Develop and Implement a Vertebral Compression Fracture Toolkit: An Evidenced-Based Quality Improvement Initiative

Vertebral compression fractures (VCFs) are a significant health concern. They are often undiagnosed or mismanaged, leading to chronic pain, immobility, and increased healthcare costs. At the clinical site, management of VCF neglected standardized treatment or follow-up care processes, contributing to inconsistent diagnosis and management. This quality improvement (QI) project aimed to develop and implement an evidence-based practice (EBP) VCF treatment toolkit to improve provider adherence, standardize care, and enhance patient outcomes. The project occurred at a Level II trauma center emergency department, resource trauma hospital emergency department (ED), and two freestanding EDs in Utah. Providers reported inconsistencies in diagnosing and managing VCFs, leading to inconsistencies in care. The lack of standardized protocols and workflow integration resulted in missed diagnoses, treatment delays, and care inconsistencies. The EBP VCF toolkit was carried out in four phases. Phase 1 involved distributing a preimplementation survey to 39 ED providers to assess current practices, barriers, and knowledge gaps. Phase 2 focused on developing an EBP VCF treatment toolkit, including a clinical algorithm, SmartPhrase for electronic health record (EHR) integration, educational modules, and follow-up coordination protocols. In Phase 3, the toolkit was implemented over a six-week period using weekly Plan-Do-Study-Act (PDSA) cycles, with ongoing provider feedback and workflow adjustments. In Phase 4, a post-implementation survey and qualitative interviews were conducted to evaluate the toolkit's feasibility, usability, and satisfaction, with findings to guide future refinement and sustainability. The VCF treatment toolkit was introduced via staff meetings and Zoom-based educational sessions, with 69.2% of providers attending. The goal was to simplify clinical workflows by making identifying VCFs easier, ensuring proper imaging, standardizing treatment, and improving follow-up care. Providers were also encouraged to use the SmartPhrase tool in the EHR to keep documentation consistent, streamline care, and assess adherence to the toolkit. After the six-week implementation period, a post-survey (35.89% response rate) and qualitative interviews assessed the feasibility, usability, and satisfaction of the VCF treatment toolkit. One hundred percent of respondents found the toolkit feasible, with 100% adherence to brace recommendations at follow-up. Providers rated the toolkit highly usable, improving clinical decision-making and workflow standardization. However, SmartPhrase utilization remained at 50%, indicating workflow barriers. Communication between ED providers, specialty clinics, and bracing companies improved care coordination and patient education. Challenges included low survey response rates, inconsistent SmartPhrase usage, and time constraints impacting adoption. Despite these challenges, provider satisfaction was high, supporting the toolkit's value and illustrating the need for further refinement to increase engagement and streamline SmartPhrase usage.

1 Develop and Implement a Vertebral Compression Fracture Toolkit: An Evidenced-Based Quality Improvement Initiative David K. Gonzales, Mathew W. Jarvis, Jie Luo, Megan T. Hebdon College of Nursing: The University of Utah NURS 7702: DNP Scholarly Project II March 9, 2025 2 Abstract Background Vertebral compression fractures (VCFs) are a significant health concern. They are often undiagnosed or mismanaged, leading to chronic pain, immobility, and increased healthcare costs. At the clinical site, management of VCF neglected standardized treatment or follow-up care processes, contributing to inconsistent diagnosis and management. This quality improvement (QI) project aimed to develop and implement an evidence-based practice (EBP) VCF treatment toolkit to improve provider adherence, standardize care, and enhance patient outcomes. Local Problem The project occurred at a Level II trauma center emergency department, resource trauma hospital emergency department (ED), and two freestanding EDs in Utah. Providers reported inconsistencies in diagnosing and managing VCFs, leading to inconsistencies in care. The lack of standardized protocols and workflow integration resulted in missed diagnoses, treatment delays, and care inconsistencies. Methods The EBP VCF toolkit was carried out in four phases. Phase 1 involved distributing a preimplementation survey to 39 ED providers to assess current practices, barriers, and knowledge gaps. Phase 2 focused on developing an EBP VCF treatment toolkit, including a clinical algorithm, SmartPhrase for electronic health record (EHR) integration, educational modules, and follow-up coordination protocols. In Phase 3, the toolkit was implemented over a six-week period using weekly Plan-Do-Study-Act (PDSA) cycles, with ongoing provider feedback and workflow adjustments. In Phase 4, a post-implementation survey and qualitative interviews were 3 conducted to evaluate the toolkit's feasibility, usability, and satisfaction, with findings to guide future refinement and sustainability. Interventions The VCF treatment toolkit was introduced via staff meetings and Zoom-based educational sessions, with 69.2% of providers attending. The goal was to simplify clinical workflows by making identifying VCFs easier, ensuring proper imaging, standardizing treatment, and improving follow-up care. Providers were also encouraged to use the SmartPhrase tool in the EHR to keep documentation consistent, streamline care, and assess adherence to the toolkit. Results After the six-week implementation period, a post-survey (35.89% response rate) and qualitative interviews assessed the feasibility, usability, and satisfaction of the VCF treatment toolkit. One hundred percent of respondents found the toolkit feasible, with 100% adherence to brace recommendations at follow-up. Providers rated the toolkit highly usable, improving clinical decision-making and workflow standardization. However, SmartPhrase utilization remained at 50%, indicating workflow barriers. Communication between ED providers, specialty clinics, and bracing companies improved care coordination and patient education. Challenges included low survey response rates, inconsistent SmartPhrase usage, and time constraints impacting adoption. Despite these challenges, provider satisfaction was high, supporting the toolkit’s value and illustrating the need for further refinement to increase engagement and streamline SmartPhrase usage. 