148 Orthogeriatrics, Just the Beginning

Abstract Background The most common cause of admission to the orthopaedic ward are low trauma falls resulting in a hip fracture. These fragility fractures occur in older, frail, multi-morbid patients and they are associated with a high mortality rate and significant loss of independence. The Irish Hip Fracture Database is a national clinical audit that aims to improve hip fracture care and patient outcomes. Using the Irish Hip Fracture Standards, we aimed to audit the care of hip fracture patients in an Irish Model 3 Hospital pre- and post- implementation of an orthogeriatrics service. Methods Local Irish Hip Fracture Database was reviewed to assess the six Irish Hip Fracture Standards prior and 4 months following the introduction of a consultant-led dedicated orthogeriatrics service. Results There were 63 hip fracture patients (mean age 81) in the pre-service group and 69 (mean age 81) in the post-service group. Standard 1: 3.2% of hip fractures were admitted to the orthopaedic ward within 4 hours in the pre-service group versus 18.8% post-service introduction (national average 11%, 2017). Standard 2: 67.9% underwent surgery within 48 hours and during working hours versus 67.8% (national average 69%, 2017). Standard 3: 3.5% developed a pressure ulcer during their stay pre-service versus 1.6% post-service (national average 3%, 2017). Standard 4: 4.8% were assessed by a Geriatrician pre-service versus 84% post-service (national average 50%, 2017). Standard 5: 24.6% received a bone health assessment versus 87.5% post-service (national average 73%, 2017). Standard 6: 1.8% received a falls assessment prior to discharge versus 82.8% post-service (national average 47%, 2017). Conclusion The introduction of a dedicated orthogeriatrics service has led to a more collaborative multi-disciplinary approach to patient care with evidence of improvements in all Irish Hip Fracture Standards. Commitment to a resourced orthogeriatric service providing rapid comprehensive geriatric assessments is essential to advance improvements in older patients’ care.

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284 Improving Adherence to Irish Hip Fracture Database Standards 1 and 2

Age and Ageing ◽

10.1093/ageing/afz103.179 ◽

2019 ◽

Vol 48 (Supplement_3) ◽

pp. iii17-iii65

Author(s):

Siofra Hearne ◽

Hannah Smyth ◽

Pheadra Monahan ◽

Hugh McGowan ◽

Shirley Timmins ◽

...

Keyword(s):

Hip Fracture ◽

Health Professionals ◽

Older Patients ◽

Orthopaedic Surgery ◽

Oral Anticoagulants ◽

Poor Performance ◽

Working Hours ◽

Close Collaboration ◽

Allied Health Professionals ◽

Orthopaedic Ward

Abstract Background The Irish Hip Fracture Database (IHFD) National Report 2017 demonstrated poor performance across all six IHFD standards in our hospital. For the purpose of this study we focused on standards 1 and 2. IHFD standard 1: All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of ED presentation/ brought directly to theatre from ED within 4 hours, and IHFD standard 2: All patients with hip fracture who are medically fit should have surgery within 48 hours of admission and during normal working hours. Methods We examined IHFD standards 1 and 2 from August 2017-January 2018 and August 2018-January 2019 after the appointment of an orthogeriatrician and use of the first Hip Fracture Pathway in August 2018. We also analysed data collected from February-April 2019 after amendment of the hip fracture pathway for patients presenting to the ED. Results IHFD Standard 1: From August to January 2017, 2.5% of patients were admitted to an orthopaedic ward within 4 hours versus 18.1% in 2018. IHFD Standard 2: in 2017, 64.8% underwent surgery within 48 hours during working hours, versus 65.3% in 2018. From February to April 2019, 32.1% of patients were admitted to an orthopaedic ward within 4 hours (IFHD 1) and 56.6% of patients underwent surgery within 48 hours and during working hours (IFHD 2). Conclusion Close collaboration between Emergency Medicine, Orthopaedic Surgery, Radiology, Nursing colleagues, Allied Health Professionals and Orthogeriatrics and amendment of the Hip Fracture Pathway have led to improvements in Standards 1 and 2. The addition of an orthogeriatric service in the hospital has resulted in an improvement in adherence to all IFHD standards. However, there are ongoing challenges to achieving Standard 2 including limited theatre access and increasing numbers of older patients on novel oral anticoagulants.

