Implementation of a Depression Screening Protocol Specific to Implantable Cardioverter Defibrillator Patients; A Quality Improvement Project

Background: Depression in patients with implantable cardioverter defibrillators (ICD) is a problem that has not been well addressed by providers. In 2012 the American Heart Association (AHA) released a scientific statement that recommended structured and routine depression screening of these patients. The AHA statement also recommended further research on depression screening instruments and their use with this population. Aims: 1.) To develop and implement an evidenced based depression screening protocol appropriate for patients with an ICD seen in an outpatient setting. 2.) Evaluate provider knowledge about depression screening (? Is this what you mean) and depression screening practices before and after the depression screening protocol implementation. 3.) Determine the efficacy of protocol implementation by evaluating provider screening practices and recommendation for treatment. Setting: A small cardiology clinic affiliated with the University of Kentucky Cardiology Fellowship program. Participants: 18 general cardiology fellows who conduct clinic hours on Monday and Wednesday afternoons in the specified clinical setting. Methods: An evidenced based depression screening protocol was created using the Patient Health Questionaire-9 (PHQ-9). Participants were asked to use this screening instrument to evaluate all patients with an ICD who were seen in their clinic over a 14-week period. Participants were to document the screening in the clinic note and bill appropriately for the diagnosis of ICD. Participants also were surveyed on their knowledge and depression screening practices within this patient population before and after implementation of the protocol. A chart review was conducted at the end of the pilot study to evaluate provider adherence with the protocol. Process evaluation was conducted at the mid and end points of the pilot study. Results: The pre and posttest data showed an increase in formal depression screening, use of depression screening instruments, and knowledge base after protocol implementation. Posttest data showed that 64% of participants reported that they formally screened ICD patients compared to only 11% stating they screened pre protocol. Pre test data suggests that 89% of participants used a formal instrument 0/10 encounters compared to posttest data which suggests that 93% used an instrument at least 1-10/10 encounters. There was also a 38% increase in knowledge base about depression in the ICD population post protocol implementation. The primary barrier to depression screening identified by participants was lack of time. Chart review data was influenced by potential billing inconsistencies and poor attendance of ICD patients to the clinic during the pilot period. This led to little documented evidence of provider adherence to the protocol in the study setting. Of the charts available for analysis, 50% contained proper execution of the depression screening protocol. It is important to note that participating physicians have interactions with ICD patients in settings outside the study clinic and may have incorporated depression screening practices in other patient encounters. This may explain the improved scores of the pre/post test that are not reflected in the chart review data. Process evaluation data suggested that participants were equally prepared and satisfied with the process at the mid and end points of the pilot study. Conclusions: This quality improvement project was successful in creating and implementing a depression screening protocol in a small cardiology outpatient clinic. There was also marked success in provider knowledge and depression screening practices based on the results of pre/post test. In accordance with the scientific statement by the AHA, further research is recommended on best practice for depression screening of the ICD population