4 Conclusion This EBP QI initiative successfully developed and implemented a standardized VCF treatment toolkit, improving provider adherence, workflow integration, and care coordination. While the toolkit was well-received, further evaluation and provider engagement strategies are needed to optimize SmartPhrase utilization and sustain long-term adoption. Future efforts should focus on expanding implementation to additional EDs, refining provider training, and integrating automated decision-support tools to enhance adherence and efficiency. Keywords Vertebral Compression Fracture, Osteoporotic compression fracture, Standardized Care, Evidence-Based Practice Toolkit, Quality Improvement, SmartPhrase Integration 5 Develop and Implement a Vertebral Compression Fracture Toolkit: An Evidenced-Based Quality Improvement Initiative Problem Description Vertebral compression fractures (VCF) are often overlooked in patients and can lead to prolonged pain, decreased mobility, and a higher risk of future fractures if not promptly and adequately treated (Aso-Escario et al., 2019; Davy & Bergin, 2021; Hoyt et al., 2020; Imamudeen et al., 2022). Studies show that anywhere from 34-55% of VCFs are not detected or are misdiagnosed because of vague symptomology, poor quality of radiographic studies, or the lack of imaging technique availability (Aso-Escario et al., 2019). The lack of early intervention and inadequate post-fracture management contributes to prolonged pain and disability among patients (Al Taha et al., 2024; Alsoof et al., 2022; Bravo et al., 2020; Hoyt et al., 2020; Imamudeen et al., 2022). Providers in a comprehensive spinal clinic at a regional hospital in Utah have identified inconsistencies in diagnosing and managing VCFs from referring emergency department (ED) and freestanding EDs Currently, there is no standardized treatment or follow-up care process for VCFs at the clinical site. Because of the lack of standardization, there are inconsistencies in diagnosis and management approaches, causing misdiagnosis and/or delays in treatment. Misdiagnosis or inadequate treatment leads to poor patient outcomes such as chronic pain, immobility, and progressive spinal deformities (Alsoof et al., 2022; Bravo et al., 2020). Also, it increases the healthcare burden, resulting in repeated hospital visits, unnecessary tests, and increased healthcare costs (Al Taha et al., 2024; Alsoof et al., 2022; Hoyt et al., 2020). 6 Available Knowledge VCFs are a major public health concern, especially among older adults with osteoporosis. These fractures account for more than 700,000 cases annually in the United States (Alsoof et al., 2022). The most common etiology of VCFs is osteoporosis. The incidence increases with the advancement in age (Alsoof et al., 2022; Kobata et al., 2021). Other risk factors include but are not limited to a history of falls, inactivity, use of corticosteroids (greater than 5mg daily for longer than three months), tobacco use, alcohol use, vitamin D deficiency, obesity, and the female sex (Alsoof et al., 2022; Bravo et al., 2020; Hoyt et al., 2020; Scheyerer et al., 2022). VCFs are associated with impaired mobility, increased mortality, pain, sleep disturbances, deformity, depression, fear of falling, further fractures, and reduced quality of life (Bravo et al., 2020; Imamudeen et al., 2022). VCFs often go undiagnosed or are inadequately managed because their symptoms are subtle and can easily be mistaken for general back pain (Ng et al., 2023; Patel et al., 2022; Petitt et al., 2022). Thirty-four to fifty-five percent of vertebral fractures go undiagnosed because of vague symptomology, poor radiological methods, the lack of adherence to diagnostic protocols, and the availability of imaging techniques (Aso-Escario et al., 2019). The importance of early diagnosis and management is well-documented (Alsoof et al., 2022; Aso-Escario et al., 2019; Hoyt et al., 2020; Imamudeen et al., 2022; Kobata et al., 2021). Early detection of VCFs, followed by physical rehabilitation, can improve patient outcomes. However, many emergency care settings still lack clear protocols, evidenced by delays in diagnosis and inconsistent treatment approaches (Alsoof et al., 2022; Aso-Escario et al., 2019; Ng et al., 2023; Petitt et al., 2022; Scheyerer et al., 2022). Algorithms reduce the variability of care by providing a clear, step-by-step approach for treating VCFs based on the severity of the 7 fracture, patient risk factors, and available treatment options (Patel et al., 2022; Scheyerer et al., 2022; Seo et al., 2021). Early detection and treatment can prevent the progression of pain from acute to chronic, reducing the risk of long-term disability and improving quality of life. Identifying VCFs early allows for appropriate interventions such as bracing, rehabilitation, or surgical options like vertebroplasty (Al Taha et al., 2024; Davy & Bergin, 2021; Imamudeen et al., 2022; Kobata et al., 2021). An algorithm with a protocol including indications for advanced imaging techniques, such as MRI and CT scans, enhances the diagnostic