High-risk Behavior Screening and Interventions in Hospitalized Adolescents

We conducted a retrospective, cross-sectional study of adolescent patients (aged 12–24 years) admitted to the pediatric hospital medicine service at an urban tertiary children’s hospital from January 1 to December 31, 2018. We reviewed a sample of 20 patient charts per month using the electronic health record (EHR). We reviewed the first 10 eligible admissions after both the 1st and the 15th day of each calendar month.

Patients discharged from the PICU, or those who were nonverbal or had altered mental status at the time of admission, were excluded. This was to exclude critically ill patients who may not be capable of participating in a conversation about risk assessment. We also excluded adolescents admitted to or discharged from the adolescent medicine service because this service exclusively admits patients with eating disorders in our institution, and our goal was to observe rates of screening during general admissions to the pediatric hospital medicine service. To maintain consistency with the principle of every visit as an opportunity to screen, repeat visits by the same patient were included.

Patient charts during this time period were audited for demographic data (sex, age, self-reported ethnicity, and insurance status and type), our primary outcome (documentation of physician-documented risk behavior screening), and our secondary outcome (documentation of risk behavior–related health care interventions). Data were entered into a Research Electronic Data Capture data collection tool (version 9.5.26; Vanderbilt University, Nashville, TN). The local institutional review board approved this study.

For each admission, we reviewed the admission history and physical note, first 2 progress notes (chronologically), and discharge summary (included to capture screening done after the first 48 hours of the hospital stay). Our primary outcome was physician documentation of risk behavior screening in any of 5 selected risk behavior domains: mood and/or mental health issues, sexual activity, substance use, abuse and/or violence, or suicidal ideation. We chose these domains because they involve risky behaviors that contribute to the leading causes of morbidity and mortality in youth¹  and because these sensitive topics require extra steps to maintain confidentiality (should not be obtained in the presence of parents and/or guardians). We examined screening in each risk domain as well as comprehensive screening in all 5 domains. We did not review or collect data on documentation of risk behaviors by nurses, social workers, or case managers because our aim was to determine rates of physician-documented risk behavior screening. We focused on physician-documented screening because physicians are ultimately responsible for both reviewing risk behaviors and acting on positive screening results (eg, ordering sexually transmitted infection testing). Additionally, some of these consultants (eg, pediatric case managers) may not be available or consistently involved in other settings that provide inpatient pediatric care, such as community hospitals. We classified as having incomplete documentation without updated verification, or if the physician has simply noted “negative HEADS (home, education, activities, drugs, sexual activity, and suicidal ideation)”, or “negative social history”, as it was difficult to determine which risk behaviors, if any, were screened for during the current admission. If screening was documented as deferred but then not completed by discharge, this was also classified as incomplete documentation.

We classified screening results as positive when a physician documented engagement in a behavior associated with higher risk of negative health sequalae (ie, mood disorder without any outpatient care plan, unprotected sex or sex with multiple partners, use of any illicit substances or use of alcohol in patients <21 years of age, report of any abuse and/or violence, and report of suicidal ideation).

Our secondary outcome was documentation of any risk behavior–related health care interventions. Specifically, these included inpatient or outpatient referrals to subspecialists (mental health and/or psychiatry, adolescent medicine, or social work), sexually transmitted infection screening, sexually transmitted infection treatment, contraceptive provision, documented counseling on harm reduction, suicidal ideation inpatient precautions, referrals to child protective services, or communication with the patient’s primary care provider regarding the risk behavior. If an intervention was documented as offered to a patient, but they declined, this still counted as provision of a risk behavior–related health care intervention. These outcomes were collected through review of the notes listed above and orders placed within the EHR. Primary and secondary outcomes were audited independently of each other.

We used descriptive statistics (counts and frequencies) to summarize demographic data, rates of screening, and risk behavior–related health care interventions. We used χ² tests to determine associations between risk behavior screening and risk behavior–related health care interventions.

We reviewed a total of 240 admissions. Significantly more female patients were included in the study sample (63% vs 38%), and the median age was 16 years. There was a higher proportion of patients with private (43%) versus public insurance (39%) (Table 1).

A total of 90 admissions (38%) had documentation of screening within at least 1 risk behavior domain. Of these, 66% had positive screening results. Screening rates varied by domain, from 3% for abuse and/or violence to 30% for mood and/or mental health (Table 2). Only 15% of charts had documented screening in at least 4 of the 5 risk behavior domains and only 2% had documented screening in all 5 domains.

In all risk behavior domains, the majority of patients who had positive screening results had documented risk behavior–related health care interventions. Rates of documented intervention for positive screening results ranged from 64% for sexual activity to 100% for abuse and/or violence (Supplemental Table 4).

