Running head: PERINATAL DEPRESSION SCREENING EVALUATION 1 Perinatal Depression Screening Program Evaluation Maeghan Murphy, Christina Ploeger, and Nicole Teeter Michigan State University College of Nursing March 20, 2022 PERINATAL DEPRESSION SCREENING EVALUATION 2 Table of Contents Abstract 6 List of Tables 4 List of Figures 5 Introduction 7 Background and Significance 7 Problem Statement and Clinical Question 10 Review of the Literature 11 Search Strategies and Selection Criteria 11 Screening for PPD 12 Quality Improvement Approach 12 Program Evaluation Theoretical Framework 13 Description of the Program 13 Evaluation Goal and Purpose Statement 14 Evaluation Team 14 Stakeholder Assessment 15 Need 17 Context 18 Target Population 18 Stage of Current Program Development 19 Resources/Inputs 19 Activities 19 Outputs 20 Outcomes 20 PERINATAL DEPRESSION SCREENING EVALUATION 3 Focus of the Evaluation 22 Methods 24 Data Collection 24 Data Analysis 25 Indicators 25 Analysis 25 Interpretation 25 Dissemination of Results 26 Implications for Nursing 26 Cost-Benefit Analysis & Budget 27 Conclusion 28 References 30 Appendix Appendix A 35 Appendix B 47 Appendix C 48 Appendix D 49 Appendix E 50 Appendix F 51 Appendix G 53 PERINATAL DEPRESSION SCREENING EVALUATION 4 List of Tables Tables Table 1. Roles and Responsibilities of the Evaluation Team Members 14 Table 2. Stakeholder Assessment and Engagement Plan 16 Table 3. Program Description 20 Table A4. Literature Review Synthesis 46 Table B5. GANTT Chart for Timeline 47 Table C6. Data Collection Tool 48 Table E7. Budget Report 50 PERINATAL DEPRESSION SCREENING EVALUATION 5 List of Figures Figures Figure 1. Logic Model Diagram for Program Evaluation 21 Figure D2. Chart Review Data 49 Figure D3. Screening Percentages 49 Figure F4. Internal Review Board Approval from Michigan State University 52 Figure G5. Data Use Agreement 53 PERINATAL DEPRESSION SCREENING EVALUATION 6 Abstract Perinatal mood and anxiety disorders (PMADs) are extremely common and can occur unpredictably during and after pregnancy. If left untreated, PMADs can be detrimental to the long-term health of both mothers and infants. The Edinburgh Postnatal Depression Scale (EPDS) is an effective and well-accepted screening method for identifying PMADs. The findings from a literature review emphasized the clinical importance of screening as well as the value of a quality improvement approach. The objective of this Doctor of Nursing Practice (DNP) project was to analyze the PMAD screening practices at a busy women’s health clinic in Metro Detroit by conducting an in-depth chart review. Data gathered from this evaluation was utilized by clinic leadership to better serve patients by addressing current screening deficits within the practice. Specific areas of improvement identified by this evaluation included the need to increase the percentage of EPDS screens completed at the initial obstetric (OB) visit and ensuring behavioral health referrals were being made when patients have a positive screen. Keywords: Perinatal mood and anxiety disorders, postpartum depression, Edinburgh Postnatal Depression Scale PERINATAL DEPRESSION SCREENING EVALUATION 7 Perinatal Depression Screening Program Evaluation Perinatal mood and anxiety disorders (PMADs), including perinatal and postpartum depression (PPD), are the leading complications of pregnancy and childbirth (Moyer & Kinser, 2021). The onset of PMADs can be gradual or sudden and can occur at any point during pregnancy, and up to one year postpartum. A busy women’s health clinic in Metro Detroit seeks to improve maternal health outcomes by addressing PMADs among expecting mothers in the community. Screening for PMADs is a crucial step in the clinic’s patient-care process, as it allows struggling mothers to be identified for behavioral health referral and treatment. The Edinburgh Postnatal Depression Scale (EPDS), a validated tool that has demonstrated accuracy and superiority to other screening methods, was already utilized in this clinic as part of the program workflow (O'Connor et al., 2016). This program evaluation project aimed to identify whether perinatal depression screening was being completed and if the appropriate patients were receiving behavioral health referrals. Background and Significance Mental health disorders pose a morbidity and mortality threat to all women of childbearing years based on being associated with approximately 9% of pregnancy-related deaths (Bauman et al., 2020). Some of the most common obstetric complications are PMADs, which include diagnoses such as depression, major postpartum depressive disorder, anxiety, obsessive compulsive disorder, and post-traumatic stress disorder (Moyer & Kinser, 2021). It is estimated that 20% of pregnant and postpartum women suffer from perinatal mood and anxiety disorders (Moyer & Kinser, 2021). PMADs have serious consequences for maternal-infant wellbeing and can lead to negative health outcomes (Moyer & Kinser, 2021). The American College of Obstetricians and Gynecologists (ACOG, 2018) endorses screening for perinatal anxiety and PERINATAL DEPRESSION SCREENING EVALUATION 8 depression, while the United States Preventive Services Task Force (USPSTF, 2016) recommends routine screening for depression during pregnancy, though preferred timing intervals are not specified. Despite these recommendations, 51% of women with perinatal depression go untreated (Lewis Johnson, Clare, Johnson, & Simon, 2020). Low socioeconomic status and violence exposure are risk factors for developing PMADs (Byrnes, 2018). Mothers who deliver preterm or have had mental health problems in the past are also at higher risk (Byrnes, 2018). Hutchens and Kearney (2020) point out that having a history of depression and experiencing abuse at the time of pregnancy are the two most important factors for predicting patterns of perinatal mental health complications. Lack of sufficient social support throughout the perinatal and postpartum periods can also influence whether a woman develops postpartum depression (Byrnes, 2018). The adolescent population is especially at risk for experiencing devastating consequences related to PMADs. Adolescents undergo significant physical, behavioral, and emotional changes during a short period of time, causing them to be predisposed to developing mental health disorders during the perinatal period. Adolescent mothers are twice as likely to experience postpartum depression as their adult counterparts (Kingston et al., 2012). Additionally, those who have health problems during their pregnancy may be at increased risk of depression in the postpartum period (Centers for Disease Control and Prevention [CDC], 2020). The economic burden of PMADs is observable at the individual, interpersonal, community, and societal levels. In the U.S., PMADs were estimated to cost $14 billion over a five-year period (Luca et al., 2020). Low-income women, who are at higher risk for developing PMADs, often lack adequate health care coverage. Insufficient coverage diminishes access to resources necessary for treatment, exacerbating the effects of PMADs and leading to an increase PERINATAL DEPRESSION SCREENING EVALUATION 9 in negative maternal and infant health outcomes. Untreated PMADs can result in income loss due to lower maternal productivity, increased use of public health services such as Medicaid, and higher health care costs caused by decreased maternal and infant health (Luca et al., 2020). More than half of costs related to PMADs occur within the first year of birth, demonstrating a need for timely screening and intervention (Luca et al., 2020). The EPDS was initially developed to detect postnatal depression but has been found to be beneficial in screening for perinatal depression as well. The EPDS has progressed to be an authenticated 10-item self-report questionnaire that can be translated into many languages (Roy- Byrne, 2016). The EPDS has demonstrated high reliability and validity, and an EPDS cut-off value of 11 or higher maximizes combined sensitivity (0.81) and specificity (0.88; Levis et al., 2020). Furthermore, the EPDS is sensitive to monitoring changes in depression