Division of General and Community Pediatrics and
James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and Departments of.
Pediatrics. 2019 Jun;143(6). doi: 10.1542/peds.2018-3085. Epub 2019 May 9.
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.
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.
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.
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.
铅暴露仍然很常见，并且与智力和行为方面的不良后果有关。尽管已经采取了质量改进措施来提高筛查率，但对铅含量升高的临床反应仍然存在差异。我们的目的是提高提供者对解决铅含量升高问题的既定指南的依从性。
我们根据已发表的指南制定了处理铅含量升高的方案。该方案包括开含铁的多种维生素，并进行后续的铅检测，教育家庭识别和减少铅暴露源，以及在需要时转介到专门的环境卫生诊所。我们使用质量改进方法，在一家大型学术性初级保健中心中提高了 9 至 27 个月大的患者的提供者对该方案的依从性。结果测量指标是提供者对方案所有内容的依从性百分比，该指标在控制图上进行了绘制。统计过程控制用于确定系统性能的显著变化。
对方案的依从性从 5%提高到了 90%。关键干预措施包括电子病历中的决策支持和每周对铅水平报告的审查。这些干预措施得到了人员配置调整和个性化反馈的支持，以建立问责制。
简单的流程变更可显著提高对初级保健中铅暴露处理的复杂指南的依从性。这些变化可用于类似地标准化对其他筛查的临床反应。