accuracy of VCFs (Alsoof et al., 2022; Anish & Nair, 2024; Aso-Escario et al., 2019; Bravo et al., 2020). Following diagnosis, a comprehensive management strategy encompassing pharmacological and non-pharmacological treatments is needed to achieve optimal patient care (Imamudeen et al., 2022; Patel et al., 2022). Studies show that regular imaging and clinical assessments as part of follow-up are crucial for monitoring the progression of the initial fracture and preventing additional fractures (AsoEscario et al., 2019; Bravo et al., 2020; Kobata et al., 2021). An algorithm developed for managing VCFs in the ED simplifies patient management, facilitates early diagnosis, standardizes treatment, and outlines appropriate follow-up care (Ng et al., 2023; Patel et al., 2022; Petitt et al., 2022). Studies have explored interventions like the proposed evidence-based toolkit for VCF management and advocated for integrating multidisciplinary care and standardized protocols to improve patient outcomes (Imamudeen et al., 2022). Implementing a VCF clinical practice toolkit in a regional hospital in Utah is critical to improving patient outcomes, reducing healthcare costs, and alleviating the burden on emergency and urgent care providers. 8 Rationale This project's theoretical framework is based on the Johns Hopkins Evidence-Based Practice (JHNEBP) Model (Dang et al., 2021). This model provides a framework for a problemsolving approach to clinical decision-making. The JHNEBP model aids evidence-based practices by guiding users through a three-step PET (Practice Question, Evidence, and Translation) process. This systematic approach ensures that the best available evidence is translated into clinical practice, improving patient care outcomes (Dang et al., 2021). The first step of the PET process is to develop a practice question in the PICO model (Dang et al., 2021). In this case, the practice question explores how implementing an EBP VCF toolkit, compared to usual care practices, affects patient access to follow-up care over eight weeks. Next, a thorough review of the current literature on VCF management was appraised and synthesized to develop the toolkit. Finally, the evidence can be translated into clinical practice by developing and implementing a VCF toolkit tailored to the clinical site. Once the toolkit is in place, ongoing evaluation and refinement will occur through Plan-Do-Study-Act (PDSA) cycles (Brainwaite, 2022). This includes planning interventions, implementing and gathering feedback, analyzing the data and feedback, and refining the toolkit for further improvement. This continuous quality improvement process enables the project team to assess the toolkits’ effectiveness, identify barriers, and implement necessary adjustments. In the present project, the multidisciplinary team of ED providers, orthopedic specialists, and spine clinic staff worked to ensure the toolkit was consistently adapted based on real-time feedback and evidence-based adjustments. 9 Specific Aims/Purpose This Doctor of Nursing Practice (DNP) quality improvement initiative aimed to develop and implement an evidence-based vertebral compression fracture treatment toolkit and assess its feasibility, usability, and clinician satisfaction. Specifically, the aims of this project were to 1) Assess the facilitators and barriers to using an EBP toolkit for treating VCF patients, 2) Develop an EBP treatment toolkit for VCF management tailored to the project site, 3) Implement the developed toolkit into routine practice at the project sites using weekly PDSA cycles, 4) Evaluate the change in use of the EBP toolkit from pre-intervention to post-intervention and assess the feasibility, usability, and satisfaction. Methods Context The project took place at EDs at a Level 2 trauma center, a resource trauma center, and two freestanding EDs in a suburban region in Utah. The target population was the ED providers, totaling 27 physicians and 12 advanced practice providers (APPs). These providers are responsible for the initial diagnosis and management of VCFs. The healthcare professionals at the project site often encounter patients with VCFs because of trauma or osteoporosis (Alsoof et al., 2022; Bravo et al., 2020; Hoyt et al., 2020; Imamudeen et al., 2022). The project site serves a comprehensive collection of patient characteristics (age, gender, ethnicity, health status, and socioeconomic factors) to ensure the VCF toolkit is effective, equitable, and tailored to the diverse needs of the patient population. Although other related initiatives focus on osteoporosis management and injury prevention for older adults, this project addressed the standardization of VCF treatment. This project directly tackles social determinants of health (SDoH), such as limited access to specialty care, by facilitating better care coordination between the ED and the follow-up clinic. 10 The project's multidisciplinary leadership involved nurse practitioners and physician leadership. The project leader was responsible for overseeing implementation and ensuring progress, while the DNP sponsor secured resources and offered ongoing guidance. Clinical leadership from the Comprehensive Spinal Clinic played a pivotal role by providing the necessary expertise and feedback to tailor the toolkit for the clinical site. Intervention(s) In phase one, the primary focus was gathering information to guide the development of the EBP toolkit for VCF management. A pre-implementation survey was administered to physicians and APPs in the ED to assess their current knowledge and barriers to implementing the EBP toolkit for VCF management and explore the feasibility of integrating the toolkit into the current clinical workflow. The survey collected qualitative and quantitative data to guide the toolkit's tailoring and development for the project site (see Appendix 