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Running Head: DEPRESSION-RISK SCREENING POST STROKE
Enhancing Depression-Risk Screening Among Post-Stroke Patients During Acute
Figure 1: Theory of Planned Behavior (TPB)...............................................................................27
Figure 2: Patient Health Questionnaire – 2 (PHQ-2).....................................................................32
Figure 3: EHR Clinical Decision Support (CDS) for Depression Screenings and Referrals........33
List of Tables
Table 1: Demographics and Descriptive Features of Registered Nurses Participating in Focus Groups............................................................................................................................................36
Table 2: Focus Group Themes to Facilitate Integrating PHQ-2 into Nurse Assessment and Workflow.......................................................................................................................................37
Table 3: Patient Demographics, Pre versus Post Intervention Subjects........................................41
Table 4: PHQ-2 Screening Times and Score Breakdown.............................................................42
Johansson, 2010). Through dialog with direct care providers, a plan for intervention
development can be created that reflects current workflow and culture (Currie, 2005).
Electronic clinical decision support (CDS) “provides clinicians with knowledge or
specific information that is intelligently filtered or presented at appropriate times, to enhance
health and healthcare. Tools may include clinical practice guidelines, alerts and reminders,
order sets, patient data report…, [and] diagnostic support” (Hebda & Czar, 2013, p. 130).
CDS can facilitate identification of patients that would benefit from further assessment and
treatment (Persell, 2012).
A study by Williams (2011) analyzed physician documentation of post-stroke
depression screenings with the use of CDS. Within the healthcare setting of study, physicians
were expected to screen all post-stroke patients with the PHQ-9 within six months of a new
stroke. Relying on physician memory, 50% of patients were screened and 31.9% had positive
results. After implementation of CDS within the EHR, screening increased to 86%, with
42.5% of patients having a positive screen. This study illustrated that implementing a formal
depression screen in conjunction with CDS within the EHR can enhance depression
screening and detection of depressive symptoms.
Staff Education Models
When providing education, different approaches should be used to meet diverse
learning styles. Learning styles can be viewed from a global perspective as right brain versus
DEPRESSION-RISK SCREENING POST-STROKE 26
left brain learning preferences; right-brain individuals are more creative, while left-brain
individuals are more logical. To enhance learning for those who are right-brain, it is
important to present the big picture first, followed by details with visuals of changes that they
can expect to see. In contrast, left-brain dominant individuals flourish with understanding
how the pieces achieve the final goal. These individuals also benefit from having an
opportunity to discuss information to assist with learning (Avillion, Holtschneider, & Puetz,
2010).
Web-based training and face-to-face content reviews are two approaches for
providing education. Web-based training is beneficial in that it is available 24/7, self-paced,
user-friendly, cost-effective, and consistent in content. However, it also lacks human
interaction, which can be a major disadvantage (Avillion et.al., 2010).
Face-to-face content reviews support individual needs for human interaction and
allow for discussion to enhance understanding (Avillion et.al., 2010). This method of staff
education has been shown to increase satisfaction (odds ratio of 2.07) (Smith, Forster, &
Young, 2008) and contribute to higher retention of new information (Commodore-Mensah &
Dennison-Himmelfard, 2012). One disadvantage of this method, however, includes lack of
time during a work shift to attend (Avillion et.al., 2010).
Gaps in the Literature
Three limitations in the literature were identified. First, the current literature primarily
focuses on detection of depression in general elderly hospitalized or cardiac patients.
Additional confounding factors associated with changes post-stroke and their impact on
development of depression would benefit from further research. Second, the PHQ-2 has a
high sensitivity for detecting major depression. Research studies conducted during acute
DEPRESSION-RISK SCREENING POST-STROKE 27
hospitalization did not differentiate between major depressive disorders and minor
depression, which have different effects on patient outcomes. Finally, rates of undetected
depression were influenced by healthcare provider practice and patient disclosure of
symptoms. More research is needed regarding how to support patient comfort with disclosing
depressive symptoms.
