Dartmouth General Hospital Fracture Liaison Service. Carla Purcell BScN, RN, CMSN(C) Fracture Navigator

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1 Dartmouth General Hospital Fracture Liaison Service Carla Purcell BScN, RN, CMSN(C) Fracture Navigator

2 Acknowledgments Dr. Diane Theriault Heather Francis DGH Ortho Clinics

3 Points to Cover Osteoporotic fractures The post fracture care gap What can be done about it? DGH Program Results after approx 1 year

4 How likely are we to break a bone? Women Men Likelihood of having a fracture 1 in 3 1 in 5

5 What Kind of Fracture? A Fragility Fracture Minimal or no trauma A COUGH OR A SNEEZE A FALL FROM STANDING HEIGHT AT WALKING SPEED

6 Impact of hip fractures Of those who survive, 25% have not regained their mobility at one year % move into nursing home 2,3 1. Miller CW, J Bone Joint Surg Am Jaglal S, Patterns in Health Care in Ontario, Papaioannou A et al, J Soc Obstet Gynaecol Can, 2000

7 Mortality 1 yr post hip #: 28% of women and 37% of men have died 1 in 15 will die during hospitalization Almost one third of those who survive to discharge will die within the year. Jiang HX et al, JBMR, 2005

8 Osteoporosis is NOT a benign disease.

9 Annual Incidence of Common Diseases Incidence of Osteoporotic Fracture, Heart Attack, Stroke and Breast Cancer in Canadian Women Hip

10 Annual Incidence of Common Diseases 138,600 Other Pelvic Incidence of Osteoporotic Fracture, Heart Attack, Stroke and Breast Cancer in Canadian Women Wrist Vertebral Hip

11 Costs of fractures Each hip fracture: $20,000 - $44,000 Tarride JE et al, Osteoporos Int, 2012

12 Osteoporotic fractures Common Devastating Expensive Fractures beget fractures

13 Fractures beget fractures After a wrist fracture.. 14% with a new fracture within 3 years 1 After a vertebral fracture.. 20% with a new vertebral fracture within 1 year 2 1. Khan SA et al, Arch Intern Med, Lindsay R et al, JAMA, 2001

14 After a Hip Fracture Risk of a second hip fracture: 9% at 1 year 20% at 5 years Risk of a non-hip fracture: 36% at 1 year 57% at 5 years Ryg J, ASBMR, 2009

15 However... Only 20% of patients who have had an osteoporotic fracture will receive treatment for that fracture The treatment is safe and effective and can reduce fracture rates by 50%

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17 First Line Treatment Alendronate Risedronate Zoledronic acid Denosumab Estrogen*** Teriparatide Fall prevention Exercise Diet Vitamin D

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19

20 Why? Fracture is treated as an acute event Patient blames the floor, not the bone Silent disease Fear of tx Medical complexity

21 The 3 i s Identification: capture fracture 1i patient + alert goes to PCP Investigation: BMD 2i Initiation of osteoporosis treatment 3i

22 Model Description BMD testing OP treatment Status Quo 54 Manitoba (2007/08) 13% 8% D Zero i No data 8% C 1i 43% 23% B 2i 60% 41% A 3i 79% 46% Ganda K et al, Osteoporosis International, 2013

23 What works FLS 3i/2i FLS with dedicated staff

24 DGH: The 3 i s Identification Ortho clinic lists Referral from clinic staff (ED patients) Referral from hospitalists Investigation/ Risk Assessment Accomplished with Medical Directive Initiation Accomplished with clear communication with PCP

25 Before we started Coordinated with Professional Practice Discussed with the Practice Coordinator at College of Registered Nurses of Nova Scotia Medical Directive so I could work independently

26 Medical Directive Part of the development was the creation of a Policy/Procedure Needed a letter of Intent and support of our DMAC (District Medical Advisory Committee) Champion supported us at DMAC

27 Before the go live Finalizing the protocol Had to involve communication with family MD Writing letters to fit in with the protocols Strong wording The checklist

28 Program in action! Role of DGH Fracture Navigator Patient >50yrs old Presents with Low Trauma Fracture Hip Spine Wrist/Shoulder Check patient list to identify. Patient follows Hip fracture Clinical Pathway Assess if low trauma # Ensure Vit D education First dose of bisphosphonate is initiated prior to d/c BMD ordered for d/c day or as out-patient if no recent one done Ensure patient has hip # Booklet and patient/family referral to DOME on d/c Letter to PCP re Dx osteoporosis on d/c Enter patient in database Phone call to pt in 3-4 mos to see if on TX Follow-up letter to PCP if patient still is not on TX Check reports for Grade 2 and Grade 3 vertebral fractures Letter to MD for referral If pt referred call for screening/ (phone/in-person) Discharge if traumatic # Order BMD if no recent Lab: egfr; CBC; ionized Ca; TSH; alk phos; Vit D (if on supplement for 3 mos), serum protein electrophoresis X-ray of spine (lateral thoracic if lumbar fracture and lumbar if thoracic fracture. Education re safe movement, falls, referral to DOME. (handout) High risk spine letter to physician Enter patient in database Phone call to pt in 3-4 mos to see if on TX Follow-up letter to PCP if patient still is not on TX Screen OPD Ortho Clinic List for applicable patients See patients in clinic if fragility fracture Order BMD if no recent Lateral spine views if no recent Complete req for labs (egfr;ionized Ca; TSH;Vit D (if on supplement for 3 mos) Recommend Vit D Education re falls, diet, exercise and referral to DOME Letter to MD (either unknown or high risk if previous fractures/prednisone) Enter patient in database Follow-up letter to MD when BMD results come back re risk level Follow-up in 3-4mos if high risk with pt to see if on Tx and PCP if not Moderate risk in hands of PCP

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30 DGH FLS (2i): 204 patients 85% have undergone full fracture risk assessment: 71% are HIGH risk (and need treatment) 29% are MODERATE risk Rate of treatment: - 60% of the entire group received treatment - 84% of the HIGH risk group received Rx 30

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