CLINICAL EVALUATION OF SERUM 25 (OH) D LEVELS IN ACUTE REHABILITATION PATIENTS
Background:Low serum 25-hydroxyvitamin D [25(OH)D] levels (the most widely recognized marker of total body VitD status) are common in ARU patients. Low levels, 25(OH)D < 20 ng/mL have been reported to affect as many as 49% to 89% of ARU patients. Measurement of plasma 25(OH)D concentrations is not routinely ordered for ARU patients. Inadequate VitD concentrations are potential risk factors affecting ARU patient outcomes. VitD status may be a modifiable risk factor for musculoskeletal status and various forms of musculoskeletal pain in ARU patients.
Approach:Following a family member’s concern about low VitD levels in an ARU patient, the hospital dietitian consulted with the hospital nurse research scientist to investigate VitD levels in ARU patients. A multi-disciplinary study team was formed including dietitian, nurses, physicians, pharmacists, and occupational and physical therapists. Monthly study team meetings were conducted to design the study questions, operationalize study variables and create an SPSS database for statistical analysis. Physicians developed standing orders for measurement of serum [25(OH)D] with a treatment protocol as indicated. The hospital laboratory assumed the cost of measurement of the serum [25(OH)D] during the one year study period. Following hospital Institutional Review Board approval, study data was collected by a hospital staff nurse and dietitian retrieving laboratory and administrative information from the electronic medical records of individuals admitted to a single, 21-bed ARU in Mission Viejo, California over one year (July 2011 to June 2012). During the study period there were 427 adult admissions (age ≥18 years) to the ARU.
Outcomes: In a preliminary evaluation of 355 patient cases, VitD levels, 220 (69%) were deficient (<31nmol/L). Of the 42 patients receiving nutrition support prior to admission 64% (N=27) were deficient (<31nmol/L). Eighty six percent of the patients were not supplemented prior to ARU admit. Those who were supplemented had a significantly higher VitD level than those not supplemented (26.3 +/- 9.2SD vs. 44.3 +/- 17 SD). Lack of vitamin D supplementation was significantly associated with increased LOS PTA (p value .032).
In a subsequent cross-sectional study, findings demonstrated that serum 25(OH)D level on admission to the ARU was inversely associated with persistent non-specific musculoskeletal pain. Among the 414 patient cases reviewed, mean (SD) 25(OH)D level was 29 (12) ng/mL and 30% were found to have non-specific musculoskeletal pain.
Implications: A research initiative to evaluate methods to advance best practices was conducted in a collaborative interdisciplinary team. Because serum 25(OH)D level on admission to ARU was inversely associated with non-specific musculoskeletal pain, standing orders to measure VitD and order supplementation was instituted. Initial study results support the need for randomized, controlled trials to test the role of vitamin D supplementation to improve non-specific musculoskeletal pain in ARU patients.