Measuring and Improving Vitamin D Promotion and Prescribing to Prenatal and

1. Measuring and Improving Vitamin D Promotion and Prescribing to Prenatal and Postnatal Women within the North West CaseNote Audit: Primary Care Trust and Hospital Trust This work was undertaken in the Clinical Effectiveness Unit, Stockport NHS FT Funded by the Greater Manchester Supra District Audit Committee

2. The Objectives • How the audit came about • Incline in rickets • The inconsistent Vitamin D advice • The many vitamin D projects across the North West • Audit • Objectives • Results • Survey Audit Results • Case Note Audit Results

3. STANDARDS The Audit CHANGES RESULTS COLLECT & ANALYSE DATA • Objectives • Establish training needs of healthcare professionals to deliver advice on vitamin D • Reduce the percentage of Vitamin D deficient prenatal and postnatal women in the Northwest • Encourage and facilitate PCTs in providing free Vitamin D supplies to all pregnant women. • Promote examples of good practice through local and regional lead networks Method Step1; Provider Services Audit: sent to each PCT and Hospital Trust to answer questions on policies and personnel. Step 2; Case Note Audit: Health Visiting and Midwifery heads were asked to cascade a proforma on practice and knowledge to all health visitors and midwives

4. Midwifery Case Notes Looking at current practice

5. Count of ID 60 50 40 30 20 10 0 CMFT FF LW NMG RI RO SFT WT Ethnicity Bangladeshi British Chinese Far Eastern Indian Irish Middle Eastern N.African Pakistani S. European South East Asian Sub Sahara W European Hospital Trust Midwifery Case Notes Ethnicity

6. Midwifery Case Notes Ethnicity Enquire to whether women at greatest risk are following advice to take Vitamin D supplements. These include: women of South Asian, African, Caribbean or Middle Eastern family origin

7. Midwifery Case Notes Booking NICE:All women should be informed at the booking appointment (ideally by 10 weeks) about the importance for their own and their baby’s health of maintaining adequate vitamin D stores during pregnancy and whilst breastfeeding.

8. Midwifery Case Notes: Body Mass Index NICE; Check if women at greatest risk are following advice to take Vitamin D supplements. These include: women with a pre-pregnancy body mass index above 30 kg/m2

9. Midwifery Case Notes: Vitamin D Literature NICE; Pregnant women should be offered information based on the current available evidence together with support to enable them to make informed decisions about their care • Types of literature referencing vitamin D; • Pregnancy book • In house Leaflet • Healthy Start Leaflet • Other

10. Count of ID 60 50 40 Did the client receive literature? TRUE 30 FALSE 20 10 0 CMFT FF LW NMG RI RO SFT WT Hospital Trust Midwifery Case Notes: Vitamin D Literature

11. Health Visiting Case Notes Looking at current practice

12. Count of ID 100% 90% Ethnicity 80% W European Sub Sahara 70% South East Asian Pakistani N.African 60% N. European Middle Eastern 50% Irish Indian 40% Far Eastern E. European Chinese 30% Caribbean British 20% Bangladeshi 10% 0% CM EL LP WN PCT Health Visiting Case Notes Ethnicity Enquire to whether women at greatest risk are following advice to take Vitamin D supplements. These include: women of South Asian, African, Caribbean or Middle Eastern family origin

13. Health Visiting Case Notes Vitamin D Discussion • Overall discussing the implications of low Vitamin D and the importance of vitamin D supplementation was poor amongst all trusts • Discussions of Vitamin D and healthy Start were low in 16-20 year old. • Highest group to be informed about vitamin D were the above 35’s,

14. Count of ID 100% 90% 80% 70% 60% Evidence of vitamin D discussion with the client? TRUE 50% FALSE 40% 30% 20% 10% 0% CM EL LP WN PCT Health Visiting Case Notes Vitamin D Discussion: By Trust

15. Health Visiting Case Notes Vitamin D Discussion: By Associated Medical Condition Disussing vitamin D with those who have Medical conditons Total Does the client have family history of bone deformity 3 Does the client have Crohn's disease / hepatic or renal disease 0 Does the client have Coeliac disease 1 Does the client have history of bone disorders 2 Evidence of vitamin D discussion FALSE TRUE Does the client have history of bone disorders Grand Total 185 FALSE 111 296 2 2 TRUE Does the client have family history of bone deformity FALSE 142 295 153 TRUE 3 3 Does the client have Coeliac disease FALSE 142 297 155 TRUE 1 1

16. Health Visiting Case Notes Vitamin D Literature Clients with an associated medical condition did not receive any Vitamin D literature Audit results show literature informing women of vitamin D was distributed to 88% of women in East Lancashire The Birth to Five book was the most distributed source of literature

17. Percentage of clients who received literature 100% 90% 80% 70% 60% 50% 40% 30% 44.6% 20% 31.9% 31.2% 10% 5.7% 0% Referred to Birth to Five book? Referred to an in house leaflet? Referred to a Health Start Leaflet Referred to other literature Type of literature given to client Health Visiting Case Notes Vitamin D Literature

18. Recommendations • An assessment of the risk factors associated indicating vitamin D deficiency to be introduced • Health professional are trained to advise to deliver verbal and written advice on vitamin D to pregnant/breast feeding women • We suggest the training is incorporate this within an existing training session OR a stand alone session • Introduce the Healthy Start Scheme to all clients • Recording and auditing the uptake of vitamin D supplements by pregnant/breast feeding women is essential, we recommend Vitamin D discussions are recorded in notes

19. Thank you for your Particpation • NHS East Lancashire • NHS Central Manchester • NHS Liverpool • NHS Heywood Middleton and Rochdale • NHS Ashton Wigan and Leigh • NHS Wirral We hope to reaudit next year If you would like to join the audit, please sign the participation form situated on your table. • Central Manchester Foundation Trust • Liverpool Women's Hospital • Pennine Acute Trust • Stockport Foundation Trust • Wirral Trust

20. Published Report: August 2011 Any Questions?