Improving adherence to CDC public health guidance for screening newly arrived refugee children through clinical decision support implementation: a primary care-based quality improvement study.

Abstract

Introduction: Many refugee children arrive in the USA from regions with higher risks of health conditions such as elevated blood lead or latent tuberculosis, making comprehensive health screening on arrival crucial for child health. Despite Centers for Disease Control and Prevention (CDC) screening guidance, clinical implementation challenges persist. To address this, we developed a clinical decision support (CDS) toolkit to support screening within the Children's Hospital of Philadelphia's refugee health programme. This quality improvement project evaluated the CDS toolkit's effectiveness in improving clinician adherence to screening guidance for newly arrived refugee children across two Plan-Do-Study-Act (PDSA) cycles.

Methods: We retrospectively evaluated health screening for refugee children aged 6 months to 21 years seen in a primary care-based refugee child health programme from 1 January 2011 to 30 September 2023. We assessed completion of recommended screenings for elevated blood lead level (EBLL), tuberculosis, hepatitis B, anaemia, HIV and eosinophilia. The CDS toolkit was updated during the second PDSA cycle to streamline order sets and align with updated CDC guidance. Screening rates were compared across three periods: baseline, first PDSA cycle and second PDSA cycle.

Results: Among 830 refugee children, initial screening completion remained high at 90.12%. Follow-up lead testing improved from 21.46% at baseline to 36.92% in the second PDSA cycle, though 43.08% of eligible children still missed timely follow-up. EBLL prevalence at arrival increased from 7.43% to 15.69%, reflecting changes in screening thresholds and demographics. These findings demonstrate the CDS toolkit's effectiveness in maintaining high initial screening rates while highlighting persistent challenges in follow-up care.

Conclusions: The updated CDS toolkit maintained high completion rates for initial screening, and after two PDSA cycles, it correlated with improvements in follow-up testing for EBLL. This project underscores the need for further interventions to improve follow-up care and supports the potential of CDS toolkits to enhance refugee health screening.