Implementation of Depression Screenings in a Cardiac Surgery Specialty Practice

Abstract

Background: Depression does not typically occur in isolation; it is a major risk factor for heart disease. The neuroendocrine disturbances, endothelial dysfunction, enhanced platelet activation, and inflammation associated with depression increase patients’ risk for cardiovascular disease. Local Problem: Although cardiac surgery providers in an academic medical center located in the Mid-Atlantic region were aware of the prevalence of depression in cardiac patients, patients were not routinely screened for depression after cardiac surgery using a validated tool. Intervention: The purpose this quality improvement project was to implement the Patient Health Questionnaire-9 depression screening tool coupled with a referral, if needed, in a cardiac surgery practice. Using the Plan-Do-Study-Act cycle as a framework for implementation, cardiac surgery nurse practitioners screened eligible patients using the Patient Health Questionnaire-9. Eligible patients were adults who understood English, were being seen for their postoperative coronary artery bypass grafting surgery visit, and were not being treated for depression at the time of the screening. The first cycle of implementation involved just-in-time training of nurse practitioners for Patient Health Questionnaire-9 administration, interpretation, and referral. Before the second cycle, barriers and facilitators were identified before implementation continued. During the second cycle, providers performed the screening using an algorithm to streamline screening and appropriate referral. Results: Two nurse practitioners in the cardiac surgery practice were trained to administer, score, and interpret the PHQ-9. Out of the 38 patients eligible for screening, 29 were screened for depression and had the PHQ-9 documented in their chart. The mean percentage of patients screened during each clinical day was 83.3%, with an upper limit of 100% and lower limit of 0%. During implementation, two patients screened positive for depression. Conclusions: The Patient Health Questionnaire-9 is a feasible and useful screening tool for depression in a busy cardiac practice. Adapting the addition of the depression screening tool to the workflow and minimizing the additional workload incurred by implementation increased the likelihood of compliance. As undertreated mental health comes to the forefront of many issues worldwide, increased depression screening in various settings that can connect patients to care is an important and necessary addition to public health resources.