Cedars-Sinai Improves Maternal Wellness Screening

Nurse training has been a critical element of an ongoing initiative to improve the screening of new mothers for mood disorders.

A postpartum depression screening, education, and referral program at Cedars-Sinai Medical Center has generated positive results.

Perinatal mood and anxiety disorders are relatively common, and they can complicate pregnancy, delivery, and the postpartum period. Despite these risks, many hospitals have difficulty identifying and supporting patients with perinatal mood and anxiety disorders.

Cedars-Sinai launched its postpartum depression screening, education, and referral program in 2017. The initiative featured four interventions, Eynav Accortt, director of the hospital's Reproductive Psychology Program, told HealthLeaders.

1. Nurse champions: The hospital identified about 20 nurses who showed an interest in mental health. These nurse champions received a full day of training, including instruction in conducting mental health screening.

2. Mental health screening: The hospital shifted from only querying mothers on the first two items of the Patient Health Questionnaire-9 (PHQ-9) to covering all nine items. More importantly, the hospital moved PHQ-9 screening out of the admission phase of a new mother's care, Accortt said.

"For our population, it is inappropriate to do the questionnaire in triage. Women are coming in in pain, with contractions, with water breaking, and they are overwhelmed. So, one of the main elements of our quality improvement initiative was to stop asking the PHQ-9 questions upon admission. We decided to get them in, get them the medical care they needed, let them have their baby, then ask all nine items on the PHQ-9 in the postpartum unit rather than asking when they were in labor and delivery," she said.

3. Nurse training: Hundreds of Cedars-Sinai nurses received hour-long, in-service, in-person training on how to conduct mental health screening of new mothers. The training sessions featured role playing, with Accortt or a social worker playing the role of a nurse conducting the PHQ-9 and a nurse playing the role of a depressed mother.

"That role playing allowed the nurses to feel more comfortable with some of the PHQ-9 items because some of the questions can be quite jarring the first time you say them out loud. For example, one of the items asks, 'Over the past two weeks, how often have you had thoughts that you would be better off dead or thoughts of hurting yourself?' The first time a nurse says that out loud, it can be uncomfortable, and they brace themselves for an answer," Accortt said.

4. Video training: Based on nurse feedback that there were traveling nurses and night nurses who could not be present for the in-service training, the hospital developed a 10-minute training video with a key partner organization, Maternal Mental Health Now.

The four interventions improved nurse screening, nurse comfort with screening, and nurse knowledge about depression, Accortt said. "The interventions also improved our screening rates. When we were screening in labor and delivery upon admission, we were only screening about 10% of our patients because for the others it was just inappropriate to ask questions. We went from a 10% screening rate to a 99% screening rate. In addition, our screen positive rates went from nearly negligible up to 2.9% of patients in the first year. Finally, and probably most importantly, the four interventions increased our rate of social work consultation from 1.7% of patients to 8.4%."

The initiative is the subject of a research article published by the American Journal of Obstetrics & Gynecology.

Social worker consultation

If a new mother screens positive for a mood disorder or anxiety, she is connected to a social worker, Accortt said.

"The social worker begins by being caring, nonjudgmental, and a listening ear. The social worker provides support, asks questions, and provides resources after a thorough assessment of the patient's needs. Sometimes, the social worker might need to consult psychiatry if a woman seems unstable and in need of a full psychiatric evaluation. Otherwise, the social worker might provide a referral to our Reproductive Psychology Program. We have an outpatient reproductive psychology program. We have an outpatient social worker—that way, the patient has a seamless connection to care from the inpatient setting to the outpatient setting," she said.

The inpatient social worker always reviews the mental health screening data and looks for red flags, Accortt said. "For example, if a woman answers with anything other than 'not at all' to the question whether there are thoughts of harm, that is something the social worker needs to inquire more about. Under those circumstances, the social worker will likely consult with an inpatient psychiatrist. It's important. Maternal suicide is one of the leading causes of death for women in the postpartum period. We do not take that lightly. We want to make sure we provide support for anyone in distress."

Recent protocol changes

In February, the hospital dropped using the PHQ-9 for new mothers and replaced it with the Edinburgh Postnatal Depression Scale. At the same time the PHQ-9 was replaced, the hospital introduced iPads to complete the screening process.

"Our nurses still do an excellent job of introducing the concept of family wellness and the importance of the need for screening, but now they just hand the patient an iPad and the more commonly used Edinburgh Postnatal Depression Scale (EPDS) is what we use now instead of the PHQ-9. This is wonderful news because the EPDS also asks about anxiety, which is more common than depression at this time of life, and the iPad allows for more privacy," Accortt said.

Related: Yale New Haven Hospital Helping New Moms to Address Mood Disorders