Patients with an osteoporotic fracture have a high risk of developing new fractures, and are, therefore, candidates for secondary prevention. Their hospitalization means pain, stress or possible complications from surgery. These circumstances make the diagnosis of osteoporosis, during hospitalization unfeasible.
Prevention remains the best solution, both for patient and health system. We suggest ways that facilitate the diagnosis of osteoporosis and the early treatment initiation. The identification of these patients must take place at the hospital, by a specialized bone health nurse (BHN) or other trained nurse at the orthopedic department or in the emergency room or at any other department. Patients, who are high risk for osteoporosis or refracture and are hospitalized for any other reason e.g urolithiasis, must be identified by nurses. Nurses in the departments have to refer these patients to specialized BNHs. The identification should be carried out as detailed below:
- Nurses need educational programs to learn more about osteoporosis, in order to learn how to identify patients at risk.
- Orthopedics in the department can additionally notice on each record/file easily and fast, which patient is at risk for osteoporosis. So nurses could intentionally approach these patients.
- At the most hospitals exist trauma lists, with the names of patients, that have visited the emergency room and were diagnosed with fracture. Those lists can help nurses in identifying older adults with possible osteoporotic fractures.
- Additionally at many hospitals, there are nursing records/files. So when a nurse in the orthopedic department or in another department takes an interview with the patient to complete the nursing file, she/he can make questions such as: did you ever have a fracture? Did you ever have back pain? Questions that exist in the FRAX score (Fracture Risk Assessment Tool, is used already by doctors) can help in identifying these high risk patients.
Back pain is an important factor that indicates the possible existence of a previous, not diagnosed vertebral fracture. Vertebral osteoporotic fractures are characterized many times as ‘’silent fractures’’, not easily recognized. Sudden back pain along or without a sudden movement like bending or lifting or sneezing, and maybe a sudden sound like "crack" means that probably a vertebral fracture has happened. So if BHNs identify these symptoms during interview / nursing record (this concerns every patient at the hospital, not only the orthopedic patient), can suspect a vertebral fracture and refer these patients to a doctor for exams, spine X- ray. So this factor (back pain) along with others risk factors (age, menopause, family history, specific medication etc. ) can catch the attention of nurses. Then follows the osteoporosis diagnosis with DEXA and the journey goes on... The empowerment role of nurses is important. It involves education and information regarding nutrition, exercise, fall prevention and psychological support. They are aimed both at patients and caregivers.
Many visits at hospital and subsequent inconvenience ought to be avoided. The BHNs function as coordinators. They arrange an appointment for DEXA examination at the hospital, on the same day that the patient visits the hospital for follow –up care after the fracture. They arrange also a visit to a physician for osteoporosis management.
Patients with severe fractures are disabled and frail, and they can’t be transported by themselves. A liaison service between the hospital and the municipality would be an ideal solution. The municipality via home care service should take on, free of charge, the transportation of these patients from their home to the hospital (for the DEXA examination) with the use of an equipped van. If the patient wants to visit a private diagnostic center, instead of hospital, then this center should provide transportation. The cost should be covered by health insurance. For the benefit of cost limitation each time transportation could be of more than one patient.
The DEXA results or other blood tests should be brought from the hospital or the diagnostic center to the attending physician via the electronic medical record (EMR).
Many patients don’t see primary care doctors (PCD) early after the fracture. BHNs should send information to the PCD during the patients’ hospitalization. PCDs type into their EMR all the information. They keep a software, like the Sap Business One. One such a program has alarm settings. If diagnosis hasn’t taken place within a 3 month period, then the alarm is activated and sounds. The PCD has to call the patient and encourage the osteoporosis management. BHNs should also until then call the patients and encourage them to take action for osteoporosis diagnosis and treatment. After the alarm activation, PCDs and BHNs should cooperate to achieve the prevention of refractures.