Quality Improvement Project: Improving Osteoporosis Treatment for Patients with a Neck of Femur Fracture

ABSTRACT

Background/Aims The Fracture Liaison Service (FLS) identifies patients >50 who have sustained a fragility fracture (FF). These patients need prompt assessment and decision on appropriate treatment for osteoporosis in order to reduce their risk of sustaining further FFs. Without treatment, 1/5 patients can go on to have a further FFs which carry significant risk to mortality and morbidity. Zoledronate is a bone agent that halves the risk of another FF. Patients with a neck of femur fracture (#NOF) present as one of the most at-risk groups for a further FF. These patients are generally elderly and frail and attendance to outpatient hospital appointments are difficult. Therefore, transforming the FLS from an out-patient-based service, to one that is streamlined to systematically identify and opportunistically treat patients whilst they are still in hospital means delivering timely, effective and efficient patient-centred care. Methods We used various Plan-Do-Study-Act cycles to aim to deliver Zoledronate to>=90% of appropriately assessed in-patients >60 who have had a #NOF within a year of commencing QIP. Results PDSA cycle 1-Involvement of ortho-geriatrician P-Improve working relationship with ortho-geriatrician with an interest in bone health over a 6-month period;D-Regular meetings with wider MDT;S-Priority of bone health assessments made greater through ward round documentation;A-Expand knowledge throughout the wider ortho-geriatrician team. PDSA cycle 2-Timing of Zoledronate delivery P-Literature review regarding delivery of Zoledronate timing;D-Discuss as MDT;SNo evidence to suggest delay in fracture healing if given on day 7;AAdopted process and communicated. PDSA cycle 3-FLS team on the wards as a result of PDSA cycle 2 not improving treatment outcomes: P-FLS nurses to join ortho-geriatrician ward round twice-weekly for 3- month trial period;D-Bank holidays and spike in Covid cases presented a challenge. Solution Improvement of MDT relationships;S-At the end of the trial period an increase in patients who received treatment was shown and proved our prediction;A-Adaptation to documentation in FLS to streamline and reduce duplication. Conclusion The ability to deliver Zoledronate to>=90% of appropriate patients with a #NOF as an inpatient was reached after 8 months of initiating QIP. Furthermore, maintaining this was consistently achieved throughout the following year and beyond. A few of the main reasons for this included earlier drug delivery, having a dedicated ortho-geriatrician as part of the FLS, and the FLS team attending the wards. A prompt bone health assessment of patients has enabled appropriate treatment to be delivered efficiently. The delivery of Zoledronate as an in-patient has meant that a significantly greater proportion of patients receive treatment, and sooner, in comparison to awaiting an outpatient assessment (that they may not attend). Therefore, this QIP has demonstrated time- and cost-effective management of patients with #NOF requiring Zoledronate.