Quality Improvement Project: Improving Pediatric Primary Care Screening and Response for Postpartum Depression by Implementing a Referral Protocol

Background: Maternal mental health is a rising problem in Utah; one-in-eight women are affected by postpartum depression (PPD). A Utah review of maternal deaths found that 65% occurred after 43 days postpartum, meaning the routine 4-week postpartum obstetric follow-up is a missed opportunity to prevent maternal death. The same Review deemed 92% of these deaths as preventable had just one reasonable change with the patient, family, provider, facility, system, or community occurred. Routine pediatric primary care visits are identified as one solution to fulfill maternal mental health screening gaps for identifying PPD. This quality improvement project aimed at developing and implementing a standardized pediatric primary care protocol with a decision support algorithm to improve providers' identification and referral/resource response for those with a PPD risk. Problem: Less than half of pediatric providers screen, even though they feel responsible for identifying postpartum depression. Reported provider barriers for screening included lack of skills, confidence, experience, time, training, and professional guidelines. Methods: The two provider components analyzed included (1) self-efficacy for identifying and responding to PPD through an anonymous provider survey, and, (2) a retrospective chart review documenting screening and referral rates. A comparative analysis of the two months before and after implementation evaluated the project. Interventions: This quality improvement project implemented a standardized screening protocol and decision support algorithm with associated referral resources in a pediatric primary care clinic. The protocol was implemented using provider training, and a pre/post-intervention comparative analysis was used to evaluate provider efficacy in using the protocol. Results: Post-survey results found that 100% (n=5) of providers agreed in feeling confident in their own ability to recognize PPD using the screener and when to refer. Also, 100% (n=5) of providers agreed they had an effective, clear care process for guiding PPD resources/referral support. The post-retrospective chart review found clinic improvement in provider documentation rates of referrals and resources for screens with identified PPD risk (χ2 (1) = 1.58, p< .05). A statistically significant increase was found for referral rates of screens who endorsed concern for suicidal ideation (χ2 (1) = 4.9, p< .05). Conclusion: Implementing a standardized protocol with a decision support algorithm and associated location-specific referral/resource improved provider self-efficacy in identification and documented response to those with PPD risk.