Achieving 100% Uptake of Intravenous Zoledronic Acid After Hip Fracture Through Rapid Vitamin D Loading: A...

Hip fracture patients are at high risk of secondary fractures. National guidance and the consensus from the literature recommend timely bone protection therapy. Delays in vitamin D testing and logistical barriers often prevent inpatient intravenous (IV) zoledronic acid use. Our aim was to determine whether a rapid vitamin D loading protocol enabling inpatient IV zoledronic acid administration before discharge could improve treatment uptake and meet national standards.

A three-cycle quality improvement project was conducted in patients aged ≥60 years with fragility hip fractures. Baseline data (2020-2022) were compared to post-intervention cycles (2024-2025). The intervention comprised a standard operating procedure (SOP) incorporating ≥160,000 IU cholecalciferol loading over seven days, renal and calcium monitoring, pre- and post-infusion checklists, and inpatient IV zoledronic acid on or after day 5 post-surgery. The primary outcome was receipt of IV zoledronic acid. Secondary measures included vitamin D result availability, process compliance, and safety outcomes.

At baseline, seven out of 29 patients (24.1%) received IV zoledronic acid. Post-intervention, all eligible patients (100%) (Cycle 2: 30/30; Cycle 3: 80/80) received inpatient IV zoledronic acid (p<0.001). Vitamin D results were unavailable at infusion in 53 patients (66.2%) of Cycle 3 patients, yet 80 patients (100%) completed anticipatory loading and 80 patients (100%) had calcium checks. No hypocalcaemia or infusion-related complications occurred. Six-month re-fracture and mortality rates were 1.25% (one patient) and 6.3% (five patients), respectively. National Hip Fracture Database (NHFD) Key Performance Indicator 7 (KPI-7)compliance reached 100%.

A rapid vitamin D loading SOP enabled timely inpatient IV zoledronic acid administration, overcoming logistical and laboratory barriers and achieving 100% compliance with national standards without adverse effects. This pathway is safe, sustainable, and scalable for secondary fracture prevention in district general hospitals.