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Too Cool? Hip Fracture Care and Maintaining Body Temperature

Geriatric Orthopaedic Surgery & Rehabilitation ◽

10.1177/2151459320949478 ◽

2020 ◽

Vol 11 ◽

pp. 215145932094947

Author(s):

James Arkley ◽

Suhib Taher ◽

Ján Dixon ◽

Gemma Dietz-Collin ◽

Stacey Wales ◽

...

Keyword(s):

Hip Fracture ◽

Temperature Control ◽

Functional Outcomes ◽

Surgical Site Infections ◽

Fragility Fractures ◽

Perioperative Period ◽

Readmission Rates ◽

Comprehensive Review ◽

Fracture Care ◽

Increase Risk

Introduction: Patients with hip fractures can become cold during the perioperative period despite measures applied to maintain warmth. Poor temperature control is linked with increasing complications and poorer functional outcomes. There is generic evidence for the benefits of maintaining normothermia, however this is sparse where specifically concerning hip fracture. We provide the first comprehensive review in this population. Significance: Large studies have revealed dramatic impact on wound infection, transfusion rates, increased morbidity and mortality. With very few studies relating to hip fracture patients, this review aimed to capture an overview of available literature regarding hypothermia and its impact on outcomes. Results: Increased mortality, readmission rates and surgical site infections are all associated with poor temperature control. This is more profound, and more common, in older frail patients. Increasing age and lower BMI were recognized as demographic factors that increase risk of hypothermia, which was routinely identified within modern day practice despite the use of active warming. Conclusion: There is a gap in research related to fragility fractures and how hypothermia impacts outcomes. Inadvertent intraoperative hypothermia still occurs routinely, even when active warming and cotton blankets are applied. No studies documented temperature readings postoperatively once patients had been returned to the ward. This is a point in the timeline where patients could be hypothermic. More studies need to be performed relating to this area of surgery.

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Vertebral Fractures in Ireland: A Sub-analysis of the DXA HIP Project

Calcified Tissue International ◽

10.1007/s00223-021-00868-7 ◽

2021 ◽

Author(s):

John J Carey ◽

Lan Yang ◽

E. Erjiang ◽

Tingyan Wang ◽

Kelly Gorham ◽

...

Keyword(s):

Hip Fracture ◽

High Risk ◽

Vertebral Fractures ◽

Fragility Fractures ◽

Vertebral Fracture Assessment ◽

International Studies ◽

Men And Women ◽

Women Subjects ◽

The World ◽

High Risk Populations

AbstractOsteoporosis is an important global health problem resulting in fragility fractures. The vertebrae are the commonest site of fracture resulting in extreme illness burden, and having the highest associated mortality. International studies show that vertebral fractures (VF) increase in prevalence with age, similarly in men and women, but differ across different regions of the world. Ireland has one of the highest rates of hip fracture in the world but data on vertebral fractures are limited. In this study we examined the prevalence of VF and associated major risk factors, using a sample of subjects who underwent vertebral fracture assessment (VFA) performed on 2 dual-energy X-ray absorptiometry (DXA) machines. A total of 1296 subjects aged 40 years and older had a valid VFA report and DXA information available, including 254 men and 1042 women. Subjects had a mean age of 70 years, 805 (62%) had prior fractures, mean spine T-score was − 1.4 and mean total hip T-scores was − 1.2, while mean FRAX scores were 15.4% and 4.8% for major osteoporotic fracture and hip fracture, respectively. Although 95 (7%) had a known VF prior to scanning, 283 (22%) patients had at least 1 VF on their scan: 161 had 1, 61 had 2, and 61 had 3 or more. The prevalence of VF increased with age from 11.5% in those aged 40–49 years to > 33% among those aged ≥ 80 years. Both men and women with VF had significantly lower BMD at each measured site, and significantly higher FRAX scores, P < 0.01. These data suggest VF are common in high risk populations, particularly older men and women with low BMD, previous fractures, and at high risk of fracture. Urgent attention is needed to examine effective ways to identify those at risk and to reduce the burden of VF.

