325 - A Template Based Approach to Improving Psychosocial Assessments for Hospitalized Adolescents

Poster Number: 325
Publication Number: 325.323

Evan M. Wiley, UCLA Mattel Childrens Hospital, Los Angeles, CA, United States; Deepa Kulkarni, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States; Huan Dong, University of California, Los Angeles, Los Angles, CA, United States; Loris Hwang, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States

Background: The HEADSS assessment addresses 6 key social history domains (home, education, activities, drug and substance use, sexual history, and self-harm and mood) that contribute to adolescent morbidity and mortality. Hospitalization is an opportunity to take a HEADSS history, but rates of inpatient screening are low.

Objective: Use quality improvement methods to improve the rate of complete HEADSS histories for teenage patients admitted to a pediatric floor by 20 percentage points within 6 months.

Design/Methods: Our team identified key drivers of incomplete HEADSS histories: forgetting to take HEADSS history, no field for HEADSS history in note templates, and concerns about patient privacy. Six months of retrospective baseline data were collected. Admission note templates were modified in month 7 to remind resident physicians to take a HEADSS history and use a confidential note format. We created new templates for HEADSS documentation with cascading prompts that triggered clinical decision support for positive findings. We also provided one time in-person and periodic written education for providers. Provider feedback led to revisions to note templates. Outcome data were shared with providers. Process measures included use of confidential notes and average number of HEADSS domains documented. Balancing measures included resident satisfaction with the new note template as assessed by survey, as well as percent of admission notes with no social history documented in case users deleted the note template prompts. Control charts were analyzed with Shewhart rules for special cause variation.

Results: The rate of complete HEADSS histories increased from 11% to 33% of adolescent admissions (Fig. 1). Confidential note usage increased from 15% to 38% (Fig. 2). There was then a large upward shift exceeding the upper control limit in both measures with the initial interventions in month 7, with all subsequent data points stably shifted above the baseline average. The average number of HEADSS domains increased from 2.2 to 3.3. Of 16 residents surveyed, 68% reported being more likely to take a complete HEADSS; 44% reported improved quality of HEADSS histories and documentation. There was no significant change in admission notes with no social history (Fig. 3).Conclusion(s): Improved note templates led to a rapid, sustained increase in complete HEADSS histories and use of confidential notes. Additional revisions to templates, repeat education, and providing project data to residents led to sustained improvement without additive impact on outcome measures. Residents reported positive perceptions of these interventions.
Figure 1Percent of adolescent patients admitted to a pediatric ward with complete HEADSS history documented each month (solid blue line) and as an average over time (dotted green line). Upper and lower control limits (dashed maroon line). Key points in improvement cycles are indicated.
Figure 2Percent of adolescent patients admitted to a pediatric ward with social history documented in a confidential note each month (solid blue line) and as an average over time (dotted green line). Upper and lower control limits (dashed maroon line). Key points in improvement cycles are indicated.