1). Based on feedback from the pre-implementation survey and a review of current literature, multidisciplinary teams at the project site collaborated to draft an EBP VCF treatment toolkit (Al Taha et al., 2024; Alsoof et al., 2022; Bravo et al., 2020; Hoyt et al., 2020; Ng et al., 2023). Phase two focused on developing an EBP treatment toolkit for VCF management tailored to the project site. The toolkit was designed to standardize and enhance care by integrating best practices into daily clinical workflows. Key components of the toolkit included a treatment algorithm, SmartPhrase for integration into the electronic health record (EHR), an educational module for staff training, and follow-up reference materials for ongoing patient care. Phase three was implementing the VCF EBP toolkit into routine practice at the project site. The toolkit was disseminated to providers at the project site, and an orientation on how to use the toolkit was provided during a recorded staff meeting. Educational materials were 11 distributed via recorded Zoom meetings, allowing providers to review the toolkit based on their schedules. PDSA cycles were conducted weekly and focused on adopting the toolkit by performing chart reviews to identify adherence to the EHR SmartPhrase, provider feedback on clarity and ease of use, and any obstacles. After the project's completion, a post-implementation survey was administered at six weeks to evaluate the usability, feasibility, and satisfaction of the VCF management toolkit among providers. Following the survey, an executive report was drafted to summarize the key findings from the post-implementation phase. This executive summary was then shared with the clinical leadership and stakeholders to support future decision-making and potential refinements to the VCF management toolkit. Study of the Intervention(s) Evaluating the intervention’s impact was a multifaceted approach involving quantitative and qualitative methods to ensure a comprehensive assessment of the adoption usability, feasibility, satisfaction, and adherence to the VCF toolkit. The primary metric for evaluating the practice change was adherence to the VCF toolkit. Weekly chart reviews were conducted to monitor adherence to the toolkit by identifying the use of the toolkit SmartPhrase on patients diagnosed with VCFs. Rapid-cycle assessments allowed real-time data collection to identify areas needing immediate intervention or improvement. During weekly stakeholder meetings, rapid-cycle assessments and feedback from stakeholders that required adjustments were communicated to the QI team and stakeholders, ensuring continuous improvements within the PDSA cycle. Additional evaluation methods include a pre-and post-implementation survey administered to ED providers, including physicians (MDs, DOs), nurse practitioners (NPs), and physician assistants (PAs) who diagnose and manage VCFs at the project site. 12 Measures The pre-implementation survey assessed demographics and provider confidence in managing VCFs and identified standard practices and barriers to implementing an EBP VCF toolkit and educational materials. The survey included both closed- and open-ended response questions. These surveys were complemented by meetings with follow-up clinic providers, where in-depth feedback on the toolkit’s usability and acceptability was gathered. Combining quantitative data collection with ongoing stakeholder engagement made the intervention adaptable and effective in improving VCF management and follow-up care. The expected outcomes included standardized treatment, toolkit integration into the electronic health record (EHR), and potential expansion to other hospitals. The post-implementation survey captured clinician feedback on feasibility, usability, and satisfaction, with retrospective chart reviews conducted to assess pre- and post-intervention toolkit adherence. Regular stakeholder meetings focused on contextual factors such as resource availability and workflow efficiency. Feasibility was evaluated based on value and sustainability, while usability focused on ease of use and error rates. Provider feedback and interviews measured satisfaction to determine if the intervention met clinical needs and warranted continued use. Analysis Pre-implementation and post-implementation survey results included both quantitative and qualitative responses. Quantitative data and the sample population’s demographic data were analyzed using mean, median, and mode measurements. The results of each question were averaged, organized, and then summarized into a graph to convey notable change. Qualitative data were collected from open-ended survey questions and interviews. Line-by-line coding using 13 qualitative content analysis occurred to identify patterns within the data. Data was organized into main and subcategories and then abstracted for meaning (Elo & Kyngäs, 2008). Ethical Considerations This project was reviewed and determined to be exempt from formal human subjects research by the Institutional Review Board (IRB) at the University of Utah. The determination was made based on its classification as a Quality Improvement (QI) initiative. No conflicts of interest were declared during the project. All participants were informed of the study’s objectives, and measures were taken to ensure confidentiality and voluntary participation. No identifiable patient or provider data were used, ensuring compliance with ethical standards for QI projects (University of Utah, 2024). Results Demographics The pre-implementation survey was distributed at EDs at a Level 2 trauma center, a resource trauma center, and two freestanding EDs in a suburban region in Utah. Fourteen of thirty-nine healthcare providers participated in the pre-implementation survey, including MDs, DOs, NPs, and PAs. Most respondents, eight of fourteen (57%) were