Standardizing clinical response to results of lead screening: A quality improvement study

Abstract

BACKGROUND AND OBJECTIVES: Lead exposure remains common and is associated with adverse intellectual and behavioral outcomes. Despite quality improvement used to increase screening rates, clinical response to elevated lead levels remains variable. Our aim was to increase provider adherence to published guidelines for addressing elevated lead levels. METHODS: We created a protocol for addressing elevated lead levels on the basis of published guidelines. The protocol included ordering multivitamins with iron and follow-up lead testing, educating families about identifying and reducing sources of lead exposure, and referring to a specialty environmental health clinic when indicated. We used quality improvement methods to increase provider adherence to the protocol in a large, academic primary care center among patients 9 to 27 months old. The outcome measure was the percentage of elevated lead levels for which providers adhered to all elements of the protocol. This measure was plotted on a control chart. Statistical process control was used to determine a significant change to system performance. RESULTS: Adherence to the protocol rose from 5% to 90%. Key interventions included decision support in the e-health records and weekly review of reports of lead levels. These interventions were supported by staffing adjustments and individualized feedback to create accountability. CONCLUSIONS: Simple process changes dramatically improved adherence to complex guidelines for addressing lead exposure in primary care. These changes could be used to similarly standardize clinical responses to other screens.