• Depression Screening Protocol for MS patients in a Neurology Clinic

      Yeasmin, Selina; Edwards, Lori A. (2021-05)
      Problem and Purpose: Depression is the most common symptom in Multiple Sclerosis (MS) patients with reported lifetime prevalence of 25-50%. Undetected and untreated depression in MS patients has been associated with poor psycho-social and treatment outcomes. Early detection and management of depression has been shown to ameliorate those negative outcomes and improve quality of life. Time constraints in ambulatory clinic settings can impact providers’ ability to perform a thorough psychological as well as physical evaluation. To address this gap adoption of a standardized depression screening tool in the care of MS patients was an important opportunity to address a critical need and improve quality of patient care. The purpose of this quality improvement (QI) project was to implement and evaluate the effectiveness of a Depression Screening Program in adult ambulatory outpatient neurology clinic with MS patients using the Patient Health Questionnaire (PHQ-9) screening tool. Methods: The primary aim of this QI project was to implement a depression screening protocols for adult MS patients in an outpatient neurology clinic using the Patient Health Questionnaire-9 (PHQ-9), a validated depression screening instrument. Medical assistants (MAs) completed the PHQ-9 with patients during telemedicine visits. The MS providers reviewed and provided brief intervention and referrals if warranted. The project leader mobilized a site team, trained MS providers and MAs, mentored champions, tracked the project on a weekly basis, and provided the staff with weekly data updates. Results: PHQ-9 tool was utilized for depression screening in 144 out of 149 patients who had health visits during the 13-week period (97% compliance). Out those of 144 patients who were screened, 50% (n=72) were positive (PHQ-9 scores 5-27) for depression. 100% (n= 144) PHQ-9 scores were discussed and reviewed by MS providers. The treatment and referrals contributed to, 27.7% of patients were prescribed antidepressant,12.5% were referred to mental health providers. One patient had suicidal ideation, necessitating an urgent transfer to the emergency department (ED). Conclusion: Depression screening program using the PHQ-9 was adopted by the neurology clinic for MS patients. This program was able to identify depression in adult MS patients and facilitate treatment or referral to mental health providers. Early detection, treatment, or referral of adult MS patients with depression may help prevent ED visit or hospitalizations and will improve the quality of life for these patients.
    • Early Screening Algorithm for Depression After Stroke (E-SAD)

      Yates, Steven M.; Yarbrough, Karen (2021-05)
      Problem: Post-stroke depression (PSD) is common and associated with poor functional recovery, decreased quality of life, and increased mortality. At a community hospital, less than 10% of patients admitted for stroke are screened for post-stroke depression. This practice is not in compliance with the American Heart Association ischemic stroke guideline recommendations. Purpose: The purpose of implementing this quality improvement project was to establish the feasibility of an evidence-based post-stroke depression screening algorithm in a community hospital. In addition, this project sought to provide early interventions to support patients’ psychological wellbeing. Methods: A PSD screening algorithm, was created for this quality improvement project incorporating the Patient Health Questionnaire-9 (PHQ-9) depression screening tool. The PSD algorithm establishes screening score ranges for depression severity and recommends specific actions based on the score to promote patient psychosocial wellbeing. Action items included: providing patient education on post-stroke depression, updating the primary health care provider of the patient’s screening results, outpatient psychiatry referral, inpatient psychiatry referral, and the consideration of starting an antidepressant medication. Patients were considered eligible to have the algorithm applied if they suffered a new ischemic stroke, were hospitalized on the stroke unit, and did not meet exclusion criteria (aphasia, critical illness, hospice, dementia, non- English speaking, and patient refusal). Results: Charts of 65 patients admitted with ischemic stroke were audited between August 30, 2020 and December 1, 2020. Of the 44 ischemic stroke patients admitted, 31 (70.46%) were assessed using the PSD algorithm, by evidence of documentation in the electronic health record PHQ-9 flowsheets. Of those 31 patients, 19 (43.18%) patients were screened with the PHQ-9 while the rest met exclusion criteria. Of the patients screened with the PHQ-9, 13 patients had a screening score indicating no depression, 4 had mild depression symptoms, and 2 patients had moderate to high depression symptoms. The median PHQ-9 score was a 3. Conclusion: Screening for post-stroke depression is feasible in a community hospital setting. Implementing a PSD screening algorithm creates greater awareness of poststroke depression and increases psychosocial support after hospitalization.
    • Implementation of Depression Screening in a Primary Care Practice