over time (Sheeder et al., 2009). Despite the growing knowledge of PMADs in clinical practice and research, the frequency of these devitalizing disorders is rising substantially in the U.S., indicating the need for effective intervention strategies (Moyer & Kinser, 2021). A recent systematic review explored a variety of intervention methods that exist in hopes of preventing perinatal depression (O’Connor et al., 2019). To date, the most widely studied interventions to prevent postpartum depression are counseling and psych behavioral strategies (O’Connor et al., 2019). The analysis concluded that there is a need for more data to assess the effectiveness of these interventions and the populations who may benefit (O’Connor et al., 2019). There are also challenges to overcome when implementing intervention programs across various communities. For example, many forms of counseling require healthcare providers to receive specialized education and training (Freeman, 2019). Service inaccessibility due to geographical location and socioeconomic status PERINATAL DEPRESSION SCREENING EVALUATION 10 presents yet another barrier to delivering effective care on a large scale (Freeman, 2019). It is warranted to conclude that further research and evaluation of perinatal depression intervention strategies are necessary to improve outcomes for both mothers and their children. A well-respected organization has established a new medical center within the Metro Detroit area that offers a variety of specialty and diagnostic services. The women's health clinic specializes in treating the perinatal population. Upon discussion with the clinical nurse manager, concern about the impact of perinatal mood and anxiety disorders on this patient population was brought forward (E. Combs, personal communication, May 17, 2021). Further analysis and conversation regarding the clinic's process for screening for perinatal depression identified a need for program evaluation as current workflow practices have been in place for two years. The clinic’s current process for perinatal depression screening consists of performing the EPDS at least once, usually during the initial obstetric intake. The evaluation provided the clinic with valuable information about current perinatal depression screening completion rates and behavioral health referrals. The results provided an understanding of whether there is a gap between perinatal depression screening rates and mental health treatment. In addition, it evaluated whether the clinic staff followed up on referrals made to behavioral health services for perinatal patients identified as high risk by the EPDS. A lack of follow-up would indicate that women who are at risk or who have depressive symptoms have an even greater chance of going untreated. Problem Statement and Clinical Question Screening for perinatal depression by implementing the EPDS for all pregnant and postpartum patients has been shown to be beneficial (Lewis Johnson et al., 2020). Several research studies and organizations identify the necessity of screening childbearing women for PERINATAL DEPRESSION SCREENING EVALUATION 11 depression (ACOG, 2018; Lewis Johnson et al., 2020; USPSTF, 2016; USPSTF et al., 2019). However, despite the necessity of perinatal depression prevention and treatment, there is a lack of initiative for standardized screening recommendations (USPSTF et al., 2019). Without routine screening for perinatal and postpartum depression, the risk for devastating maternal- infant health outcomes includes increased risk of maternal suicide, risk for preterm labor, emotional attachment difficulties, decreased breastfeeding, and higher healthcare expenditures (Moyer & Kinser, 2021). The women’s health clinic selected for this project was requested by the stakeholder for a program evaluation. Per the director, the program involves screening women once during the initial perinatal intake using the EPDS, and if a score of 10 or greater is achieved, a referral to behavioral health services is made (E. Combs, personal communication, May 17, 2021). The approach for program evaluation consisted of performing chart reviews from the start of program implementation to a three-month period. During the chart review, an analysis was conducted of whether the EPDS was completed and whether a behavioral health referral and follow up by clinical staff was completed if a score of 10 or greater was achieved. Review of the Literature Search Strategies and Selection Criteria A thorough review of currently relevant literature pertaining to perinatal depression screening was performed in order to execute this project. Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed were utilized as primary databases for this review. The initial search included studies from within the last five years published in the English language. Keywords for the search included “perinatal depression screening”, AND “Edinburgh Postnatal Depression Scale”, OR “EPDS”, AND frequency or occurrence or prevalence. An additional search using key terms “importance of quality improvement PERINATAL DEPRESSION SCREENING EVALUATION 12 evaluation” was conducted. A total of 112 articles were populated. The initial selection of studies was based on the abstract and title. After an in-depth review, only five articles were deemed relevant to the focus of this program evaluation. An additional four articles directly relating to the purpose of this evaluation were found by examining references of articles used in the literature review. A detailed review of all nine articles can be found in Appendix A. Screening for PPD The ACOG (2018) and USPSTF (2019) have recommended screening patients at least once during the perinatal period for depression and anxiety using a standardized, validated tool. However, perinatal depression screening is not a universal practice. Several studies have examined the effects of implementing a standard for routine perinatal depression screening throughout pregnancy as opposed to six weeks postpartum (Bhat et al., 2021; Clevesy et al., 2019; Klawetter et al., 2020; Long et al., 2020; Venkatesh et al., 2016). Research has demonstrated that perinatal and PPD screening improves clinical outcomes by identifying the need for follow-up treatment. Numerous studies have found that women’s symptoms of depression vary throughout the perinatal period and with regular screening, providers avoid failing to recognize those patients in need of mental health treatment (Bhat et al., 2021; Clevesy et al., 2019; Long et al., 2020; Venkatesh et al., 2016). Early detection of depression through routine screening increases quality of life in pregnant women and reduces the likelihood of adverse maternal and fetal health outcomes, and postpartum mental health problems (ACOG, 2018; USPSTF, 2019; Venkatesh et al., 2016; O'Connor et al., 2016). Quality Improvement Approach Flanagan & Avalos (2018) implemented an efficient, cost-effective approach for perinatal depression identification at a large health system that led to the completion of over 80,000 PERINATAL DEPRESSION SCREENING EVALUATION 13 screens. To successfully screen patients, these authors suggest the use of a quality improvement method that encompasses best practices, clinician education, use of data, and an efficient workflow (Flanagan & Avalos, 2018). Quality improvement programs are necessary in clinical practice as they provide the opportunity to improve patient healthcare. Garcia-Elorrio (2019) identifies the significance of assessing quality improvement programs to identify areas of improvement. Data evaluating and measuring are fundamental components for determining existing gaps and identifying unavoidable harm that may occur as a result of the interventions in which patients are enrolled (Garcia-Elorrio, 2019). The application of retrospective review of health systems databases is a valuable asset and foundation of healthcare research, as it serves as a framework for validating and providing answers to clinical problems (Garcia-Elorrio, 2019). Program Evaluation Theoretical Framework The CDC’s (2015) Framework for Program Evaluation guided the activities of this