South West Falls, Fractures and Bone Health Review July – Sept 2009

Overview of Secondary Fracture Prevention and Falls services

Dr Karen Harding

A systematic approach to falls and fracture prevention

Fragility Fractures – Fracture Liaison• Secondary fracture prevention will be optimised by

seamless integration of post-fracture falls risk assessment and osteoporosis management asadvocated by the British Orthopaedic Association and British Geriatric Society Blue Book on care of patients with fragility fracture.

• The National Institute for Health and Clinical Excellence guidance on secondary fracture prevention (TAG 161) can be delivered through fracture liaison services for patients presenting to hospital with new fractures and pro-active case finding in primary care of un-assessed, prior fracture patients.

Fragility Fractures – Fracture Liaison

• Good evidence for fracture liaison services e.g. the Glasgow model (McLellan, Gallacher) and the cost effectiveness of these services.

• Detailed economic analysis in Department of Health Prevention Package resources section In this model, over a 5 year period £290,708 is saved in NHS acute and community services and local authority social care costs, against an additional £234,181 revenue costs. This is for an annual patient cohort of 797 hip, humerus, spine and forearm fractures, anticipated from a 320,000 population. At a national level, this equates to approximately £8.5 million saving over 5 years.

Fracture Liaison Services in the South West

• Some sort of FLS exists in the acute trusts in Bath, Bristol (UHB and NBT), Gloucestershire, Yeovil. These are variable in terms systematic identification of all new fractures in over 50 year olds, nursing support and performance on audit.

• The majority of acute trusts in our region have no fracture liaison service whatsoever.

Community FLS / Historical Case Finding• Some Primary Care Trusts have good uptake of

DES and / or LES for Osteoporosis and these tend to have the best focus on identifying previous fractures that need assessment or treatment.

• Bournemouth and Poole, Gloucestershire and Somerset have primary care services that are innovative or particularly focussed on this work.

• Overall historical case finding is patchy and inconsistent and in many areas non-existent

Falls

• The South West Strategic Health Authority ambition is to reduce emergency admissions, as a result of a fall, by 30% from 06/07 baseline by March 2010 through effective falls and bone health prevention programmes.

• The review looked at the approach to patients presenting with falls, services to reduce further falls and falls prevention strategies.

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Falls Presenting to Emergency Departments and Ambulance Services

• There is lack of data about patients presenting with falls – in ED they are usually coded as the injury that results from the fall and Ambulance Services are not collecting robust data about non conveyed fallers

• Most EDs have links with their local rapid response community therapy teams and some Fallers presenting 9-5pm were assessed at the time of presentation (mainly driven by admission avoidance schemes)

• Only a proportion were assessed and systems to identify those presenting out of hours or with no discharge issues were generally poor

• Communication with the primary care about the presentation was not systematic so opportunities for falls assessment for this high risk group were frequently missed

• Similar picture for non conveyed fallers although ambulance services are increasingly using Emergency Care Practitioners to assess fallers and link to other services

Falls assessment in fracture clinic• Older patients who have suffered a fracture

are the highest risk group for further falls and fractures

• Most fracture clinics do not assess falls risk although some are starting to perform the Falls Risk Assessment Tool (FRAT) and link patients with high scores to community falls co-ordinators

• Trusts with a Fracture Liaison Service have the best systems for assessing falls in fracture patients

Falls – In patients• Most acute trusts have in patient falls strategy

groups and use various tools to assess falls risk and reduce risk in high risk patients

• The safer patient initiative has driven some of the improvements for in patients and root cause analysis is routinely being done for falls resulting in serious injury such as hip fracture

Falls – In patients

• There are examples of audit showing reduced rates of in patient falls when this is a particular focus within a trust e.g. Yeovil set an internal performance target to reduce falls by 10% and has achieved a 6% reduction to date. Their target for next year is a 15% reduction and they have invested in falls reduction equipment such as low beds and falls alarms.

Specialist Falls Prevention Clinics

• Most (but not all) trusts provide a Consultant led clinic for assessment of patients with multiple / unexplained falls and investigation of syncope

• There are capacity issues for some of these clinics and investigations

• Interventions recommended are not always actioned e.g. Referral for cataract surgery, initiation of Ca + vit D supplements

A systematic approach to falls and fracture prevention

Community Falls Prevention

• This aspect of the great pyramid seems to have been the area most focussed on by commissioners with some good partnership working with local authorities, social care and third sector organisations.

• Wide variations exist, even within PCT areas, and services were often described as like a patchwork quilt. Effectiveness of services often depended on the efforts of a small number of hard pressed key individuals

Community Falls Prevention

• Some localities had particularly good services:• BaNES was felt to be particularly good at

joining up their approach to falls, fractures and bone health.

• Gloucestershire had made falls services a Local Area Agreement stretch target and had a Partnership for Older People’s Project (POPPs) that addressed preventive schemes in care homes in relation to falls and bone health.

Community Falls Prevention

• Exercise and balance classes were provided in all areas but not all were evidence based programmes and issues with capacity and transport were common but good examples exist :

• In Torbay there is an open referral system to access exercise, diet, strength and balance classes, and an Otago exercise programme led by a physiotherapist with one to one home-based sessions for those unfit to travel.

Tele-care and Assistive Technology

• Lifeline alarm type services are available in most areas but some areas had developed the range of tele-care services further e.g.

• In Wiltshire this service provides out of hours contacts and triage. 48% of people assessed for alarms are supplied a system with equipment in addition to the Lifeline and all patients are followed up and receive a wellbeing check.

Where are we now with the Review?

• All areas have had their individual report from the review and almost all have returned action plans in response to the report

• An overview report for the region will be presented to the SHA and then be circulated to localities. This includes a summary of current performance against the ambitions, a suggested dataset and examples of good practice

• The website is being further developed as a resource to aid service improvement

www.southwestfallsandfractures.org.uk