Theoretical Framework
The Theory of Planned Behavior (TPB) originates from social sciences, and is used to
assist with explaining four key concepts that should be addressed to achieve a clinical
practice change: attitude, subjective norms, perceived behavioral control, and intention.
Figure 1: Theory of Planned Behavior (TPB)
Source: Hankins, M., French, D., & Horne, R. (2000). Statistical guideline for studies of the theory of reasoned action and the theory of planned behavior. Psychology and Health, 15, 151-161.
Attitude is defined as a person’s belief about a practice, positive or negative.
Subjective norm is defined as social pressures that support performance or non-performance.
Perceived behavioral control is defined as the ease or difficulty of performing a practice
change, based on the power an individual possesses to achieve the desired outcome.
Intention is defined as the willingness to perform a practice change.
DEPRESSION-RISK SCREENING POST-STROKE 28
This theory proposes that an individual’s intention to perform a task is based on
attitude, subjective norms, and perceived behavioral control. Changes in behavior are
influenced by intention and perceived behavioral control. Therefore, not only would an
individual need to have the willingness to change practice, but he or she would also need to
know they had the ability or authority to as well (Godin, 1996; Hankins, French, & Horne,
2000; Houme, Abdeljelil, & Gagnon, 2012).
Methods
Overview
This project implemented two interventions based on results from staff nurse focus
groups and the literature, with the goal of strengthening screening for depression in
hospitalized stroke patients during the period of 24 to 48 hours post-admission. The
effectiveness of the interventions were analyzed through the perspective of the Theory of
Planned Behavior, which states that behavior change occurs when attitudes, subjective
norms, perceived behavioral control, and intentions align.
First, focus groups were conducted with registered nurses to explore current practices
and perceptions regarding screening for depression and nurse workflow, and to gain insight
regarding nurses’ attitudes, subjective norms, perceived behavioral control, and intention to
change practice. Second, web-based and face-to-face staff nurse education was provided,
guided by the feedback from the focus groups and a review of current literature. Third, the
depression-risk screen PHQ-2 was embedded into the EHR and nurses’ routine workflow.
Setting
This project took place at Portsmouth Regional Hospital (PRH), a 209-bed for-profit
community hospital in Portsmouth, NH. The hospital received Primary Stroke Accreditation
DEPRESSION-RISK SCREENING POST-STROKE 29
in January 2013 and identified depression recognition post-stroke as an area in which to
improve care processes. Stroke patients involved in the project were cared for on five
different units: two cardiac, one intensive care, one medical, and one surgical. All patient
rooms were private with telemetry capability. Physician and mental health counselor support
was available 24 hours per day, seven days a week.
Ethics
Approval from the Simmons College Institutional Review Board (IRB) and the PRH
IRB was obtained for the nurse focus groups. The nurse education and patient depression
screen interventions were quality improvement methods, and thus exempt from IRB
oversight.
The rights of nurses and patients were protected within this study. To protect nurses’
rights during the focus groups, they were asked to provide written consent prior to
participating (see Appendix A). In addition, the nurses’ names were not included on the tape
or transcript. During the nurse education intervention, results of the pre- and post-education
test were accessed only by the principal investigator. To ensure patient privacy and
confidentiality, personal information was removed from the data collected during chart
reviews and replaced with identification numbers.
Sample
Registered Nurses (RNs) working on five separate units (two cardiac, one intensive
care, one medical, and one surgical) were eligible for inclusion. To participate in the focus
groups, nurses were required to have a minimum of three months of experience in their
current unit and work a minimum of eight hours per week. Upon completion of the focus
DEPRESSION-RISK SCREENING POST-STROKE 30
groups, educational materials were developed and all RNs from the above units received
education.
For the patient intervention, patient electronic health records were accessed to collect
data regarding depression-risk screenings. Patient records were included in the project if the
following inclusion criteria were met: (a) patient admitted to one of the aforementioned five
inpatient units with a diagnosis of new onset Transient Ischemic Attack (TIA), ischemic, or
hemorrhagic stroke established by brain imaging or physician documentation; (b) minimum
of 24-hour length of stay and discharged in 14 days or fewer; and (c) capacity to
communicate with a minimum of “yes” or “no” answers appropriately. Patients with
impairments that prohibited reliability of information (i.e., advanced dementia or intubation)
and palliative or end-of-life patients were excluded.
