A Quality Improvement Study on Calcium and Vitamin D Supplementation in Long-term Care

Vitamin D and Calcium Supplementation in Nursing Homes-A Quality Improvement Study

Even though dietary supplements with vitamin D and calcium are recommended to nursing home residents, we recently reported a low adherence to this recommendation. The objective of this 20-week quality improvement study was to use the Model for Improvement and Plan-Do-Study-Act (PDSA) cycles to improve adherence in Danish nursing homes. We included two nursing homes with 109 residents at baseline. An information sheet including the rationale for the recommendation was developed for the nurses to urge residents to take the supplements and seek approval by the general practitioner afterwards (PDSA cycle 1). Moreover, it was included in admission meetings with new residents to address supplementation (PDSA cycle 2). A nurse reviewed patient records for number of residents prescribed adequate doses of vitamin D (≥20 µg) and calcium (≥800 mg) before, during and after the intervention. At baseline, 32% (n = 35) of the residents had adequate doses of vitamin D and calcium. After implementation of the information sheet and adjustment to admission meetings, this increased to 65% (n = 71) at endpoint (p < 0.001). In conclusion, in this quality improvement study, we improved the number of prescriptions of adequate doses of vitamin D and calcium over 20 weeks using the Model for Improvement and PDSA experiments.

Quality improvement in long-term care settings: a scoping review of effective strategies used in care homes

PURPOSE

We conducted a scoping review of quality improvement in care homes. We aimed to identify participating occupational groups and methods for evaluation. Secondly, we aimed to describe resident-level interventions and which outcomes were measured.

METHODS

Following extended PRISMA guideline for scoping reviews, we conducted systematic searches of Medline, CINAHL, Psychinfo, and ASSIA (2000-2019). Furthermore, we searched systematic reviews databases including Cochrane Library and JBI, and the grey literature database, Greylit. Four co-authors contributed to selection and data extraction.

RESULTS

Sixty five studies were included, 6 of which had multiple publications (75 articles overall). A range of quality improvement strategies were implemented, including audit feedback and quality improvement collaboratives. Methods consisted of controlled trials, quantitative time series and qualitative interview and observational studies. Process evaluations, involving staff of various occupational groups, described experiences and implementation measures. Many studies measured resident-level outputs and health outcomes. 14 studies reported improvements to a clinical measure; however, four of these articles were of low quality. Larger randomised controlled studies did not show statistically significant benefits to resident health outcomes.

CONCLUSION

In care homes, quality improvement has been applied with several different strategies, being evaluated by a variety of measures. In terms of measuring benefits to residents, process outputs and health outcomes have been reported. There was no pattern of which quality improvement strategy was used for which clinical problem. Further development of reporting of quality improvement projects and outcomes could facilitate implementation.

Improved vitamin D supplementation in hospitalized breastfed infants through electronic order modification and targeted provider education

OBJECTIVE

To examine effectiveness of an intervention promoting vitamin D supplementation in hospitalized breastfed infants.

METHODS

Our urban tertiary care hospital instituted a 2-part intervention: brief education for providers on vitamin D guidelines and insertion of an opt-in order for vitamin D supplements into electronic admission order sets. Data downloads on admissions of patients aged <1 year were obtained. We excluded those not breastfed, with a dietary restriction, or admitted to intensive care. Intervention effects were compared from 6 months postintervention to the 6 same months 1 year earlier. We applied χ2 and logistic regression, including the patient as a random effect to adjust for repeated admissions.

RESULTS

Data on 471 exclusively or partially breastfed admissions (441 infants) were analyzed (221 preintervention, 250 postintervention). Admission characteristics did not differ by period: 55.0% boys; 40.6% Medicaid; 63.7% hospitalized ≤2 days; 72.0% on a general medical service; 16.6% received nutritionist consultation. In-hospital vitamin D prescribing rates significantly increased postintervention (19.5% vs 44.4%; P<.001). Postintervention admissions were more than twice as likely to receive vitamin D supplementation (adjusted odds ratio 2.3, 95% confidence interval 1.6-3.2). Other associated factors included vitamin D as a medication used before admission (adjusted odds ratio 14.3, 95% confidence interval 4.9-41.6), nutritionist consultation during admission, hospitalization≥3 days, and admission to a general medical service. Prescribing of vitamin D at discharge increased significantly (9.0% vs 19.6%; P<.001).

CONCLUSIONS

Medical provider education and modification of electronic ordering templates significantly increased use of vitamin D supplementation in hospitalized breastfed infants.

