Pediatric Lead Screening – Moving the Dial with Quality Metrics

Learning outcome: Describe how a pediatric clinic used Lean methodology to increase the numbers of eligible patients receiving lead screening, driving quality improvement and improved patient care using evidence-based practices.
Background: In October of 2022, a pediatric ambulatory care clinic within a large academic medical center in the Midwest identified the need to improve compliance with routine lead screening for pediatric patients before turning 12 months old. In the state of Kansas, children under the age of six continue to be at risk for lead poisoning because large numbers of buildings in the state were built before changes to lead paint regulations were implemented in 1978. Early testing and intervention can help mitigate long-term health risks caused by exposure to lead, such as brain development issues and damage to kidney and nervous systems. In October 2022, only 58% of eligible patients had completed lead screening. Barriers to performing lead screening were identified, including the time and burden of an additional lab visit and resistance to having a blood sample drawn by venipuncture. The clinic was tasked with improving the percentage of pediatric patients receiving lead screenings by their 12-month visit.
Methods: Lean standard work processes were implemented. To ensure patients were screened for lead by their 12-month appointment, nurse-driven pre-visit planning was completed, identifying those patients scheduled in clinic one week in advance. The focus age for screening is initially 12 months of age at the patient’s well check. If we were unable to complete at the 12-month visit, we would try to capture at the next visit, at 15 months, with the overall goal of completion prior to the patient’s second birthday. To help remove the lab barrier, the clinic partnered with an external vendor to provide a lead screening kit that used a fingerstick rather than a lab draw. The test could be performed in the clinic at the time of their scheduled visit. Nurses and medical assistants were trained in performing the new lead screening process. The technique required a precise amount of blood placed on a specific place on a specimen filter paper.
Results: By implementing pre-visit planning and in-clinic testing using a fingerstick, this urban clinic with 35 nurses and 16 medical assistants has been able to screen 87% of our patients within the focused age range, a 29% increase over a two-year period.
Conclusion: With these practice changes, this pediatric clinic has been able to screen for lead the children that may otherwise have missed testing, mitigating the risks caused by lead poisoning. Using a systematic process to adjust workflows and added pre-visit planning can play a key role in improving overall screening percentages in children.