Improving Adherence to the Lead Exposure Protocol at Boston Medical Center's Pediatric Clinic

Using plan-do-study-act cycles, our team aimed to increase mean provider adherence to the Lead Exposure Protocol at the Boston Medical Center Pediatric Primary Care Clinic from 16% (baseline global mean provider adherence) to 80% from April 1, 2021, to February 1, 2023, thereby curbing the secondary effects of lead exposure.

Our team performed a chart review of patients 6 months to 5 years of age with blood lead levels (BLLs) ≥2 µg/dL (n = 853) to track provider adherence to Boston Medical Center's Lead Exposure Protocol. We created p charts to track the efficacy of interventions to improve adherence. Interventions included (1) electronic medical record SmartPhrases, (2) provider education, (3) provider feedback, (4) implementation of a follow-up nursing workflow, and (5) simplification of nursing workflow.

For BLL 2-4 µg/dL (n = 783), a centerline shift in provider adherence was observed, with >8 points above the preintervention mean after intervention (2) and an increase in mean adherence from 14.1% to 50%. For BLL 5-9 µg/dL (n = 58), no centerline shift was observed, with only 6 points above the upper control limit after intervention (4). The 2-4 µg/dL range changes indicate special cause variance and system change. Global mean provider adherence increased by 3.3 times to 53%.

Simple, low-cost process changes improved adherence to complex guidelines for managing lead-exposed children in the primary care setting. Similar interventions could be implemented on a broader scale to standardize the management of other routine pediatric screens.