# Achieving 100% Uptake of Intravenous Zoledronic Acid After Hip Fracture Through Rapid Vitamin D Loading: A Three-Cycle Quality Improvement Study in a District General Hospital

## TL;DR

A new protocol for rapid vitamin D loading allowed all eligible hip fracture patients to receive bone protection treatment before hospital discharge, meeting national standards safely.

## Contribution

A rapid vitamin D loading protocol that achieves 100% uptake of IV zoledronic acid in hip fracture patients.

## Key findings

- 100% of eligible patients received IV zoledronic acid post-intervention compared to 24.1% at baseline.
- No hypocalcaemia or infusion-related complications occurred despite 66.2% of patients lacking vitamin D results at infusion.
- National compliance standards were fully met with no adverse effects over 6 months.

## Abstract

Introduction: 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.

Methods: 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.

Results: 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%.

Conclusion: 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.