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Implementation of an integrated care programme to avoid fragility fractures of the hip in older adults in 18 Bavarian hospitals – study protocol for the cluster-randomised controlled fracture liaison service FLS-CARE

BMC Geriatrics ◽

10.1186/s12877-020-01966-1 ◽

2021 ◽

Vol 21 (1) ◽

Cited By ~ 1

Author(s):

Isabel Geiger ◽

◽

Christian Kammerlander ◽

Christine Höfer ◽

Ruth Volland ◽

...

Keyword(s):

Hip Fracture ◽

Healthcare System ◽

Fragility Fractures ◽

Term Care ◽

Care Programme ◽

Secondary Fracture ◽

Cluster Randomised ◽

German Healthcare System ◽

Randomised Controlled ◽

Fracture Liaison

Abstract Background The economic and public health burden of fragility fractures of the hip in Germany is high. The likelihood of requiring long-term care and the risk of suffering from a secondary fracture increases substantially after sustaining an initial fracture. Neither appropriate confirmatory diagnostics of the suspected underlying osteoporosis nor therapy, which are well-recognised approaches to reduce the burden of fragility fractures, are routinely initiated in the German healthcare system. Therefore, the aim of the study FLS-CARE is to evaluate whether a coordinated care programme can close the prevention gap for patients suffering from a fragility hip fracture through the implementation of systematic diagnostics, a falls prevention programme and guideline-adherent interventions based on the Fracture Liaison Services model. Methods The study is set up as a non-blinded, cluster-randomised, controlled trial with unequal cluster sizes. Allocation to intervention group (FLS-CARE) and control group (usual care) follows an allocation ratio of 1:1 using trauma centres as the unit of allocation. Sample size calculations resulted in a total of 1216 patients (608 patients per group distributed over 9 clusters) needed for the analysis. After informed consent, all participants are assessed directly at discharge, after 3 months, 12 months and 24 months. The primary outcome measure of the study is the secondary fracture rate 24 months after initial hip fracture. Secondary outcomes include differences in the number of falls, mortality, quality-adjusted life years, activities of daily living and mobility. Discussion This study is the first to assess the effectiveness and cost-effectiveness/utility of FLS implementation in Germany. Findings of the process evaluation will also shed light on potential barriers to the implementation of FLS in the context of the German healthcare system. Challenges for the study include the successful integration of the outpatient sector as well as the future course of the coronavirus pandemic in 2020 and its influence on the intervention. Trial registration German Clinical Trial Register (DRKS) 00022237, prospectively registered 2020-07-09

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151 Optimising Bone Health on Sheffield Frailty Unit Through Quality Improvement

Age and Ageing ◽

10.1093/ageing/afab030.112 ◽

2021 ◽

Vol 50 (Supplement_1) ◽

pp. i12-i42

Author(s):

C M Orton ◽

N E Sinson ◽

R Blythe ◽

J Hogan ◽

N A Vethanayagam ◽

...

Keyword(s):

Quality Improvement ◽

Fracture Risk ◽

Fragility Fracture ◽

Bone Health ◽

Assessment Tool ◽

Health Assessment ◽

Fragility Fractures ◽

Improvement Project ◽

Number Of Patients ◽

Fracture Risk Assessment Tool

Abstract Introduction NICE and the National Osteoporosis Guidance Group (NOGG) advise on evaluation of fracture risk and osteoporosis treatment1,2, with evidence suggesting that screening and treatment reduces the risk of fragility fractures 3,4,5. However, it is often overlooked in the management of older patients within secondary care. Audit data from Sheffield Frailty Unit (SFU) in 2018 showed that national guidance was not routinely followed. Fracture Risk Assessment Tool (FRAX®) scores were not calculated and bone health was poorly managed. Therefore, we undertook a quality improvement project aiming to optimise bone health in patients presenting to SFU. Method & Intervention In January 2019 we collaborated with Sheffield Metabolic Bone Centre (MBC) to develop a pathway aiming to improve bone health assessment and management in patients presenting to SFU with a fall or fragility fracture. This included a user-friendly flow chart with accompanying guidelines, alongside education for staff. Performance was re-evaluated in May 2019, following which a tick box prompt was added to post take ward round documentation. A re-audit was performed in March 2020. Results In March 2018 0% of patients presenting with a fall had a FRAX® score calculated and only 40% of those with a new fragility fracture were managed according to guidelines. In May 2019, this had improved to 18% and 100% respectively. In March 2020 86% of patients had a FRAX® score calculated appropriately and 100% of fragility fractures were managed according to guidelines. In both re-audits 100% of FRAX® scores were acted on appropriately. Conclusions There has been a significant increase in the number of patients who have their bone health appropriately assessed and managed after presenting to SFU. However, achieving optimum care is under constant review with the aim to deliver more treatment on SFU, thereby reducing the need for repeat visits to the MBC.

