An interdisciplinary Team Approach for the Prevention of Minimal Trauma Fractures in long-term care residents

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1 An interdisciplinary Team Approach for the Prevention of Minimal Trauma Fractures in long-term care residents Dr Kuen LAM Associate Consultant, Cheshire Home (Shatin)

2 Long Term Care (Infirmary Care) in HK In Hong Kong, long-term care residents who are in need of continuous medical and nursing care for their activities of daily living (such as bathing, toileting, feeding, grooming, and transfer) are placed on the central infirmary waiting list (CIWL) The estimated total number of this population is over 57,000.* *Social Welfare Department of the Government of the Hong Kong Special Administrative Region: Services for the Elderly. Available at:

3 Minimal Trauma Fracture (MTF) Minimal trauma fractures (MTFs) or spontaneous bone fractures commonly occur in long term care residents without the degree of trauma that usually causes a bone break They usually occur in the most immobile and dependent infirmry residents Unlike the usual type of fractures, MTFs occur without fall or other major trauma. They are also known as care-related fractures, as these incidents occur mostly during basic care procedures such as grooming, transfer or changing napkin etc.

4 Impact of MTFs to the frail Infirmary Residents Mortality Pain & suffering Pressure ulcer/ pneumonia / DVT

5 Medico-legal issues after MTF Family members usually question the possibility of mistreatment and inadequate care procedures of the institution after a MTF

6 What are the risk factors of MTFs? Currently there is lack of data on the risk factors associated with MTFs, and no direct investigation into the prevention of MTFs has been published. Only one prospective cohort study published in 1995 showed that the only risk factor of MTFs was severely impaired mobility

7 First Long-Term Cohort Study in HK on the Risk Factors of MTFs 396 Infirmary residents were followed between the period with comprehensive assessments to determine the incidence and predictors of MTFs

8 First Long-Term Cohort Study in HK on the Risk Factors of MTFs Participants.. All consecutive long-term care residents who were in the CIWL and were under the care in the Cheshire Home (Shatin) from March 2007 to March No. of Participants (Male:148 ) Mean Follow-up duration: 33 months Bedbound or chair-bound : 98.4% Double Incontinence : 81% Previous History of fracture: 17.2% Previous History of Stroke : 68% Known Diabetic Melllitus : 25%

9 Flow Chart of the Study All 396 residents received a baseline comprehensive multidisciplinary assessment including medical comorbidities, limb spasticity and contractures, nutritional status, cognitive and functional status All residents were followed for a mean duration of 33 months and any occurrence of MTFs were recorded Uni-variate analysis followed by Cox Regression Model were used to identify any independent predictor of subsequent MTFs

10 Characteristics of Subsequent MTFs During the follow up of 396 residents for a mean duration of 33 months, 12 MTFs occurred. The incidence of MTFs in our cohort is 1.1 per 100 persons per year Gender : Male, n Female, n 5 (41.7%) 7 (58.3%) Age, mean ± SD 79.4 ± 13.6 Fracture site Femur, n(%) Humerus, n(%) Foot ( 1 st MTPJ), n(%) Pelvis, n(%) 8 (66.7%) 2 (16.7%) 1( 8.3%) 1( 8.3%) Received operation, yes, n(%) 2(16.7%) Died, n(%) 7 ( 58.3%) Survival time after fracture ( months), mean ± SD 17.9 ± 12.6

11 Multivariate Analysis of Factors Associated With Subsequent MTFs Factors HR* 95% CI # P Value Severe Bilateral Spastic Knee contractures <0001 Diabetes Mellitus CI. Confidence Interval *HR estimated from Cox proportional hazard regression model # CI of the estimated HR

12 Why residents with severe spastic contracture are more prone to develop MTFs? Increase difficulty in daily care procedures and therefore increase the risk of patient injuries during routine care

