. This is likely due to the time constraints in clinic. This project was successful in highlighting the current problem to the clinicians and has led the development of a further separate clinic, where bone heath can be addressed. The risk assessment tool plays an important role in identifying high risk patients who would be referred into this service.

Introduction

Hip fracture is the most common fracture in adults over 60 years, affecting approximately 70,000 people in the UK in 2019. Mortality after hip fracture continues to be high and the cost of hip fracture is estimated at £1.1 billion per year for the NHS. It has been shown that there are key clinical indicators which can improve patient outcomes. These are monitored annually in the UK by the national hip fracture database (NHFD).

Methods

Our aim was to look at the demographics and clinical codes for patients admitted with hip fracture, codes when they are readmitted and cause of death. Information analysts at both hospitals provided authors with these data from hip fracture admissions in 2020. Inclusion criteria reflected the inclusion criteria for the NHFD. Cause of death was identified from records in the medical examiner's offices for inpatient deaths. Data were viewed and analysed in Microsoft Excel.

Results

In total, there were 878 admissions for hip fracture in 2020, 312 at Barnsley Hospital (BH) and 566 Sheffield Teaching Hospitals (STH). Average age was 80.9 at BH and 82.6 at STH. The most frequent codes on admission were 'fall' and the most common complication was pneumonia, coded in 23% of patients. 174 (56%) individuals at BH had at least one readmission in the first year and 318 (57%) at STH. The codes for readmission were varied, most commonly for musculoskeletal or orthopaedic conditions, including fracture. 85 died within one year (27.2%) and 26 died within 30 days (8.3%) at BH. 186 died within one year (32.7%) and 69 within 30 days (12.1%) at STH. The commonest cause of death was pneumonia, in 26 of 66 inpatient deaths.

Conclusions

This analysis of coding data confirms known complications following hip fracture. Morbidity and mortality following hip fracture remains extremely high.