Major Finding: A concerted, multidisciplinary effort increased adherence to vitamin D supplementation in elderly nursing home residents from 29% to 87% after 5 months.
Data Source: Project implemented in a 114-bed community nursing home affiliated with an academic medical center.
Disclosures: The investigators reported having no disclosures.
LONG BEACH, CALIF. — Adherence to a vitamin D supplementation protocol improved from 29% to 87% after 5 months among elderly residents of a 114-bed community-based nursing home.
The quality improvement interventions used in the project could be implemented in other nursing homes, Dr. Mamata Yanamadala and associates reported in a poster presentation at the annual meeting of the American Medical Directors Association.
Previous studies have shown that vitamin D supplementation reduces falls by approximately 22% in nursing home residents and that 700–800 IU of vitamin D supplements are needed per resident per day to reduce the risk of fracture in nursing home populations.
The project employed a FOCUS quality improvement model: find an issue, organize the team, clarify current practice, understand the causes of variation, and select a strategy to effect change.
The Duke University–affiliated nursing home had a per-resident target of 800 IU/day of vitamin D to reduce falls. The team incorporated the medical director, clinicians, the director of nursing, the home's committee on falls, nurses, and a pharmacist. At the start of the project, 30% of residents were receiving at least 800 IU/day of vitamin D. The team set a goal of 80%.
Nurses received education on the importance of vitamin D supplementation and were asked to notify physicians about patients who were not receiving adequate supplementation. To spark competition, graphs at each nurses' station displayed the number of residents currently receiving adequate supplementation, and staff were offered a prize if their unit met the 80% goal.
Pens with the saying “800 D a day Keep Falls Away” were distributed as reminders, and the admissions coordinator put a note in the charts of new patients reminding physicians to start supplementation. The falls committee alerted a physician about any patient who was vitamin D deficient despite receiving 800 IU/day, so that person could start receiving 50,000 IU/day of vitamin D.
The rate of falls averaged 30–40 per month before the project and did not significantly decrease as supplementation rates increased, contrary to findings in previous studies. But the current study was not designed to assess the affect of vitamin D on falls, said Dr. Yanamadala, of Duke University, Durham, N.C.
One of the four nursing units studied, which had high staff turnover, was slow to show progress toward the target, but 5 months after the start of the study, adherence rates on the units ranged from 83% to 91%. Out of 10 patients who kept falling while on 800 IU/day of vitamin D, 3 were found to have deficient serum concentrations of vitamin D.
In a separate poster presentation, Dr. Michael E. Felver of the Cleveland Clinic reported low vitamin D serum concentrations in 97% of 62 patients admitted for subacute care following hospitalization. He called that prevalence “staggeringly high.”
His study assessed 142 consecutive admissions to the clinic's Center for Rehabilitation and Post-Acute Care, and screened for vitamin insufficiency in any patient with clinical signs or risk factors for malnutrition but no current diagnosis of vitamin D deficiency.
Screening found that 97% had low vitamin D and 32% had vitamin D deficiency (with deficiency defined as a serum concentration below 20 ng/mL).
Nutritional status seemed to be the best predictor of vitamin D deficiency in this population, which was younger, was more likely to be male, and had a higher average body mass index and shorter length of stay than nursing home residents. Vitamin D amounts used to supplement long-term care residents may not be adequate for this population, Dr. Felver said, noting that most post-acute patients have had a disabling or prolonged episode of acute care and have multiple comorbidities, and many show exacerbations of chronic illnesses. All of this puts them at higher risk, he said.