project. This framework was developed to assist professionals in conducting program evaluations that enhance overall project success by utilizing a logical, stepwise approach (CDC, 2015). Utility, feasibility, propriety, and accuracy are standards integrated into each step of the evaluation process to ensure evaluation results are applicable to the goals of the organization (CDC, 2015). Furthermore, the inclusion of the viewpoints of many stakeholders is encouraged as a planning strategy (CDC, 2015). This framework’s practical approach is a good fit for this busy clinic as it was specifically designed to be compatible with the everyday workflow of the organization to be evaluated (CDC, 2015). Description of the Program The program currently in place at this clinic is centered around routine EPDS screening. The first screening takes place over the telephone at expecting patients’ PERINATAL DEPRESSION SCREENING EVALUATION 14 obstetric intake appointment. If, at this first visit, the EPDS score is found to be 10 or above, a referral will immediately be sent to behavioral health for that patient. A second EPDS screening is performed as close to the in-person 32-week visit as possible. The final EPDS screening occurs during the postpartum visit. The screenings are performed by a medical assistant within the clinic and the scores are electronically entered into the patient’s chart. An entered score of 10 or greater flags the provider to refer the patient to behavioral health (E. Combs, personal communication, September 17, 2021). Evaluation Goal and Purpose Statement The objective of this program evaluation was to determine the effectiveness of perinatal depression screening in recognizing mood disorder symptoms among the pregnant population. This evaluation sought to appraise the extent to which perinatal depression screening was consistently implemented at a large Metro Detroit women’s health clinic over a three-month period. It evaluated the effectiveness of the screening practice workflow in establishing behavioral health referrals and whether behavioral health clinics were actively contacting patients referred to them. This evaluation also assisted the women’s health clinic in determining whether the perinatal depression screening program had been successful in early recognition of mood disorders and patients’ need for additional mental health resources in the future. Evaluation Team The evaluation team consisted of three Doctorate of Nursing Practice (DNP) students and the women’s health clinical manager. An advisor was assigned to participate on the team to review plans and ensure needs for objectives were met. Table 1. Roles and Responsibilities of the Evaluation Team Members Individual Title or Role Responsibilities Maeghan Murphy Lead Evaluator and Managed all evaluation activities Data Analysis to ensure evaluation was PERINATAL DEPRESSION SCREENING EVALUATION 15 conducted as designed. Coordinated meetings with stakeholder and advisor. Performed chart reviews. Analyzed data collection. Ensured implementation of findings. Christina Ploeger Lead Evaluator and Managed all evaluation activities Data Analysis to ensure evaluation was conducted as designed. Coordinated meetings with stakeholder and advisor. Performed chart reviews. Analyzed data collection. Ensured implementation of findings. Nicole Teeter Lead Evaluator and Managed all evaluation activities Data Analysis to ensure evaluation was conducted as designed. Coordinated meetings with stakeholder and advisor. Performed chart reviews. Analyzed data collection. Ensured implementation of findings. Edith Combs Stakeholder Provided resources for program evaluation and guidance regarding the need for evaluation. Kara Schrader Advisor Coordinated relationship with the stakeholder. Offered support and guidance throughout program evaluation. PMAD patients within Stakeholder Provided data necessary for a the clinic comprehensive program evaluation to be completed by lead evaluators. Stakeholder Assessment During a routine weekly meeting, the evaluation team discussed potential stakeholders with clinic leadership. Several were identified, each with a unique role and perspective. Overall, stakeholders fell into three main categories: those involved in program operations, those affected by the program, and those intended to benefit from the program evaluation. The stakeholders within this project evaluation included the individuals of the community receiving PERINATAL DEPRESSION SCREENING EVALUATION 16 care, the providers and staff who ensured health promotion to this population, and the organization leaders within the women’s health clinic. Further information about each stakeholder’s involvement can be found below. Table 2. Stakeholder Assessment and Engagement Plan Stakeholder Interest or Role in the How and When to Category Perspective Evaluation Engage Persons involved in program operations DNP Students See program Planning Direct roles in planning evaluation as a evaluation. program evaluation. success. Increase the Identifying, Attending weekly opportunity to treat collecting and meetings. and prevent perinatal interpreting depression. data. Disseminating results to stakeholders. Clinical See program Defining the Weekly meetings Manager evaluation as current program. throughout program reflection of success. Providing access evaluation. to the database for chart reviews. Providers Fear of change, Evaluate If patients score 10 or increased workload. patients and higher, refer to refer to behavioral health. behavioral. Nurses Fear of change, Providing Screening completed at increased workload. screening and initial visit and if score referral if is 10 or higher refer to needed. behavioral health. Behavioral Increased workload. Accept referrals If a patient's score is 10 Health and provide or higher they will resources/treatm accept a referral and ent. schedule appointment. Persons affected by the program Patients of the Fear screening, stigma Providing data EPDS screening tool women's health with depression. Want perspective. utilized at every initial clinic access to services. intake visit. Retrospective chart analysis. Persons intended to benefit from program evaluation DNP Students Show effectiveness. Interpreting data Direct role in program Present findings to and presenting evaluation. After PERINATAL DEPRESSION SCREENING EVALUATION 17 stakeholders to results. retrospective analysis is enhance clinical Developing complete, meeting with outcomes. recommendation stakeholders to s based on disseminate findings. findings. Clinical Know if the program Providing Meetings with DNP Manager is successful. Whether administrative students and a final changes need to be access. presentation to made to better serve Interpreting final disseminate results. the population. findings. Clinical Staff Provide effective Modifying Inform of findings and screening and practice if relevant current practice treatment options for needed. results. Meeting and those with perinatal practice changes depression. Behavioral Improve community Interpreting their Meeting can be present Health health and outreach of role and on presentation to those requiring findings. stakeholders. Inform of assistance. Modifying findings. referral process if needed. Need In 2019, a Metro Detroit women’s health clinic informally reviewed its daily operations and noted an unusually high number of perinatal patient referrals to behavioral health (E. Combs, personal communication, September 17, 2021). Following this observation, select clinicians attended a seminar highlighting the importance of early mental health referrals (E. Combs, personal communication, September 17, 2021). To address the rise in mood disorders among pregnant women, a reliable perinatal depression screening program was necessary. These events led to the implementation of the EPDS at all initial perinatal intake appointments with the intention of identifying pre-existing or early mental health complications as soon as possible (E. Combs, personal communication, September 17, 2021). PERINATAL DEPRESSION SCREENING EVALUATION 18 Context At the population level, the clinic’s