Intervention and Implementation
Nurse focus groups
Two separate nurse focus groups were conducted to assist with this portion of the
project. Nurse participants were recruited by posting flyers on the unit and via hospital and
home email.
A different moderator was used for each focus group, both of whom were Bachelor of
Science in Nursing (BSN) prepared professional development educators with experience
facilitating meetings. They received training from the principal investigator regarding the
purpose of the focus group and their role as moderators. They were also provided a focus
group interview script to facilitate probing for key concepts of the Theory of Planned
Behavior, including attitude, subjective norms, perceived behavioral control, and intention to
DEPRESSION-RISK SCREENING POST-STROKE 31
support a change in behavior. Results from the first focus group led to modifications in the
interview guide for the second focus group (see Appendix B).
Focus groups were audio recorded and field notes were taken. Discussions lasted until
the respondents had nothing new to add, which occurred in approximately 60 minutes for
each session. At the end of each session, the moderator summarized the main points from the
discussion to capture nurses’ comments and assist with clarification and additional insights.
Nurse education intervention
The nurse education intervention was designed to affect nurse attitudes and align
subjective norms and perceived behavioral control to foster positive intentions in regards to
performing the depression-risk screening as indicated. A PowerPoint educational
presentation (see Appendix C), which took 10 to15 minutes to complete, was created in the
hospital’s web-based staff education program and assigned to all nurses on the five inpatient
units. Nurses were given 14 days to complete the education at home or during a routine work
shift; they were compensated by the hospital for either completion option selected. In
addition, 103 nurses that worked at least eight hours per week also received a five-minute
face-to-face education during a normally scheduled work day.
The web-based education material included a PowerPoint presentation and two
handouts that could be printed for reference. The presentation provided depression statistics,
screen shots of new EHR screens, and electronic CDS embedded in the EHR to facilitate
completion (see Appendix C). The first one-page handout provided staff education
summarizing key points of the depression screen intervention as well as a copy of the
verbatim PHQ-2 depression-risk screening questions (see Appendix D). The second one-page
handout provided patient education to assist in explaining the risk of depression for stroke
DEPRESSION-RISK SCREENING POST-STROKE 32
patients and the meaning of the screening tool results (see Appendix E), which nurses were
encouraged to provide to every stroke patient. These handouts were reviewed during the
face-to-face education.
Patient depression screen and referral intervention
This intervention embedded the depression-risk screen PHQ-2 into the EHR used on
the designated five inpatient units. The PHQ-2 (see Figure 2) was selected because it had
been successfully used in a wide variety of inpatient and outpatient settings with stroke
patients as outlined in the literature review, was simple and brief, and correlated well with
formal interviews for major depressive disorder.
Figure 2: Patient Health Questionnaire – 2 (PHQ-2)“Over the past two weeks, how often have you been bothered by any of the following problems:”
Not at all Several days
More than half the days
Nearly every day
Little interest or pleasure in doing things
0 1 2 3
Feeling down, depressed, or hopeless
0 1 2 3
(de Man-van Ginkel, 2012; Williams, 2005)
PHQ-2 scores are computed by summing responses to the two items. A PHQ-2 score
of two or greater was chosen as the cutoff for a positive depression screen based on a review
of the literature. Among stroke patients, this cutoff had been shown to have a sensitivity of
75% to 86% and specificity of 76% to 84% for post-stroke major depression (Arroll, 2010;
de Man-van Ginkel, 2011).
Based on the focus group feedback, several changes were implemented to support
completion of the depression-risk screens within 24 to 48 hours. First, the PHQ-2 was
embedded within the nurses’ electronic shift assessment based on feedback that a separate
DEPRESSION-RISK SCREENING POST-STROKE 33
documentation screen would be overlooked. Second, four electronic clinical decision support
(CDS) triggers were added to the EHR to facilitate depression-risk screening and referrals
when indicated (see Figure 3).
