The audit findings
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Transcript of The audit findings
Measuring and Improving Vitamin D awareness and promotion for pre and postnatal women across Greater Manchester 2013The audit findings
Deborah LeeLucy Wilcoxon
Department of Epidemiology
Introduction
First audit took place in 2011 Findings:
poor knowledge very little evidence of promotion of
vitamin D to pre- and postnatal women Number of recommendations made
to participating trusts Awarded further funding in 2012 to
re-audit.
Methodology
Provider services Audit Establish policies, personnel and training
at trust level Staff Survey
Determine knowledge and reported current practice of staff
Case note audit Establish current practice through
documentation in case notes
Standards
Standard1. Midwives and health visitors to receive training on
vitamin D promotion and supplementation 100%2. Pre and postnatal women to undergo a risk
assessment to identify risk factors for vitamin D deficiency
100%3. Pregnant women to be verbally advised of the
importance of vitamin D and suitable supplementation at the booking appointment with the midwife
100%
4. Postnatal women verbally advised on the importance of vitamin D and suitable supplementation at the initial appointment with the health visitor
100%
5. Pre and postnatal women to be given literature containing information on vitamin D 100%
Participating trustsRepeating trusts (2011 & 2013)
New trusts (2013)
Midwifery
Wrightington, Wigan and Leigh NHS FT (survey only in 2011)
University Hospital of South Manchester NHS FT
Stockport NHS FTRoyal Bolton NHS FT (survey only in 2011)Central Manchester NHS FT
Health Visiting
NHS Manchester NHS BoltonNHS BridgewaterNHS StockportNHS Salford
Provider services audit
TrustPolicy
in placeTeam/
coordinator in place
In-house leaflet
Information
distributed
Training provided
Midwifery
Central Manchester FT* Stockport FT* Royal Bolton FT South Manchester FT Wrightington, Wigan and Leigh FT*
Health visiting
NHS Bolton NHS Bridgewater NHS Manchester* NHS Salford NHS Stockport
= Improvements made since 2011
*Repeating trusts
Staff Survey – response rateResponse Rate:A total of 237 midwives and 121 health visitors from 10 healthcare providers participated in the survey.
This give an overall response rate of 22% for Midwives 20% for Health Visitors
Response rates ranged from 9% to 83% at individual Trusts
Staff Survey - Vitamin D Knowledge Staff knowledge of vitamin D was relatively poor.
RDA 5 food sources
Percentage obtained
from the sun
Minerals it helps the body to absorb
3 main roles within the
body
Risk factors/ symptoms of
deficiency
0%10%20%30%40%50%60%70%80%90%
100%
73%
26%
38%
50%
13%22%
53%
26% 30%
63%
23%16%
Midwives
Perc
enta
ge o
f sta
ff
p <0.001
p <0.05
p <0.05
Training Rates
Trust
Percentage attended vitamin D training within the last year
Central Manchester NHS FT 6%Stockport NHS FT 20%University Hospital South Manchester NHS FT 17%Royal Bolton NHS FT 17%Wrightington, Wigan and Leigh NHS FT 24%TOTAL Midwives 14%NHS Bolton 38%NHS Bridgewater 42%NHS Manchester 93%NHS Salford 53%NHS Stockport 36%TOTAL Health Visitors 47%
Staff Survey - Vitamin D Training and Knowledge
0%10%20%30%40%50%60%70%80%90%
100%
73%
25%35%
60%
23% 20%
72%
30%39%
59%
16%22%
Trained Staff Untrained Staff
Perc
enta
ge o
f Sta
ff
Staff Survey – Vitamin D PracticeVitamin D Practice:
Report discussing vitamin D with 'all' or 'most' of their clients
Report feeling 'very confident' or 'confident in discussing vitamin D
with clients
0%10%20%30%40%50%60%70%80%90%
100%
53%40%
65%56%
MidwivesHealth Visitors
Perc
enta
ge o
f Sta
ff
Main reason for not discussing with ‘all’ clients: MW – a lack of risk factors presented by the client (28%) HV – lack of training or confidence (33%)
p <0.05
p <0.001
Staff Survey – Practice and Training
0%10%20%30%40%50%60%70%80%90%
100%
77%63%65%
44%Trained StaffUntrained Staff
Main reason for not discussing with ‘all’ clients: Trained staff– lack of knowledge/confidence (29%) Untrained staff – lack of risk factors presented (32%)
p <0.05 p <0.001
Staff Survey – Healthy Start Scheme Healthy Start scheme - vouchers exchanged for
vitamin supplements
72% of HV discuss Healthy Start with ‘all’ or ‘most’ of their clients, compared to 43% of MW.
69% of trained staff discuss Healthy Start with ‘all’ or ‘most’ of clients compared to 52% of untrained staff
Client not considered eligible - most common reason for not discussing the Healthy Start Scheme.
Comparison of repeated Trusts
Trusts that took part in the staff survey for both 2011 audit and the 2012/2013: Midwifery:▪ Central Manchester NHS Foundation Trust▪ Royal Bolton Hospital NHS Foundation Trust▪ Stockport NHS Foundation Trust▪ Wrightington, Wigan and Leigh NHS
Foundation Trust Health Visiting:▪ NHS Manchester
Comparison of repeated Trusts
RDA
Food
sou
rces
Perc
enta
ge o
b-ta
ined
from
the
su
n
Risk
fact
ors/
sym
p-to
ms
of d
efici
ency
Dis
cuss
‘all’
or
‘mos
t’ c
lient
s
Feel
‘ver
y co
n-fid
ent’
or
'con
-fid
ent'
whe
n di
scus
sing
wit
h cl
ient
s
Vitamin D knowledge Vitamin D Practice
0%10%20%30%40%50%60%70%80%90%
100%
39%
8%14%
8%
22%13%
68%
30%
43%
23%
52%41%
2011 2013
Perc
enta
ge o
f St
aff
p <0.001
p <0.001
p <0.001
p <0.001
Data from responses to knowledge and practice questions across Trusts who participated in both the 2011 and 2013 audit.
p <0.001
p <0.001
Summary of staff survey Knowledge is relatively poor and is not
shown to improve through recent training. HV and trained staff discuss Vitamin D
and Healthy Start more with ‘all’ or ‘most’ clients and feel more confident in doing so.