13 Why LTC residents with Diabetes Mellitus are more prone to develop MTFs? Diabetes can induce diabetic osteodystrophy and increase greater bone fragility as a result of increased cortical porosity, accumulation of advanced glycation end products, impaired vascular supply and neuropathy and etc. Epstein S, Defeudis G, Manfrini S, et al, Scientific Committee of the First International Symposium on Diabetes and Bone. Diabetes and disordered bone metabolism (diabetic osteodystrophy): Time for recognition. Osteoporos Int 2016;27:1931e1951

14 An interdisciplinary Team Approach to prevent MTFs Doctors Nurses PT OT Dietitian Spasticity Management and Contracture Prevention ( Chemo-denervation therapy, stretching, splinting, mobilization ) Comprehensive Staff Education Identify the high risk group for MTFs and alert the caregivers Maintain Nutrition with adequate Calcium and Vitamin D supplement Treatment of Osteoporosis Prevention of MTFs

15 Spasticity Management and Contracture Prevention Botulinum Toxin IM injection and motor nerve block / neurolysis guided by Ultrasound and / or Electrical Stimulator

16 Spasticity Management and Contracture Prevention Chemo-denervation Therapies in Spasticity Management and Contracture Prevention in LTC residents: Evidence-based Practice

17 Spasticity Management and Contracture Prevention Splinting to provide a lowload prolonged stretch to the affected joints Passive stretch to maintain joint mobility

18 Spasticity Management and Contracture Prevention Correct positioning to prevent increase in abnormal tone of the limbs and joint contractures

19 Comprehensive Staff Education : Lectures, live demonstration and hand-on workshop

20 Simulation Training for Nurses and Supporting Staff on Basic -care skills to prevent MTFs

21 Stimulation Training for Nurses and Supporting Staff on Basic - care skills to prevent MTFs Inappropriate torsion force on long bone during caring procedure which should be avoided

22 Regular Audit on the Basic Care Skills to prevent MTFs

23 Adaptive Clothing to prevent MTFs Special design to avoid bending or rotating of the limbs or joints during dressing

24 Alert Sign for high risk patients of MTFs

25 Osteoporosis Treatment to prevent MTFs Additional Cow s skimmed milk and high calcium soya milk to increase the dietary calcium intake Routine vitamin D and calcium supplement Pharmacological treatment of osteoporosis

26 Public Education Lectures and Hand-on Workshops for healthcare workers in Residential Care Homes for Elderly ( RCHE) in Hong Kong

27 Public Education More than 2,000 educational posters has been distributed to the RCHEs in Hong Kong

28 Public Education Press Release to increase the public awareness on MTFS in LTC residents

29 Conclusion Currently there is lack of attention to MTFs despite their frequency and poor outcomes Our study showed that Severe Spastic contractures and DM independently predicts subsequent MTFs An interdisciplinary team approach is recommended for the prevention of MTFs, and has been implemented in SCH We desperately need more rigorous research, concerted effort and resources to identify ways to minimize the occurrence of MTFs.

30 Acknowledgement Interdisciplinary Team Program in SCH: Mr K C Tang, Nursing Team Mr Samuel Yui, Occupational Therapy Team Ms Lydia Wong, Physiotherapy Team Ms Christine Leung, Physiotherapy Team Ms WC Kam, Dietetic Team Dr YK Yuen, Medical Team & All Clinical Staff in SCH Research on MTFs : Professor Joseph Kwan, Department of Medicine, HKU Dr CW Kwan, Department of Statistics and Actuarial Science, HKU Dr M F Leung, Department of Medical and Geriatrics, United Christian Hospital Public Education Program Ms Mandy Mak, Hong Kong Physiotherapy Association Ms Wendy Cheung, Hong Kong Occupational Therapy Association Ms Samuel Chan, Hong Kong Occupational Therapy Association Dr K S Leung, Hong Kong Spasticity Management Society Dr Lily Chuang, Private Geriatrician

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