Donna Rowe is a clinical nurse specialist at Imperial College Healthcare NHS Trust in London. She was bought into post in 2019 to establish the Imperial Trust Fracture Liaison Service (FLS). This remote-working ‘helicopter’ nurse-led service has achieved the best overall statistics on consecutive national Royal College of Physician FLS Database audits over the past two years. We spoke to her about establishing this service, her day-to-day work and her amazing career trajectory.

Please tell us about the Fracture Liaison Service

The service covers all Imperial College Healthcare NHS Trust sites, to identify all patients above 50 years of age presenting with a potential fragility fracture at any of the entry points to secondary care. We also monitor the orthopaedic wards daily for patients who may have transferred from another Trust, for example. We identify patients for assessment against FLS criteria (mechanism of injury, age, type of fracture, etc.) to determine whether they are appropriate for our service and a bone health review.

Is it challenging to work with both outpatients and inpatients?

It could, without doubt, be perceived as challenging, given the actual numbers involved! The majority of patient identification utilises electronic systems to streamline our service, improve its efficiency and maximise our reach. One example is our daily review of fracture admissions/fracture clinic lists/radiology and all incoming referrals. Our radiology improvement project, which began in 2022, ensures we include incidentally reported vertebral fractures; this is crucial for an effective FLS proactively delivering a continuing reduction in re-fractures – the ‘fragility fracture trajectory’ – including major osteoporotic fractures.

Incidentally reported vertebral fractures are significant, and require assessment/treatment to positively impact future fracture rates, including hip fracture. To date, our vertebral fracture detection rates are consistently positive – we currently achieve 204% of the anticipated figure for our Trust.

What exactly is the cycle that the patient goes through?

We initially review the fracture mechanism of injury. The FLS excludes various fracture sites, including patella/cranium/cervical spine/metatarsals/metacarpals. We ensure the patient is within our North West London catchment and review accessible GP notes/documented medications/clinical history (specifically whether the patient is known to another specialism or Trust, for example). We look at radiology, particularly in the case of vertebral fractures, to assess the fracture against the Genant grading scale. That is pretty much our starting point for an early FLS review post-fracture.

If accepted, patients are then contacted and the review process begins, if they consent. A letter to the patient will include an appointment and, most importantly, information in relation to our service, and osteoporosis.

It’s really vital for our patients to understand why we have been in touch and what we may propose following a consultation (blood tests, DEXA (dual energy X-ray absorptiometry), etc.). This transparency is important as patients will be receiving a letter from a service that they have probably not heard of. I facilitate our patients’ understanding of osteoporosis as a frequently occurring problem that is not always well identified. Our literature supports our patients’ understanding of FLS involvement and the process of a bone health review with our service.

During our planned telephone consultation, we collate both modifiable and unmodifiable risk factors to bone health, including falls risks, and seek consent to initiate further elements of the FLS review. This includes arranging DEXA, requesting thoracolumbar imaging (when indicated – i.e. if a loss of height >2 inches in 12 months is reported, or if the patient describes a kyphotic posture etc.), bloods, community specialist input re falls/mobility, etc. To ensure consistency, we utilise a template which has continually evolved to ensure we capture modifiable and unmodifiable risk factors.

Following all investigations, we use the results and the risk assessment responses to determine both treatment and onward management in the community. At this point, we can also refer to community services, or signpost other services to the patient (such as smoking cessation or alcohol services). We aim to deliver a further positive impact on patients’ bone health in the longer term and engage the patient in improving their bone health.

FLS patients are retained in our service for 12 months post-fracture. This is really important in maximising patient concordance with the treatment recommendations. Literature shows average concordance at 12 months following treatment initiation is about 14%. Throughout the identification, assessment and treatment initiation phases, we maintain personalised contact with our patients. They have a named nurse, and we use regular touch points, around every 3 months or so, and at the 12-month point, to make sure the treatment plan is in place. We liaise with primary care providers if patients are experiencing issues with their medication during that time.

We also follow up patients who’ve had either inpatient or outpatient parenteral treatment (zoledronic acid). At 12 months, patients’ GPs are contacted by letter, and recommended to consider oral bisphosphonate or referral to the Metabolic Bone Clinic for a consultant review regarding further infusion or other treatment options, if oral medication is contraindicated.

You’re achieving a lot in that time: how big is the team for this service?

We are a tiny team of two clinical nurse specialists, with access to a consultant endocrinologist, Professor Alex Comninos, as clinical lead. The multidisciplinary team (MDT) meeting is every 2–3 weeks. We present any patients outside our clinical remit, who may require a clinic appointment to see a consultant, for instance if other treatment options may be required (such as teriparatide, romozosumab). We collectively present around eight patients. The vast majority of our remaining FLS patients are not discussed, and will remain within the nurse-led service and not require clinic review.

Do you have any memorable patient experiences?

Oh gosh, so many. One that stands out for me is a chap late last year. I identified the fracture but he wouldn’t have been a classic FLS patient. because of the fracture site (radial head). However, he was in his early 50s and without any particular medical history. I’m really glad I identified the patient and that he consented to my review. He had an underlying myeloma and was fast-tracked to haematology, via the MDT. That really was a memorable moment for me.

What would your top tips be for a Trust wanting to set up this service?

As you may know, there is a recently publicised Government commitment for an FLS in all Trusts in England by 2030. (At the moment there is an FLS in about 50%.) With my previous experience at the Royal Osteoporosis Society as a Service Delivery Lead, my general top tips would be to ensure you have the right key stakeholders, the up-to-date data detailing fracture incidence, your Trust’s national Hip Fracture Database figures for the preceding 5 years, say, and a well-written, cohesive business case (presented by a credible, relevant clinical lead) to effectively promote the need for the service.

Often, FLS services are underfunded and there are misconceptions about the skill required of its nursing team. Fortunately, my colleague and I come from FLS backgrounds elsewhere. I previously set up a community FLS and community infusion service across Nottinghamshire. We both provide an excellent breadth of highly transferable skills and experience. FLS clinical staff recruitment and subsequent staff retention are frequently problematic, and may be a stumbling block for those looking to establish and deliver an effective, sustainable FLS.

Please tell us about your career journey, as others may want to follow in your footsteps

I’ve had quite an interesting career over the last 12 years or so. Initially working in medicine, and then moving to emergency care, I was subsequently offered a promotional post in the Trust’s Risk Management Team. Following another promotion opportunity, I worked with the cross-boundary Palliative Service. During that time, following structural changes and after attaining an MSc in advanced nursing, I began to take an active interest in service development/design, and was presented with an opportunity to move into a community-based senior role to develop/deliver an intravenous service to administer zoledronic acid in patients’ GP practices or their own homes in Nottinghamshire, which would incorporate elements of fracture liaison. During that time, I undertook a Level 7 Postgraduate Certificate in osteoporosis and falls management.

Ever since, I have remained within an FLS/osteoporosis role and have nearly 10 years’ experience. In the early days of my FLS experience it was very challenging: seeking to deliver a service whilst engaging with all opportunities (both ad hoc and academic) to develop knowledge and skill in a new specialty. I have never lost my passion for the FLS and it continues to be an extremely satisfying role, providing me with clinical development opportunities, extensive patient engagement and wider MDT engagement, which is rarely available.

I always enjoy sharing information about the FLS and what can be achieved. My patients and our service are very dear to me. So thank you for this opportunity.