Overall, Trusts who participated in the 2011 audit improved in both their vitamin D knowledge and practice in 2013.
Case note audit - sampling
Requested sample of 100 pre/postnatal women per trust
Sample to be selected from women who gave birth between Oct 2011 and Mar 2012
However, miscommunication led to women being sampled from bigger cohort – Jan 2011 and Jan 2013
Case note audit - SampleTrust n Average
age of sample
Prenatal
Central Manchester NHS FT 102 29Stockport NHS FT 96 29Royal Bolton NHS FT 84 27University Hospital South Manchester NHS FT
100 30
Wrightington, Wigan and Leigh NHS FT 100 27TOTAL 482 28
Postnatal
NHS Bolton 106 28NHS Bridgewater 104 30NHS Manchester 28 30NHS Salford 97 29NHS Stockport 73 31TOTAL 408 29
Evidence of verbal/written vitamin D information given to all women
Cent
ral M
anch
este
r
Stoc
kpor
t
Roy
al B
olto
n
Sout
h M
anch
este
r
Wri
ghti
ngto
n, W
igan
and
Lei
gh
NH
S Bo
lton
NH
S Br
idge
wat
er
NH
S M
anch
este
r
NH
S Sa
ford
NH
S St
ockp
ort
prenatal postnatal
0%20%40%60%80%
100%
Evidence of vitamin D discussed (%)
Evidence of risk factors
Risk factors: Ethnicity: women of South Asian, African,
Caribbean or Middle Eastern descent Medical: personal/family history of bone
disorders, coeliac disease, Crohns disease, bone deformity, multiparity (short spacing between pregnancies)
BMI: women with a BMI of 30 or above at booking (prenatal only)
Breastfeeding: women who are exclusively breastfeeding (postnatal only)
Evidence of at least one risk factorCe
ntra
l Man
ches
ter
Stoc
kpor
t
Roya
l Bol
ton
Sout
h Ma
nche
ster
Wrig
htin
gton
, Wig
an a
nd Le
igh
NHS
Bolto
n
NHS
Brid
gewa
ter
NHS
Manc
hest
er
NHS
Safo
rd
NHS
Stoc
kpor
t
prenatal postnatal
0%10%20%30%40%50%60%70%80%90%
100%
83%
22%30% 33%
20%
51%
38%
79%
32%
51%
Evidence of vitamin D information given to those identified as having a further risk factor for vitamin D deficiencyCe
ntra
l Man
ches
ter
Stoc
kpor
t
Roya
l Bol
ton
Sout
h M
anch
este
r
Wri
ghti
ngto
n, W
igan
an
d Le
igh
NH
S Bo
lton
NH
S Br
idge
wat
er
NH
S M
anch
este
r
NH
S Sa
ford
NH
S St
ockp
ort
prenatal postnatal
0%10%20%30%40%50%60%70%80%90%
100%
80% 81%
28%
91% 90%
17%
35%
50%
87%76%
Comparison of 2011 and 2013 audit
3 trusts participated in both 2011 and 2013 case note audits: Midwifery▪ Central Manchester FT▪ Stockport FT
Health visiting▪ NHS Manchester
Comparison of 2011 and 2013 audit
No significant differences between the samples for age and ethnicity
No significant differences in the number of risk factors except for BMI – large increase at CMFT (26% 74%)
Comparison of 2011 and 2013 audit
0%20%40%60%80%
100%
17%
59% 63%42% 39%
74%
20112013
p <0.05
p <0.001
p <0.001
Summary of case note audit Some trusts performing better than others. Evidence of 65% receiving some form of
information Evidence for at least one risk factor of
vitamin D deficiency present in 41%... …of which 62% received some form of info Those who repeated the audit appear to
have made significant improvements to practice.
Standards achieved
Standard 1: 100% midwives and health visitors to receive training on vitamin D promotion and supplementation.Standard 2: 100% Pre and postnatal women to undergo a risk assessment to identify risk factors for vitamin D deficiencyStandard 3: 100% of pregnant women verbally advised on the importance of vitamin D and suitable supplementation at the booking appointment.Standard 4: 100% of postnatal women verbally advised on the importance of vitamin D and suitable supplementation at the initial appointment.Standard 5: 100% of women to be given literature relating to the importance of vitamin D and suitable supplementation for pre and postnatal women.
Limitations Poor response rate for staff survey – may not
be representative Women sampled from bigger than requested
cohort for the casenote audit (2011-2013 rather than Oct 2011 – Mar 2012)
Possibility of inaccurate documentation Evidence of written info given not clear Training – frequency and level of training
unclear
Conclusion Standards not achieved – all women to
receive verbal and written information on vitamin D
Even those at a greater risk do not always receive verbal/written information
Whilst each of the risk factors are routinely assessed, they are not being linked to vitamin D deficiency
However, policy and practice improvements have been made in trusts repeating audit.
Recommendations
1. Documentation of verbal and written literature on vitamin D required in all case notes
2. Training programmes to be rolled out to all staff
3. Routine assessment – women with risk factors need to be flagged up.
4. Women with further risk factors to be offered further screening for vitamin D deficiency???
Thank you
Any questions?