Joints

Introduction

Current NICE guideline recommends the use of either the FRAX or Qfracture score to assess the probability of future fragility fractures before measuring a patient’s bone mineral density. However, Qfracture has poor predictive ability in patients above the age of 85. As such, we investigated if the addition of clinical frailty status may enhance Qfracture risk prediction in an older age group.

Methods

Data were collected from consecutive admissions to an Emergency Frailty Unit (EFU) ofoin Ysbyty Ystrad Fawr Hospital, between 1 April 2015 to 31 March 2017. Demographic information, Clinical Frailty Score (CFS), Charlson Co-morbidity Index (CCI), and Barthel Index (BI) were obtained on patient admission. Qfracture scores were calculated and the database was reviewed for any fragility fractures sustained. Receiver operating characteristics (ROC) curves were generated for all possible variables that may predict fragility fractures in patients. Area under the curve (AUC) results were also calculated, with standard error, significance, and 95% confidence intervals.

Results

A total of 1503 admissions were recorded. After filtering for missing data and repeated admissions for the same patients, 790 patients (Male n=304, Female n=486) were included in the final analysis. A total of 148 fragility fractures were recorded. Average CFS (Male 6.4±1.2, Female 6.5±1.1) and CCI (Male 6.5±2.3, Female 6.2±2.0) is as noted. Average Qfracture score (10 year risk for all fractures) were recorded to be 14.9±10.3 for male participants and 25.7±11.3 for female participants respectively. ROC curves and AUC analyses generated shows that CFS (AUC 0.466 p=0.200), CCI (AUC 0.500, p=0.986) and BI (AUC 0.511, p=0.671) have no predictive ability for fragility fractures.

Conclusion

This study did not demonstrate enhanced predictive ability in the Qfracture score, with the additional of clinical frailty status. (283 words)

Introduction

During 2022, non-femoral fractures that didn’t require operative management had 30 days median inpatient length of stay (LOS) at SBUHB. Femoral fracture patients >65 years had LOS 36 days (GIRFT average 19 days), with 720 admissions. High local incidence is believed to be contributed by historical failures to identify and treat non-femoral fragility fractures. A new service was created from a collective effort to do better for our patients and prevent avoidable harm by breaking down barriers between services and promoting effective collaborative working.

Methods

A collaboration between the following key services was formed :- 1. Older Persons Assessment Service (OPAS) -identify fragility fractures presenting to ED 2. Orthogeriatrics -identify suitable femoral fracture patients 3. Physiotherapy -early assessment and transfer to reablement into the community. 4. Virtual Wards –ongoing CGA and reablement in the community Additional resource was secured to provide short-term bridging of care and community therapy input. Data was prospectively collected and included demographics, site of fracture, referrer and LOS.

Results

From March 2023, the service identified 457 patients, 312(68.7%) Female, median age 86 years. 157(34.6%) patients had a femoral fracture and 300(65.4%) were non-femoral fragility fractures, majority identified by OPAS, with 206(68.7%) being discharged same day. Overall, admission was avoided in 207(45.3%) patients and 247(54.6%) had an early discharge/reduced LOS with 3(0.1%) re-admissions avoided. The mean LOS on discharge is 6.6 days with a calculated monthly bed saving of 13.9 days across the service.

Conclusion

Collaborative working has created an early supported discharge pathway. Femoral fracture patients are discharged earlier, some 3 days post-op, with the necessary support to continue reablement at home. Fragility fractures are identified at the front door and offered same-day discharge with ongoing comprehensive geriatric assessment and reablement within the virtual wards with positive feedback from patients and their families.

Introduction

During 2022, non-femoral fractures that didn’t require operative management had 30 days median inpatient length of stay (LOS) at SBUHB. Femoral fracture patients >65 years had LOS 36 days (GIRFT average 19 days), with 720 admissions. High local incidence is believed to be contributed by historical failures to identify and treat non-femoral fragility fractures. A new service was created from a collective effort to do better for our patients and prevent avoidable harm by breaking down barriers between services and promoting effective collaborative working.

