Download v 3.5 FLS-DB Facilities proforma (FLS)

Annual FLS-DB Facilities audit
Proforma for sites that DO have an FLS
Definitions
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This audit captures information about your site from Jan – Dec 2014
A Fracture Liaison Service (FLS) is a service that systematically identifies, treats and refers to appropriate services eligible patients aged over 50 years
within a local population who have suffered a fragility fracture with the aim of reducing their risk of subsequent fractures.
A site is defined as a hospital, primary care practice, network and/or other community service.
A fragility fracture is a fracture that occurs after low trauma (equivalent to a fall from standing height or less) excluding skull, face and digits.
An inpatient stay is defined as requiring a hospital bed overnight on a ward and does not include accident and emergency attendances.
A clinical spine fracture is defined as a clinical episode due to the symptoms of the spine fracture.
Monitoring includes any review performed at the patient level to ascertain medication use, re-fracture and/or falls.
Please note that the national audit will operate electronically with an online webtool to enter data. This document has been developed for the purposes of
assisting with data collection. Please answer all the following questions (unless the instructions state otherwise).
1. Resources
Help Notes
This should be the name of the site for
which you will be submitting data and will
be used to identify your results in the
report. It should reflect how you feel your
FLS is organised.
Question
1.1
What is the name of your site:
Reply options
1.2
Is your site based around a (select all that apply)
 Hospital
 Hospital trust
 Community service
 Other- Please specify:
1.3
Do you have a dedicated FLS?
1.3a
If yes to 1.3, who is your FLS lead?
Yes 
An FLS is a service that systematically
identifies, treats and/or refers to
appropriate services eligible patients
aged over 50 years within a local
population who have suffered a fragility
fracture with the aim of reducing their
risk of subsequent fractures.
No 
Name:
Email:
1.3.b
If yes to 1.3, which hospitals do you provide the FLS to?
1.4
How is the FLS currently funded? Please indicate the relative contributions below:
(should total 100%)
Unable to estimate
CCG (England)
Health Board (Wales)
Local Authority/Better Care funding
Trust/Department
Other 1
This is the funding for the dedicated staff to
run the FLS.

%
%
%
%
%
Please specify funding source:
1.5
What is the estimated annual cost of staff for the service?
1.6
Do you receive additional funding for DXA scanning?
If you are unable to estimate please leave
blank.
£
Yes 
Please answer
1.6.a
1.6a
If you answered yes to question 1.6, how are the costs
for DXA scanning charged?
1.7
What month and year did your FLS start
seeing patients?
1.8
What month and year did you start the current form of
FLS?
No 
Skip to 1.7
 Block contract
 Per scan
 Other, please give details:
This the data the current resourced level of
FLS started as per the number of staff, as
described in 1.10
1.9
If you are based in Wales, please use the
Which of the following best describes the current contract?  Pilot
 Fixed term then need to completely re-bid ‘other’ option to answer this question.
 Fixed term then need to renew
 Part of general contract
 Block payment
 Per patient tariff
 Other - Please give details:
1.10
For each type of staff, please enter how much time is spent working within the FLS as the whole time
equivalent (WTE). (eg 0.5 for a nurse working half time and 2.0 for two full time nurses)
Profession
PAs
 Orthogeriatrician
 Clinician other (please detail
speciality …………………..
 Clinician other (please detail
speciality …………………..
Band
2 3 4 5 6 7 8a 8b 8c
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Nurse
Radiographer
Physiotherapist
Occupational therapist
Administrative support including
Other, please specify:
 Other, please specify:
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This is the proportion of activity
dedicated to identification, investigation,
initiation and monitoring of patients
within the FLS.
A PA is a ‘Programmed Activity’ – one PA
is 4 hours.
1.11
Do you use a database to collect your data?
Section 1 Comments:
 No
 Microsoft Excel Spreadsheet
 Microsoft Access database
Locally developed solution
Commercially bought solution
Other - please specify:
Please use this field to add your comments
about section 1. Including whether any of
the questions were impossible to answer or
the questions needed clarifying, and any
other comments you may have.
