12Nursing Times 02.07.14 / Vol 110 No 27 / www.nursingtimes.netKeywords: Fracture/Osteoporosis/Fragility/Bone density/Falls This article has been double-blindpeer reviewedNursing PracticeInnovationOsteoporosisSPLAuthor Mayrine Fraser is lead osteoporosis nurse specialist, Bone Metabolism Unit, Western Inrmary, Glasgow.Abstract Fraser M (2014) Using nurse-led liaison to prevent further fractures. Nursing Times; 110: 27, 12-14.Osteoporosis-related fractures are common and associated with substantial morbidity and mortality. Having one such fracture at least doubles the risk of experiencing another. Nurse-led assessment of future fracture risk and of any underlying osteoporosis can ensure treatment is ofered to reduce the risk of another fracture. However, many hospitals do not ofer a fracture liaison service, although evidence shows these services deliver high-quality care in a systematic way and are cost efective. In Glasgow, hip fracture rates have fallen over a decade since a fracture liaison service, was introduced while fracture rates have risen elsewhere. Nurses working in hospitals that do not have secondary prevention services should advise patients to seek these through theirGP.Osteoporosisisalong-term condition that causes bones to becomebrittleandincreases theriskofbonefracture. Almost three million people in the UK have osteoporosisandthereare300,000fra-gilityfractureseachyear(NationalOsteo-porosis Society (NOS), 2014). The combined cost of hospital and social care for patients with a hip fracture alone amounts to more than2.3bnperyearintheUKapproxi-mately 6m a day (NOS, 2014). In addition, 10% of patients with a hip fracture will die withinamonthand30%willdiewithina year (National Institute for Health and Care 5 key points 1 Almost three million people in the UK have osteoporosis and there are 300,000 fragility fractures each year210% of hip fracture patients will die within a month and 30% within a year 3Fracture liaison services exist in 38% of hospitals in England and 66% in Scotland4Secondary fracture prevention, including drug therapy for osteoporosis, reduces the risk of subsequent fractures5Hip fracture rates in Glasgow fell by 7% over a decade compared with a rise of 17% in EnglandExcellence,2011).Deathafterhipfractures canbetheresultoffrailty,co-morbidity, complications after surgery or immobility, and infections. People who have sustained a fracture at any site, including at the hip, are at greatest risk of further fracture (Van Staa et al, 2002). Afracturemaybetherstsignalthat osteoporosisispresentandshouldrou-tinelypromptassessmentforunderlying osteoporosis.Ifosteoporosisispresent, drug treatments have the potential to halve theriskoffurtherfractures(Boneetal, 2008; Black et al, 2007, 1996; McClung et al, 2001; Neer et al, 2001).TheDepartmentofHealth(2009)has endorsed the importance of responding to the rst fracture and preventing a second this is termed secondary fracture preven-tion.Thisisnecessaryafteranyfracture, including hip fracture. Secondary fracture prevention is regarded as an essential com-ponentofhigh-qualitycareofferedafter hip fracture (Sahota and Currie, 2008). Our fracture liaison serviceBefore1999,patientswithfractureswho wereadmittedtoWesternInrmaryin Glasgowweregivenlittleornoinforma-tionaboutosteoporosisorfracturepre-vention by hospital staff. GPs had access to dual-energy X-ray densitometry (DXA) via adirectreferralschemebutonly3%of patientswithawristfractureand12%of thosewithahipfractureunderwentbone densityassessment;veryfewpeople startedtreatmenttopreventsecondary fractures.Asaresult,thesecondaryfrac-ture prevention needs of patients with new fractureswerebeingneglected.This failingwasnotuniquetoourserviceand subsequentreportssuggestitmightbe In this article... Denition of secondary fracture prevention How a nurse-led fracture liaison service works Advising patients who have had a fractureNurse-led fracture liaison services help patients who have had one fracture avoid another one but fewer than 40% of hospitals in England ofer