269 - Improving Provider Adherence to the Lead Exposure Protocol at Boston Medical Center's Pediatric Primary Care Clinic: A Quality Improvement Study

Poster Number: 269
Publication Number: 269.453

Julie R. Barzilay, Boston Children's Hospital, Boston Medical Center, Brookline, MA, United States; Anthony J. Mell, Boston Medical Center, Boston, MA, United States; Noah Buncher, Boston University School of Medicine, Boston, MA, United States; Priscilla Gonzalez, Boston Children's Hospital, Boston, MA, United States; Sarah Meyers, Boston Medical Center, Boston, MA, United States; MaryKate Driscoll, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, United States

Background: Childhood lead exposure remains a significant public health burden despite improvements in federal and state regulations – particularly during the pandemic, when hundreds of thousands of children missed their screenings. Elevated blood lead levels (BLL) are associated with adverse developmental and behavioral outcomes. Despite established guidelines, provider interventions for elevated BLL remain inconsistent.

Objective: The primary goal of this quality improvement project is to improve guideline-adherent care, and thereby curb or halt the secondary effects of lead exposure. Lead exposures disproportionately impact lower income communities and communities of color, making lead exposure a critical health equity issue. This project aims to promote health equity by decreasing missed intervention opportunities that propagate the effects of lead exposure disparities.

Design/Methods: Using rapid Plan-Do-Study-Act cycles, our project aims to increase provider adherence to the Elevated Blood Lead Level protocol at the Boston Medical Center (BMC) Pediatric Primary Care Clinic in Boston, MA from April, 2021 through March, 2023 (preliminary data through August, 2022). We performed IRB-exempt chart review of patients aged 6 months to 5 years with BLL greater than or equal to 2 mcg/dL who were not already receiving treatment in the BMC Lead Clinic (n= 725). We measured adherence to BMC’s lead protocols each month and created run charts to track the efficacy of interventions aimed at improving adherence. Interventions included (1) the introduction of electronic medical record smart phrases explaining the protocol for each BLL; (2) resident and provider education including a “2 is 2 High” awareness campaign; (3) feedback for individual providers; and (4) implementation of a dedicated nursing role to coordinate lead follow-up.

Results: Non-paired Wilcoxon Rank Sum Test analysis showed that, with our interventions, protocol adherence for patients with BLL between 2-4 mcg/dL (n= 668) increased from 14.6% to 44.1% (p=0.004) between April-August, 2021 and April-August, 2022. For patients with BLL between 5 and 9 (n= 48), the pattern is also promising, though results are not yet statistically significant due to small sample size: adherence increased from 40% to 80% (p = 0.08) over the same time periods.

Conclusion(s):

Simple process changes significantly improved adherence to complex guidelines for managing lead exposed children in the primary care setting. We believe similar interventions could be implemented on a broader scale and used to standardize management of other routine pediatric screens.