Beacon Hospital

FRACTURE LIAISON SERVICE (FLS)
BEACON HOSPITAL, SELANGOR, MALAYSIA
 
Introduction
Studies have shown that one in three women and one in five men will sustained osteoporosis related fractures in their life time. This is due to a common but often neglected problem called “OSTEOPOROSIS”, a systemic skeletal disease where there is compromised bone strength, secondary to deterioration of bone density and bone quality. Osteoporosis is often known as a silent epidemic, it is often diagnosed only following a fragility fracture. The common fragility fractures (fractures following fall from standing height) include distal radius fractures, vertebral fractures, proximal humerus fractures and hip fractures which carry the highest morbidity and mortality. More importantly, “fracture begets fracture”, which means presence of a preexisting fracture increases the risk of subsequent fractures.
 
Patients present with fragility fractures are often seen by orthopedic surgeons. They receive treatment for their fractures, either surgical or non-surgical treatment. However, very often, there is no further assessment of their skeletal status including bone mineral density to rule out underlying osteoporosis. They have not been assessed for their future fracture risks, their dietary intake for bone health, the functional status, the compliance to anti-osteoporosis medicine if they have been given such medicines. This leads on to subsequent fractures which carry even higher morbidity and mortality.
 
Fracture Liaison Service (FLS)
 
Fracture Liaison Service has been a standard clinical practice in United Kingdom since many years ago. This concept, also known as Capture the Fracture has been introduced worldwide by International Osteoporosis Foundation (IOF) over the past few years. It is a Coordinated Standard Clinical Practice in which patients present with fragility fractures are seen by orthopedic surgeon and receive orthopedic treatment. At the same time, patients are seen by physician for their concomitant medical conditions, rehabilitation team and dietician to assess their physical, functional and dietary status for bone health. Patients receive Bone Mineral Density Scan to assess the underlying osteoporosis with subsequent treatment with anti-osteoporosis medicines. The compliance to medicines and functional status are assessed with phone call or home visit periodically. All these are being coordinated by a Fracture Liaison Service Coordinator.
 
The Objectives of FLS
1. To provide appropriate and early fracture treatments for patients presenting with fragility fracture
2. To provide medical assessment and treatment for concomitant medical conditions as well as preoperative assessment for those who undergo surgery
3. To provide rehabilitation treatment for post fracture care as well as assessment of functional status and home environment of patients
4. To provide dietary advice and assessment to ensure adequate calcium, vitamin D and protein intake and suggest supplementation if inadequate
5. To ensure patients undergoing Bone Mineral Density assessment and blood test to rule out secondary causes of osteoporosis
6. To ensure patients receive appropriate anti-osteoporosis treatments, with good compliance and adherence
7. To provide a COORDINATED APPROACH for all the above to prevent subsequent fragility fractures
8. Family members who are the first degree relatives of patients captured under FLS Program are advised to have DXA scan done as they are at high risk of developing osteoporosis and fractures. This is an important step to prevent first fracture in this group of individuals.
 
The Start
FLS Program was initiated since 3rd of April 2017 in Beacon Hospital. The program proposal was presented to the hospital management as well as the Orthopedic and Supporting Team members during the first quarter of 2017. The objectives and process of FLS were explained to every member of the team. FLS Service forms were prepared by various department and compiled to become the standard FLS recruitment form. Every patient captured under the FLS will have a standard recruitment form to record the relevant information and later to be filed by FLS Coordinator.
The FLS service was initiated officially on the 3rd of April and all the relevant parties involved were notified.
 