Ensuring vitamin D supplementation in nursing home patients--a quality improvement project

Randomized controlled trials have shown that adequate vitamin D supplementation in nursing home (NH) residents reduces the rates of falls and fractures. In our NH, review of medication administration records of all patients (n = 101) revealed that only 34.6% of the patients were currently prescribed adequate doses of vitamin D, revealing a need for intervention. We designed a Quality Improvement (QI) project with the objective of improving the vitamin D prescription rate in our NH. We used the Plan-Do-Study-Act (PDSA) approach to implement this QI project. Patients not currently prescribed an adequate dose of vitamin D were identified and started on a daily dose of 800 IU of vitamin D. Additionally, patients who were experiencing falls while on an adequate dose of vitamin D for 3 months were examined for the possibility of vitamin D deficiency and were started on 50,000 IU of vitamin D per week for 12 weeks if they were found to be vitamin D-deficient based on blood levels of 25-hydroxy-vitamin D below 30 ng/mL. We found that with several PDSA cycles over a period of 5 months, the prescription rate for vitamin D was increased to 86%, surpassing our initial goal of 80%. In conclusion, we found that a multidisciplinary QI program utilizing multiple PDSA cycles was effective in reaching target prescription rates for vitamin D supplementation in a population of NH patients.

Nutritional assessment of residents in long-term care facilities (LTCFs): recommendations of the task force on nutrition and ageing of the IAGG European region and the IANA

Unintentional weight loss and Undernutrition are major problems among older people living in Long-Term Care Facilities (LTCF). Undernutrition manifests in LTCF particularly as weight loss and low Body Mass Index (BMI) and is associated with increased morbidity and mortality as well as with functional decline. There are many factors associated with poor nutritional status and affecting protein-energy intake and/or energy expenditure. These include age of 85 years or older, low nutrient intake, loss of ability to eat independently, swallowing and chewing difficulties, becoming bed-ridden, pressure ulcers, history of hip fracture, dementia, depressive symptoms and suffering from two or more chronic illnesses. Nutritional evaluation is an essential part of the Comprehensive Geriatric Assessment (CGA). This evaluation ranges from methods such as BMI to several validated tools such as Mini-Nutritional Assessment (MNA). After diagnosis, the management of undernutrition in LTCF requires a multidisciplinary approach which may involve dietary and environmental improvements and managing multiple co-morbidities, while avoiding polypharmacy as far as possible. Finally, the need for supplementation or artificial (tube) feeding may be considered taking into account the CGA and individual needs. This document presents a succinct review and recommendations of evaluation and treatment of undernutrition.

Use of osteoporosis medications in older nursing facility residents

INTRODUCTION

Epidemiologic studies demonstrated that 70% to 85% of nursing home residents have osteoporosis. Few studies report comprehensive information about treatment of osteoporosis in nursing facilities.

OBJECTIVE

To determine the prevalence of osteoporosis treatment and identify resident characteristics associated with the use of antiresorptive medications or supplements indicated to treat osteoporosis in nursing homes.

METHODS

The study design was cross-sectional. The Systematic Assessment of Geriatric Drug Use via Epidemiology database provided the data. From this database, 186,221 residents were identified as newly admitted to nursing facilities in Kansas, Maine, Missouri, Ohio, and South Dakota between 1998 and 2000. The outcome measure was the use of antiresorptive medications (alendronate, risedronate, calcitonin, estrogen, raloxifene) or supplements (calcium with vitamin D) indicated for treatment of osteoporosis. The independent variables included demographic, health status, and fracture risk factors.

RESULTS

Of the overall sample, 9.1% received antiresorptive medications and/or supplements indicated for osteoporosis treatment. The most commonly used treatment was the combination of calcium and vitamin D (5.0%). Calcitonin (2.5%) use exceeded that of any other antiresorptive. Multivariable logistic regression analyses revealed that a diagnosis of osteoporosis and female gender were strongly associated with being more likely to receive an osteoporosis treatment (OR 6.34 with 95% CI 6.11-6.64 and OR 2.67 with 95% CI 2.53-2.83 respectively). The number of medications residents received was also strongly associated with receiving osteoporosis treatment. Being black and having 4 or more active diagnoses were strongly associated with lower odds of receiving treatment (OR 0.63 with 95% CI 0.57-0.68 and OR 0.71 with 95% CI 0.68-0.74 for 4 to 6 diagnoses).

DISCUSSION

Newly admitted nursing facility residents infrequently received an indicated osteoporosis treatment, including calcium with vitamin D, despite the expected high prevalence of osteoporosis in this setting. Few demographic, health status, and fracture risk factors were strongly associated with receiving indicated treatment.