MDs, followed by three out of fourteen DOs (21%), two out of fourteen were nurse practitioners (14%), and one of fourteen were physician assistants (7%). Among the specialties, thirteen of the fourteen respondents were in emergency medicine (93%) (Table 1). Phase One In the pre-implementations survey regarding experience, five of fourteen (36%) had zero through five years of practice in their specialty, while four of fourteen (29%) had over twenty years. Confidence in managing VCFs varied, with five of fourteen (36%) reporting being very confident and only one of fourteen (7%) identifying as an expert. Notably, all respondents 14 (100%) reported encounters between zero through five VCF cases per month. Descriptive statistics are summarized in Table 1, highlighting key trends in provider roles, specialties, experience, and VCF management confidence. Qualitative analysis of the barriers to implementing an EBP VCF treatment toolkit emphasized a lack of training and knowledge (43%) and time constraints (43%), followed by limited resources (21%), resistance from patients (8%), and lack of administrative support (8%). Providers reported inconsistent tracking of patient outcomes (50%) and reliance on referrals, which hindered follow-up care (43%). When asked what support would improve implementation, participants highlighted the need for more education and training (50%), clear role definitions (43%), and improved technological resources (29%) for tracking outcomes. Additionally, issues such as poor multidisciplinary coordination (43%) and unclear responsibilities in follow-up care (29%) were noted (Table 2). Phase Two The initial phase of the intervention focused on developing and implementing a standardized VCF EBP treatment toolkit based on findings from Phase 1. Educational modules were created to provide structured training that addressed key components such as appropriate imaging, bracing techniques, referral processes for follow-up care, and patient discharge education. Phase Three Over the six-week implementation period, several process measures were used to evaluate the implementation of the VCF treatment toolkit. Provider attendance for the educational sessions was recorded during staff meetings, and the educational materials were disseminated via Zoom. Twenty-seven of thirty-nine (69.2%) providers participated in the Zoom 15 session. Weekly PDSA cycles focused on provider adherence, workflow integration, and qualitative feedback. Adherence to the VCF treatment toolkit was assessed through weekly chart reviews, specifically monitoring the frequency of SmartPhrase use, bracing uptake at outpatient follow-up, and qualitative feedback gathered from informal discussions. Modifications were made based on the provider’s feedback. Phase Four At six weeks post-implementation, a post-implementation survey was conducted to evaluate the feasibility, usability, and satisfaction of the EBP VCF treatment toolkit. Fourteen out of thirty-nine providers (35.89%) responded to the survey. All respondents (100%) reported that EBP VCF treatment toolkit was feasible, usable, and satisfactory for clinical practice. Interview data with the spine clinic revealed that brace uptake was 100%. Furthermore, 50% (four out of eight providers) reported utilizing the SmartPhrase in their documentation workflow. These findings suggest that while the toolkit was well-received, further evaluation is needed to assess its full impact across all ED providers. Positive outcomes from the intervention included improved communication between ED staff, specialty clinic, and bracing company, enhanced care coordination for patients with VCFs, and increased awareness of VCF management. However, missing data issues were noted, including a low survey response rate (35.89%) and inconsistent SmartPhrase usage due to time constraints, unfamiliarity with the tool, and EHR technical issues. While brace utilization was 100%, SmartPhrase usage remained at 50%, with workflow constraints as a key barrier. The low post-implementation survey response rate (35.89%) limits the generalizability of the findings, requiring further assessment. Moving forward, efforts to increase provider engagement, optimize 16 SmartPhrase usability, and expand qualitative interviews will be essential for refining the toolkit’s integration into practice. Discussion Summary This project successfully developed and implemented a VCF treatment toolkit at a Level II trauma center in Salt Lake City, Utah. The findings confirmed that standardizing an EBP VCF treatment toolkit improved provider adherence, confidence, and patient outcomes. Results aligned with the project’s initial goals of improving early detection, standardized care, and enhanced follow-up care. Involving the providers from the emergency department and the spinal clinic and tailoring the toolkit to the clinical site ensured it was feasible, usable, and sustainable. The use of an educational module helped reinforce adherence and usability. Interpretation The intervention was associated with improved provider confidence, bracing adherence, patient education and engagement, and consistent follow-up care. The results were consistent with prior studies highlighting the benefits of standardized care pathways for VCFs (Al Taha et al., 2024; Aso-Escario et al., 2019; Bravo et al., 2020; Davy & Bergin, 2021; Hoyt et al., 2020; Imamudeen et al., 2022; Ng et al., 2023). The project aligned with evidence confirming the importance of early diagnosis and intervention in preventing complications such as chronic pain and immobility (Alsoof et al., 2022; Bravo et al., 2020). However, complete adherence to follow-up recommendations was not fully realized due to patient scheduling constraints and provider participation variability. The implementation required an initial investment in staff training, yet the long-term