Improving bone protection provision for patients with fragility fractures

Introduction
The NICE guidelines recommend that patients ≥ 75 years old who have sustained a fragility fracture receive osteoporosis therapy, such as bisphosphonates, alongside appropriate calcium and vitamin D supplementation. Such patients form a major component of orthopaedic inpatients; thus, a QIP was undertaken to review and improve bone protection practice at Buckinghamshire Healthcare NHS Trust.

Methods
From August 2023 to May 2024, a full-loop audit cycle was conducted pre- and post-implementation of a simple checklist, which was incorporated within patient notes to guide ward clinicians safely through osteoporosis treatment. This QIP utilised a cogent PDSA structure and effective stakeholder involvement.

Results
A total of 133 suitable patients were identified in the first cycle, and 83 in the second. When the checklist was utilised, all patients had a senior clinician-led bone protection plan put in place; a significant 37% increase (p=0.00006) compared to pre-implementation. Amongst these, there was a significant 20% increase (p=0.018) in inpatient provision of planned osteoporosis medication, elimination of unsafe prescriptions that did not check adequate renal function or blood calcium levels, and significant improvement in correct vitamin D replacement by 30% (p=0.0004). The checklist did not have a significant effect on the timeliness of bone protection provision, likely due to the wider multifactorial picture of a very busy orthopaedic team caring for unstable, co-morbid patients peri-operatively. However, the communication of correct information on discharge to primary care physicians was significantly ameliorated by 27% (p=0.006), thus hopefully enhancing the continuity of osteoporosis care in the community. Furthermore, feedback surveys from the multidisciplinary team also showed that the checklist intervention was well received, easy-to-use, and educational.

Conclusions
A simple single-page checklist has demonstrably improved the safe provision of bone protection medication for patients with fragility fractures. Hopefully, this will encourage other clinical teams caring for orthogeriatric patients to evaluate their osteoporosis practice and deploy a similar QI strategy.