this serviceUsing nurse-led liaison to prevent further fracturesOsteoporotic hip fracture: the liaison service assesses fracture patients for osteoporosiswww.nursingtimes.net / Vol 110 No 27 / Nursing Times 02.07.1413servicestructuresinScotland,at21%and 25%respectively(McLellanetal,2004).In addition,theRoyalCollegeofPhysicians (2007)hasfoundcomparedwiththe>90% assessmentratereportedinorganisations with a fracture liaison service, sites with no such service achieved an assessment rate of only35%forhipfracturepatientsand19% following non-hip fracture.An independent review of the impact of GreaterGlasgowsosteoporosisandfalls strategyreportedthat,between1998and 2008,hipfractureratesreducedby7.3%. Over the same period of time, hip fracture rates increased by 17% in England (Skelton and Neil, 2009). Dell et al (2008) reported a study from southern California that showed a 37% reduction in the expected hip fracture rateoverthreeyearsfollowingtheimple-mentation of a systematic approach to sec-ondaryfracturepreventionin11hospitals serving a population of 3.1 million patients.Further details of the Glasgow service are available(McLellanetal,2003);thismodel hasbeenshowntobebothcost-effective and cost-saving. Nurse leadership is crucial to its success in delivering high-quality care systematically to large numbers of patients with fractures in a cost-effective way.ClunieandStevenson(2008)imple-mented a similar fracture liaison service in Ipswichanddescribeindetailthe resourcesrequiredtosetitup.IntheUK, thereareothermodelsofservicethat achievethesamefundamentalgoalsbut reect variations in local practice. The postcode lotteryTheRCP(2009)auditoffallsandbone healthserviceshighlightedthatmuchof the NHS in England had failed to put ade-quate systems in place to ensure secondary preventionofosteoporoticfragilityfrac-tures. Figures released in 2011 showed that only38%ofhospitalsinEngland,Wales and Northern Ireland had a fracture liaison service(RCP,2011),comparedwith66%of hospitals in Scotland.andbenetswiththepatientandsendsa treatmentrecommendationletterto their GP. Furtherwritteninformationispro-videdtosupporteducationgivenatthe clinic,alongwithcontactdetailsforthe NOS where patients can obtain more infor-mationiftheywish.Patientsarealso advisedonlifestylechange,including exerciseclassesattheirlocalleisurecen-tres. Those who have a degree of frailty are referred for physiotherapy assessment and a12-weekexerciseprogramme.Patients are advised about the potential duration of treatmentandwhenfollow-upisrecom-mended.Patientsarealsotoldthatifthey experienceanyside-effectsfromtheir medication,theyshouldcontacttheirGP orthenursespecialisttoreceiveadvice regarding an alternative. Patientswhoareperceivedtobeata higherriskoffallingarereferredtothe community falls prevention service. Some patients require more complex treatment, suchasparenteraldrugtherapy,andour servicerefersthemtotheconsultant endocrinologist-run bone clinic. Further education is offered to all those recommendedtreatment,intheformof afternoon sessions about osteoporosis and fracture prevention. The efectiveness of the fracture liaison servicesA fracture liaison service transforms post-fracturecare.Itsprimaryroleistoensure thatpatientswhowillbenetfrominter-ventions,includingmedication,receive them to prevent secondary fractures.Themodelofcareworksbecauseit assumesresponsibilityforidentication, investigation and for intervention it does notrelyonorthopaedicsurgeonsorGPs referringpatientsforassessment.It ensuresthatpatientswhoareatthe highest risk of fracture within any popula-tioncanroutinelyaccessthetreatment they require (McLellan and Fraser, 2007).TheBritishOrthopaedicAssociation identiesanintegratedfractureliaison service as the most effective means of pro-viding secondary fracture prevention (BOA and British Geriatrics Society, 2007).Thefractureliaisonserviceoffered assessmentto95%ofwristfracturesand 97%ofhipfracturescomparedwithother widespread.Hippisley-Coxetal(2007) identiedthatamongolderpatientswho had had a fragility fracture, only