This work was undertaken in the Clinical Effectiveness

This work was undertaken in the Clinical Effectiveness Unit, Stockport NHS FT Funded by the Greater Manchester Supra District Audit Committee

• 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

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 Step 1; 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

Hospital Trust Stockport FT Central Manchester FT North Manchester General Royal Oldham Hospital Heywood Middleton and Rochdale Fairfield General Hospital Liverpool women's Hospital

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

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 Evidence of vitamin D discussion with the client? Ethnicity FALSE Bangladeshi 5 British 191 Chinese 2 Far Eastern TRUE Grand Total 5 4 195 2 1 1 Indian 3 3 Irish 1 1 Middle Eastern 7 7 N. African 6 6 Pakistani 15 S. European 2 2 South East Asian 1 1 Sub Sahara 10 W European 1 Grand Total 244 2 2 17 12 1 9 253

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. Evidence of vitamin D discussion with the client? FALSE Total TRUE 258 Grand Total 10 268

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/m 2 Did the client receive literature? Pre-pregnancy BMI above 30 kg/m 2 FALSE TRUE 36 Grand Total 28 64 Evidence of vitamin D discussion with the client? Pre-pregnancy BMI above 30 kg/m 2 TRUE FALSE TRUE 62 Grand Total 2 64

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 Did the client receive literature? FALSE Total TRUE 162 Grand Total 106 268

60 Count of ID 50 40 Did the client receive literature? TRUE FALSE 30 20 10 0 CMFT FF LW NMG Hospital Trust RI RO SFT WT

Primary Care Trust NHS East Lancashire NHS Liverpool Community Health NHS Ashton Wigan and Leigh NHS Manchester

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 100% Count of ID 90% Ethnicity W European Sub Sahara South East Asian Pakistani N. African N. European Middle Eastern Irish Indian Far Eastern E. European Chinese Caribbean British Bangladeshi 80% 70% 60% 50% 40% 30% 20% 10% 0% CM EL LP PCT WN

Evidence of vitamin D discussion with the client? Total number of clients FALSE TRUE Grand Total 187 111 298 • 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,

100% Count of ID 90% 80% 70% 60% Evidence of vitamin D discussion with the client? TRUE 50% FALSE 40% 30% 20% 10% 0% CM EL LP PCT WN

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 Does the client have history of bone disorders FALSE 185 TRUE Does the client have family history of bone deformity 2 FALSE 153 TRUE Does the client have Coeliac disease 3 FALSE 155 TRUE 1 Grand Total TRUE 111 296 2 142 295 3 142 297 1

Did the client receive literature? % Total FALSE 52 TRUE 48 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

Percentage of clients who received literature 100% 90% 80% 70% 60% 50% 40% 30% 20% 44. 6% 31. 9% 31. 2% 10% 0% 5. 7% Referred to Birth to Five book? Referred to an in house leaflet? Referred to a Health Start Leaflet Type of literature given to client Referred to other literature

• 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

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