The impact of a standardized order set for the management of non-hip fragility fractures in a Fracture Liaison Service

Abstract

SummaryWe analysed the impact of a standardized order set empowering staff nurses to independently manage a Fracture Liaison Service over a 9-month period. Nurses identified between 30 and 70 % of non-hip fragility fractures to the unit in charge of management over time. The latter managed 58 % of referred patients.IntroductionThe main goal of this study was to evaluate the impact of a standardized order set empowering nurses to independently manage a fracture liaison service (FLS).MethodsSince November 2014, an order set allowed nurses of a Montreal hospital, Quebec, Canada to entirely manage an FLS on their own. Nurses followed an 6-h training program on-site. Emergency department (ED) and orthopaedic outpatient clinic (OC) nurses identified non-hip fragility fractures. Medical day treatment unit (MDTU) nurses were in charge of the management (investigation and treatment initiation). The list of patients, 50 years and older, with a fracture were retrieved for the period of November 2014 to July 2015. Performance was assessed with the rate of identification over time and the rate of management of non-hip fragility fractures.ResultsOver the 9-month period, 346 patients of ≥50 years old were seen for a fracture, of which 190 met fragility criteria (excluding hip fractures). A sinusoid pattern of rates of identification between 30-70 % was observed over time. An average proportion of 58.1 % of fracture patients were managed by MDTU nurses.ConclusionsA standardized order set legally allowing nurses to manage an FLS led to identification rates varying from 30–70 % and a management rate close to 60 % for referred patients over a 9-month period, which largely exceeds that of standard care. Identification was mostly compromised by difficulty integrating the order set into routine practice. Enforcement of the hospital policy on fragility fractures could help yield efficiency of identification of osteoporosis-related fractures by the staff.

Patient-Related Factors Associated with Adherence to Recommendations Made by a Fracture Liaison Service: A Mixed-Method Prospective Study

“…Participants sustaining multiple FFs during a single event were counted only once; major FFs took precedence over fractures at other sites [ 31 ]. Data related to the FLS coordinators’ professional background were obtained, i.e., nurses with a standardized order set for the initiation of osteoporosis treatment [ 32 ] or other disciplines without a similar prescription tool (biomedical specialist or physiotherapist). Data related to adherence to FLS recommendations were also extracted.…”

Imminent fracture risk assessments in the UK FLS setting: implications and challenges

“…Results from the 2017 UK national audit of FLSs demonstrated that only 6% of submitted patients had a sentinel vertebral fracture, 41% of patients were monitored within 16 weeks of index fracture, and 31% had initiated therapy [5]. Improving detection of vertebral fractures is likely to require integration with radiology systems [43]; reducing the time to treatment is likely to need integration of FLS directly into existing orthopaedic pathways, minimising additional clinical workup [44]. While the benefits of potent AOMs in the setting of a recent fracture have not been formally tested, subgroup analyses from studies stratified by recency of fracture have been encouraging [34,45].…”

Fracture liaison services: improving outcomes for patients with osteoporosis

“…Despite varying models, a common theme within these programs is that they are usually coordinated by a specified individual, usually a clinical nurse specialist, who will be case-finding, working to prescribed protocols, with assistance and referral access to specialist physicians 11. The “4i” Lucky Bone FLS in Montreal, Canada, demonstrated that there was overwhelming consensus between their physicians and the decisions made by their specialist nurses when they were empowered within a system involving an order set to allow them to investigate and manage patients,24 suggesting that such a service can be safely and efficiently run with minimal supervision from physicians 35. In terms of identifying patients at risk of osteoporosis, most services would initiate an assessment in patients over the age of 50 years presenting with a fragility fracture,21,25,26,28 although some centers also included women as young as 40 22.…”