Across all risk behavior domains, patients who were screened were significantly more likely to receive risk behavior–related health care interventions (Table 3). For patients documented to have positive abuse and/or violence screening results, 6 of 6 (100%) of them received a related intervention. In patients within our sample that had documented screen results positive for suicidal ideation, 10 of 12 (83%) received intervention. One of the patients who did not receive intervention for suicidal ideation had a documented safety contract (not included in our predetermined suicidal ideation–related interventions), and 1 was determined to have a nonacute positive screening result.

Hospitalizations represent an important opportunity for risk behavior screening and risk behavior–related health care provision for adolescents. Our findings indicate low rates of screening documentation, with only 38% of patients having any risk behavior screening documentation and only 15% of patients having documented screening in at least 4 of 5 risk behavior domains. Only 2% of patients in our sample had screening documented in all 5 risk behavior domains. Adolescents who were screened were more likely to receive risk behavior–related interventions during hospitalization. To our knowledge, this is the first study in which researchers examine rates of documentation of comprehensive risk behavior screening among hospitalized adolescents in the United States. In these findings, we underscore that hospitalizations are a potentially missed opportunity to provide needed care for adolescents.

In our findings, we echo an Australian study in which Yeo et al¹⁷  also examine comprehensive risk behavior screening in the inpatient setting. Unlike our study, in which we focused on 5 high-risk behavior domains, Yeo et al¹⁷  additionally included screening in less sensitive/lower-risk domains within HEADSS (home, education and/or employment, activities and/or peers). They found that 10% of patients had complete comprehensive screening (≥5 domains) and 29% had incomplete screening (1–4 domains).¹⁷  In their study, Yeo et al¹⁷  similarly highlight the fact that screening and identification of risk behaviors lead to needed health care interventions (75% rate of intervention in adolescents with positive screening results).

In previous studies, researchers have identified barriers to risk behavior screening and risk behavior–related care provision in the inpatient setting. In a cross-sectional, multicenter survey study assessing hospitalists’ beliefs and practices regarding inpatient sexual and reproductive health screening and interventions, the primary barriers reported were lack of time, concern about patient follow-up, and clinician lack of knowledge or comfort on the subject.⁹  Despite these barriers, adolescents report wanting risk behavior–related care in the inpatient setting. In a study by Guss et al,¹⁰  the authors found that adolescent inpatients expressed interest in receiving inpatient reproductive health information and services, including adolescents who have a primary care provider.

In studies of adolescent risk behavior screening in emergency department and outpatient settings, researchers have found promising interventions for addressing some of these physician-identified barriers. Screening reminders and templates in paper or electronic charts have been effective in increasing screening, even into the busy workflows of emergency department physicians.^12,13  In the outpatient setting, Jasik et al¹⁸  found adolescent patients preferred electronic self-disclosure screeners; these screeners increased rates of disclosure of sensitive information while also increasing efficiency for clinicians. Thus, promising interventions for the inpatient setting include educational sessions on risk behavior screening and risk behavior–related care provision (to increase clinicians’ knowledge and comfort), screening reminders for clinicians, and/or electronic self-disclosure screeners.^9,12,13,18 

In this retrospective study, we determined rates of documentation of screening and interventions. We may be missing instances (1) in which screening or interventions may have been offered and declined by a patient (eg, contraception recently provided in the outpatient setting and thus declined) or (2) in which screening or interventions were not fully documented (eg, negative HEADSS). These latter situations may explain our findings of instances in which an adolescent received a risk behavior intervention without having documented screening. We only reviewed documentation done by physicians, so we may be underestimating screening rates if we missed situations in which a physician chose not to document screening because it had already been documented by another type of clinician (eg, social worker). However, our results align with previous literature revealing low rates of screening across all clinicians involved in a patient’s care.¹⁷  Physicians who documented risk behavior screening may have also been more likely to order risk behavior–related interventions, thus driving our finding of association between screening documentation and intervention. Reverse causality could also be playing a role if physicians were more likely to document screening in cases in which screens had positive results. In addition, we classified a complete screen as one in which all 5 risk behavior domains were screened; however, there may be instances in which less screening is deemed adequate (eg, in the case of a screen positive for suicidal ideation, further screening of that domain, such as access to weapons, is done instead of sexual risk screening). Finally, our study took place at a single tertiary, academic children’s hospital, which may limit generalizability to other hospital settings.

We found that rates of adherence to risk behavior screening among hospitalized adolescents were low. There was a high prevalence of positive screening results, and those who had documented screening were significantly more likely to receive risk behavior–related health care interventions. In future studies, researchers should explore interventions, such as electronic self-disclosure screening tools and clinician reminders, to overcome previously identified barriers and increase adolescent risk behavior screening and interventions in the inpatient setting.