2. Scope
2.1
2.2
2.3
Question
Estimated population size
Reply options
How many hip fractures were seen at your site from 1 January 2014 to 31
December 2014?
Help notes
If you do not know this answer, please
leave blank.
How many fragility fracture patients (including hip fractures) were
identified by your FLS from 1 January 2014 to 31 December 2014?
2.3.a Is your answer to 2.3 (select one only)
 An estimate
 Based on actual numbers seen
by service
2.4
Which patient groups does your FLS cover? (select all that apply)
Hip fracture (including inpatient fractures)
Non-hip inpatient fragility fracture on orthopaedic/trauma wards
Non-hip inpatient fractures on non-orthopaedic/trauma ward (including
inpatient fractures)
Orthopaedic/ trauma fracture outpatient clinics (e.g. wrist fractures)
Presenting with a clinical vertebral fracture
Vertebral Fracture Assessment using DXA spine imaging
Incidental Radiological vertebral fractures
2.4.a Pelvic fragility fractures
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 Please select all the apply:
 as inpatient
 outpatient
 emergency department
 community setting
Non-hip inpatient fractures on nonorthopaedic/trauma ward (including
inpatient fractures): This may include
proximal humeral fracture admitted for
rehabilitation to a general medical or
geriatric ward setting.
Presenting with a clinical vertebral
fracture: These are patients who present to
your site because of the vertebral fracture
2.4.b Rib fragility fractures Please select all the apply:
 as inpatient
 outpatient
 emergency department
 community setting
2.4.c Other fractures Please specify:
2.5
What restrictions are there on the patients seen by your service? Please select all that apply
Please detail what age range and gender
restriction apply in the other box below
None 
Age range 
Gender 
Fracture site (please select all that apply) 
2.5.a Which fracture site is
restricted? (Please select all that
apply)
 Ankle
 Scaphoid
 Metacarpal
 Metatarsal
 Face/ skull
 Rib
 Patella
 Other - give details:
Other (free text) 
2.5.b If yes, please specify:
Section 2 comments:
Please use this field to add your comments
about section 2. Including whether any of
the questions were impossible to answer or
the questions needed clarifying, and any
other comments you may have.
3. Case characteristics
Question
Patient Identification for secondary fracture prevention
3.1.a
3.1.b
How does your site identify hip fracture patients?
Please select all that apply
How does your site identify other non-hip fracture inpatients?
Please select all that apply
Reply options
Help notes
 Not applicable
 FLS visits the
orthopaedic/trauma ward
 Ward/emergency room
admissions lists
 Seen by Orthogeriatric service
not FLS
 Fracture clinic lists
 IT systems
 Trauma lists
 Other - please specify:
This relates to how patients are identified
for secondary fracture prevention.
 Not applicable
 FLS visits the
orthopaedic/trauma ward
 Ward/emergency room
admissions lists
 Seen by Orthogeriatric service
 IT systems
 Fracture clinic attended
 Other - please specify:
This relates to how patients are identified
for secondary fracture prevention.
IT systems includes radiology IT systems.
IT systems includes radiology IT systems.
3.1.c
3.1.d
How does your site identify fracture outpatients? Please select all
that apply
How does your site identify patients with vertebral fracture(s)?
Please select all that apply
 Not applicable
 FLS visits the
orthopaedic/trauma clinic
 Fracture clinic lists
 Referral from fracture clinic
 IT systems
 Emergency Department lists
 Referral from Emergency
Department
 Other – please specify:
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Not applicable
FLS visits spine clinic
Dedicated DXA imaging (VFA)
Screening general radiology
reports
Re-reading radiology reports
Fracture clinic lists
Emergency department lists
Other - please specify:
This relates to how patients are identified
for secondary fracture prevention.
IT systems includes radiology IT systems.
This relates to how patients are identified
for secondary fracture prevention.
IT systems includes radiology IT systems.
