TOP 32 - A Quality Improvement Initiative to Reduce Fractures Associated with Metabolic Bone Disease of Prematurity

Publication Number: 3761.TOP 32

Kehinde A. Adebisi, The Children's Hospital at Montefiore, Bronx, NY, United States; Lakshmi Menon, The Children's Hospital at Montefiore, Bronx, NY, United States; Lenora Codrington, The Children's Hospital at Montefiore, Bronx, NY, United States; Shantanu Rastogi, The Children's Hospital at Montefiore, Bronx, NY, United States; Jillian Connors, The Children's Hospital at Montefiore, New York, NY, United States

Background: Metabolic Bone Disease of Prematurity (MBDP) refers to impaired bone mineralization commonly observed in premature infants. Reported prevalence ranges from approximately 20-25% among very low birth weight (VLBW, < 1500 g) infants to over 50% among those with extremely low birth weight (ELBW, < 1000 g). In our Level IV NICU, the baseline incidence of MBDP was 60%, with a fracture rate of 20%. MBDP increases the risk of fractures, prolonged ventilation, and overall morbidity, yet management remains challenging due to inconsistent screening, variable ALP thresholds, and absence of standardized care guidelines.

Objective: To reduce MBDP-associated fractures by 25% among preterm infants born at < 30 weeks' gestation between January and December 2025.

Design/Methods: The project applied the Institute for Healthcare Improvement's Model for Improvement, using a key driver diagram and five sequential PDSA cycles: (1) creation and implementation of standardized screening and treatment guidelines, (2) staff education, (3) posting of "MBDP Screening Tool" reminders, (4) integration of screening into the one-month bundle with electronic reminders, and (5) tracking OT/PT orders for infants >4 weeks or ≥30 weeks corrected age.

Data Collection: Weekly screening compliance was monitored via the electronic health record (EHR). Run charts were used to assess adherence to screening guidelines (process measure: mean age at first MBDP screening), along with MBDP incidence and fracture rates (outcome measures). The number of screening tests per hospital stay served as a balancing measure. Once adequate data are collected, run charts will be converted into statistical control charts.

Results: In the historical cohort, incidence of MBDP was found to be 60% (Figure 2); of the 20 infants meeting biochemical criteria for MBDP, 4 were diagnosed with MBDP-associated fracture (Figure 1). Median age at first MBDP screening was 18 days in the historical cohort (Figure 3). With initiation of QI interventions, there was a centerline shift and an increase in median age at first screening to 29.8 days. To date, there have been no cases of metabolic bone disease-associated fractures With implementation of subsequent PDSA cycles, an increase in lab testing has not been observed (balancing measure).

Conclusion: A multidisciplinary QI initiative implementing evidence-based guidelines showed high protocol adherence, with zero MBDP-related fractures observed. Early data also suggest a declining MBDP incidence, and ongoing real-time monitoring aims to ensure sustained improvement and identify special cause variations.

Figure 1
Run chart of incidence of metabolic bone disease of prematurity associated fractures. X-axis denotes historical and prospective consecutive n=5 subgroups, and Y-axis denotes % of patients with each group diagnosed with fracture. Median is denoted by the center line (CL).

Figure 2
The median incidence of MBDP is 60% for infants <30 weeks' gestatation. There is a trend towards a lower incidence in the QI cohort, but more data is needed to identify special cause variation or shift the center line (CL).

Figure 3
Run chart of age at first MBDP screening. Starting with the first prospective subgroup (P1), there was a center line (CL) shift from baseline with an increase in the median age at first MBDP screen to 29.8 days.