Kathryn ThompsonOsteoporosis Clinical Nurse Specialist
FLS: Starting from scratch
Rotherham Osteoporosis & Bone Health Service
Bone Health, Falls and Fracture Liaison Service
2006 2016
In the beginning
Then Now
20061995
1997 1999
2003 2005
Recalling the nine year journey…
Time-line for Service Development
• 1995 – Interested clinicians from primary and secondary care began a series of evening meetings;
• 1997 – Rotherham Guidelines for prevention, detection and management of Osteoporosis published;
• 1999 – Tessa Jowell, Minister for Health, required Health Authorities to develop a strategy for osteoporosis & fracture prevention;
• 2003 – Rotherham Strategy and action plan launched;
Time-line for Service Development (2)
• 2005 - RFT responded to tendering process offered by Rotherham PCT to provide an osteoporosis service with allied bone metabolism clinic;
• 2006 – (September) – ‘Rotherham Osteoporosis & Bone Health Service’ commenced in main outpatient department at RGH;
• 2007 – (November) – Official opening by Trudie Goodwin, NOS Patron;
• 2009 – (February) – Service visited by HRH Duchess of Cornwall, President of NOS.
Rotherham Osteoporosis & Bone Health Service2006-2009
Source of Referrals for BMD Scans Q 1&2 2007April-June
2007July-September
2007
Primary care 206 184
SecondaryCare (excl Fracture clinic)
142 153
Fracture clinic 15 29
Aims of study(Orthopaedic 2003)
1. How many patients attending fracture clinics have fragility fractures?2. Are we identifying and treating them appropriately?
– How are they then treated in primary care? (Does it matter if we don’t take the lead?)
• Initial presentation to fracture clinic• Over 18 years old• Consecutive patients from 1st March 2003 to identify 100 patients with
fractures
Appropriate Management
• BOA and NICE guidelines• All fragility fractures:
– Bone health advice– Calcium/Vitamin D
• DEXA scan if < 65 years / risk factors
• Consideration drug treatment
Results
Distribution of Fragility Fractures
Metatarsal
Ankle
Calcaneum
Humerus
NOF
Patella
Phalanx
Radius
Tibial plateau
Conclusions
• A significant number of potentially osteoporotic fractures are seen in the fracture clinic
• In an average clinic (20 new patients) only 4 patients would have fragility fractures
• Is this enough to justify a specialist nurse (as advised by BOA)?
Conclusions
• Neither orthopaedic surgeons or GPs are presently very good at identifying and managing these patients
• If they are not identified and managed by orthopaedic surgeons they are unlikely to be identified by their GPs
• We have a duty to improve level of care
Health impact
• Mortality• Morbidity• Future fractures
Vertebral fractures
1. Back pain2. Height loss3. Loss of function
Morbidity – wrist fractures
1. 20% Hospital2. 20% complications
– Malunion– RSD– osteoarthritis
Morbidity – Hip Fractures
• 100% Hospital• 40% assistance with mobility• 20% nursing home
INITIAL THOUGHTS FOR FLS-LOOK AT NUMBERS/DEMAND LOCALLY
• From 1.4.07 – 31.3.08 RFT A&E assessed 5,228 # pt’s– Total male pt’s 2,826– Total female pt’s 2,402
• From 5,228 pts – >50yrs total 1,674– # NOF 266– # wrist 1051– VFX 37– Other 320
• Without a # liaison service or formal referral process it is not possible to determine how many #s were fragility
Standards for data collection (standard to be obtained 100%, for each )
The audit became necessary as part of service evaluation/development
1. Audit ID, gender & age for all pts – 2. Is patient on oral glucocorticoid therapy?3. Is patient on any form of osteoporosis treatment?4. Were any possible risk factors for osteoporosis documented?5. Was patient referred for a BMD scan?6. What was result of scan?7. What treatment recommendations were made on the scan report?8. Was a referral for BMD scanning not applicable due to the patient’s age being
>75yrs?
Method 1
• Retrospective study
• Data collected from # clinic lists dated for the four week period: 2.1.08-31.1.08
• Between these dates 19 lists were reviewed
• 7 Orthopaedic Consultants provide a # clinic
• All patients were checked on EPR to ensure only 1 appointment was given during these dates to avoid duplication of data
Method 2
• Age of patients audited for this study were age 50+
• 189 pts >50yrs were identified from the 19 lists
• Male and female pts taken randomly (60 patients))
• Only patients where low trauma/fragility # recorded in case notes were included.
