Dartmouth General HospitalDartmouth General Hospital Fracture Liaison ServiceFracture Liaison Service

Carla Purcell BScN, RN, CMSN(C)Fracture NavigatorFracture Navigator

AcknowledgmentsDr. Diane TheriaultHeather FrancisHeather FrancisDGH Ortho Clinics

Points to Cover

• Osteoporotic fractures• The post fracture care gap• The post fracture care gap• What can be done about it?• DGH Program

Results after approx 1 year• Results after approx 1 year

H lik l t b k b ?How likely are we to break a bone?

Women Men

Lik lih dLikelihood of having a 1 in 3 1 in 5gfracture

What Kind of Fracture?A F ilit F t• A Fragility Fracture– Minimal or no traumaMinimal or no trauma – A COUGH OR A SNEEZE

A FALL FROM STANDING HEIGHT– A FALL FROM STANDING HEIGHT– AT WALKING SPEED

Impact of hip fractures• Of those who survive, 25%

have not regained theirhave not regained their mobility at one year1y y

• 15-25% move into nursing 2 3home2,3

1. Miller CW, J Bone Joint Surg Am 19782 Jaglal S Patterns in Health Care in Ontario 19982. Jaglal S, Patterns in Health Care in Ontario, 1998 3. Papaioannou A et al, J Soc Obstet Gynaecol Can, 2000

Mortality1 t hi # 28% f• 1 yr post hip #: 28% of women and 37% of men have died

• 1 in 15 will die during hospitalizationhospitalization

• Almost one third of those who survive to discharge will die within the yearwithin the year.

Jiang HX et al, JBMR, 2005

Osteoporosis is NOT a benign gdisease.

Incidence of Osteoporotic Fracture, Heart Attack, , ,

Stroke and Breast Cancer in Canadian Women

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Incidence of Osteoporotic Fracture, Heart Attack, 

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Stroke and Breast Cancer in Canadian WomenOther

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Costs of fractures

• Each hip fracture: $20,000 -Each hip fracture: $20,000 $44,000

Tarride JE et al, Osteoporos Int, 2012

Osteoporotic fractures• Common• Devastating• Expensive• Fractures beget fractures• Fractures beget fractures

Fractures beget fractures• After a wrist fracture….. 14%

with a new fracture within 3with a new fracture within 3 years1

• After a vertebral fracture….. 20% with a new vertebral20% with a new vertebral fracture within 1 year2

1. Khan SA et al, Arch Intern Med, 20012. Lindsay R et al, JAMA, 2001

After a Hip Fracture• Risk of a second hip fracture:

9% at 1 year–9% at 1 year–20% at 5 yearsy

• Risk of a non-hip fracture:–36% at 1 year

57% at 5 years–57% at 5 yearsRyg J, ASBMR, 2009

However...• Only 20% of patients who have had

an osteoporotic fracture will receivean osteoporotic fracture will receive treatment for that fracture

f ff• The treatment is safe and effective and can reduce fracture rates by 50%

First Line Treatment• Alendronate• Risedronate

• Fall prevention• ExerciseRisedronate

• Zoledronic acid• Denosumab

Exercise• Diet• Vitamin DDenosumab

• Estrogen***• Teriparatide

Vitamin D

• Teriparatide

Why?• Fracture is treated as an acute• Fracture is treated as an acute

event• Patient blames the floor, not the

bonebone• Silent disease• Fear of tx• Medical complexity

The 3 i’s

• Identification:  capture fracture patient + alert goes to PCP

1ipatient + alert goes to PCP

• Investigation:  BMD 2i• Initiation of osteoporosis 

3itreatment 3i

Model Description BMD testing OP treatmentSt t M it bStatus Quo54

Manitoba (2007/08) 13% 8%

D Zero i No data 8%

C 1i 43% 23%

B 2i 60% 41%

A 3i 79% 46%A 3i 79% 46%Ganda K et al, Osteoporosis International, 2013

What works• FLS 3i/2i• FLS 3i/2i • FLS with dedicated• FLS with dedicated staffstaff

DGH: The 3 “i”sId tifi ti• Identification– Ortho clinic lists– Referral from clinic staff (ED patients)– Referral from hospitalists

I i i / Ri k A• Investigation/ Risk Assessment– Accomplished with Medical Directive

• Initiation– Accomplished with clear communication with PCP

Before we started… • Coordinated with Professional

Practice• Discussed with the Practice

Coordinator at College of RegisteredCoordinator at College of Registered Nurses of Nova Scotia

• Medical Directive so I could work independentlyp y

Medical Directive• Part of the development was the

creation of a Policy/Procedurecreation of a Policy/Procedure • Needed a letter of Intent and support

of our DMAC (District Medical Advisory Committee)y )

• Champion supported us at DMAC

Before the “go live”• Finalizing the protocol

– Had to involve communication with family MD

• Writing letters to fit in with theWriting letters to fit in with the protocols

Strong wording– Strong wording

• The checklist

Role of DGH Fracture NavigatorProgram in action!

Patient >50yrs old Presents with Low Trauma Fracturein action!

Hip Spine Wrist/Shoulder•Check patient list to identify.•Patient follows Hip fracture Clinical Pathway

•Check reports for Grade 2 and Grade 3 vertebral fractures•Letter to MD for referral

•Screen OPD Ortho Clinic List for applicable patients •See patients in clinic if fragility

•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

•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

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)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 Dxosteoporosis on d/c

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.

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 previousosteoporosis 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

•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

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

on TX•Follow-up letter to PCP if patient still is not on TX

with pt to see if on Tx and PCP if not•Moderate risk in hands of PCP

DGH FLS (2i): 204 patients• 85% have undergone full fracture risk assessment:–71% are HIGH risk (and need treatment)–29% are MODERATE risk29% are MODERATE risk

• Rate of treatment:f h d‐ 60% of the entire group received treatment

‐ 84% of the HIGH risk group received Rx

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