Methods

A collaboration between the following key services was formed :- 1. Older Persons Assessment Service (OPAS) -identify fragility fractures presenting to ED 2. Orthogeriatrics -identify suitable femoral fracture patients 3. Physiotherapy -early assessment and transfer to reablement into the community. 4. Virtual Wards –ongoing CGA and reablement in the community Additional resource was secured to provide short-term bridging of care and community therapy input. Data was prospectively collected and included demographics, site of fracture, referrer and LOS.

Results

From March 2023, the service identified 457 patients, 312(68.7%) Female, median age 86 years. 157(34.6%) patients had a femoral fracture and 300(65.4%) were non-femoral fragility fractures, majority identified by OPAS, with 206(68.7%) being discharged same day. Overall, admission was avoided in 207(45.3%) patients and 247(54.6%) had an early discharge/reduced LOS with 3(0.1%) re-admissions avoided. The mean LOS on discharge is 6.6 days with a calculated monthly bed saving of 13.9 days across the service.

Conclusion

Collaborative working has created an early supported discharge pathway. Femoral fracture patients are discharged earlier, some 3 days post-op, with the necessary support to continue reablement at home. Fragility fractures are identified at the front door and offered same-day discharge with ongoing comprehensive geriatric assessment and reablement within the virtual wards with positive feedback from patients and their families.

Introduction

A quarter of people with hip fractures sustain another fragility fracture within 5 years, but most receive no osteoporosis medication as secondary prevention. To coincide with the publication of ‘A call to action: a five nations consensus on the use of intravenous zoledronate after hip fracture" Age and Ageing, September 2023, we set out to explore clinicians’ reasons for not previously using zoledronate (IV Zol).

Methods

Prior to first presentation of the ‘Call to Action’ at the Global Fragility Fracture Network (FFN) and British Geriatrics Society conferences in autumn 2023, we used conference apps to run an online survey of 156 attendees (99 from UK, and 57 working in other countries).

Results

Licensing of IV Zol excludes people with creatinine clearance (CrCl) <35ml/min. Our surveys found that 27% of UK clinicians (9% of non-UK) already use a 30ml/min CrCl threshold. In addition, 13% (vs. 26%) use eGFR 30ml/min, and 23% (vs. 51%) eGFR 35ml/min as their threshold. This suggests that 63% of UK (87% of non-UK) clinicians already administer IV Zol if CrCl <35ml/min. UK clinicians indicated fewer concerns over reduced effectiveness if IV Zol was given within 14 days of fracture (56% vs. 86%), and greater preparedness to consider 4mg, rather than more expensive 5mg, doses (42% vs. 18%) and single infusions without a subsequent dose (91% vs. 68%).

Conclusions

It is important to understand why people feel reluctant to use IV Zol, despite this being the first-line recommendation of the National Osteoporosis Guideline Group (NOGG).

In particular, our demonstration that many clinicians in the UK and around the world are already using IV Zol, off license, in people with CrCl of 30-35 ml/min will support the ‘Call to Action’ paper, helping many more hip fracture patients with renal function in this category to receive a medication of proven effectiveness.

Introduction Many patients admitted with fragility femoral fractures have established cognitive impairment but no formal diagnosis of dementia. This lack of pre-existing diagnosis impacts care, counselling and discharge planning. This audit assessed how many people aged >65 admitted with a fragility fracture had information, at the time of admission, suggesting a likely but unconfirmed diagnosis of dementia and how their length of stay (LOS) and discharge destination compared to patients with confirmed dementia.

Methods 47 consecutive patients aged >65, admitted with a fragility femoral fracture had their electronic care records reviewed to identify information suggesting the presence of cognitive impairment/dementia. 30-day mortality, LOS and discharge destination was compared for three groups, 1) dementia, 2) informal dementia diagnosis and 3) no evidence of cognitive impairment.