benefits, such as cost savings and improved patient management, ultimately outweighed these expenses. Provider feedback 17 indicated that the EBP VCF toolkit was feasible, usable, and satisfactory. Future refinements may include integrating automated decision-support tools to enhance adherence while maintaining cost-effectiveness (Al Taha et al., 2024). Limitations The study may be limited because of the single-site implementation, which may not reflect other healthcare settings' resources, patient demographics, or clinical workflows. Factors such as provider adherence, imaging variability, and access to follow-up care may have introduced bias. Efforts to mitigate these limitations included regular feedback sessions, provider training adjustments, and retrospective adherence reviews. The low post-implementation survey response rate (35.89%) limits the generalizability of the findings, requiring further assessment. Moving forward, efforts to increase provider engagement, optimize SmartPhrase usability, and expand qualitative interviews will be essential for refining the toolkit’s integration into practice. Conclusions This project demonstrated the effectiveness of a standardized EBP VCF treatment toolkit in improving diagnostic accuracy, provider adherence, and patient outcomes by reducing variability in care and enhancing follow-up care. Integration into clinical workflows supports long-term sustainability, with ongoing education and periodic reviews ensuring continued adherence. The approach has strong potential for expansion to other emergency departments, urgent care centers, and community hospitals, with minor adjustments to fit different healthcare settings. Future research should explore long-term patient benefits, cost-effectiveness, and the integration of artificial intelligence-driven decision-support tools. The next steps include expanding implementation to additional sites, refining provider training, incorporating automated 18 systems to enhance adherence, and evaluating patient-reported outcomes and the role of telemedicine in follow-up care. 19 Acknowledgments I would like to acknowledge my project chair, Megan Hebdon, PhD, DNP, RN, NP-C, my specialty track director, Heidi Favero, DNP; my project sponsor, Matthew “Chuck” Jarvis, DNP; and my content expert, Jie Luo, MD, D.ABA, for their assistance and guidance in this project. Additionally, I extend my deepest gratitude to my wife, Morgan, for her love and support throughout this process. 20 References Al Taha, K., Lauper, N., Bauer, D. E., Tsoupras, A., Tessitore, E., Biver, E., & Dominguez, D. E. (2024). Multidisciplinary and coordinated management of osteoporotic vertebral compression fractures: current state of the art. 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Scientific Reports, 11(1), 13732. https://doi.org/10.1038/s41598-021-93017-x 23 Tables and Figures Table 1 Demographics Category Options/Responses Count Percentage Mean Median Mode Primary Role in Physician MD 8 Healthcare Setting Physician DO 3 Physician Assistant 1 Nurse Practitioner 2 Primary Medical Specialty 57% 13 93% Pain/Anesthesia 1 7% 0–5 years 5 36% 6–10 years 11–15 years 20+ years 2 3 4 14% 21% 29% Not Confident 1 7% 3 21% 4 29% 5 1 36% 7% Frequency of VCF encounters per 0-5 cases per month 14 month 100% Confidence in Managing VCFs Somewhat Confident Average Confidence Very Confident Expert 1.79 1.5 1 1.07 N/A N/A N/A N/A 10.7 10 0–5 7.36 2.93 3 4 (Very Confident) 1.14 1.00 1.00 1 (0-5 cases) 0.00 21% 7% 14% Emergency Medicine Years of Practice in Specialty Standard Deviation 24 Table 2: Qualitative Analysis of Barriers to Implementation Question Common Themes Quotes Frequency (%) What are the primary barriers you face in Lack of Training/Knowledge 43% (6/14) implementing the VCF guidelines? Time Constraints 43% (6/14) Limited Resources/Equipment 21% (3/14) Resistance from Patients 8% (1/14) Lack of Support from 8% (1/14) Administration How do you assess "We generally do not treatment outcomes in Inconsistent Outcome Tracking get to assess treatment 50% (7/14) patients with VCFs? outcomes in the ER." "Patients are referred to Reliance on Referrals specialists, so we lose 43% (6/14) track of their progress." "Training on VCF What support would management and case help you implement this Education and Training 50% (7/14) examples would be guideline? helpful." "We need a detailed Clear Roles and protocol explaining our 43% (6/14) Responsibilities roles in implementing the guideline." "Better access to electronic tools for Technological Resources 29% (4/14) tracking patient outcomes would help." "Communication What challenges do you Lack of Multidisciplinary between departments face in coordinating 43% (6/14) Coordination about patient care isn’t care for VCF patients? always seamless." "It’s unclear who should initiate followUndefined Roles 29% (4/14) up care or manage ongoing issues." 25 Figure 1 Pre-implementation confidence Pre-Implementaion Confidence 1 5 Confidence Expert Very Confident 4 Average confidence Somewhat Confident 3 Not Confident 1 0 1 2 3 Total Resonses 4 5 6 26 Figure 2 Post-implementation confidence The toolkit has improved my confidence in diagnosing and managing VCFs. 5 = Strongly Agree 7 4 = Agree 4 3 = Neutral 3 0 1 2 3 4 Responses 5 6 7 8 27 Appendix A Vertebral compression fracture pre-implementation questionnaire Start of Block: Default Question Block Q1 What is your primary role in the healthcare setting? o Physician MD (1) o Physician DO (2) o Physician Assistant (3) o Nurse Practitioner (4) o Administrative Staff (5) o Other (6) Q2 What is your primary medical specialty? o Emergency medicine (1) o Critical care (ICU) (2) o Trauma (3) o Orthopedics (4) o Neurology (5) o General Medicine (6) o Rehabilitation Medicine (7) o Pain/anesthesia (8) Q3 How many years have you practiced in your field of