P4.041: Enhanced Care for Children with Lead Poisoning in Pediatric Primary Care: A Quality Improvement Project

Purpose/Objectives: Lead poisoning has serious impacts on child development. Primary care providers are uniquely situated to mitigate the effects of lead poisoning through timely follow up visits and developmental screening. We used a multidisciplinary team to design and implement a standardized care plan for patients at first diagnosis of elevated blood lead level (EBLL) of greater than 4.9 mcg/dL. Our SMART AIM was to: Increase the rate of follow up visits for children with EBLL within 2 months of diagnosis by 20% over a 6-month period.

Design/Methods: We completed a retrospective chart review of patients with first identified EBLL from 5/1/2023 to 11/1/2023 (baseline) and 11/2/2023 to 9/30/2024 (follow up). We collected data on demographics, date of diagnosis, follow up (including developmental screening and neurologic exam) within 2 months of diagnosis, and prior diagnosis of development delay. Our multidisciplinary team included MDs, APPs, RNs, RD, social work, scheduler, and care managers.

Results: Among patients with first identified EBLL in our baseline cohort (n=17, 52% male, 53% Black Non-Hispanic), we found that no patients received developmental screening and a neurologic exam within 2 months after diagnosis. Among this group 29% were previously diagnosed with developmental delays. Our multi-disciplinary team developed a standardized care plan for follow up at the time of first identified EBLL which included: 1) a clinical pathway of screening tools. 2) instructions for care, and 3) a follow up visit for formal developmental assessment, neurological exam, nutritional assessment, and screening for social determinants of health (with referrals to appropriate resources). We implemented this new initiative in 11/2023 and used clinic-wide teaching to communicate changes to team members. Among our follow up cohort (n=46), 35 patients (76%) were seen for follow up visits. Follow up visits for first EBLL increased from 0% to 76%. (Run chart, Figure 1). Developmental screening at these follow-up visits identified delays in over 50% of the children (figure 2).

Conclusion/Discussion: We developed a clinical pathway to address the need for improved follow up of lead poisoning in our community. While the high percentage of children with developmental delays is striking, the etiology of these delays is unknown, however lead is likely a contributing factor. Baseline chart review identified important opportunities for improved early mitigation of lead poisoning which were not being utilized. Implementation of a standardized pathway for follow up of first identified EBLL is feasible and effective in improving timely follow up. Several patients were identified with developmental delays as a result of the follow up visit. Further cycles will include looking at resource utilizations for children who had follow up visits versus those who did not, as well as monitoring long-term effects of lead poisoning.