location in Wayne County, Michigan presented unique considerations. The microsystem perspective of this program consists of an ethnically diverse and vulnerable population made up of women. The microsystem consists of a predominately African American population (TownCharts, 2021). This microsystem exists within a macrosystem of a large women’s health clinic that is associated with a major hospital system in the Metro Detroit area. The mesosystem level of the women’s health clinic serves the economically underprivileged community as the majority of patients are insured through Medicaid. Recent statistics indicate that teen birth rates are significantly higher than the national average at 27 births per 1,000 teens (County Health Rankings & Roadmaps [CHR&R], 2021). Though not unique to Wayne County, lack of available mental health professionals presents another challenge, as there is an average of one provider for every 330 individuals (CHR&R, 2021). Recent data shows that mothers in region 10 of the state, this project’s region, experience the highest rates of postpartum depression (PPD) in Michigan (Michigan Department of Health and Human Services [MDHHS], 2018). Although this community has a high demand for perinatal depression screening and treatment, the capacity and resources available are inadequate. The perinatal depression screening program, which was created in response to this need, uses early detection to target women in the community. Over three months the clinic experienced environmental problems including flooding, power outages, and mold exposure. Since the clinic had to close and operations took place to ensure safety of the clinic there were no other anticipated environmental issues impacting program. Target Population The target population for the perinatal depression screening program was women within PERINATAL DEPRESSION SCREENING EVALUATION 19 the Metro Detroit area that were patients of the obstetric and gynecological services at this organization's women’s health clinic. Stage of Current Program Development At the start of this project, the EPDS had been utilized routinely at this clinic for approximately two years (E. Combs, personal communication, September 17, 2021). Initially, these screenings took place only at in-person visits, but restrictions caused by the Covid-19 pandemic led to the introduction of virtual and telephone appointments (E. Combs, personal communication, September 17, 2021). This change was perceived as beneficial by clinic staff, who planned to continue virtual visits regardless of future Covid-19 restrictions, as this visit modality improved the clinic’s efficiency and workflow (E. Combs, personal communication, September 17, 2021). Resources/Inputs Clinic staff included eight obstetrician-gynecologist physicians, at least one maternal fetal medicine physician, four midwives, one women’s health nurse practitioner, 16 resident physicians, six registered nurses (RNs), and 10 medical assistants (MAs). The practice has a total of 23 exam rooms. Project implementation consisted of perinatal depression screening using the EPDS once during the obstetrics intake interview over telephone or virtually by an RN and then administered once again at a visit at 27 to 32 weeks of pregnancy by a MA. The EPDS tool can be completed in less than five minutes. The program partners with a behavioral health clinic within the same medical building for referrals when patients score 10 or higher on the EPDS. Activities As a result of the efforts of clinical leadership to engage early recognition and referral for PERINATAL DEPRESSION SCREENING EVALUATION 20 perinatal depression symptoms, the program has trained RNs, MAs and providers, mood disorder resources and groups coordinated, EPDS tool utilized, and referrals to behavioral made if necessary. Outputs Prior to the initiation of the program, clinical staff attended seminars to highlight mood disorder prevalence and treatment. Additional staff, RNs, and MAs were trained on the EPDS tool and how to utilize the electronic health record to document results. During the initial intake meeting, RNs can submit a referral to behavioral health per protocol for patients scoring 10 or higher on EPDS. During obstetrics visits around 32 weeks, the MA completes the EPDS and if a patient scores 10 or higher the MA notifies the provider for further evaluation and referral to behavioral health. Outcomes Short-term outcomes included: completion of EPDS by all patients at predetermined intervals, increased patient knowledge, acceptance of treatment, and follow-up with behavioral health referrals. Long-term outcomes included: earlier identification of perinatal mental health complications, completion of treatment, and reduction of behavioral health referrals later in pregnancy. Table 3. Program Description Resources Activities Outputs Outcomes Initial Subsequent Short-/Mid- Long-term term Clinical Perinatal Referrals EPDS tool Early Increased Staff depression utilized and detection and utilization of screening referral made interventions perinatal to behavioral provided. depression health. screening and PERINATAL DEPRESSION SCREENING EVALUATION 21 behavioral health services. Behavioral Outreach to Prescribing Treatment Patient Increased Health patients treatment plan accepts completion of with developed treatment and behavioral referrals attends health referral referral rates. therapy. Logic Model Short-term Intermediate Inputs Activities Outputs Long-term Outcomes Outcomes Outcomes Staff Adherenc Earlier Clinical Hire and educated Trust built e to detection of Staff train and trained perinatal Perinatal Support Patient Behaviora Patient Improved depression provided to knowledge l Health uses quality of screening patient increased Referral for Patient Decreased treatment accept Complete morbidity made treatment d therapy and mortality rates due to postpartum depression Figure 1. Logic Model Diagram for Program Evaluation PERINATAL DEPRESSION SCREENING EVALUATION 22 Focus of the Evaluation Stakeholder Needs The evaluation team met with the clinical nurse manager to learn how findings would be distributed and utilized following the evaluation’s completion. Clinic staff and Behavioral Health would be notified of findings (E. Combs, personal communication, September 17, 2021). Results of the evaluation determined subsequent actions, and if an issue was identified, steps in the program’s process that were missed or completed incorrectly would be identified (E. Combs, personal communication, September 17, 2021). If it was determined that the problem was rooted in nursing activities, clinic leadership planned to conduct an intervention focused on nursing staff (E. Combs, personal communication, September 17, 2021). If results showed that nurses are in fact completing all required tasks, this may necessitate meeting with colleagues from behavioral health (E. Combs, personal communication, September 17, 2021). Evaluation Questions This evaluation sought to determine whether the screening program had been carried out consistently over a three-month period and whether it had been successful in its goal of connecting at-risk patients with mental health resources. To identify whether the screening program was implemented as designed, this evaluation answered the question: • What percent of patients received EPDS screening at the intake, 32-week, and postpartum visits? To determine the program’s success in prompting referrals, the following questions will be answered: • What percentage of patients with a positive EPDS score were referred to PERINATAL DEPRESSION SCREENING EVALUATION 23 behavioral health? Evaluation findings guided the clinic in identifying potential deficits and correcting them if needed. Results helped determine if there was a need for additional resources necessary to support at-risk women. Resource Considerations Prior to this project, the women’s health clinic had never evaluated the effectiveness of the screening program and there was no analysis underway by the organization. Considering this, there were no clinic resources available that are specific to the purpose of program