Not funded
Unable to access radiology images
Still developing pathway
Other
If applicable, what barriers have you experienced
in finding patients with vertebral fractures (e.g. Do
you follow ISCD guidance)? (select all that apply)
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3.1.f
What action is taken for patients who do not turn
up for any part of FLS pathway? (select all that
apply)
 Send reminder letter
 Discharge to GP
 Other – please specify:
3.1.g
Does your site have a process for identifying
potentially eligible fragility fracture patients who
should have but did not received assessment for
secondary fracture prevention (i.e. a regular data
quality review/ audit of secondary fracture
prevention assessments)?
3.1.e
3.1 Comments
Yes 
Please give details:
No 
2013 International Society for Clinical densitometry
guidance for Lateral Spine imaging with Standard
Radiography or Densitometric VFA is
indicated when Tscore is < 1.0 and of one or more
of the following is present:
• Women age ≥ 70 years or men ≥ age 80
years
• Historical height loss > 4 cm (>1.5 inches)
• Self-reported but undocumented prior
vertebral fracture
• Glucocorticoid therapy equivalent to ≥ 5 mg
of prednisone or equivalent per day for ≥ 3
months
Some centres use more than one method for
identifying patients. This may include a rolling audit
of admissions with a fragility fracture or of fracture
clinic letters.
Please use this field to add your comments about
section 3.1. Including whether any of the questions
were impossible to answer or the questions needed
clarifying, and any other comments you may have.
3.2 Assessment/ investigation for secondary fracture prevention
3.2.a
3.2.b
3.2.c
3.2.d
Does your FLS provide secondary fracture
prevention assessment/ investigation?
Do you refer on for secondary fracture prevention
investigation?
Yes 
No 
If yes –
go to 3.2.c
If no –
go to 3.2.b
Yes 
No 
If yes –
go to 3.2.g
If yes - 3.4.a
Does your FLS use protocols for secondary fracture
prevention assessment/investigation that: Please
select all that apply
 Have been developed locally?
 Are consistent with healthcare policy
and guidelines agreed region-wide?
 Are consistent with healthcare policy and
guidelines agreed nation-wide (e.g. NICE
TA 161/ 204?)
 Do not know
Who performs secondary fracture prevention
assessments? Please select all that apply
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FLS specialist practitioner
Clinician speciality
Delegated to Primary care physician
Other – Please specify:
This may include questionnaires, blood/urine tests
and/or DXA.
We recognise this may vary by patient type so
please list all that apply
3.2.e (i)
What tests do you routinely use for identifying
underlying secondary causes of
osteoporosis (select all that apply)
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3.2.e (ii)
Please specify any restrictions on these tests
(e.g. only perform Testosterone in men aged less
than 75 years)
Serum Calcium
Serum phosphate
Serum alkaline phosphate
Serum 25OH vitamin D
Serum Parathyroid hormone
Full blood count
Erythrocyte sedimentation rate / ESR
Liver function
Thyroid function
C-reactive protein
Liver function tests
Renal function tests
Coeliac disease screen
Serum Immunoglobulins for myeloma
screen
Testosterone/ Sex hormone binding
globulin
Spot urinary calcium
24 hour urinary calcium
Other
These are tests patients would be recommended to
have done if not already done recently.
Testosterone/ Sex hormone binding globulin:
Applies to men only
Serum Electrophoresis for myeloma screen:
includes urine electrophoresis
3.2.f
What else do you routinely included in the postfracture assessment performed by the FLS? Please
select all that apply
 Fracture risk assessment with scoring
tools such as FRAX
 DXA at hip and/or spine
 Vertebral fracture assessment by DXA
(VFA or IVA)
 Plain spine radiology if not done
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already (for unrecognised vertebral
fractures)
Falls risk assessment for appropriate
falls interventions (by FLS itself)
Falls risk assessment for appropriate
falls interventions (by referral to falls
service from FLS)
Peripheral DXA
Peripheral ultrasound
Peripheral CT
Other - please specify
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DXA available on site
Refer to another DXA provider
Peripheral densitometer/QUS
Peripheral DXA
FRAX or other risk assessment tool
Other - please specify:
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3.2.g
Do you have access to DXA scan or do you use an
alternative provider or tool? (please select one)
3.2 Comments
Please use this field to add your comments about
section 3.2. Including whether any of the questions
were impossible to answer or the questions needed
clarifying, and any other comments you may have.
