ABSTRACT
Background: Bisphosphonates are used to prevent skeletal-related events (SRE), such as pathological fracture and spinal cord compression1 in patients with multiple myeloma. Although intravenous bisphosphonates are generally well tolerated, potential serious complications include osteonecrosis of the jaw (ONJ) and hypocalcaemia. Monitoring, such as a dental review, and blood tests (creatinine, calcium and vitamin D) are important to detect early signs of ONJ.1 A suspected case of ONJ at the Haematology Day Care Unit (HDCU) highlighted that checks and monitoring before prescribing and administering bisphosphonate infusions was suboptimal. The aim of this quality improvement project was to improve bisphosphonate monitoring in the HDCU to identify and manage suspected cases of ONJ. Method: The Model for Improvement provided a framework to structure the project enabling small tests of change using plan-do-study-act (PDSA) cycles to improve patient safety.2 We planned three PDSA cycles, each conducted at four-week intervals. We recorded when blood tests (calcium, vitamin D, phosphate, PTH, creatinine) and dental checks were documented. To measure the scale of the problem, baseline measurements were recorded during November and December 2019. An education and training session for the multidisciplinary HDCU team was undertaken in January (PDSA cycle 1) to raise awareness of monitoring. PDSA cycle 2 (February) involved the inclusion of dental and blood monitoring on the HDCU referral checklist. A third PDSA cycle planned for March 2020 was to implement dental alert cards for patients.1 Results: A total of 71 patients received bisphosphonate infusions between November and December 2019. Of these, no records were found of patients having had a dental review and 10% of patients had all bloods tests done at baseline. After training (PDSA cycles 1) 70% of patients had dental reviews recorded and 71% of patients had all blood tests completed. This improved to 86% of patients having had dental reviews and 95% having all blood tests completed after introduction of monitoring parameters on the referral checklist (PDSA cycle 2). PDSA 3 was not completed. Discussion and conclusion: We demonstrated that simple interventions led to improvements in dental reviews and blood monitoring for patients on bisphosphonate infusions. Limitations of the project were the small sample size and short duration of data collection. Furthermore, PDSA cycle 3 was interrupted in March 2020 due to national guidelines3 mandating delay of non-urgent treatment during the COVID-19 pandemic. Staff training and the introduction of a monitoring checklist represent feasible methods to ensure safe prescribing and administration of bisphosphonate infusions. Since the project, there have been no reported cases of bisphosphonate-related ONJ in the HDCU. Further work is required to increase patient and healthcare team awareness of the need for regular dental reviews..