evaluation. However, data was made available for the evaluation team to assess via chart review. Information already collected as part of the clinic’s day-to-day operations was sufficient for the purposes of this evaluation. This data included crucial information such as completed EPDS screens and behavioral health referrals and served as an essential resource throughout the evaluation process. Routine meetings were a useful resource in conducting this evaluation as the lead evaluators touched base frequently with a key stakeholder via weekly virtual meetings. These meetings allowed for the opportunity for regular communication and continued planning. Ethical Considerations/Protection of Human Subjects Michigan State Internal Review Board (MSU IRB) approval was obtained before starting the implementation phase of this DNP project. This program evaluation project was deemed non-research by MSU IRB (see Appendix F). The required IRB Determination Form was submitted as soon as the program evaluation project proposal was approved. Following approval of the project by MSU IRB, a second IRB application was submitted to the health system with which this clinic is affiliated after privacy office correspondence (J. Skolnik, personal communication, October 29, 2021). See Appendix G for direct communication exchange with PERINATAL DEPRESSION SCREENING EVALUATION 24 the health system’s privacy officer. The standards for effective program evaluation was addressed by ensuring the data collection will serve the stakeholders. The program evaluation provided efficient information for the clinic leaders to establish if their practices were serving the community. Feasibility standards were addressed by remaining practical and sensible when performing the retrospective chart analysis. For constructive evaluation, the IRB submission and approval of the program evaluation establish propriety by legal and ethical standards. IRB forms regarding protection of human subjects were submitted to ensure the health and safety of those involved. Detailed methods provided guidelines for the stakeholders with accuracy standards to reveal adequate information that determine the effectiveness of the program. Methods Data Collection Data Collection Method The primary method of data collection for this project was through chart reviews during the initial three-month period of program implementation. In order to obtain this information, DNP students completed organization-specific training modules centered around HIPAA maintenance and acceptable data use. To further maintain patient confidentiality, no protected health information (PHI) was stored on students’ personal computers or devices. An Excel spreadsheet was created to log collected information during chart reviews, refer to Appendix C for example. A total of 60 charts were reviewed for the data collection process. Each DNP student completed 20 charts from a different month within the initial three-month implementation period. Plan Timeline During the program evaluation period, project planning, retrospective chart intervention, PERINATAL DEPRESSION SCREENING EVALUATION 25 data analysis, and data interpretation took place. See Appendix B for a complete timeline of the project. Data Analysis Indicators To measure the success of the program, an EPDS screening goal of 80% over a three- month period was established prior to the data collection process. Analysis A quantitative approach to data analysis was utilized for this program evaluation. The two evaluation questions were the major focus for the data analysis. Ensuring the chart review data provided an observation to whether the current screening methods are meeting the program's goals. A college statistician helped organize the data in collaboration with the DNP students. Following data collection and analysis, the DNP students generated a graph table with chart review data analysis and percentages to better illustrate findings. See Appendix D. Interpretation The DNP students were responsible for obtaining and reviewing the data collected during the program evaluation. Data analysts assisted in providing measurable data that was in turn interpreted by the DNP students. The interpretation of data revealed answers to the evaluation questions. The percentage of patients who received EPDS screening at intake was 62% and any additional time throughout pregnancy was 48%. Among those patients that had a EPDS score of 10 or greater, 60% were referred to behavioral health for further evaluation and treatment. Further analysis provided that among those patients who were referred to behavioral health for evaluation 86% of them were contacted by a behavioral health provider. This information was then shared with the advisor and program director. Collectively, the DNP students and clinic PERINATAL DEPRESSION SCREENING EVALUATION 26 manager were able to come together to disseminate the results. Dissemination of Results Upon completion of the evaluation, the findings were presented to the clinic leadership and staff by lead evaluators as requested by the stakeholder. This information was provided to clinic leaders and stakeholders by the presented data tables in Appendix D and a PowerPoint presentation of the completed program evaluation summary. Colleagues from behavioral health were also notified of results to increase transparency and facilitate an understanding of the program’s status. Data was used by clinical management to determine whether there were deficits present in the program’s current implementation method and to initiate a conversion regarding what next steps should be taken to resolve them. Implications for Nursing As aspiring advanced practice registered nurses, it is critical to participate in the continuous improvement of patient quality care. This includes taking a step back and evaluating current practice standards with updated evidence-based research as healthcare evolves. The perinatal population, in general, but especially for routine health screenings, is an essential population to reach. As discussed throughout this paper PMADs hold great significance on the outcomes of pregnancy and childbirth, with primarily being the number one cause for complications (Moyer & Kinser, 2021). A perinatal depression screening program is a reliable resource to assess mood disorder symptoms among the pregnant population. In order to get the full benefit from an established screening program it is imperative to ensure the program is meeting the suggested guidelines that were constructed from the beginning. A program evaluation provides clinical leadership and stakeholders with the knowledge of whether the current screening program is meeting perinatal depression screening standards of care. PERINATAL DEPRESSION SCREENING EVALUATION 27 The data analysis revealed that the Metro Detroit clinic’s present prenatal depression screening program had some clinical importance. The stakeholder’s established an EPDS screening goal of 80% over a three-month period. Overall EPDS screening for the program evaluation’s data analysis was under their suggested goal of 80%, with a result of 62% of patients meeting the program’s screening at the OB intake over that three-month period. Most interestingly, the number of patients who had a positive EPDS screen of 10 or higher and were referred to behavioral health was 60%. This is important since it indicates that clinical personnel had the opportunity to discuss the patient's positive EPDS score at the time of the appointment. This program evaluation project reveals a need for clinical staff and providers to be re-educated on the guidelines of the perinatal screening program established at the clinic in order to meet their goal of 80% patients being screened. Holding an educational session with staff and stakeholders may increase patient screening rates and may improve PMADs impact on this population with early recognition and treatment. Cost-Benefit Analysis and Budget For reference, an overview of this program evaluation project’s budget report is available in Appendix E. Key materials for determining this budget included financials and time for the evaluation. The