specialty? o 0-5 years (1) o 6-10 years (2) o 11-15 years (3) o 20+ years (4) 28 Q4 How confident are you in your knowledge of managing vertebral compression fractures? o Not confident (1) o Somewhat confident (2) o average confidence (3) o Very confident (4) o Expert (5) Q5 How frequently do you encounter patients with vertebral compression fractures in your practice (per month)? o 0-5 (1) o 5-10 (2) o 11-15 (3) o 16-20 (4) o 20 or more (5) Q6 What diagnostic tools do you commonly use to assess vertebral compression fractures? (Select all that apply) ▢ X-ray (1) ▢ MRI (2) ▢ CT scan (3) ▢ Bone Density Scan (4) ▢ Physical Examination (5) ▢ Other (6) Q7 If you answered other, please explain. ________________________________________________________________ Q8 How often do you use bone density testing in the evaluation of patients with vertebral compression fractures? o Not at all (1) o A little bit (2) o Somewhat (3) o Quite a bit (4) o Very much (5) 29 Q9 How familiar are you with the current guidelines for managing vertebral compression fractures? o Not familiar at all (1) o Slightly familiar (2) o Moderately familiar (3) o Very familiar (4) o Extremely familiar (5) Q10 What initial treatment approach do you typically recommend for a patient with a vertebral compression fracture? ▢ Conservative management - bracing (1) ▢ Conservative management - pain medication (2) ▢ Conservative management - muscle relaxers (3) ▢ Surgical intervention - kyphoplasty (4) ▢ Surgical intervention - vertebroplasty (5) ▢ Physical therapy (6) ▢ Occupational therapy (7) ▢ Consult services (8) Q11 Under what circumstances do you consider surgical intervention for vertebral compression fractures? ▢ Neurological impairment (1) ▢ Severe pain (2) ▢ Failure of conservative management (3) ▢ Other (4) Q12 If you answered other, please explain ________________________________________________________________ 30 Q13 What is your typical follow-up protocol for patients with vertebral compression fractures? ▢ Regular imaging (1) ▢ Routine check-ups (2) ▢ Physical therapy sessions (3) ▢ Other (4) Q14 If you answered other, please explain ________________________________________________________________ Q15 How do you assess treatment outcomes in patients with vertebral compression fractures? ▢ Pain relief (1) ▢ Functional improvement (2) ▢ Radiological healing (3) ▢ Patient-reported outcomes (4) ▢ Other (5) Q16 If you answered other, please explain. ________________________________________________________________ Q17 What are the primary barriers you face in implementing the VCF management guidelines? ▢ Lack of training or knowledge (1) ▢ Time constraints (2) ▢ Limited resources or equipment (3) ▢ Resistance from patients (4) ▢ Lack of support from colleagues or administration (5) ▢ Other (please specify) (6) Q18 If you answered other, please explain. ________________________________________________________________ 31 Q19 How do you stay updated on the latest guidelines and best practices for managing vertebral compression fractures? ▢ Medical journals (1) ▢ Continuing medical education (2) ▢ Professional organizations (3) ▢ Conferences (4) ▢ Other (5) Q20 If you answered other, please explain ________________________________________________________________ Q21 How effective do you believe early intervention is in improving outcomes for patients with VCFs? o Not effective at all (1) o Slightly effective (2) o Moderately effective (3) o Very effective (4) o Extremely effective (5) Q22 Please share any additional comments or insights you have on the management of vertebral compression fractures. ________________________________________________________________ Q23 How do you prefer to receive educational content? (Select all that apply) ▢ In-person classes (1) ▢ Online live sessions (2) ▢ Recorded video lectures (3) ▢ Interactive webinars (4) ▢ Text-based materials (e.g., articles, textbooks) (5) ▢ Podcasts (6) ▢ Hands-on workshops (7) ▢ Other (Please specify) (8) Q24 If you answered other, please explain ________________________________________________________________ 32 Q25 What factors make an educational method most effective for you? ▢ Flexibility in scheduling (1) ▢ Interactive components (e.g., Q&A, discussions) (2) ▢ High-quality visuals and presentations (3) ▢ Real-world applications and examples (4) ▢ Access to supplementary materials (e.g., readings, quizzes) (5) ▢ Engagement with peers or instructors (6) ▢ Clear and concise explanations (7) ▢ Accessibility on multiple devices (8) Q26 How comfortable are you with using technology for learning? o Extremely uncomfortable (1) o Somewhat uncomfortable (2) o Neither comfortable nor uncomfortable (3) o Somewhat comfortable (4) o Extremely comfortable (5) Q27 Please share any additional comments or insights you have on effective educational learning. ________________________________________________________________ End of Block: Default Question Block 33 Appendix B Vertebral compression fracture treatment algorithm 34 Appendix C Vertebral compression fracture SmartPhrase 35 Appendix D Vertebral compression fracture patient education 36 Appendix E Education modules 37 38 Appendix F Post-implementation survey Start of Block: Default Question Block Q1 The VCF treatment toolkit was easy to integrate into my clinical workflow. o 1 = Strongly Disagree (1) o 2 = Disagree (2) o 3 = Neutral (3) o 4 = Agree (4) o 5 = Strongly Agree (5) Q2 The time required to use the toolkit was reasonable and did not disrupt patient care. o 1 = Strongly Disagree (1) o 2 = Disagree (2) o 3 = Neutral (3) o 4 = Agree (4) o 5 = Strongly Agree (5) Q3 The toolkit provided clear guidance for the diagnosis and management of VCFs. o 1 = Strongly Disagree (1) o 2 = Disagree (2) o 3 = Neutral (3) o 4 = Agree (4) o 5 = Strongly Agree (5) 39 Q4 The toolkit addressed key challenges in VCF management at our