265 - Encouraging Big Smiles: Improving Patients' Oral Health through Fluoride Varnish Application in Continuity Clinic

Poster Number: 265
Publication Number: 265.453

Nicole Mann, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Laura N. Hodo, Icahn School of Medicine at Mount Sinai, Hastings on Hudson, NY, United States; Michelle L. Mikhno, The Mount Sinai Kravis Children's Hospital, New York, NY, United States; Carolyn Birbiglia, The Mount Sinai Kravis Children's Hospital, Florham Park, NJ, United States; Lien Le, The Mount Sinai Kravis Children's Hospital, Houston, TX, United States; Dayana C. Sanchez, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Sruti Patel, The Mount Sinai Kravis Children's Hospital, New York, NY, United States; Brianna Evans, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Orin G. Donaldson, Icahn School of Medicine at Mount Sinai, Jamaica, NY, United States; Michael Kornblit, The Mount Sinai Kravis Children's Hospital, New York, NY, United States; Divya Hoon, The Mount Sinai Kravis Children's Hospital, New York, NY, United States; Lillian Jin, The Mount Sinai Kravis Children's Hospital, New York, NY, United States; Cynthia Katz, Icahn School of Medicine at Mount Sinai, New York, NY, United States

Background: Dental caries is the most common chronic disease of childhood in the United States, predominately affecting marginalized children. The AAP recommends fluoride varnish application in primary care settings as an effective cavity prevention strategy.  To meet this standard of care we implemented a new process to apply fluoride varnish during well child care (WCC) at a pediatric resident continuity clinic.   

Objective:

Aim: To increase the percentage of eligible patients 12 months to 5 years old presenting for WCC, receiving fluoride varnish from 0% to 50% by June 2023.  

Design/Methods: We conducted a needs assessment to understand housestaff knowledge and comfort around oral health, and establish buy-in. Discussion with stakeholders informed the creation of a process map. We identified areas of failure by completing a Fishbone diagram (Fig 1) and then created a Key Driver Diagram (Fig 2). We defined our outcome measure as percentage of eligible patients with fluoride applied, using procedure code as a proxy for administration.  Data was generated from a weekly EMR report. We defined our process measure as available fluoride supply, recorded on weekly log. We defined our balancing measure as extra time needed per patient encounter, collected through resident feedback. Measures were tracked across PDSA cycles, starting 3/22. Interventions included didactics, changing fluoride supply location, creation of EMR order set, and gamification to reward resident participation. Patients were excluded if varnish was applied within the last 3 months. The study was approved by the Pediatrics QI Project Committee. 

Results: Fluoride application varied between 0-18%. Data trended upward and showed a significant shift above the median line at the end of our study period. This shift allowed for a recalculation of our median from 8% to 12.5% (Fig 3). Fluoride supply was documented as sufficient each week. Providers reported < 5 minutes of added time to visit.  

Conclusion(s): Despite overall improvement throughout our study period, we did not achieve our aim of 50% of eligible patients receiving fluoride varnish.  Our most impactful interventions were placing fluoride in a more convenient location, the EMR order set, and, most recently, rewarding top performers. Increase in provider time was minimal. We are hopeful that continued education of new residents each academic year will also contribute to establishing routines around fluoride varnish application. Future directions include EMR reminders through a Best Practice Alert and assessing results for equity of care through analysis of preferred language.