most significant factor for budget consideration was the amount of time applied to complete data retraction and perform evaluation. The DNP students and clinical manager spent approximately 180 hours on the program evaluation project. Non-material costs included information technology report and use of the electronic health record ($100,000). The organization’s resources for this initiative were budget neutral as utilization consisted of current clinical staff and screening tools already implemented throughout clinical practice. Direct and indirect assets for general cost perspectives were considered with attainment to the organization. PERINATAL DEPRESSION SCREENING EVALUATION 28 Revenue was not generated by this project. However, Luca et al. (2020) estimate that untreated PMADs cost an average of $5,300 per year for each mother and infant affected—a significant financial burden for both patients and healthcare systems. Conclusion PMADs are a prevalent and costly perinatal problem that complicate the health and wellness of both mothers and infants (Moyer & Kinser, 2021) and lead to unnecessary healthcare expenditures (Luca et al., 2020). Effective interventions such as counseling are available, but at- risk patients must be identified before receiving treatment. To ensure the Metro Detroit clinic was facilitating prompt identification of PMADs, the perinatal depression screening program evaluation was initiated and completed. Data analysis revealed that the 80% EPDS screening goal established by stakeholders was not met. The DNP students’ program evaluation clearly demonstrated a need for an additional education session or discussion with clinical staff regarding current barriers to meeting the perinatal screening program standards. This can help establish whether there is a lack of knowledge regarding PMADs or the screening process as a barrier affecting the perinatal depression screening rates among this vulnerable population. Specifically, to successfully screen patients Flanagan & Avalos (2018) recommend using a quality improvement technique that includes best practices, provider and staff education, data analysis, and an efficient workflow. Over the course of nine months, this program evaluation identified the extent to which perinatal depression screening was consistently implemented at a large Metro Detroit women's health clinic. It assessed the effectiveness of the screening practice workflow in establishing behavioral health referrals based on positive EPDS screenings and whether a behavioral health provider-initiated contact with women who qualified. Ultimately this program evaluation helped PERINATAL DEPRESSION SCREENING EVALUATION 29 the women's health clinic determine whether the perinatal depression screening program was effective in detecting mood problems early and identifying individuals who would benefit from extra mental health support in the future. This DNP program evaluation project serves as a starting point for addressing areas of improvement for increasing perinatal depression screening rates in perinatal and postpartum populations. This program evaluation's findings can be used to create future interventions focused on enhancing prenatal depression screening and PMAD self- awareness. PERINATAL DEPRESSION SCREENING EVALUATION 30 References American College of Obstetricians and Gynecologists. (2018). Screening for perinatal depression. Obstetrics & Gynecology, 132(5), 208-212. Retrieved from https://www.acog.org/-/media/project/acog/acogorg/clinical/files/committee- opinion/articles/2018/11/screening-for-perinatal-depression.pdf Bauman, B. L., Ko, J. Y., Cox, S., D'Angelo, D. V., Warner, L., Folger, S., Tevendale, H. D., Coy, K. C., Harrison, L., & Barfield, W. D. (2020). Vital signs: Postpartum depressive symptoms and provider discussions about perinatal depression - United States, 2018. MMWR. Morbidity and Mortality Weekly Report, 69(19), 575–581. doi: 10.15585/mmwr.mm6919a2 Bhat, A., Nanda, A., Murph, L., Ball, A. L., Fortney, J., & Katon, J. (2021). A systematic review of screening for perinatal depression and anxiety in community-based settings. Archives of Women’s Mental Health. doi: 10.1007/s00737-021-01151-2. Byrnes, L. (2018). Perinatal mood and anxiety disorders. The Journal for Nurse Practitioners, 14(7). 507-513. doi: 10.1016/j.nurpra.2018.03.010 Centers for Disease Control and Prevention. (2015). Workplace health promotion: Evaluation. Retrieved from https://www.cdc.gov/workplacehealthpromotion/model/evaluation/index.html Centers for Disease Control and Prevention. (2020). Depression in women. Retrieved from https://www.cdc.gov/reproductivehealth/depression/index.htm Clevesy, M. A., Gatlin, T. K., Cheese, C., & Strebel, K. (2019). A project to improve postpartum depression screening practices among providers in a community women's health care clinic. Nursing for Women's Health, 23(1), 21–30. doi: 10.1016/j.nwh.2018.11.005 PERINATAL DEPRESSION SCREENING EVALUATION 31 County Health Rankings & Roadmaps. (2021). Michigan 2021 rankings: Wayne (WY). Retrieved from https://www.countyhealthrankings.org/app/michigan/2021/rankings/wayne/county/outco mes/overall/snapshot Flanagan, T., & Avalos, L. A. (2018). Perinatal office depression screening and treatment: Implementation in a health care system. Obstetrics & Gynecology, 127(5). doi: 10.1097/AOG.0000000000001395 Freeman, M. P. (2019). Perinatal depression: Recommendations for prevention and the challenges of implementation. Journal of the American Medical Association, 321(6), 550–552. doi: 10.1001/jama.2018.21247 Garcia-Elorrio, E. (2019). The importance of evaluating performance to understand changes. International journal for quality in health care : Journal of the International Society for Quality in Health Care, 31(4), 245. https://doi.org/10.1093/intqhc/mzz038 Hutchens, B. F., & Kearney, J. (2020). Risk factors for postpartum depression: An umbrella review. Journal of Midwifery & Women’s Health, 65(1), 96-108. doi: 10.1111/jmwh.13067 Kingston, D., Heaman, M., Fell, D., Chalmers, B., & Maternity Experiences Study Group of the Canadian Perinatal Surveillance System, Public Health Agency of Canada. (2012). Comparison of adolescent, young adult, and adult women's maternity experiences and practices. Pediatrics, 129(5), e1228–e1237. doi: 10.1542/peds.2011-1447 Klawetter, S., McNitt, C., Hoffman, J. A., Glaze, K., Sward, A., & Frankel, K. (2020). Perinatal depression in low-income women: A literature review and innovative screening approach. Current Psychiatry Reports, 22(1), 1–8. doi: 10.1007/s11920-019-1126-9 PERINATAL DEPRESSION SCREENING EVALUATION 32 Levis, B., Negeri, Z., Sun, Y., Benedetti, A., Thombs, B. D., & Depression Screening Data (DEPRESSD) EPDS Group. (2020). Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: Systematic review and meta-analysis of individual participant data. BMJ (Clinical research ed.), 371, m4022. doi: 10.1136/bmj.m4022 Lewis Johnson, T. E., Clare, C. A., Johnson, J. E., & Simon, M. A. (2020). Preventing perinatal depression now: A call to action. Journal of Women’s Health (15409996), 29(9), 1143– 1147. doi: 10.1089/jwh.2020.8646 Long, M. M., Cramer, R. J., Bennington, L., Morgan, F. G., Wilkes, C. A., Fontanares, A. J., Sadr, N., Bertolino, S. M., Paulson, J. F., & Morgan, F. G. (2020). Perinatal depression screening rates, correlates, and treatment recommendations in an obstetric population. Families, Systems & Health: The Journal of Collaborative Family HealthCare, 38(4): 369–79. doi:10.1037/fsh0000531. Luca, D. L., Margiotta, C., Staatz, C., Garlow, E., Christensen, A., & Zivin, K. (2020). Financial toll of untreated perinatal mood and anxiety disorders among 2017 births in the United States. American Journal of Public Health, 110(6), 888–89. doi: 10.2105/AJPH.2020.305619 Michigan Department of Health and Human Services (2018). Michigan Pregnancy Risk Assessment Monitoring System (PRAMS): Prosperity region report: Maternal mental health. Retrieved from https://www.michigan.gov/documents/mdhhs/2018-05- 01_Regional_PRAMS_Mental_Health_Tables_final_622047_7.pdf PERINATAL DEPRESSION SCREENING EVALUATION 33 Moyer, S. W., & Kinser, P. A. (2021). A