244 - Use of QI methodology to create and implement an Osteopenia of Prematurity (OOP) screening protocol

Poster Number: 244
Publication Number: 244.128

Nicole M. Rau, University of Illinois College of Medicine at Peoria, Dunlap, IL, United States; Ashley Fischer, University of Illinois College of Medicine Peoria; OSF Children's Hospital of Illinois, Peoria, IL, United States

Background: Up to 40% of very low birthweight (VLBW) preterm infants are at risk of osteopenia of prematurity (OOP) and fractures due to missed placental transfer of vitamins and minerals during the third trimester. Prevention of OOP may be achieved by early recognition of bone demineralization and optimization of mineral supplementation. Prior to implementation of a screening protocol, it was recognized that our providers had a variety of practices related to TPN content, supplementation with calcium and phosphorus, and the frequency of screening labs for osteopenia.

Objective: To reduce the rates of fracture and osteopenia of prematurity in our VLBW population through the development of an OOP screening protocol.

Design/Methods: We assembled a multidisciplinary team of pharmacists, dieticians, neonatologists, endocrinologists, and nephrologists to develop our OOP screening protocol. We utilized four PDSA cycles to screen and monitor 106 infants admitted to our midwestern level IV neonatal intensive care unit. Interventions included education on goal mineral intakes, monitoring intakes weekly and providing feedback by email, adding vitamin D monitoring and optimization, and updating our protocol inclusion criteria. Process measures (intake of calcium, phosphorus, and vitamin D), outcomes measures (fractures and osteopenia), and balancing measures (use of supplements and nephrocalcinosis) were collected on a weekly basis from October 2019 until June 2021 and were analyzed using control charts.

Results: Compliance with mineral intakes for calcium and phosphorus improved from 60% to 77% and 80% to 91%, respectively. Adherence to a goal calcium to phosphorus ratio of 1.3-1.8:1 improved from 59.5% to 88% (Figure 1). Vitamin D intakes improved from 29% to 77% (Figure 2). The prevalence of patients with fractures decreased from 12% to 1% (Figure 3) and the prevalence of osteopenia decreased from 13.6% to 2.8%. Three patients developed nephrocalcinosis, however none of these patients were on calcium or phosphorus supplements at the time of diagnosis or in the week prior.Conclusion(s): Utilizing QI methodology and multiple PDSA cycles, we increased our adherence to goal calcium, phosphorus, and vitamin D intakes while reducing the incidence of fractures and osteopenia of prematurity.
Figure 1: Goal Ca/Phos ratio p chartCompliance with the goal calcium to phosphorus ratio of 1.3-1.8:1 increased from baseline of 59.5% to 88%.
Figure 2: Goal Vitamin D intake p chartVitamin D intakes improved from baseline of 29% to 77%