3.3 Initiation for secondary fracture prevention
3.3.a
3.3.b
3.3.c (i)
Who discusses the results of the above
secondary fracture prevention assessments
with the patient? Please select all that apply
FLS specialist practitioner
Clinician speciality - Please specify:
Delegated to Primary care physician
Other - please specify:
Who assesses the need for treatment? Please  FLS specialist practitioner
 Clinician speciality. Please specify:
select all that apply
 Delegated to Primary care physician
 Other - please specify:
What interventions can be recommended or
initiated by the FLS? (Falls interventions will
be asked about later) Please select all that
apply
 None (eg. delegated to another health care
provider)
 Written material on maintaining bone health,
lifestyle, nutrition and bone-protection
treatments (Must cover all risk factors or be
tailored to the individual)?
 Calcium and vitamin D supplementation advice
 Oral bisphosphonates
 Denosumab
 Intravenous bisphosphonates
 Strontium ranelate
 Additional education programmes/resources
(beyond any discussion at initial
 contact/or at FLS clinic)
 Clinic follow-up by appropriate specialist if
abnormalities are identified on
 blood tests
 Other - please specify:
3.3.c (ii)
Can Teriparatide be recommended or
initiated by the FLS?
3.3.d
How do patients obtain their first
prescription of bone sparing treatment, if it is
recommended? Please select all that apply:
 FLS recommends therapy to orthogeriatrician
Has the NOS supported the FLS from 1
January 2014 to 31 December 2014? Please
select all that apply
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3.3.e
o
o
o
Yes
No
Unavailable,
If unavailable, please specify why
and/or primary care physician
FLS prescribes
Orthogeriatrician prescribes
Trauma prescribes
metabolic bone disease / osteoporosis specialist
prescribes
 Other - please specify:
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Don’t know
None of the below
Use NOS leaflets in the FLS
Arrange NOS education events
Local support group
Service development
Other – please specify:
Please use this field to add your comments about
section 3.3. Including whether any of the questions
were impossible to answer or the questions needed
clarifying, and any other comments you may have.
3.3 Comments
3.4 Falls Interventions for secondary fracture prevention
3.4.a
Do you routinely provide a falls
assessment as part of your FLS?
Please give details if differ by drug (e.g.
denosumab) or patient group (e.g. hip fracture only)
 Yes
Go to
3.4b
 No –
 No
we refer patients on
for a falls
Go to go to 3.5
assessment
Go to 3.5
3.4.b
Which of the following are covered by
the falls risk assessment in the FLS?
 A formal assessment of cognition
(select all that apply)
Any objective assessment acceptable (including short form
AMTS, AMTS, MMSE etc)
If Yes, 3.4.b.1 Which assessment tool is used:
 AMT4
 AMT10
 MMSE
 Other (please specify)
 Assessment of continence and toileting?
An assessment of the history and nature of urinary
incontinence.
 Assessment of a history of falls?
 Number of falls in the last 12 months?
 Assessment for fear of falling?
Any formal record of fear of falling, anxiety about falls or similar
phrasing; a tool or score is not required.
 Assessment of a history of blackouts or
syncope?
 Review of all medications and combinations of
medications that increase falls risk?
 Assessment of gait, balance and mobility
If yes, 3.4.b.2 what type of assessment is used?
(tick all that apply)
 None
 Ask about gait problems
 Timed up and go
 Berg balance
 Chair rise
 Other
Medication review: the medications should be assessed to
identify any drugs or combination of drugs that might
contribute to falls and modifications / withdrawals made in
light of this as appropriate
3.4.c
3.4.d
Are falls assessments and
interventions provided by the same
FLS staff who determine the need for
treatment for secondary fracture
prevention?
Do you refer patient to any form of
exercise programme:
A requirement to check lying and standing BP?
Must be lying and standing, in that order (and not sitting instead
of either lying or standing). Should use a manual
sphygmomanometer, if available.
Pulse check for rhythm and rate?
For at least 30 seconds
An evaluation of vision?
Any objective assessment acceptable (including basic ability to
identify objects, read print). Solely asking patient if they have
eyesight problems would count as not assessed.