comprehensive conceptual framework to guide clinical practice and research about mental health during the perinatal period. Journal of Perinatal & Neonatal Nursing, 35(1), 46–56. doi: 10.1097/JPN.0000000000000535 O’Connor, E., Rossom, R. C., Henninger, M., Groom, H. C., & Burda, B. U. (2016). Primary care screening for and treatment of depression in pregnant and postpartum women: Evidence report and systematic review for the US Preventive Services Task Force. Journal of the American Medical Association, 315(4). doi: 10.1001/jama.2015.18948 O'Connor, E., Senger, C. A., Henninger, M. L., Coppola, E., & Gaynes, B. N. (2019). Interventions to prevent perinatal depression: Evidence report and systematic review for the US Preventive Services Task Force. Journal of the American Medical Association, 321(6), 588–601. doi: 10.1001/jama.2018.20865 Roy-Byrne, P. (2016). Postpartum blues and unipolar depression: Epidemiology, clinical features, assessment, and diagnosis. Uptodate, Post, TW (Ed), Uptodate, Waltham, MA. Sheeder, J., Kabir, K., & Stafford, B. (2009). Screening for postpartum depression at well-child visits: Is once enough during the first 6 months of life? Pediatrics, 123(6), e982–e988. doi: 10.1542/peds.2008-1160 TownCharts. (2021). Zip code 48202, Michigan economy data. Retrieved from https://www.towncharts.com/Michigan/Economy/48202-Zipcode-MI-Economy-data.html United States Preventive Services Task Force. (2016). Screening for depression in adults: US Preventive Services Task Force recommendation statement. Journal of the American Medical Association, 315(4), 380-387. doi: 10.1001/jama.2015.18392 PERINATAL DEPRESSION SCREENING EVALUATION 34 United States Preventive Services Task Force. (2019). Perinatal depression: Preventive interventions. Journal of the American Medical Association, 321(6), 580–587. doi: 10.1001/jama.2019.0007 Venkatesh, K. K., Nadel, H., Blewett, D., Freeman, M. P., Kaimal, A. J., & Riley, L. E. (2016). Implementation of universal screening for depression during pregnancy: Feasibility and impact on obstetric care. American Journal of Obstetrics and Gynecology, 215(4), 517.e1–517.e5178. doi: 10.1016/j.ajog.2016.05.024 PERINATAL DEPRESSION SCREENING EVALUATION 35 Appendix A Author/Title/ Level of Purpose of the Framework (if Results How does this Implications for Reference Evidence project/research none indicate) relate to your Practice project? Clevesy, M. RCT to improve health Plan-do-study-act Screening rate Calls for Women should be A., Gatlin, Level 2 care providers' (PDSA) went from 56% standardized PPD educated on how to T. K., postpartum to 92.7% after screening monitor themselves Cheese, C., depression (PPD) implementation for PPD; screening & Strebel, knowledge and of intervention practices need to be K. (2019). A screening more consistent Project to practices with the among providers Improve implementation of Postpartum a standardized Depression screening tool. Screening Practices Among Providers in a Community Women's Health Care Clinic. Nursing for women's health, 23(1), 21– 30. https://doi.or PERINATAL DEPRESSION SCREENING EVALUATION 36 g/10.1016/j. nwh.2018.11 .005 Prospecti to assess the N/A Among 8985 Screening for This study Venkatesh, ve feasibility of women who perinatal demonstrates the K. K., Cohort large-scale were enrolled in depression feasibility of universal Nadel, H., Study implementation of prenatal care at throughout depression screening Blewett, D., Level IV universal the participating pregnancy, instead during both the Freeman, M. screening for sites, 8840 of only the antepartum and P., Kaimal, depression in women (98%) postpartum period, postpartum periods A. J., & pregnancy and were screened can improve with the use of the Riley, L. E. during the for depression maternal health EPDS as an initial (2016). postpartum period antepartum, and outcomes. screen followed by Implementat with the use of the 7780 women mental health referral ion of Edinburgh (86%) were for further diagnostic universal Postnatal screened evaluation and screening for Depression Scale postpartum. A treatment. The depression total of 576 population of women during women (6.5%) who screened positive pregnancy: screened positive and who accepted feasibility for probable additional services and impact depression; of differed at the 2 time on obstetric these, 69% points, which care. screened positive reinforces the utility American antepartum, and of screening during journal of 31% screened both the antepartum obstetrics positive and postpartum and postpartum (P < periods. Although gynecology, .01). All women universal screening 215(4), who screened for depression is 517.e1– positive were feasible, further study 517.e5178. referred for an of the barriers to PERINATAL DEPRESSION SCREENING EVALUATION 37 https://doi.or evaluation by a mental health g/10.1016/j.a mental health evaluation and jog.2016.05. professional; treatment and the 024 79% of the impact of treatment women were on obstetric outcomes evaluated, which are needed. was more common antepartum than postpartum (83% vs 71%; P < .01). One hundred twenty-one women (21%) were not evaluated further after a positive screen; primary reasons included declining a mental health evaluation (30%) or transferring obstetric care (12%). Among women who underwent a mental health evaluation, 67% were diagnosed with major depression; 37% were diagnosed PERINATAL DEPRESSION SCREENING EVALUATION 38 with an anxiety disorder; 28% were diagnosed concurrently with major depression and an anxiety disorder; 76% were diagnosed with either depression or anxiety, and 35% were treated with an antidepressant medication, which was more frequent during the postpartum period than during the antepartum period (54% vs 28%; P < .001). After adjustment for maternal age, parity, race, and household income, women who screened positive antepartum were significantly more likely to PERINATAL DEPRESSION SCREENING EVALUATION 39 link to mental health services compared with women who screened positive postpartum (adjusted odds ratio, 2.09; 95% CI, 1.24-3.24; P = .001). Klawetter, Qualitati To review N/A This study supports S., McNitt, ve literature on the The mean EPDS Vulnerable the need for further C., Hoffman, systemat prevalence of score for the populations with research to be done to J. A., Glaze, ic review perinatal sample was 3.9 higher risk factors explore ways to K., Sward, Level V depression in low (SD = 4.5), with for perinatal integrate perinatal A., & income women. values ranging depression screening and mental Frankel, K. from 0 to 22. experience barriers health care in (2020). Further, 12.2% to mental health accessible locations, Perinatal (n = 93) of the services. In order to particularly for Depression sample scored at improve the rates women least likely to in Low- or above the of perinatal receive mental health Income clinical threshold depression support such as low- Women: A of 10 and 3% (n acknowledge the income women and Literature = 23) of barriers by offering women of color. Review and respondents regular screening Innovative reported and mental health Screening experiencing support throughout Approach. thoughts of self- community Current harm. EPDS accessibility Psychiatry scores were programs. Reports, compared across 22(1), 1–8. those who did PERINATAL DEPRESSION SCREENING EVALUATION 40 https://doi- and did not org.proxy2.c experience l.msu.edu/10 thoughts of self- .1007/s1192 harm, revealing 0-019-1126- significantly 9 higher scores (t = 6.768, p < 0.001) for those who had thoughts of self-harm (M = 13.3, SD = 6.8) as compared with those who did not (M = 3.6, SD = 4.0). Long, Molly RCT To assess the N/A With standardized The distinction M., Robert J. Level II frequency of Throughout the perinatal between screening Cramer, screening for study women depression completion rates Linda perinatal had a rate of screening, indicates a need for Bennington, depression with 96.8% for being increasing the perinatal depression Frank G. rates of elevated screened for frequency from one screening at every Morgan Jr., EPDS scores and perinatal to two times per clinical visit. This