Figure 3: EHR Clinical Decision Support (CDS) for Depression-Risk Screenings and Referrals
1 Admission Database
If a nurse answered “Yes” to a patient “admitted for stroke or stroke-like symptoms,” the nurse was prompted to complete the PHQ-2 depression-risk screening tool in the EHR shift assessment.
2 Nurse Planex Results of the previous depression screen and actions taken were added to the nurse planex (a computer-generated summary of patient information that included orders, medications, allergies, risk screen results, etc., that was reviewed when a new nurse assumed responsibility for a patient) (see Appendix F).
3 Documented Actions
Positive screen results: Nurse would document if a patient wanted a “mental health clinician,” “chaplain,” or if “patient declined” referrals.Negative screen results: Documented as “risk not identified”Inability to screen: Documented as “patient unable to complete.”
4 Referral Order Nurse submitted a mental health clinician or chaplain electronic referral order prior to finalizing shift assessment documentation (see Appendix G)
Nurses were provided prompts from the admission database, during nurse hand-off-reports,
and within the EHR nurse shift assessment to facilitate depression-risk screening and referral
when indicated. Finally, to overcome delayed mental health counselor referrals related to
needing a physician order, a mental health counselor order was added to the ischemic/TIA
and hemorrhagic stroke paper admission order sets (see Appendix H).
DEPRESSION-RISK SCREENING POST-STROKE 34
Method of Evaluation
Nurse focus groups
The audio tapes from the focus groups were transcribed verbatim by the principal
investigator. The transcripts were reviewed by the principal investigator and a graduate
student independently to extract and compare themes based on the Theory of Planned
Behavior to answer research question one: “What methods will nurses propose to facilitate
the integration of a depression-risk screening tool into stroke patient assessment and nurse’s
workflow in the EHR?”
Nurse education intervention
A 10-question computerized pre- and post-education test (see Appendix I) was
developed to evaluate the effectiveness of the educational intervention. To evaluate question
clarity, the test was administered to three nurses not included in the intervention. Feedback
was received regarding the questions and responses, and adjustments to the test were made.
The modified test was administered to another three nurses, who confirmed interpretation of
the questions and response choices.
Before starting the web-based education, nurses completed the validated computer-
based 10-question test. Upon completion of education, nurses re-took the same test to
evaluate the effectiveness of education. Nurses were included in the data analysis if the pre-
and post-education tests were completed before the EHR intervention was implemented.
The nurses’ understanding of the education regarding the new process was also
evaluated through chart reviews. Nurses were expected to complete a PHQ-2 depression-risk
screen at least once a shift 24-48 hours post-admission for stroke patients. Each patient could
have one to three depression-risk screens documented in the EHR during this timeframe. The
DEPRESSION-RISK SCREENING POST-STROKE 35
number of screens completed varied based on a nurse’s work shift (12 hours versus 8 hours)
and the patient’s hospital length of stay.
Patient depression screen and referral intervention
Evaluation of depression-risk screening results and mental health referrals were
performed through chart reviews. In total, 60 patient records were reviewed for this project,
from which patient demographic, depression-risk screening, and interventions after positive
screen results were collected. Pre-intervention data was obtained starting with discharges in
March 2013 and ending once 30 patients met the inclusion and exclusion criteria (August
2013). Post-intervention data collection started in September 2013 and ended once 30
patients met the inclusion and exclusion criteria (December 2013).
Analysis
The nurses’ focus group transcripts were analyzed for similarity of themes, identified
by two separate reviewers. From there, major themes were compiled and included in the
findings. To analyze the education intervention, the difference in nurse test scores (pre- and
post-) was assessed using a paired t-test. Descriptive statistics were used to analyze nurse
screening documentation in the EHR.
The data from stroke patients eligible for depression-risk screening and referrals was
also analyzed. An independent t-test was used to compare the age and length of hospital stay
pre- and post-intervention. Cross-tabulations and chi-square were used to analyze pre- and
post-intervention data regarding gender, race, admit stroke type, admit National Institute of
Health Stroke Scale (NIHSS), depression documented on the physician’s admission history
and physical (H&P), and antidepressant medication prescribed prior to admission. Frequency
descriptive statistics were used to analyze depression-risk scores, and a mean was computed
DEPRESSION-RISK SCREENING POST-STROKE 36
for the number of hours post-admission each screen was performed. An additional post-
intervention analysis was performed, comparing age and length of stay for patients with
positive versus negative screens. In addition, interventions received were described.
