A Collaborative Approach to Bone Health

Purpose/Aims

Background: Osteoporosis is a global problem; people living with osteoporosis have increased dramatically in the last few decades due to the aging population and changes in lifestyle. The project aims to improve post-fracture care and use a preventative service for compromised bone quality patients in the Emergency Room (ER). The QI project aims to increase ER providers' awareness about osteoporosis and to refer appropriately to Bone Health Clinic (BHC) to prevent future fractures.

Rationale/Background

Methods: Most fractures are first treated in the ER, making ER the gateway for treating fractures. A fragility fracture (FF) care pathway was developed to help providers to identify patients at risk for osteoporosis and guide the providers in placing appropriate referrals to BHC. Educational sessions for providers, FF care pathway posters, and modified EPIC discharge smart phrases for fracture patients that prompted the ER providers to add Bone Health recommendations while discharging the FF patients were developed as part of the framework. The number of new fragility fracture patients, including spine fractures, wrist, humerus, and ankle fractures seen in ER with appropriate BH recommendations, ultimately determined the project's success.

Brief Description of the Undertaking/Best Practice

The Plan-Do-Study-Act (PDSA) model created a process change and improved patient outcomes. The conceptual framework helped to implement the proposed change, ensured leadership and management support, and established the feedback process to sustain the implemented change. Post-fracture care process improvement enabled ER physicians to recommend patients to BHC to ensure appropriate osteoporosis management, resulting in improved care from 2% to 66% of patients with fragility fractures.

Outcomes achieved/documented

The outcome measure of the intervention is the percentage of bone health recommendations made by ER providers for fragility fracture patients. The ICD code with fragility fracture patients analyzed in ER data found that 0% to 25% percent of patients were recommended to the BHC through ER providers after the intervention. The process measures report the validity of the intervention and tracked 30% of ER providers who attended the educational session; 10% to 20% of ER providers adhered to the fragility fracture pathway recommendations. Ten percent of patients accepted the BHC referrals. In contrast, 10% of patients were admitted as in-patients after surgery, and 5% of patients were discharged to skilled nursing facilities or hospice for further care without accepting the bone health referrals. Balancing measures increase patient waiting time for BHC appointments to see the provider, estimated three to four weeks from discharge. The conceptual framework emphasizes sustaining improvements; thus, upon QI completion, weekly reports will be transitioned to monthly for review and will be evaluated at quarterly multidisciplinary meetings for compliance and fiscal reports.

Conclusions

The need for this project came from my clinical experience seeing patients who suffered frequent subsequent fractures because of the failure to identify the patient as a high risk for secondary fractures and not utilizing proper preventative care. The project identified the clinical problems and reinforced Evidence-Based Practice (EBP) in FF patients related to osteoporosis to close treatment gap interventions. The project offered an opportunity to promote positive change in the post-fracture care program with collaboration and coordination with providers by recognizing at-risk patients to reduce future fractures.