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?