Implementing an identification tool to accurately capture non-ambulatory fragility fractures: a quality improvement project

Non-Ambulatory Fragility Fractures (NAFFs) are low-energy fragility fractures that result in impaired mobility and require hospital admission. They are frequently under-recognised due to inconsistent diagnostic criteria and excessive reliance on clinician judgement. Baseline data at Medway Maritime Hospital showed only 50% of NAFFs were accurately identified and tagged, risking delayed multidisciplinary input and inequitable provision of care. We hypothesised that a structured quality improvement intervention combining education with system-level prompts would significantly improve NAFF identification. This quality improvement project aimed to improve NAFF identification accuracy by 50% through the implementation of two Plan-Do-Study-Act (PDSA) cycles. The initial cycle introduced targeted teaching sessions to increase clinician awareness of the formal NAFF definition: low-energy trauma, inability to mobilise, hospital admission, and a pre-injury Clinical Frailty Score (CFS) > 6. While awareness improved, tagging remained variable. In response, the second cycle focused on system-level change: we co-designed a mandatory NAFF identification prompt embedded within the hospital's eTrauma system. The tool required clinicians to confirm whether each fracture met NAFF criteria during patient admission. To address usability concerns, we integrated a quick-reference version of the full CFS tool and simplified decision-making by highlighting that only the first CFS screening question was needed in most cases. Post-intervention data showed substantial improvement: NAFF identification accuracy rose to 89.1%, with a 72.2% reduction in missed cases. Though false positives increased slightly, this was considered an acceptable trade-off. The intervention exceeded its SMART aim, demonstrating that combining clinician education with structured electronic prompts can drive consistent, high-quality documentation and care. The NAFF identification tool is now fully integrated in clinical practice and induction training, offering a scalable, cost-effective model for broader implementation across orthopaedic departments nationwide.