102 - Optimizing Early Detection and Management of Vitamin D Deficiency in NICU Patients: A Quality Improvement Initiative

Publication Number: 4100.102

Andrea M. Devaris-Martinez, Johns Hopkins All Children's Hospital, Saint Petersburg, FL, United States; Preceous S. Jensen, Johns Hopkins All Children's Hospital, St Petersburg, FL, United States; Fauzia M. Shakeel, Johns Hopkins All Children's Hospital, St. Petersburg, FL, United States

Background: Vitamin D deficiency (VDD) in infants impairs bone mineralization and increases the risk of metabolic bone disease (MBD) and rickets, particularly among preterm and very low birthweight (VLBW) infants. At Johns Hopkins All Children's Hospital (JHACH) NICU, no standardized guidelines existed for screening, defining deficiency severity, or dosing supplementation. Electronic medical record review of preterm and term infants (January 2023-May 2024) revealed a 60% prevalence of VDD ( < 30 ng/mL). Current testing at 4-6 weeks of life only after full enteral feeds delayed detection and management. Evidence supports earlier supplementation once minimal feeds are tolerated or 50% of total intake is achieved.

Objective: SMART

Aim: Decrease vitamin D deficiency in preterm and term infants in the NICU by 4 weeks of age from 60% to 40% by December 2025 through early detection and optimization of vitamin D supplementation.
Sub-

Aim: Standardize definitions of vitamin D deficiency severity and establish a protocol for appropriate supplementation dosing based on deficiency severity.

Design/Methods: This QI project used the DMAIC framework and four PDSA cycles:
Cycle 1 (Feb-April 2025): Developed evidence-based clinical practice guidelines (CPG) for screening, severity cutoffs, and dosing with input from dietitians, neonatologists, and endocrinologists.
Cycle 2 (May-June 2025): Conducted education sessions for NICU staff and providers on guideline development.
Cycle 3 (July-Aug 2025): Implemented the CPG, incorporating dietitian collaboration during rounds and adding a discharge smart phrase for PCP follow-up recommendations.
Cycle 4 (Sept-Oct 2025): Re-educated providers and staff to reinforce adherence.
Measures included outcome (VDD prevalence), process (adherence, timeliness), and balancing (hypervitaminosis D, blood draws, length of stay) metrics.

Results: Baseline VDD prevalence was 60%. After CPG implementation, July data showed a reduction to 44%, August to 46%, September to 41%, and October to 42%, with a mean shift to 43% near the target goal. Improvements were observed in early screening, timely supplementation, and provider adherence.

Conclusion(s): Standardized vitamin D screening and supplementation improved early detection and management of deficiency in NICU infants. The CPG was integrated into JHACH's internal portal "Connect" for streamlined access in October 2025. Next steps include dietitian reinforcement during rounds, addition of a smart phrase in clinical notes for timely monitoring, monthly audits to track adherence and outcomes, and quarterly reviews with the NICU team to sustain improvement.

CV
Andrea Devaris Hopkins CV 10.25.pdf

Vitamin D deficiency p-chart


Vitamin D deficiency rate based on additional blood draw stick