The Team
1. FLS Lead : Dato’ Dr. Lee Joon-Kiong
2. FLS Coordinator : Miss Shafina bt Nadzri
3. Orthopaedic Surgeons : Dr. Siow Yew Siong
Dr. Thaveethu Moses
Dr. Terence Tay Khai Wei
Dr. Chua Yeok Pin
4. Physician In Charge : Dr. Hendricks Chia
5. Chief Medical Officer : Dr. Albert Lum
6. Chief Rehabilitation : Miss Chelvi
7. Dieticians : Miss Gurdip, Miss Ng Seow Wei
8. Marketing Team : Miss Monica Low, Miss Priya Menon
The Recruitment
 
Individuals age 50 years and above, both female and male, who sustained Fragility Fractures (defined as fractures following fall from standing height) are captured into this FLS Program. Patient may be captured from their presentation through Emergency Department, Orthopedic Outpatient Clinic, Health Screening Clinic and referral from other units, both inpatient and outpatient.
FLS has been incorporated into the Standard Care Service in Beacon Hospital for those present with fragility fractures. The orthopedic surgeon in charge will explain to patients and their family members the whole concept and the importance of the FLS service to them.
 
The Process
 
Patients eligible for the FLS program will be attended by the Orthopedic Surgeon in charge who will initiate the treatment for the fracture patient presented with. This can be non-surgical or surgical treatment which will be determined by the Orthopedic Surgeon In-Charge. Patients may receive inpatient or outpatient treatment depending on the type of fractures and orthopedic treatment required.
 
The FLS Team will be activated via FLS Whatsapp Group Chat created solely for this purpose. FLS Coordinator will insert the FLS check list into patient’s folder to ensure all the necessary steps are being done. Patient will be referred to other FLS Team members for further assessments and interventions. This includes Physician referral for concomitant medical problems like hypertension, diabetes mellitus, heart problem and others especially for those who need to undergo surgery for the fracture. Patient will be referred to dietician to assess the dietary intake in terms of the amount of calcium, vitamin D and protein intake. Inadequate calcium, vitamin D and protein intake are very common in the elderly and this has been shown repeatedly in studies performed both locally and globally. Patient will also be referred to the rehabilitation team for physiotherapy and occupational therapy to achieve the best functional status possible. Besides strengthening exercise, mobilization exercise and ambulation training, the rehabilitation team will also assess the home environment to ensure a safe home environment to prevent subsequent fall.
 
Bone Mineral Density BMD using DXA scan will be done to assess the status and severity of the underlying osteoporosis. Appropriate anti-osteoporosis treatment will be initiated to treat the underling osteoporosis besides adequate calcium, vitamin D and protein intake.
 
After being discharged from the ward (in-patient) or clinic from further follow up (out-patient), patients will be followed up for another one year in which the FLS Coordinator will call patient/family members to find out the progress of patient in terms of compliance to anti-osteoporosis medicines, functional status of patients and any further fall or difficulties patient face at home. During this period of time, patients can opt for follow up with their orthopedic surgeons, family doctors/general practitioners or their community pharmacists whom they are most comfortable with. Patients will be referred back to their orthopedic surgeon or physician in Beacon Hospital whenever necessary.
Compliance to anti-osteoporosis medicines is often the difficult issue with most patients. There are medicines available to treat the underlying osteoporosis in order to improve the quality and density of bone. However, more than fifty percent of patient do not continue their anti-osteoporosis medicines
within six months of initiation of treatment. This can be improved with regular call and reminder from FLS Coordinator to the patients and the family members.
 
Dietary advice provided by the dietician is of paramount important as many elderly patients with osteoporosis are often being neglected. Asian Osteoporosis Study showed that the dietary calcium intake in elderly admitted for hip fracture is less than 450 mg a day. Vitamin D inadequacy and poor protein intake are also two problems often being neglected.
 
Functional status of patient after fractures are crucial as further fall will lead on to further fracture. The ability to ambulate independently or not, the muscle power and strength in standing and walking, the balancing and coordination are all very important factors being assessed and attended by a good and reliable rehabilitation team of this FLS Service.
 