      Flores, Jacqueline N.; Davis, Alison D. (2021-05)
      Problem & Purpose: Depression is a common mood disorder that affects over 19.4 million adults annually in the United States. Depression is a leading cause of disability, absenteeism, and suicide. Primary care providers can diagnose and treat depression; yet, 50% of all depression diagnoses are missed in the absence of effective screening. Clinical practice guidelines support routine use of the Patient Health Questionnaire-9 depression screening tool among primary care patients. The purpose of this quality improvement project was to implement and evaluate the effectiveness of depression screening using the Patient Health Questionnaire-9 among adult patients at a suburban primary care clinic. Methods: The project was implemented by a team of primary care providers and nurse practitioner students during a 12-week period beginning in September of 2020. Staff and students received education on the importance of depression screening and intervention prior to implementation. Participants included primary care patients ages 18 or older who could speak and understand English, presenting for sick- or well-visits, either in-person or through telehealth. Participants were asked to complete the Patient Health Questionnaire-9 prior to their visit. Each patient’s sum score was calculated to determine presence of depression, severity, and assign corresponding interventions: watchful waiting, counseling referral and/or pharmacotherapy referral. Screening rates, specific scores, intervention rates, and specific interventions were collected weekly through chart audit and review of Patient Health Questionnaires. Results: Clinic personnel screened 61.3% (n=233) of eligible patients and 18.5% of these patients (n=43) had scores > 5 requiring intervention. All patients identified with depression were offered an intervention, of which 86% (n=37) accepted intervention and 14% (n=6) refused. Conclusions: The implementation of Patient Health Questionnaire-9 screening may increase rates of depression identification and facilitate treatment. Routine depression screening in primary care settings may guide patient management, staging of depression, and corresponding treatment plans.
    • Screening for Depression in a Rural Primary Care Setting

      Wallander, Jacquelyn C.; Yarbrough, Karen (2020-05)
      Problem and Purpose: The United States Preventative Services Taskforce recommends depression screening in the general adult population. Patients with untreated depression have higher morbidity rates in many diagnosis groups. Detecting and managing depression allows patients to better self-manage chronic diseases and contributes to an overall sense of improved well-being. In a private primary care setting a practice gap existed in which patients were not routinely screened for depression. The purpose of this quality improvement (QI) project was to implement a screening process for adults in a primary care practice to detect depression symptoms and offer treatment if indicated. Methods: The primary aim of this QI project was to implement a depression screening process for adults in a primary care practice using the Patient Health Questionnaire-9 (PHQ-9), a validated depression screening instrument. Primary outcomes measured: provider compliance in obtaining depression screenings and calculating the percentage of patients identified with depression. Eligible patients were aged 18-64 being seen for an annual exam with two Nurse Practitioners (NP). The NPs were provided PHQ-9 education and weekly reminders to complete the screening. During each patient annual exam, the patient was provided a copy of the PHQ-9. The NP reviewed results and treated when indicated. Charts were audited weekly for: provider compliance and depression classification. Results: Depression screening compliance was 67%, (n=30/45) and 30% of patients screened (n=9/30) were diagnosed with depression. All depressed patients were offered treatment. 20% were new depression diagnoses (n=6/30) and 10% had a history of depression (n=3/30). 13% (n=4/30) of patients were provided referrals to psychotherapy and 7% (n=2/30) were started on a medication for depression. The majority of the positive depression screenings (67%, n=6/9) were detected as mild. Conclusion: Depression screening using the PHQ-9 instrument is an effective way to detect depression. This will reduce the untreated depression rates in the practice and connect patients to proper treatment. Once depression is managed, patients are able to better self-manage chronic diseases. Implementation of the PHQ-9 into the provider workflow will increase depression screening compliance. As a result of this project, the primary care practice built the PHQ-9 instrument into the electronic health record to facilitate provider compliance.