 Yes
 No
If no, who provides falls
assessments and
interventions?
 Yes
 No
If yes go to 3.4.e
If no go to 3.5
3.4.e
Does the exercise program include
strength and balance training:
 yes
 no
3.4.f
Is this a validated exercise programme
delivered by appropriately trained
 yes
professionals (OTAgo, FaMe, HELP)?
 no
3.4.g
What is the service standard waiting
time to start a class?
3.4.h
What is the standard total number of
hours of exercise (supervised and
unsupervised) that participants of the
programme are expected to complete?
3.4 Comments
Please give your answer in number of weeks.
(number)
Please use this field to add your comments about section 3.4
Including whether any of the questions were impossible to
answer or the questions needed clarifying, and any other
comments you may have.
3.5 How does the FLS communicate recommendations for patients?
3.5.a Who receives the report from your  Patient
FLS that summarises the outcomes  Primary care physician
of assessing patient need for
 Orthopaedic surgeon or clinician responsible for fracture care
treatment to prevent secondary
 Falls service
fractures? Please select all that
 Service that referred to FLS
apply
 Other - please specify:
3.5.b
What information is included in the  Date and type of fracture
report? Please select all that apply  Fracture risk score
 DXA – BMD
 DXA – vertebral fracture assessment or spine X-ray result if done instead
 Primary osteoporosis risk factors
 Secondary causes of osteoporosis (if applicable)
 Fracture/fall risk factors
 Current drug treatment recommendations (if applicable)
 Medication compliance review
 Follow-up plan
 Lifestyle/health risk-factor assessment
 Other - please specify:
3.5 Comments
If your reports are different for different
types of fractures please give details in
the ‘other’ section.
Bone therapy recommendations and
supplement recommendations can be
listed under ‘other’ and specified.
Please use this field to add your
comments about section 3.5. Including
whether any of the questions were
impossible to answer or the questions
needed clarifying, and any other
comments you may have.
3.6 Long-term management of patients for secondary fracture prevention covered by the FLS
3.6.a
3.6.b
3.6.c
Who is responsible for monitoring patients seen in the FLS?
Please select all that apply
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FLS coordinator
Non-clinical specialist practitioner
Rheumatologist
Specialist nurse
Orthogeriatrician
Clinician – speciality. Please specify speciality:
Delegated to Primary Care physician
Delegated to other healthcare provider
Other - please specify:
For those FLSs who are based in primary
care, ‘delegated to other primary care
physician’ means a primary care
physician outside of your FLS.
Non-clinical specialist practitioner
means a Non-clinical specialist
practitioner other than an FLS
coordinator.
Which patients undergo re-evaluation by the FLS? Please select all that apply
Less than
50 %
50 – 90
%
90% or
more
Don’t
know
N/A - not
covered
Hip fracture
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Inpatient, non-hip
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Outpatient fragility fracture
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Clinical vertebral fractures
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Radiological vertebral fractures
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What does the re-evaluation include? Please select all that  Medication adherence
apply
 Medication persistence
 Medication adverse effects
 Re-fracture check
 Fracture risk factors
 Recurrent falls
Other - please specify:
Adherence asks is the patient taking the
drug properly in terms of method of
administration and frequency.
Persistence asks if the patient still
taking the drug.
3.6.d
How is adherence assessed or re-evaluated? Please select
all that apply
3.6.e
How long after initiating treatment for secondary fracture  Less than 6 months
prevention are patients recommended to be re-evaluated? 7-12 months
Please select all that apply
13-24 months
>25 months
 No
Do you routinely check patient’s life status using the NHS  Yes
3.6.f
Spine before arranging monitoring?
 Prescription review
 Telephone interview
 Postal questionnaire
 Clinic review
 DXA
 Other - please specify:
 I am located in
Wales (NHS Spine only
incorporates England)
The Spine is a collection of national
applications, services and directories
that support the NHS in the exchange
of information across national and
local NHS systems.
http://systems.hscic.gov.uk/spine
3.6 Comments
Please use this field to add your
comments about section 3.6. Including
whether any of the questions were
impossible to answer or the questions
needed clarifying, and any other