Postpartum Depression: Development and Evaluation of a Screening Workflow Process in the Neonatal Intensive Care Unit

Background: Postpartum depression (PPD) is the most common complication of childbirth. Typically, screening for PPD is performed in the immediate postpartum period, followed by interval screening at the pediatrician office during well child visits. Within the general population, about 10-15% of mothers experience PPD. Furthermore, admission to the Neonatal Intensive Care Unit (NICU) places mothers at an increased risk for PPD. Current literature supports routine screening of mothers for PPD within the NICU, and referral for positive screens. Local Problem: At this Level III NICU, there is no routine screening of mothers for PPD using a verified screening tool. Methods: For this quality improvement (QI) project, a new workflow process was developed with a goal of increasing identification, documentation, education and referral for mothers with positive PPD screens. Pre-implementation surveys were distributed to NICU caregivers to obtain perceived knowledge and barriers of PPD screening. In accordance with current evidence, a workflow process was created and implemented. Chart reviews were conducted post-implementation to determine the adherence to the workflow process and evaluate the prevalence of PPD. A post-survey was distributed to evaluate the usability, feasibility, and satisfaction of the new workflow process. Results: Fifty-five NICU staff members completed the pre-implementation survey and twenty-one completed the post-implementation survey. After educational measures, self-reported knowledge of PPD signs/symptoms increased from 67.3% to 80.9%, self-reported comfort level in discussing PPD with mother of NICU infants increased from 45.4% to 66.7%, and self-reported knowledge of the long-term effects of PPD increased from 34.6% to 57.2%. With implementation of the new workflow process, eighteen mothers were screened for PPD using the Edinburgh Postnatal Depression Scale (EPDS) screening tool, with a positive rate of 22%. Accurate documentation in the electronic medical record (EMR) was only performed 33.3% of the time. Eleven screenings were performed at one month postpartum (61.1%), six screenings were performed at two months postpartum (33.3%), and one screening was performed at four months postpartum (5.5%). The social work team was notified of all four positive EPDS screenings. Conclusions: Educational interventions were effective in increasing NICU caregivers perceived knowledge of PPD in various domains. Implementation of a PPD screening workflow process was effective in identifying PPD in mothers of NICU infants. In this QI project, NICU mothers were found to have higher prevalence of PPD than the general population. Maternal PPD screening should be performed within all NICUs. Future projects should focus on improving compliance of PPD screening documentation in the EMR. Postpartum mood disorders should not be the sole responsibility of obstetricians or primary care providers/pediatricians, as these mood disorders can have major negative consequences on infants.