one in 10 women and one in 50 men had evidence of having been referred for a DXA in their pri-mary care records.In1999,wepioneeredthefracture liaison service. This service takes responsi-bility for three key steps in the pathway to fracture secondary prevention: Identication identifying all patients aged over 50 years with new presentations of low trauma or fragility fractures. Low trauma fractures are those that occur with little trauma or force, from a standing position or lower, that is usually not great enough to cause broken bones. Investigation patients are investigated for osteoporosis by DXA and for its underlying causes and their risk of further fractures is determined. Intervention this includes drug treatments to prevent further fractures (where indicated) and strategies to lessen future risk of falls. Osteoporosis nurse specialist roleAllthreeofabovestepsaretheresponsi-bilityofthefractureliaisonserviceosteo-porosisnursespecialist,whoactsasthe linkpersonbetweentheorthopaedic department and the bone metabolism unit. To identify those with new clinical frac-tures, the nurse specialist visits the ortho-paedicwardsdaily,andattendsfracture clinics or checks fracture clinic lists. Identicationofpatientswithnew reports of vertebral fractures also requires accesstoradiologyreportingsystems,as patientswithvertebralfracturesseldom presentacutelytoourhospitalwards or clinics.PatientsaregivenNOSinformation leaetsaboutosteoporosisandfragility fractures at this stage to make them aware thattheirfracturemaybecausedby osteoporosis. Approximatelysixweeksaftertheir fracture,patientsattendtheone-stop nurse-led fracture liaison service clinic for investigation(includingDXA)andinter-vention.Atthisappointment,patients bringinaself-completedquestionnaire thatcoversriskfactorsforosteoporosis and for falling (Box 1).Thenursespecialistinterpretsthe resultsoftheDXA,anddeterminesthe patientsfuturefracturerisk.Iftreatment forsecondaryfracturepreventionis required,thenursespecialistuseslocal treatment protocols to decide on the most appropriatetreatment,discussesitsrisks BOX 1. RISK FACTORS FOR OSTEOPOROSIS Risk factors for osteoporosis include:Family history of osteoporosis or parental hip fracturePrevious fracture historyEarly menopauseSteroid useSmokingExcess alcohol intakeLack of exerciseQUICK FACT| |||||||||||||| | | ||||||||||||||2.3bnCombined annual cost of hospital and socialcare for patients witha hip fractureEmbrace every opportunity that comes your way and dont limit your horizonsRachael Corser p3014Nursing Times 02.07.14 / Vol 110 No 27 / www.nursingtimes.netAs a result of this, thousands of people whosustainfragilityfracturesarenot assessedforosteoporosisandmaynotbe offeredtreatmenttopreventsecondary fractures. If there is no fracture liaison ser-vicelocally,evidencesuggeststhat patientswithfracturesmaynothavethe opportunitytoaccesssecondaryfracture prevention. It is unclear if including osteo-porosisintheGPQualityandOutcomes Frameworkhasresultedinmorepatients undergoing post-fracture assessment.Ifthereisnoserviceavailabletooffer secondaryfractureprevention,nurses working in orthopaedic wards and fracture clinicsareinanexcellentpositionto empowerpatientsandadvisethemthat theyshouldgototheirGPtodiscusssec-ondaryfractureprevention,includingthe availability of assessment services locally.In October 2013, NOS launched the Stop at One campaign to raise public awareness offracturescausedbyosteoporosis.The campaign encourages people 50 years and over who have experienced a fragility frac-ture to make their rst break their last by speaking to their GP about full assessment oftheirfuturefracturerisk.Itrecom-mendsthatafractureliaisonservice shouldbelinkedtoeveryhospital receivingfragilityfracturesintheUK,to ensure that every fragility fracture patient gets the treatment and care they need.ConclusionProvision of fracture liaison services in the UKissuboptimalandsecondaryfracture prevention is postcode driven. Large num-bers of people in the UK are missing out an opportunity to reduce