Increasing Prescription Rates for Supplemental Vitamin D for Young Infants in a Primary Care Clinic and Across a Healthcare System

Purpose/Objectives: Vitamin D is important to prevent consequences of vitamin D deficiency, such as nutritional rickets. In 2008, the American Academy of Pediatrics (AAP) recommended that infants receive 400IU of vitamin D daily, with a recent update stating this should begin soon after birth.1,2 Infants can receive sufficient vitamin D through supplementation or by consumption of 1 liter of formula daily. A review from 2009-2016 showed that only 28.2% of infants in the United States overall met this standard of care (20.8% of breastfeeding infants and 35.3% of non-breastfeeding).1 More work is needed to develop strategies to improve the rates of vitamin D supplementation in this vulnerable population. Our SMART aim was to increase the percentage of infants less than 10-weeks-old with a prescription for vitamin D supplementation from 35% to 80% by 10/2021 for well-child visits at the Vanderbilt Children’s Primary Care Clinic.

Design/Methods: All infants less than 10-weeks-old who were seen at the Vanderbilt Children’s Primary Care Clinic for a well-child check were included. The Model for Improvement was used to test interventions based on five key drivers (Figure 1). Interventions included parent and provider education, updating note templates and order sets, and discharging patients from the newborn nursery at the Vanderbilt University Medical Center (VUMC) with a prescription for appropriate supplementation. We used statistical process control charts to study all measures and Nelson’s rules were used to identify instances of special cause variation. The primary measure was the percentage of infants with prescriptions for 400IU daily vitamin D supplementation (cholecalciferol or poly-vi-sol); data on patients seen for well-child-checks was abstracted weekly.

Results: Baseline data demonstrated an average of 35% of infants with prescriptions for vitamin D. Order set release and note template development were associated with special cause variation and a center-line shift to 53%. The addition of a reminder to the morning clinic huddle was associated with special cause variation and another centerline shift to 64%. Finally, providing discharge prescriptions for neonates from their birth admission was followed by special cause variation in both a trend (six consecutive increasing points) and a center-line shift, with a new sustained mean of 82% (Figure 2).

Conclusion/Discussion: Providing supplementation at nursery discharge appears to be a high reliability intervention. This intervention, in addition to creation of an order set and note templates and reminders during daily clinic huddles, is associated with improvement in the primary outcome to the goal.