Results
Capstone Question #1
What methods will nurses at PRH propose to facilitate the integration of a depression-risk
screening tool into stroke patient assessment and nurse’s work flow in the EHR?
Subjects
Different perspectives were obtained during two focus groups (n=9 unique
respondents). The first focus group recruited three staff nurses from the medical and cardiac
unit. The second focus group, after expanding eligible participants, recruited six staff nurses.
Of note, all of the participants were Caucasian women (99% of the hospital’s staff nurses
were Caucasian), and the majority of the nurses’ education level was an associate degree
(67%) (55% of the hospital’s staff nurses held an associate degree). See Table 1 for
additional demographic data.
Table 1: Demographics and Descriptive Features of Registered Nurses Participating in Focus Groups
N MeanAge (years) 9 44.4Hours Worked/Wk. 9 34.2RN Experience (years) 9 10.6Worked Current Unit (years) 9 6
This practice inquiry project incorporated nurse insights before embedding the PHQ-2
depression-risk screening tool in the nurses’ EHR at Portsmouth Regional Hospital. Web-
based and face-to-face staff nurse education and electronic clinical decision support were
implemented to strengthen depression-risk screening and referral when indicated.
Pre-intervention, 3.3% of stroke patients were screened for depression, compared to
86.7% of patients post-intervention. In addition, 15.4% (n=4) of the post-intervention
patients had a positive screen. Of these patients, 50% (n=2) agreed to further assessment by a
mental health counselor, 50% (n=2) accepted an additional antidepressant prescription at
discharge, and 25% (n=1) only agreed to speak with a chaplain for support. As a result of this
practice inquiry project, depression-risk screening significantly increased leading to
increased surveillance and potential mental health referrals by the nurse. The project results
suggest further investigation is warranted to probe the theoretical perspectives of attitudes,
subjective norms, perceived behavior control, and intentions that support nurses in screening
and referral.
DEPRESSION-RISK SCREENING POST-STROKE 49
Recommendations for Future Research
During this project inquiry project, three opportunities for future research were
identified. First, explore if degree level impacts nurses’ perceived behavioral control for
depression-risk screening and initiating needed mental health services. Potential strategies to
conduct this research could include interviews or surveys, reducing the influence of peer
pressure that can develop within focus groups.
A second area for exploration is nurse attitudes and perceptions regarding
documentation. Despite education and electronic CDS prompting completion of the
depression-risk screen, several patients were not screened. More research is needed to
understand why some nurses do not complete screenings despite real time EBP
recommendation availability. Research could be performed to determine if there is an
association between a nurse’s education level, experience, and perceived purpose of
documentation with documentation compliance. Potential strategies to conduct this research
include a combination of chart reviews and nurse surveys, comparing demographics of
nurses completing the screen as indicated, versus nurses that bypassed the mandatory
documentation screen.
A final area for future research includes validation of depression screen results. The
literature and focus groups identified that nurses may complete screening tools based on
information received during their general assessment versus asking screening questions
verbatim. Failure to ask depression-risk screening questions verbatim can result in lower
detection and treatment. Therefore, research could be performed to evaluate how screening
tool data is collected by staff nurses; comparing their results to screens completed
independently by a nurse researcher. Potential strategies to conduct this research include
DEPRESSION-RISK SCREENING POST-STROKE 50
patient interviews, nurse interviews, and chart reviews; comparing nurse researcher and staff
nurse results for consistency.
Depression has a significant impact on a patient’s recovery post-stroke. Early
detection of depressive symptoms while in the hospital setting may help reduce the severity
of depressive symptoms experienced post-hospital discharge. To maximize depression
detection, use of a PHQ-2 depression-risk screening tool within the nurses’ EHR and
electronic CDS can enhance screening and mental health referrals when indicated.