Method 3
• From the 189 patients aged >50yrs, analysis of the first 60 showed 38 patients had sustained a fracture as a result of low trauma.
• These patients would have been eligible for osteoporosis assessments e.g.– Review of lifestyle risk factors – Checking compliance with prescribed treatments– Referral for BMD scanning (as per guidelines)– Commencement of osteoporosis therapy, in some cases without need
for DEXA (as per guidelines)
How did FLS TRFT begin
• O/P CNS and Clinical Lead attended Glasgow FLS training• Many opportunities as possible to seek advice, training, attend other FLS• NOS study days• Applying for NOS ICAP funding• NOS Parliamentary lobbying• Help from NOS with TRFT CCG Commissioner for long term conditions• On & on & on & on & on until
FUNDING
WHAT ELSE DO WE NEED
• Audit/database• Secured funding• Employ staff (nurse, admin, HCA, scan technicians, medics)• Job plan for FLS CNS• Develop protocols• Patient information leaflets• Set up nurse led clinics• Advertise launch• Get going
Joining Together
Bone Health, Falls and Fracture Liaison Service
Osteoporosis & Bone Health
2006
Fracture Liaison
2015Bone Health,
Falls & Fracture Service
Community Falls Service
2009Integrated Falls & Bone Health
2014
Service model for integrated Bone Health ,Falls &Fracture Liaison Service
Previous model– Community falls which included bone health on assessment– Bone health service– Ortho-geriatrician TRFT was part of DoH Hip # best practice data
All previously delivered as a single service with minimal joint workingIntegration 2015 services aligned as a single service with one business, governance & management structure plus one consultant leadNew model
– Integrated service delivers care and treatment to patients across 3 sites– All members of the team work in all 3 sites to meet service needs– Band 2/3 HCA roles became generic providing resources across all elements– Band 7 FLS nurse recruited 2015
Aims and objectives of service
• To identify patients presenting with fragility fracture and assess them to determine their need for bone active therapy to prevent future osteoporotic fractures
• To ensure people at high risk of falls and fracture are given comprehensive assessment and evidence based intervention
• To introduce a care management pathway with clear lines of referral for an integrated approach to bone health, fracture liaison and falls prevention
• To reduce the year on year increase in falls that result in hospital admission and serious injury and to reduce the numbers of people who sustain fractured neck of femur following a fall
FRACTURE LIAISON SERVICE COMMENCED 22ND JUNE 2015
Fracture Liaison Service (FLS) NOS Model
FLS Service
Identify
Investigate
Ensure Quality
Integrate
Intervene Inform
Data report from A&E of recent fractures
Bone Health, Falls & Fracture Liaison Service> 75 years 50 – 75 years
vertebral fracture? Referral to Bone Health Clinic to carry out further investigations. (not necessarily scanned)GP to initiate Rx to avoid delay if appropriate.
DXA Scan and results in FLS clinic
Bone Health InterventionsReport to GP with advice on treatment (as per NICE) including blood test investigations to be undertaken in Primary Care
Does patient have a diagnosis of Osteoporosis/Osteopenia
Falls PreventionMulti-factorial falls assessment.12 week fall prevention programme.The Community Otago/Tai Chi.The Active Always/Keep moving classes
No
Yes
No
Yes
Expectations for Rotherham FLS
Case finding in both primary and acute care. Improve the patients outcome.Respond to the patients first fracture and prevent further
fractures.Develop pathways for referral to FLS.Patient assessment/advice/education/ investigation/evaluation.Promote best practice using local and national guidelines and protocols.
Osteoporosis Osteopenia Normal BMD0
10
20
30
40
50
60
10
53
37
BMD Results for FLS
BMD
%
summary
Osteoporosis fractures are common, costly and getting worse.
Low trauma fractures are a strong predictor of future fractures with risk increasing with number of prior fractures.
Risk is most marked in the year following fracture.
Conclusion
• Target people at the highest risk of further fracture• Transforms post fracture care – providing a holistic approach to
care – thinking long term• Equal opportunity to all patients within our catchment area • Drug treatments /lifestyle advice are recommended
appropriately dependent on scan results
Any questionsor feedback?