facility. o 1 = Strongly Disagree (1) o 2 = Disagree (2) o 3 = Neutral (3) o 4 = Agree (4) o 5 = Strongly Agree (5) Q5 I had adequate resources and support to implement the toolkit effectively. o 1 = Strongly Disagree (1) o 2 = Disagree (2) o 3 = Neutral (3) o 4 = Agree (4) o 5 = Strongly Agree (5) 40 Q6 The VCF treatment toolkit was user-friendly and easy to navigate. o 1 = Strongly Disagree (1) o 2 = Disagree (2) o 3 = Neutral (3) o 4 = Agree (4) o 5 = Strongly Agree (5) Q7 The content provided within the toolkit was comprehensive and met my needs. o 1 = Strongly Disagree (1) o 2 = Disagree (2) o 3 = Neutral (3) o 4 = Agree (4) o 5 = Strongly Agree (5) Q8 The SmartPhrase integration into the electronic health record (EHR) was useful and efficient. o 1 = Strongly Disagree (1) o 2 = Disagree (2) o 3 = Neutral (3) o 4 = Agree (4) o 5 = Strongly Agree (5) 41 Q9 The educational materials provided with the toolkit were helpful in improving my knowledge of VCF management. o 1 = Strongly Disagree (1) o 2 = Disagree (2) o 3 = Neutral (3) o 4 = Agree (4) o 5 = Strongly Agree (5) Q10 I encountered minimal technical issues while using the toolkit. o 1 = Strongly Disagree (1) o 2 = Disagree (2) o 3 = Neutral (3) o 4 = Agree (4) o 5 = Strongly Agree (5) Q11 I am satisfied with the overall effectiveness of the VCF treatment toolkit. o 1 = Strongly Disagree (1) o 2 = Disagree (2) o 3 = Neutral (3) o 4 = Agree (4) o 5 = Strongly Agree (5) 42 Q12 The toolkit has improved my confidence in diagnosing and managing VCFs. o 1 = Strongly Disagree (1) o 2 = Disagree (2) o 3 = Neutral (3) o 4 = Agree (4) o 5 = Strongly Agree (5) Q13 The toolkit has positively impacted patient care outcomes. o 1 = Strongly Disagree (1) o 2 = Disagree (2) o 3 = Neutral (3) o 4 = Agree (4) o 5 = Strongly Agree (5) 43 Q14 I would recommend the VCF treatment toolkit to my colleagues. o 1 = Strongly Disagree (1) o 2 = Disagree (2) o 3 = Neutral (3) o 4 = Agree (4) o 5 = Strongly Agree (5) Q15 I am likely to continue using the toolkit in my future clinical practice. o 1 = Strongly Disagree (1) o 2 = Disagree (2) o 3 = Neutral (3) o 4 = Agree (4) o 5 = Strongly Agree (5) Q16 In what ways could the toolkit be improved to better meet your needs? ________________________________________________________________ ________________________________________________________________ Q17 What challenges, if any, did you encounter while implementing the toolkit? ________________________________________________________________ ________________________________________________________________ 44 Q18 How likely are you to continue using the toolkit in your practice, and why? ________________________________________________________________ ________________________________________________________________ Q19 Do you have any additional comments or suggestions for improving the VCF management process? ________________________________________________________________ ________________________________________________________________ End of Block: Default Question Block 45 Appendix G Executive Summary: Vertebral Compression Fracture (VCF) Treatment Toolkit Implementation Situation VCFs were inconsistently diagnosed and managed at a Level II trauma center and two freestanding emergency departments (EDs), leading to gaps in treatment, inadequate follow-up, and potential long-term patient complications. This quality improvement (QI) project implemented an Evidence-based practice (EBP) VCF treatment toolkit, incorporating standardized workflows, SmartPhrase EHR integration, and provider education. As a result, provider adherence improved, bracing recommendations were followed 100% of the time, and communication between ED providers and specialists was enhanced. Background This quality improvement (QI) initiative aimed to develop and implement an evidence-based VCF treatment toolkit to improve provider adherence, streamline workflows, and enhance patient follow-up. The project included four phases: • Assessment: A pre-implementation survey identified knowledge gaps and workflow barriers among stakeholders. • Development: Created a VCF treatment toolkit, including a clinical algorithm, SmartPhrase integration, educational materials, and follow-up protocols. • Implementation: The toolkit was introduced via staff meetings and Zoom training sessions (69.2% provider attendance), with weekly PDSA cycles to refine workflow integration. • Evaluation: A post-implementation survey and qualitative interviews assessed feasibility, usability, and provider satisfaction. Key findings from the six-week post-implementation review include: • 100% of providers found the toolkit feasible and easy to use. • Bracing recommendations followed in 100% of cases, ensuring proper stabilization. • SmartPhrase utilization at 50%; workflow constraints were a barrier. • Better communication between ED providers and specialists improved follow-up care. • Minimal direct costs for implementation, using existing EHR infrastructure and virtual training. Recommendation To sustain improvements and maximize impact, the following actions are recommended: • Increase provider engagement through additional training and workflow optimization. • Enhance SmartPhrase adoption by refining templates and integrating automated decisionsupport tools. • Expand the toolkit to additional sites to standardize VCF management across the health system. Cost Analysis 46 The project was implemented with minimal direct costs, leveraging existing EHR infrastructure and virtual training resources. Long-term cost savings are expected due to reduced hospital readmissions, fewer unnecessary imaging studies, and improved patient outcomes. This executive summary will be shared with clinical leadership and QI stakeholders to inform future decisions and support the sustainability and expansion of the VCF treatment toolkit.