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The impact of an orthogeriatric intervention in patients with fragility fractures: A cohort study

10.21203/rs.2.13090/v3 ◽

2019 ◽

Author(s):

Charlotte Abrahamsen ◽

Birgitte Nørgaard ◽

Eva Draborg ◽

Morten Frost Nielsen

Keyword(s):

Cohort Study ◽

Hip Fracture ◽

Postoperative Complications ◽

Fragility Fractures ◽

High Energy ◽

Historical Cohort ◽

Increased Risk ◽

Observational Cohort ◽

The Impact ◽

Acute Patients

Abstract Background: While orthogeriatric care to patients with hip fractures is established, the impact of similar intervention in patients with fragility fractures in general is lacking. Therefore, we aimed to assess the impact of an orthogeriatric intervention on postoperative complications and readmissions among patients admitted due to and surgically treated for fragility fractures. Methods: A prospective observational cohort study with a retrospective control was designed. A new orthogeriatric unit for acute patients of sixty-five years or older with fragility fractures in terms of hip, vertebral or appendicular fractures was opened on March 1, 2014. Patients were excluded if the fracture was cancer-related or caused by high-energy trauma, if the patient was operated on at another hospital, treated conservatively with no operation, or had been readmitted within the last month due to fracture-related complications. Results: We included 591 patients; 170 in the historical cohort and 421 in the orthogeriatric cohort. No significant differences were found between the two cohorts with regard to the proportion of participants experiencing complications (24.5% versus 28.3%, p = 0.36) or readmission within 30 days after discharge (14.1% vs 12.1%, p = 0.5). With both cohorts collapsed and adjusting for age, gender and CCI, the odds of having postoperative complications as a hip fracture patient was 4.45, compared to patients with an appendicular fracture (p < 0.001). Furthermore, patients with complications during admission were at a higher risk of readmission within 30 days than were patients without complications (22.3% vs 9.5%; p < 0.001). Conclusions: In older patients admitted with fragility fractures, our model of orthogeriatric care showed no significant differences regarding postoperative complications or readmissions compared to the traditional care. However, we found significantly higher odds of having postoperative complications among patients admitted with a hip fracture compared to other fragility fractures. Additionally, our study reveals an increased risk of being readmitted within 30 days for patients with postoperative complications.

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Management of patients admitted to hospital with acute vertebral fragility fractures: a modified Delphi study

Age and Ageing ◽

10.1093/ageing/afaa225 ◽

2020 ◽

Author(s):

Terence Ong ◽

Opinder Sahota ◽

John R F Gladman

Keyword(s):

Fragility Fracture ◽

Delphi Study ◽

Hospital Care ◽

Health Assessment ◽

Fragility Fractures ◽

Clinical Area ◽

Modified Delphi ◽

Line Imaging ◽

Strongly Agree ◽

Vertebral Fragility Fracture

Abstract Introduction Acute vertebral fragility fracture requiring hospital admission is common, painful and disabling. No comprehensive clinical guideline for their care exists. To support the development of such a guideline, we sought the views of experts in the field. Methods A modified Delphi study was used. A total of 70 statements were presented, using an online platform, over three consensus-seeking rounds, to participants with experience in the hospital care of patients with acute vertebral fragility fractures from UK-based specialist societies. Participants rated the level of their agreement with each statement on a 5-point Likert scale. Consensus was defined at 70% of respondents choosing either agree/strongly agree or disagree/strong disagree. Over the first two rounds, statements not reaching consensus were modified in subsequent rounds, and new statements proposed by participants and agreed by the research team could be added. Results There were 71 participants in the first round, 37 in the second round and 28 (most of whom were geriatricians) in the third round. Consensus was reached in 52 statements covering fracture diagnosis, second-line imaging, organisation of hospital care, pain management and falls and bone health assessment. Consensus was not achieved for whether vertebral fragility fractures should be managed in a specific clinical area. Discussion These findings provide the basis for the development of clinical guidelines and quality improvement initiatives. They also help to justify research into the merits of managing acute vertebral fragility fracture patients in a specific clinical area.

