Arch Dis Child 2012;97:A64 doi:10.1136/archdischild-2012-301885.154
British Society of Paediatric Gastroenterology, Hepatology and Nutrition/Neonatal Nutrition Network
LC Winckworth, E Day, J Bailey, F Katz
Community Paediatrics, Camden MOSAIC CDC, London, UK
Aims – Design a screening and treatment pathway for vitamin D deficiency in a targeted high risk population of children with limited mobility
– Employ a continuous process of evaluating the steps and outcome measures resulting in ongoing service improvements
Methods Children with limited mobility attending a special school were considered “high risk” for vitamin D deficiency. The patient pathway was analysed, from initial individual identification through to sample collection, result interpretation and treatment thresholds. Steps which were more challenging to complete given local staffing and other logistical factors were highlighted. From this a new pathway algorithm, covering screening and treatment processes over a 6 month period, was implemented. The pathway was designed to continually “re-cycle”.
Clinically relevant process and outcome measures were established to monitor the success of pathway implementation. Continuous measurement was made integral to the process, allowing opportunities for improvements to the service at regular intervals.
Results 27 children were identified as “high-risk”. 74% had baseline insufficient (50-75 nmol/L) or deficient (<50 nmol/L) vitamin D levels. All entered the pathway. Two cycles have been completed to date, covering 3 transition periods of doctor rotations.
After introducing the new pathway, there have been significant improvements in several clinically-relevant areas. A greater proportion of “high-risk” children are being appropriately screened (P 0.03) and started successfully on the correct vitamin D replacement therapy (P 0.02). After completing one cycle, significantly more had vitamin D levels in the acceptable range (P<0.05) and underwent appropriate hip radiology screening (P < 0.01).
Parents identified compliance-increasing aspects of the programme as:
the school-based screening and medication prescriptions being issued by post, rather than by appointment.
Conclusions High risk groups require robust vitamin D screening and treatment programmes. Using a school-based surveillance pathway with clear time-defined steps prevents delays caused by logistical factors, including potential disruptions from the six monthly rotations of doctors running the programme, and the difficulties faced by families in accessing hospital-based clinics. The process of continuous evaluation improves service planning, provision and patient care. All of these result in better standards of care for vulnerable children.