DEPRESSION-RISK SCREENING POST-STROKE 51
AppendicesAppendix A: Consent Form
Focus Groups of Hospital Employees
I am asking you to participate in a quality improvement project about depression after stroke. This consent form should give you the information you need to decide whether to be in the quality improvement project. I welcome your questions about the purpose of the project, what you would be asked to do, the possible risks and benefits, your rights as a volunteer, and anything else about the project or this form that is not clear. When I have answered all your questions, you can decide if you want to be in the project. This process is called “informed consent.” I will give you a copy of this form for your records.
PURPOSE OF THE PROJECT
The goal of this project is to develop a nursing work flow process where stroke patients are screened for depression in the electronic health record 24-48 hours after acute hospitalization and through telephone interview 28-35 days post-discharge, with appropriate referrals made based on screening results. The purpose of the focus group is to gain insights regarding how to proceed with nurse education and the best method for integrating the screening tool into shift assessment and nurse’s work flow.
STUDY PROCEDURES
There will be a focus group for RNs who work a minimum of 8 hours per week. The focus groups will take 60 to 90 minutes, depending on the number of people. I would like to tape the focus group so it can be transcribed. No names will be attached to the focus group, and the tape will be destroyed as soon as it is transcribed, or within three months, whichever comes first.
RISKS, STRESS, OR DISCOMFORT
I do not anticipate that the questions will be difficult to answer, but some may cause you to share your knowledge and areas where knowledge deficits may exist, which may cause emotional discomfort. You may refuse to answer any question at any time, leave the focus group at any time, and may withdraw from the project at any time without penalty.
CONFIDENTIALITY
No findings in this study will be linked to individual respondents. I will ask participants to respect each other’s confidentiality, but we cannot ensure this.
Portsmouth Regional Hospital leadership or Simmons College faculty will not have access to interview notes. Data will be handled by Tracey Collins, Simmons College DNP student.
Tracey Collins, MSN Printed name of individual obtaining consent Signature Date
If you have questions about the project or your rights you should contact Tracey Collins at 603-433-6926 and/or the Human Protections Administrator in the Office of Sponsored Programs at 617-521-2414.
Participant’s statement
This project has been explained to me. I volunteer to take part in this project. I have had a chance to ask questions. If I have questions later about the research, I can ask one of the resources listed above.
I agree to
Participate in a focus group.
Have the focus group taped.
Printed name of participant Signature Date
DEPRESSION-RISK SCREENING POST-STROKE 52
Appendix B: Moderator Guide
1. What are verbal and nonverbal signs of depression?
2. Would you interpret your assessments differently if a patient had a stroke? How?
* I’m going to ask a few questions about screening tools and PARS consults
3. What is the purpose of screening tools, such as the suicide screen you complete on
admission?
4. When a patient has a “positive” result, what does that mean?
5. What is your opinion about screening tools?
6. When asking screening questions, do you ask the patients these questions as written or
based on information you obtain?
7. How would you support a patient when they express having problems with depression or
extreme sadness?
8. Are you familiar with the PHQ-2 depression-risk screening tool? Have you ever used it?
9. What criteria are you currently using to decide if a patient would benefit from a mental
health counselor (PARS) referral?
*I’m going to ask a few questions about nursing documentation
10. What is the best way to incorporate a 2-question screening tool into Meditech if it should
be completed within 24 to 48 hours after admission?
11. If a reminder were to be placed on status board, what would you find helpful?
12. What are advantages and disadvantages of stand-alone screens, like the sedation vacation
screen?
* Last section – A few questions regarding how you prefer to learn new information
DEPRESSION-RISK SCREENING POST-STROKE 53
13. How do you like to receive new information? Healthstream, face-to-face, flyers, e-mail,
etc.?
14. When you receive education during your work day, when is the best time? How long
should it last?