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870 Early Weight Bearing In > 60 Years - Is It All A Dream?

British Journal of Surgery ◽

10.1093/bjs/znab134.332 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

S Kapoor ◽

B Choudhry ◽

M Ahmed

Keyword(s):

Weight Bearing ◽

Group Versus ◽

Femoral Fractures ◽

Fragility Fractures ◽

Analysis Data ◽

Lower Limb Injuries ◽

Early Weight Bearing ◽

Limb Injuries ◽

Operative Fixation ◽

Reoperation Rates

Abstract Background: Early weight bearing (EWB) is increasingly considered acceptable in surgically managed fractures. However, there are two different outlooks for rehabilitation. EWB in a biologically weak bone may lead to implant failure compared to EWB being beneficial for quicker recovery. We aim to review outcomes for EWB in surgically managed fragility fractures. Method: This was a retrospective analysis; data was collected from departmental records of operative fixation of lower limb injuries in patients above 60 years. We excluded patients who had procedures for proximal femoral fractures and polytrauma. We compared SF-12 scores, complications, and reoperation rates in those that were EWB to those that were at the conventional 6-week mark. Results: During a 6-month period from November 2019 to April 2020 we performed 60 operations. N = 30 surgeries were performed in EWB group versus 30 surgeries in late weight bearing group (LWB). The average physical and mental SF-12 score in EWB group was 44.82 and 56.36 compared to a SF-12 score of 44.51and 52.18 in LWB. Conclusions We found that the SF-12 scores were different despite EWB. There was no evidence of early complications in the EWB group. Therefore, we advocate EWB for group >60 who were known to have osteoporosis.

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Failure in the application of fragility fracture prevention guidelines

Annals of The Royal College of Surgeons of England ◽

10.1308/003588414x13946184901164 ◽

2014 ◽

Vol 96 (5) ◽

pp. 381-385 ◽

Cited By ~ 10

Author(s):

MH Elvey ◽

H Pugh ◽

G Schaller ◽

G Dhotar ◽

B Patel ◽

...

Keyword(s):

Hip Fracture ◽

High Risk ◽

Fragility Fracture ◽

Fragility Fractures ◽

Fracture Prevention ◽

Consecutive Series ◽

National Guidelines ◽

Fracture Population ◽

The Mean ◽

The Uk

Introduction The cost of fragility fractures to the UK economy is predicted to reach £2.2 billion by 2025. We studied our hip fracture population to establish whether national guidelines on fragility fracture prevention were being followed, and whether high risk patients were identified and treated by local care services. Methods Data on a consecutive series of trauma hip fracture admissions were collected prospectively over 14 months. National Institute for Health and Care Excellence (NICE) and National Osteoporosis Guideline Group (NOGG) recommendations and FRAX® risk calculations were applied to patients prior to their admission with a new hip fracture. Results Overall, 94 patients were assessed against national guidelines. The mean population age was 77 years. Almost a quarter (22%) of patients had suffered a previous fragility fracture. The mean FRAX® ten-year probability of hip fracture was 7%. According to guidelines, 45% of the study population required treatment, 35% fulfilled criteria for investigation and reassessment, and 20% needed no further management. In practice, 27% received treatment, 4% had undergone dual energy x-ray absorptiometry and were untreated, and 69% had not been investigated and were untreated. In patients meeting intervention thresholds, only 33% of those who required treatment were receiving treatment in practice. Conclusions In conjunction with NICE and NOGG recommendations, FRAX® was able to identify 80% of our fracture population as intermediate or high risk on the day of fracture. Correct management was evident in a third of cases with a pattern of inferior guideline compliance seen in a London population. There remains a lack of clarity over the duty of care in fragility fracture prevention.

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