Charles A. provide treatment depression with pregnancy to more provides a better Wilkes, recommendations. EPDS at some frequent intervals opportunity to avoid Arlene J. point during their such as every missing women who Fontanares, pregnancy. clinical visit offers are in need of Nikki Sadr, Highest success an opportunity for therapeutic or Siobhan M. rates were at the early recognition of behavioral health Bertolino, intake perinatal interventions. The James F. appointment depression. results indicate that PERINATAL DEPRESSION SCREENING EVALUATION 41 Paulson, and 60.14% and the 6 depressive symptoms Frank G week follow up get worse throughout Morgan. appointment pregnancy and into (2020). postpartum of postpartum. With Perinatal 85.46%. increased frequency Depression providers may Screening recognize depression Rates, symptoms earlier and Correlates, be able to refer the and patient for services Treatment within a timely Recommend manner. ations in an Obstetric Population. Families, Systems & Health: The Journal of Collaborativ e Family HealthCare 38 (4): 369– 79. doi:10.1037/ fsh0000531. Flanagan, T., Level VI To implement a N/A The study had The This study offers a & Avalos, L. quality 96% compliance implementation of demonstration on the A. (2018). improvement rates for mothers quality implementation Perinatal program with four being screened at improvement process for perinatal office steps, use best least once for programs with depression screening depression practices, depression. utilization of the PERINATAL DEPRESSION SCREENING EVALUATION 42 screening education, data four steps are in office cares that is and analysis and reproducible in feasible and effective. treatment: workflow. clinical settings. Implementat ion in a health care system. Obstetrics & Gynecology, 127(5). doi: 10.1097/AO G.00000000 00001395 Bhat, A., Systemat To evaluate the N/A EPDS was most Support of multiple This study suggests it Nanda, A., ic timing and frequently used screenings as may be optimal to Murph, L., Review frequency, and tool; screening opposed to one screen at many Ball, A. L., Level 1 follow up of widely screening only. different points during Fortney, J., positive perinatal implemented a woman’s pregnancy & Katon, J. depression screens although there is (see discussion) (2021). A in community a lack of systematic settings guidelines about Authors recommend review of how often and that screening for screening for when screening depression should perinatal should occur; occur AT MINIMUM depression determining if once during in anxiety in someone has pregnancy and ideally community- perinatal at many different based depression can points throughout the settings. help prevent pregnancy to promote Archives of postpartum best outcomes. Women’s depression; Mental PERINATAL DEPRESSION SCREENING EVALUATION 43 Health. doi: 10.1007/s00 737-021- 01151-2. Garcia- Committ To express the N/A The significance There is profit from This study suggests Elorrio E. ee importance of of evaluating retrospective interpretation of (2019). The Opinion performance performance of a review of database retrospective analysis importance Level evaluation in quality electronic health may help providers of VII quality improvement record chart make corrections in evaluating improvement stand point systems. Collecting the way patient care is performanc projects. through data and measuring data delivered. e to analysis offers for analysis to understand opportunities for confirm or deny changes. research to be current practice Internation further guidelines. al journal processed. for quality in health care : journal of the Internation al Society for Quality in Health Care, 31(4), 245. https://doi.o rg/10.1093/i ntqhc/mzz0 38 PERINATAL DEPRESSION SCREENING EVALUATION 44 O’Connor, Systemat “Review of N/A Among pregnant Screening pregnant The use of routine E., Rossom, ic harm/benefit of and postpartum and postpartum screening tools R C., Review depression women 18 years women suggested a provides consistent Henninger, (Level 1) screening and and older, 6 trials positive result in ways to identify M., Groom, treatment, and (n = 11 869) decreasing the perinatal depression. H. C., accuracy of showed 18% to prevalence of The EPDS showed Burda, B. U. certain screening 59% relative perinatal higher success rates (2016). instruments for reductions with depression. when compared to Primary care pregnant and screening PHQ. screening for postpartum programs, or and women” 2.1% to 9.1% treatment of absolute depression reductions, in the in pregnant risk of and depression at postpartum follow-up (3-5 women: months) after Evidence participation in report and programs systematic involving review for depression the US screening, with Preventive or without Services additional Task Force. treatment Journal of components, the compared American with usual care. Medical Association, 315(4). Doi: 10.1001/jam PERINATAL DEPRESSION SCREENING EVALUATION 45 a.2015.1894 8 Levis, B., Systemat To evaluate the N/A Individual The EPDS is a An EPDS cut-off Negeri, Z., ic Edinburgh participant data reliable screening value of 11 or higher Sun, Y., Review Postnatal were obtained tool to screen for maximized combined Benedetti, (Level 1) Depression Scale from 58 of 83 depression in sensitivity and A., Thombs, (EPDS) for eligible studies pregnant and specificity; a cut-off B. D., & screening to detect (70%; 15 557 of postpartum women. value of 13 or higher Depression major depression 22 788 eligible was less sensitive but Screening in pregnant and participants more specific. To Data EPDS postpartum (68%), 2069 with identify pregnant and Group women. major postpartum women (2020). depression). with higher symptom Accuracy of Combined levels, a cut-off of 13 the sensitivity and or higher could be Edinburgh specificity was used. Lower cut-off Postnatal maximized at a values could be used Depression cut-off value of if the intention is to Scale for 11 or higher avoid false negatives screening to across reference and identify most detect major standards. patients who meet depression Among studies diagnostic criteria. among with a semi- pregnant and structured postpartum interview (36 women: studies, 9066 Systematic participants, review and 1330 with major meta- depression), analysis of sensitivity and individual specificity were participant 0.85 (95% PERINATAL DEPRESSION SCREENING EVALUATION 46 data. BMJ confidence (Clinical interval 0.79 to research 0.90) and 0.84 ed.), 371, (0.79 to 0.88) for m4022. a cut-off value of https://doi.or 10 or higher, g/10.1136/b 0.81 (0.75 to mj.m4022 0.87) and 0.88 (0.85 to 0.91) for a cut-off value of 11 or higher, and 0.66 (0.58 to 0.74) and 0.95 (0.92 to 0.96) for a cut-off value of 13 or higher, respectively. Accuracy was similar across reference standards and subgroups, including for pregnant and postpartum women. Table A4. Literature Article Synthesis PERINATAL DEPRESSION SCREENING EVALUATION 47 Appendix B Activity May Jun2 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May 21 1 21 21 21 21 21 21 22 22 22 22 22 Literature Review Stakeholder meetings Complete proposal & presentation Committee review & approval Apply for and receive IRB approval Review IT collected Data Retrospective Chart Reviews Collect outcome data Analyze data Write final report Table B5. GANTT Chart: Simplified Project Timeline PERINATAL DEPRESSION SCREENING EVALUATION 48 Appendix C Table C6. Data Collection Tool PERINATAL DEPRESSION SCREENING EVALUATION 49 Appendix D Figure D2. Chart Review Data Figure D3. Screening Percentages PERINATAL DEPRESSION SCREENING EVALUATION 50 Appendix E Budget Report Expenditures Amount Three DNP Student X 180 hours 540 hours Electronic Health Record $25,000 Information Technology Support $75,000 Consult Time with Clinical Manager 180 hours Time for Data Extraction Reports 4-8 weeks Total $100,000 Table E7. Budget Analysis PERINATAL DEPRESSION SCREENING EVALUATION 51 Appendix F PERINATAL DEPRESSION SCREENING EVALUATION 52 Appendix F Figure F4. Internal Review Board Approval from Michigan State University PERINATAL DEPRESSION SCREENING EVALUATION 53 Appendix G Figure G5. Data Use Agreement