Quality Improvement: A Template-Based Approach to HEADSS Assessments for Hospitalized Adolescents

Hospitalizations are opportunities to screen adolescents for risk behaviors, but screening occurs infrequently. At our institution, adolescent inpatients on pediatric services have an array of medical acuity and complexity, and only 11% had complete home; education; activities; drug, alcohol, and tobacco use; sexual history; and self-harm, suicidality, and mood (HEADSS) histories. The aim of this quality improvement project was to increase the HEADSS completion rate to 31% within 8 months of the initial Plan-Do-Study-Act cycle.

A working group identified key drivers of incomplete HEADSS histories. Interventions focused on creating and modifying note templates to encourage providers to obtain and document HEADSS histories, sharing data with providers, and educating providers. The primary outcome measure was the percent of patients with a complete HEADSS history. Process measures included use of a confidential note, documentation of a sexual history, and number of domains documented. The balancing measure was patients with no social history documented.

A total of 539 admissions were included, 212 in the baseline period and 327 in the intervention period. The percent of patients with a complete HEADSS history increased from 11% to 39%. Use of a confidential note increased from 14% to 38%, documentation of a sexual history increased from 18% to 44%, and average number of domains documented increased from 2.2 to 3.3. The number of patients with no social history documented was unchanged.

A quality improvement initiative using note templates can significantly increase the rate of complete HEADSS history documentation in the inpatient setting.