their future fracture risk following a fracture. TheNOSStopatOnecampaignwill helptoraisepublicawarenessandhope-fullyinuencepolicymakersatnational andregionallevelstoensurethatfracture liaisonservicesbecomeavailableevery-where in the UK. Nurses will continue to play a vital role in leading fracture liaison services and raising awareness of secondary prevention. NTReferencesBritish Orthopaedic Association, British Geriatrics Society (2007) The Care of Patients with Fragility Fracture. London: BOA.Bone HG et al (2008) Efects of denosumab on bone mineral density and bone turnover in postmenopausal women. Journal of Clinical Endocrinology and Metabolism: 93: 6, 2149-2157.Black DM et al (1996) Randomised trial of efect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet; 348: 9041, 1535-1541.Black DM et al (2007) Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. New England Journal of Medicine; 356: 1809-1822.Clunie G, Stevenson S (2008) Implementing and running a fracture liaison service: an integrated clinical service providing a comprehensive bone health assessment at the point of fracture management. Journal of Orthopaedic Nursing; 12: 3, 159-165.Dell R et al (2008) Osteoporosis disease management: the role of the orthopaedic surgeon. Journal of Bone and Joint Surgery: American Volume; 90: Suppl 4, 188-194.Department of Health (2009) Falls and Fractures: Efective Interventions in Health and Social Care. Leeds: DH.Hippseley-Cox J et al (2007) Evaluation of Standards of Care for Osteoporosis and Falls in Primary Care. tinyurl.com/OsteoporosisCareMcClung MR et al (2001) Efect of risedronate on the risk of hip fracture in elderly women. The New Nursing PracticeInnovationEngland Journal of Medicine; 344: 333-340.McLellan A et al (2004) Efectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland. tinyurl.com/fracture-Scotland McLellan A et al (2003) The fracture liaison service: success of a program for the evaluation and management of patients with osteoporotic fracture. Osteoporosis International; 14: 12, 1028-1034.McLellan A, Fraser M (2007) Orthogeriatric care/fracture clinic liaison. In: Lanham-New S et al (eds) Managing Osteoporosis. Oxford: Clinical Publishing. Neer R et al (2001) Efect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. The New England Journal of Medicine; 344: 1434-1441.National Institute for Health and Care Excellence (2011) Hip Fracture. The Management of Hip Fracture in Adults. guidance.nice.org.uk/cg124National Osteoporosis Society (2014) Key Facts and Figures. tinyurl.com/nos-factsRoyal College of Physicians (2011) Falling Standards, Broken Promises. London: RCP.Royal College of Physicians (2009) National Audit of the Organisation of Services for Falls and Bone Health of Older People. London: RCP/Healthcare Quality Improvement Partnership.Royal College of Physicians (2007) National Clinical Audit of Falls and Bone Health in Older People. London: RCP/Healthcare Commission.Sahota O, Currie C (2008) Hip fracture care: all change. Age and Ageing; 37: 2, 128-129.Skelton D, Neil F (2009) NHS Greater Glasgow and Clyde Strategy for Osteoporosis and Falls Prevention 2006-2010: An Evaluation 2007-2009. Glasgow: Health Qwest/Glasgow Caledonian University.Van Staa TP et al (2002) Does a fracture at one site predict later fractures at other sites? A British cohort study. Osteoporosis International: 13: 624-629. Reduction of bone density, which may be caused by osteoporosis, predisposes patients to bone fractureOsteoporosis is most common in women who are post-menopausal; one in two women will experience a fragility fracture in the post-menopausal periodHip fractures are a common consequence of falls in people with osteoporosisA web-based tool, FRAX (www.shef.ac.uk/FRAX/tool.jsp), is available to help determine 10-year fracture probability by integrating clinical risk factors and bone mineral densityAnti-fracture drugs can reduce the risk of fracture but need to be taken consistently for many yearsBOX 2. 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