Improving Bone Health in the Orthopedic Outpatient Clinic

Upon completion of a literature review by nurses in ambulatory care services (ACS), it was determined that a knowledge gap exists among the patient population regarding fragility fractures and osteoporosis. Patients who visit our orthopedic clinic (general orthopedics, fracture, and spine) are at increased risk of fractures due to age, gender, prior fragility fracture, family history, chronic diseases, poor nutrition, inactivity, smoking, alcohol consumption, and certain medications.
Methodology: The Iowa Model was applied to facilitate the implementation of evidenced-based practice.
Purpose: To assure that ACS patients at high risk for fractures were identified, educated, and appropriately referred for osteoporosis screening.
Following a review of the literature, a multidisciplinary team created a fracture risk assessment questionnaire, using the US Bone and Joint Initiative as a resource. Pre-implementation data was collected in 3rd and 4th quarters of 2019 via chart audits of patient visits using the newly developed fracture risk assessment questionnaire. The inclusion criteria applied were age 50 and over who were seen by a nurse during the clinic visit. Of the 83 patients that were screened for fracture risk, 42.17% were positive for at least one or more risk factors. Pre-implementation data collection for 4th quarter 2019 indicated 40.52% of 116 patients screened for fracture risk were positive for at least one or more risk factor. To address those at risk, the workflow for ACS nurses was redesigned to include provision of patient education, and if needed, a physician referral for a DEXA scan and/or treatment letters that indicated increased fracture risk were sent to patients who were screened and their primary care providers. After roll out in January 2020, feedback was elicited from ACS nurses to ensure that the new redesigned workflow was feasible. Some changes were made; for instance, the implementation of the redesigned workflow was divided into two separate phases, phase I and phase II. ACS nurses also conducted peer-to-peer chart audits to ensure standardization of the new redesigned workflow.
Results: Implementation of a risk assessment will provide identification of patients who are at risk for a fracture via a nursing assessment utilizing a standardized fracture risk assessment tool. Providing patients with educational interventions via an individualized tailored educational plan for patients identified as high risk. Patients will be provided a referral to the osteoporosis clinic for a DEXA scan or a referral to their primary physician for possible DEXA scan and initiation of bone-strengthening treatment if warranted. Implementation of phase I began in January 2020 and phase II began in February 2020. For 1Q20, of the 60 patients that were screened for fracture risk, 45% were positive for at least one or more risk factors. In addition, patients with a history of fragility fracture were referred to the osteoporosis clinic as well as referral for a DEXA Scan.
Conclusions/implications: In conclusion, osteoporosis is underdiagnosed and undertreated among the aging population. More attention is needed to improving osteoporosis screening. ACS has proved to be a beneficial location for conduction of fracture risk screenings.