15. What are your thoughts regarding pre-test and post-tests?
16. Anything else that would help with staff education, offering support to patients, or incorporating screening into practice that you feel would be beneficial
1. Stroke patients should be asked the following questions (as Written) every shift for the first 48 hours after admission:
“Over the past 2 weeks, how often have you been bothered by any of the following problems:”
Not at all Several Days
More than half the
days
Nearly Every Day
“Little interest or pleasure in doing things” 0 1 2 3
“Feeling down, depressed, or hopeless” 0 1 2 3
Score of 2 or Greater: Refer to Mental Health Counselor
2. Document depression screen results in Meditech shift assessment3. If indicated and patient approves, place mental health clinician consult
a. Provider order for mental health clinician (PARS) included in stroke order sets4. If patient declines mental health clinician, offer chaplain for support 5. If patient declines both support services, document in Meditech 6. Provide patient education pamphlet
NOTE:
Administer depression screen every shift for first 48 hours after admission unless:◦ Patient with significant cognitive impairment/intubated◦ Patient screens positive and mental health clinician consult made (Consult shown on planex)
Read screening questions verbatim Positive depression screen does NOT diagnose depression If Mental Health Clinician needed sooner than 24 hours – call X4952 in addition to placing order in
Meditech OE (IE: Marked anxiety, panic attacks, or suicidal thoughts)
Depression Screening for Stroke Patients
DEPRESSION-RISK SCREENING POST-STROKE 70
Special Considerations◦ Patients with current depression treatment should still be screened – to evaluate for presence of
depressive symptoms◦ Communication deficits (IE: aphasia) –
Consider showing patient screening tool and asking patient to point to response (or) Seek assistance from speech therapist
Dealing with stroke rehabilitation while also handling the normal stresses of everyday life can be overwhelming.
DEPRESSION-RISK SCREENING POST-STROKE 71
Appendix E: Patient Education
A stroke can be a life-changing event that can cause physical, mental, and emotional changes.
Signs of Depression (feeling sad or unhappy)
While recovering from your stroke, your body will begin to experience physical and mental changes.
Mental changes, like physical changes, are important to identify and manage.
No matter how good your progress, you could experience depression while recovering.
During your admission you may be asked the following questions to see if you could benefit from additional support:
Over the past 2 weeks, how often have you been bothered by any of the following problems:
Little interest or pleasure in doing things Feeling down, depressed, or hopeless
Response options include:
Not at all Several Days More than half the days Nearly every day
Mood Changes Associated with Stroke
DEPRESSION-RISK SCREENING POST-STROKE 72
** This screening does not diagnose depression; it identifies when more support could be helpful**
Talk With Your Doctor or Nurse
If you are worried that you may be having symptoms of anxiety (frequent worrying), depression, or other emotional changes speak with your doctor or nurse
Mental Health Clinicians can assist with identifying if your symptoms are related to stress, expected changes after a stroke, or need treatment.
Chaplains can also assist with offering spiritual and non-spiritual support if desired.
DEPRESSION-RISK SCREENING POST-STROKE 73
Appendix F: Nurse Planex
DEPRESSION-RISK SCREENING POST-STROKE 74
Appendix G: EHR Order Entry Prompt Before File Documentation
DEPRESSION-RISK SCREENING POST-STROKE 75
Appendix H: PARS (Mental Health Counselor) in Paper Stroke Provider Orders
DEPRESSION-RISK SCREENING POST-STROKE 76
Appendix I: Nurse Education Pre and Post-Test
*Answers in bold
1. What percentages of patients with depression are identified when depression screening occurs through routine assessment?
a. 20% to 30%b. 30% to 50%c. 40% to 50%d. 75% to 86%
2. What percentages of patients with depression are identified when a 2-question depression-risk screening tool is used?
a. 20% to 30%b. 30% to 50%c. 40% to 50%d. 75% to 86%
You are working on an inpatient unit. You are assisting J.B., an 86-year-old man admitted with a stroke, with ambulating to the bathroom. During this time, J.B. tells you his wife died 9 months ago. He proceeds to become tearful when telling you about his loneliness. He tells you he feels sad much of the time, hasn’t been involved in his normal activities, has had difficulty sleeping for over a month, and has been drinking alcohol daily.