Results Of 47 patients reviewed, 35(74%) were female, mean age 80.6 years (range, 68-94). Of these, 7/47(15%) had an established dementia diagnosis (mean age 82.4 years), 9/47 (19%) had unconfirmed cognitive impairment/dementia but without a formal diagnosis (mean age 82.2years) and 31/47 (66%) had no evidence of cognitive impairment(mean age 79.7 years). In cases of confirmed dementia diagnosis, the mean LOS was 54.7 days (range, 16-114). One patient died 1/7 (14.3%) and 3/7 (42.9%) were discharged home. For patients with an informal dementia diagnosis, the mean LOS was 35 days (range, 7-74). Two patients (2/9) died (22.2%), and 3/9 (33.3%) were discharged home. For those with no cognitive impairment, the mean LOS was 36 days (range, 7-92). Three patients 3/31 (9.7%) died, and 22/31 (71.0%) were discharged home.

Conclusion A significant minority of patients had likely undiagnosed dementia, with mortality and discharge destinations similar to patients with recognised dementia. Services need to consider how best to identify and diagnose cognitive impairment/dementia at the time of admission for fragility fractures.

Introduction:

Inappropriate polypharmacy is recognised as a contributing factor towards adverse outcomes in frail patients. Current efforts at national level are centred around primary care initiatives in completing structured medication reviews (SMR) where shared decision making takes place with open discussion around risks and benefits of treatments. The aim of this review was to assess whether recommendations for discussion in SMR have been adopted for patients attending frailty bone health clinic led by Consultant Pharmacist, in hospital outpatient setting.

Method:

Retrospective analysis of notes was undertaken in a sample of 30 patients reviewed in clinic in the period 01.09.22 - 28.02.23 who were on at least five medications, were still alive six months post review and where suggestions with regards to actions to discuss during a structured medication review were made.

Results:

Average age of patients sampled was 79 years with average CFS of 5.75. Number of medicines documented at outpatient appointment was on average 10.6 which reduced to 9.95 at review six months after the appointment. Around a third of recommendations were adapted fully, with another third partially completed and a third not completed. Interventions included review of falls risk increasing drugs (FRIDs), reduction of anticholinergic load, identification of possible prescribing cascades, review of opioiod medication in chronic pain context and review of medicines where benefit may no longer be derived due to frailty progression. In cases where review of medication with high anticholinergic load was advised, an average reduction of -3 was achieved at six month review.

Conclusion(s):

Starting a structured medication review in outpatient clinic has the potential to reduce the risk of adverse events and improve outcomes for patients. Further work will be undertaken to ascertain reasons for not adopting the recommendations and continuous collaboration with primary care colleagues will continue to address problematic polypharmacy.

Introduction:

Assessment of lying and standing blood pressure is commonly undertaken in geriatric medicine to make a diagnosis of orthostatic or postural hypotension. We carried out the audit to review the clinical practice and assess its adherence to the Royal College of Physicians (RCP) guidance on how to accurately measure the lying and standing blood pressure (Falls and Fragility Fracture Audit Programme).

Method:

It was a prospective audit. The first audit cycle was conducted in July 2020 and the second cycle in April 2021

Results:

During the first data collection, the practice was reviewed in 69 patients. 35 were female (age range 63-92 years) and 34 male (age range 72-95 years). The lying and standing blood pressures were measured in 27 patients. Only 4 were performed as per the RCP guidance. 34 team members (including doctors, nurses, healthcare assistants, etc.) were randomly surveyed on how to correctly measure lying and standing blood pressure. None were aware of the RCP guidance in this context. We delivered local presentations of the results of the audit and RCP guidance flyers were displayed on the bulletin boards in the department. During the second cycle, the practice was reviewed in 58 patients. 30 were female (aged 67-94 years) and 28 male (aged 68-96 years). The lying and standing blood pressures were measured in 32 patients, of which 20 were recorded according to the RCP guidance. There was an increase of adherence to the guidance from 14.8% to 62.5% after undertaking the aforementioned interventions.

Conclusions:

Following dissemination of the RCP guidance on how to accurately measure the lying and standing blood pressures, we witnessed an improvement in the practice suggestive of an improved clinical effectiveness. Robustly evaluating a service followed by education of the staff can lead to enhanced clinical care and quality improvement.

Introduction: Best practice tariff for Neck of Femur Fractures (NOFF) includes establishing a bone protection plan (BPP). Optimal management is often delayed due to insufficient vitamin D levels. Here we reviewed the administration of anti-resorptive (AR) therapies when giving vitamin D loading doses over 7 weeks compared to stat high dosing followed by maintenance therapy.