The Awareness on FLS Service
 
Beacon Hospital has conducted series of talks, both round table discussion and GP seminar to introduce the FLS Service to our GP colleagues. General Practitioners/Family Physician play an important role in identifying patients with fragility fracture and refer them for early intervention. They also play an important role in following up with patients and improve their compliance to treatment and identifying future fractures. Many patients are more comfortable with their own family doctors for long term treatment of their chronic diseases. Therefore, family doctors are recruited into our FLS Service Team as part of this complete patient care service.
Public awareness, self-motivation and initiatives are even more important than case findings by doctors for chronic diseases like osteoporosis. Public should be informed that there is FLS Service available for themselves or their family members who have sustained fragility fractures. They will look for hospitals with FLS Service who can provide a complete care both for their fractures and underlying osteoporosis. Radio and television interviews (Aifm, NTV7), newspaper interviews and write up (Sin Chew Daily, Nanyang Daily, China Press), magazines as well as public forums on osteoporosis (Sin Chew Daily Hall, various senior citizen clubs) have been carried out actively to inform the public that FLS Service is available in Beacon Hospital. The response has been very encouraging with many of them do come forward to find out more about this service in Beacon Hospital.
 
Community Pharmacists also play an important role in continuous care of patients with chronic diseases. Many patients will prefer to seek advice from their community pharmacist on long term medicines that they need to take for their osteoporosis. Therefore, it is important to invite the community pharmacist to participate in our FLS Program. Seminars on osteoporosis with special emphasis on FLS has been conducted. That has also stirred the interests of a local pharmacy chain to look forward for collaborations to include them into our Beacon FLS Service.
 
Regional and International Collaborations on FLS
Beacon Hospital FLS Service has been presented in many FLS regional meetings and FLS workshops in this region. To name a few, on the 8th of October 2017, Beacon FLS Service was presented in the Amgen Asia Pacific FLS Symposium in Hilton Hotel Kuala Lumpur in conjunction with the 5th Asian Federation of Osteoporosis Societies (AFOS) Scientific Meeting. We had also shared our experience with experts from Asia Pacific Region in the 2017 Asia Pacific Consensus Meeting of Fracture Liaison Services on the 14th of October 2017 in Taiwan in conjunction with the 2017 Annual Meeting of Taiwanese Osteoporosis Association.
 
International Osteoporosis Foundation (IOF) Capture the Fracture Map of Best Practice
Beacon Hospital had submitted our FLS Service to the IOF to be mapped inside the Map of Best Practice for Capture the Fracture Program. It was our honor that Beacon is the FIRST HOSPITAL IN MALAYSIA to be mapped in the Capture the Fracture Map of Best Practice on the 28th of September 2017. This becomes the catalyst and a very positive motivating factor to push us to do better with our FLS Program.
 
Result
To date, Beacon Hospital FLS Service has captured twenty five (25) patients under our care. The average age is 69.8 years old. There are four male and twenty female patients. Seven patients are treated as in-patient and seventeen receive out-patient treatment. There are eight patients treated for distal radius fractures, four with proximal humeral fractures, four vertebral fractures, two foot fractures, two pelvic fractures, three hip fractures and two atypical femoral fractures. Seven patients undergone surgeries and seventeen are treated non-surgically. All patients have been assessed carefully for referral to dieticians and rehabilitation. Most of the patients had Bone Mineral Density (DXA) scans done to assess whether they have underling osteoporosis. Patients with osteopenia and osteoporosis are advised possibility of starting anti-osteoporosis treatment. The commonest agent used is Denosumab which is a six monthly subcutaneous injection. All patients captured and their family members are comfortable with the FLS as part of their standard clinical care.
 
Conclusions
Fracture Liaison Service (FLS) Service was set up for about six months in Beacon Hospital. We managed to build a very strong team of members from our own hospital from various disciplines and departments. We had invited family doctors, community pharmacist as well as patients and family to be part of this FLS FAMILY to ensure a complete care for patients with fragility fractures, both for their fractures as well as the underlying osteoporosis. All of us are working towards the same vision and mission, to prevent subsequent fractures in those who had suffered from an existing fragility fracture. FLS Service also allow us to identify the high risk individuals to prevent the first fracture.
A TEAM APPROACH is always the spirit of Beacon Hospital, to achieve a much better patient care.
 
Note: Kindly refer to Appendix 1 for our FLS activities compilation.
 

Location

Beacon Hospital FLS Program
1, JALAN 215, SECTION 51, OFF JALAN TEMPLER, Petaling Jaya
46050 Selangor
Malaysia
MY