3. What symptoms could BEST indicate depression?a. Crying, feeling sad much of the time, decreased activity, difficulty sleepingb. Crying, wife died 9 months agoc. Crying, feeling sad much of the time, decreased activityd. Crying, feeling sad much of the time, difficulty sleeping
4. Based on the scenario in question 3, which of the following symptoms would place the patient at highest risk for suicide?
a. Frustration over lack of sleepb. Loss of wifec. Drinking alcohol d. Advanced age
DEPRESSION-RISK SCREENING POST-STROKE 77
You are caring for K.C., a 65 year old ischemic stroke patient. K.C. shows little interest or pleasure in doing things, and shares she has felt this way for weeks. She complains of pain in her unaffected side with no known cause, and requires discharge to an acute rehabilitation center related to severe fatigue, and slow functional recovery.
5. Which of the following symptoms BEST indicates risk of depression?a. Unexplained painb. Little interest or pleasure in doing things for weeksc. Severe fatigued. Slow functional recovery
6. To administer the 2-question depression-risk screening tool, a patient is asked “Over the past 2 weeks, how often have you been bothered by any of the following problems”?
a. Feeling down, depressed, or hopeless AND Feeling bad about yourself — or that you are a failure or have let yourself or your family down
b. Have little interest or pleasure in doing things AND Feeling down, depressed, or hopeless
c. Little interest or pleasure in doing things AND Poor appetite or overeatingd. Feeling down, depressed, or hopeless AND Trouble falling or staying asleep, or
sleeping too much
7. The depression-risk screening tool questions should be completed in the following manner:
a. Perform routine physical assessment, then answer screening questions based on verbal and non-verbal information collected
b. Pull up the computer screen and read questions verbatim, with back to patientc. By asking the patient or family member if they have felt depressed within the
past 2 weeksd. As part of routine assessment, incorporate asking screening tool questions
as written, every shift, for the first 48 hours after admission
8. The patient has a “positive” depression-risk screening score. How would you explain what this means to the patient?
a. “Your depression-risk screening score was 2 or greater. This means that you have depression, and may benefit from starting an antidepressant. I will notify the provider to request orders.”
b. “Your depression screening shows that you might be at risk for depression, which is common for stroke patients. Would you like to speak with a mental health counselor, who can assist with offering you support?”
DEPRESSION-RISK SCREENING POST-STROKE 78
c. “Your depression-risk screening score was 2 or greater. Because you had a stroke, your feelings are expected. We will continue to check you every shift to continue to monitor how you are feeling.”
You are caring for K.C., a 65 year old ischemic stroke patient. K.C. shows little interest or pleasure in doing things, and shares she has felt this way for weeks. She complains of pain in her unaffected side with no known cause, and requires discharge to an acute rehabilitation center related to severe fatigue, and slow functional recovery.
9. Would this patient warrant an urgent or routine mental health counselor consult if their depression-risk screen was positive? Within what time frame would you expect the mental health evaluation to occur?
a. Non-urgent, patient seen within 12 hoursb. Non-urgent, patient seen within 24 hoursc. Urgent, patient seen within 12 hoursd. Urgent, patient seen within 24 hours
10. In addition to feeling hopeless and having suicidal thoughts, which patient characteristic are urgent and would warrant calling a mental health counselor to facilitate a consult as soon as possible?
a. Patient repeatedly declines to participate in rehabilitationb. Patient suffers from mood disorder, PTSD, or alcohol/substance abusec. Patient exhibits marked anxiety or panic attacksd. Altered sleep/wake cycle for over two weeks
DEPRESSION-RISK SCREENING POST-STROKE 79
References
Aarts, J., Doorewaard, H., & Berg, M (2003). Understanding implementation: the case of a
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Journal of the American Medical Informatics Association, 11(3), 207-216.
Achten, D., Visser-Meily, J., Post, M. W. M., & Schepers, V. P. M. (2012). Life satisfaction
of couples 3 years after stroke. Disability and Rehabilitation, 34(17), 1468-1472.
Amatayakul, M. (2011). Why workflow alone is not enough for EHR success. Healthcare
Financial Management, 65 (3), 130, 132.
American Heart Association (2013). Heart disease and stroke statistics—2014