Method: Pre-intervention, we reviewed vitamin D levels, treatment given and bone protection therapy administered in all new NOFF admissions over 3 months. We introduced once-only high dose vitamin D therapy in deplete individuals over subsequent 3 months; deplete (Vit D <50) patients received 140,000 units stat colecalciferol, patients with insufficient levels(Vit D 50-70) received 60,000 units stat colecalciferol and replete individuals received adcal maintenance. Patients were given in-patient AR therapy or referred to fracture liaison service (FLS).

Results: Pre-intervention included 64 patients, of which 61% (N=39) had low vitamin D levels. These patients were loaded with once weekly 40,000 units of colecalciferol for 7 weeks and referred to FLS; 51% (N=24) received an appointment within 4 months. Only 14% (N=9) received in-patient AR treatment. Post intervention, 84 patients were reviewed. Vitamin D replacement was required in 69% (N=59) of patients, of which 83%(N=49) received the new loading regimen. This allowed 53% (N=20) of eligible patients to receive in-patient AR therapy.

Conclusion: Administrating high dose vitamin D to NOFF patients allowed us to increase in-patient AR therapy treatment 3.7 times. This simple intervention results in less out-patient appointments and treatment is given before opportunity to re-fracture.

Introduction

There are around 250,000 inpatient falls in English hospitals each year. Inpatient falls are associated with poor outcomes. Evidence suggests multifactorial assessment and intervention is the most effective way to prevent inpatient falls. There are National Institute of Health and Care Excellence (NICE) quality standards for safe post fall management. National audit supports improvement in the quality and safety of clinical care.

Methods

The National Audit of Inpatient Falls (NAIF) began collecting continuous data from all femoral fractures (as identified on the National Hip Fracture Database) in England and Wales from 2019. Prospective documentation review collects data on multifactorial falls risk assessment (MFRA) prior to the femoral fracture as well as immediate post fall management and presents performance indicators related to NICE guidelines/quality standards.

Results

There are around 2000 inpatient femoral fractures each year. Those with an inpatient fracture have double the 30-day mortality of those who fracture elsewhere, highlighting the vulnerability of this group of patients. There has been improvement in most aspects of MFRA and the proportion of patients checked for injury before moving from the floor has increased from 69 to 77%, use of flat lifting equipment from 22 to 29% and medical assessment within 30mins of the fall from 52 to 60%.   

Discussion

There have been steady improvements in guideline compliant inpatient fall-prevention and post-fall management, but there is more to do. The programme also produces improvement resources and activities and will be expanding the range injuries covered in the next 2 years.

Inpatient falls remain a huge problem in hospital, causing significant injuries to patients and are an avoidable cost to the NHS. Therefore, the National Audit of Inpatient Falls (2015-2017) set out key recommendations for management of falls, including the measurement of LSBP within 3 days of hospital admission.

Our project was conducted in a major acute teaching hospital in North West London across three geriatric wards. Our aim was to improve the measurement of LSBP and correct documentation across the wards in line with the NAIF guidelines. We excluded patients unable to mobilise to standing with support, patients too unwell or unable to follow instructions and actively dying patients.

Prior to any intervention, we found that only 24% of patients had LSBP performed within three days of admission. We focused our intervention in raising education and awareness across our staff. We arranged weekly reminders during MDT meetings, created posters and organised twice monthly teaching sessions, including one to one, on how to document correctly electronically.

After one month of intervention, 73% of patients had LSBP as part of the ward round plan and almost half of patients had it correctly recorded on our system. After 4 months, we reaudited our project and found that only 32% of patients had LSBP appropriately recorded. This significant decrease can be explained by the changeover of junior doctors and emphasises the need of a more sustainable change.

Our goal is making LSBP part of a routine preadmission checklist when appropriate. We are currently working on making changes to our electronic patient record (EPR) to facilitate documentation to members of staff. This includes a new falls assessment tool and the newly incorporation of Smartzone feature on EPR. This will allow staff to put non-critical jobs in the workflow showing a less intrusive alert until completed.