• Implementation of Depression Screenings in a Cardiac Surgery Specialty Practice

      Dizon, Kristen; Davenport, Joan (2019-05)
      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.
    • Screening for Depression in Primary Care Practice

      Ruff, Sarah; Scrandis, Debra (2019-05)
      Background Ineffective screening of depression in primary care practice contributes to the number of patients with poor quality of life and mismanaged care, leading to fatalities and higher healthcare costs to repair the system brokenness. Primary care providers have a leading role in communicating patient information, such as risk for depression and treatment options, National guidelines and goals exist for providers to effectively screen the general adult population for depression, in order to provide appropriate care and help patients to avoid suicide, implementing a standardized screening tool can improve patient outcomes and reduce costs in primary care practice, Local Problem Ineffective screening of depression was an observed and verbalized practice problem at a primary care doctor's office in a suburban location of Maryland. The purpose of this Doctor of Nursing Practice quality improvement project was to implement and evaluate the Patient Health Questionnaire-9 (PHQ-9) as a standardized screening tool to increase the detection of depression and appropriate treatment options for the general adult population. Interventions This quality improvement project occurred over a total of 14 weeks, including eight weeks of an implementation phase, During the first two weeks, a medical doctor and two medical assistants at a primary care office were instructed on how to implement and score the PHQ-9. The primary provider was also educated on the proposed treatment actions. The project leader assessed facilitators and barriers, and randomly selected patient charts of participants to review for data collection. Pender's Health Promotion Model (HPM) was used to guide this practice change. Results During the implementation phase, the primary me provider reported observing an increase in the number of patients diagnosed with depression, referred to psychiat7, and/or treated with a new antidepressant, based on PHQ-9 results. A significant number of adult patients completed the PHQ-9 questionnaire, while a smaller sample size was randomly selected for further data analysis (n= 95), Based on the ease of implementation and improved detection rates of depression, the staff within this primary care office continued to administer the PHQ-9 beyond the implementation phase. Results were saved within the patients' electronic health record. Conclusion Ineffective screening for depression in primary care practice continues to lead to adverse events. National guidelines supporting use of the PHQ-9 are recommended but not required for the general adult population. The large number of questionnaires administered during the implementation phase of this project was both a benefit and limitation, considering the extent of data analysis is to be completed in a short timeframe. Other limitations included the small number of staff involved and at two-week outage of the electronic health system in this office. Sustainability of this project may be obtained, as key stakeholders accept the organizational changes, benefit from the cost savings, and continue to improve quality of life.
    • Screening for Depressive Symptoms Using the Cornell Scale for Depression in Dementia

      Jono, Yumi; Windemuth, Brenda (2019-05)
      Background: Dementia and depression are two of the most common mental illnesses among the older adults. Some older adults have both diagnoses. The prevalence of depression among those over 65 years of age ranges between 1-5% in the community, 13.5% in those who require homehealth care, and 25% in those residing in long-term and assisted living facilities. Prevalence of depression among older adults residing in long-term facilities or assisted living facilities is a significant issue because the number of these facilities in the United States is increasing. However, it is difficult to assess depressive symptoms in patients with dementia in long-term and assisted living facilities as those patients are often unable to accurately articulate their feelings and thoughts. Local Problem: The provider for residents at an assisted living facility on the east coast currently has the Patient Health Questionnaire-9 as a screening tool for depressive symptoms. The screening for depressive symptoms is not being conducted because most residents have moderate to severe dementia and are unable to answer the questions on PHQ-9. Therefore, there is a need for another screening tool that could be used for those with dementia. Interventions: The purpose of this DNP project was to screen residents at the assisted living facility using the Cornell Scale for Depression in Dementia (CSDD) to identify those who may need intervention and to educate and involve the staff in screening. The CSDD is a screening tool for depressive symptoms that can be used for those with and without dementia. The CSDD is useful because the questions can be answered by those around individuals with dementia. The possible score for CSDD ranges between 0 and 38. The score of 8 is considered a person is presenting with depressive symptoms. Score of 12 and above is considered significant depressive symptoms. Results: Fifty residents were screened using the Cornell Scale for Depression in Dementia. Among those screened, the lowest score was 0 and the highest was 13. The mean score was 5.36 (SD 2.66). Eleven out of 50 residents had CSDD score of 8 or above. All residents with a diagnosis of depression were already receiving a pharmacological intervention. A significant number of residents without diagnosis of were also on pharmacological interventions for other medical diagnoses such as anxiety, insomnia, and Parkinson’s disease Conclusion: The screening for depressive symptoms using CSDD provided a structure to screen residents with dementia. It also provided an objective measurement of residents’ level of depressive symptoms. Having an objective number allows the provider to assess the improvement or progression of depressive symptoms in residents in the future. This assisted living facility had a small number of residents with frequent access to their provider, which may explain a low mean CSDD score and their existing treatments. This screening can be implemented in other facilities that do not have a screen tool or have large volume of patients with dementia, especially in underserved areas. However, the need for screening for depressive symptoms must be assessed prior to the actual screening.