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

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. At this Level III NICU, there is no routine screening of mothers for PPD using a verified screening tool. 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. 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. 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.

1 Postpartum Depression: Development and Evaluation of a Screening Workflow Process in the Neonatal Intensive Care Unit Chloe C. LaBerge, Jenn Anker, Jenny Hearne College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project Spring 2023 2 Abstract 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 3 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. Keywords: Postpartum Depression, Newborn Intensive Care Unit, Edinburgh Postnatal Depression Scale 4 Postpartum Depression: Development and Evaluation of a Screening Workflow Process in the Neonatal Intensive Care Unit Problem Description About 85% of all women experience a variation of mood disorders during the postpartum period (Ryan & Kostaras, 2005). After childbirth, women experience a drastic decrease in progesterone and estrogen, which may contribute to postpartum mood disorders (see Figure 1). Postpartum mood disorders include postpartum blues, postpartum depression (PPD), and postpartum psychosis and these are differentiated by severity of symptoms (Earls et al., 2019). Postpartum blues are transient and mild, affecting many mothers in the perinatal period. The postpartum blues is defined by symptoms of sadness, crying, exhaustion, irritability, anxiety, decreased sleep, decreased concentration, and labile mood. These symptoms usually do not impair daily function. Postpartum depression is considered a major depressive disorder and tends to last longer than the postpartum blues. This severely affects everyday function as well as the maternal-infant relationship. The pathogenesis is not clearly understood, but is likely multifactorial, involving hormonal, psychosocial, and genetic factors (Tahirkheli et al., 2014). Postpartum psychosis is a rare event, affecting 1-2 per 1,000 women, and includes severe symptoms that require immediate medical attention and hospitalization (Earls et al., 2019). Postpartum psychosis has a rapid onset, most often within the first two weeks postpartum, but can occur any time within the first year. The mother will experience a break from reality, and in this psychotic state, the delusions and hallucinations feel real. This places the mother and her family at risk for serious consequences, such as suicide, filicide, or both (Raza & Raza, 2022). Worldwide, PPD affects approximately 10-15% of mothers, and it is considered the most common complication of a childbirth (Shovers et al., 2021). Furthermore, prevalence of PPD in mothers of infants admitted to the NICU increases to 40% (Shovers et al., 2021). This is due to a combination of factors, including increased stress due to the infant’s health status, diagnoses, pregnancy complications, a sense of loss of a healthy child, and decreased contact between the mother and infant (Shovers et al., 2021). 5 Postpartum depression is a type of major depressive disorder. The symptoms of PPD include depressed mood, loss of interest or pleasure, insomnia or hypersomnia, psychomotor agitation, feelings of worthlessness or guilt, loss of energy or fatigue, suicidal ideation and/or attempt, impaired concentration or indecisiveness, and major changes in weight or appetite (Mughal et al., 2022). These symptoms are often undetected by clinicians and interfere with activities of daily life. In most cases, the peak incidence of PPD occurs at six weeks, and another peak occurs at six months postpartum (Earls et al., 2019). Therefore, the American Academy of Pediatrics (AAP) recommends PPD surveillance and screening at one-, two-, four- and six-month well-child visits, using a validated screening tool. Infants are hospitalized for prolonged periods in the NICU for a variety of reasons. This prolonged hospitalization can exceed the timeframe in which infants would attend their one-, two-, four- and six-month well-child visits. Due to the hospitalization of their infant, mothers are not attending their child’s well child visits, and are therefore not screened for PPD in this setting. This creates a gap in surveillance screening of a high-risk population of mothers. Postpartum depression disrupts the family unit and has negative consequences for infants and mothers alike (Slomian et al., 2019). In a systematic review of 122 studies, negative outcomes of untreated PPD and the effects on children between the ages of zero to three were identified (Slomian et al., 2019). For mothers, it was found that there were more difficulties in their relationships, more risky behaviors, lower self-esteem, increased anxiety, decreased libido, increased prevalence of suicidal ideation and increased stress (Slomian et al., 2019). For infants, potential negative consequences include decreased weight gain, stunted growth, significant impairment in cognitive, language, motor and social development, poor sleep quality, and poor overall infant health (Slomian et al., 2019). In addition, PPD negatively affects the care that a mother provides for her infant. The effects of PPD on this relationship may cause bonding difficulties, breastfeeding problems and early discontinuation of breastfeeding, poor parenting practices, and an increased risk of maltreatment (Slomian et al., 2019). The numerous negative effects that PPD causes highlights the need for maternal mental health promotion in the postpartum 6 period. Currently, there is a paucity in the literature with minimal recommendations for routine, interval PPD screening protocols for mothers of hospitalized NICU infants. Available Knowledge Hospitalization of an infant in the NICU is a particularly stressful period for parents and families. Increased stressors in the NICU setting are associated with significant psychological morbidity, including PPD. In one cross-sectional study performed in a level III NICU, major stressors that were found to increase risk of PPD for mothers included the ill appearance of their infant and parental role alteration (Varma et al., 2019). Other stressors that may contribute to the development of PPD include the environment of the NICU (low-lighting, alarms, etc.), and the separation between the mother and infant (Suhana Yahya et al., 2021). Nutritional status may also influence the incidence of PPD among mothers. Some reports indicated an association between deprivation of certain nutrients and PPD, including essential fatty acids, folate, vitamin B12, and some trace elements, including antioxidants, selenium, iron and zinc (Suhana Yahya et al., 2021). These nutrients are involved in essential brain function, including the optimal functioning of neurotransmitters, neuronal membrane fluidity, and synaptic plasticity, which have implications on the development of depression and anxiety (Suhana Yahya et al., 2021). This emphasizes the need for a nutritious diet during the postpartum period to decrease risk of developing PPD. In a meta-analysis of 27 studies, maternal risk factors associated with development of PPD were evaluated. It was found that gestational diabetes mellitus, depression during pregnancy, giving birth to a boy, history of depression in a previous pregnancy, and history of depression, were major risk factors that led to developing PPD (Liu et al., 2021). When evaluating long-term outcomes in children of mothers who experience PPD compared to mothers who did not, several adverse outcomes were found. These negative long-term outcomes included lower ego-resiliency, lower peer social competence, and lower school adjustment (Kersten-Alvarez et al., 2012). Daughters of mothers who experienced PPD were found to have lower verbal intelligence scores 7 (Kersten-Alvarez et al., 2012). This study by Kersten-Alvarez et al. adds to the literature that PPD in mothers negatively impacts children in several developmental domains. Although there are no specific recommendations on how often and what tool is best to evaluate for postpartum depression in mothers of NICU infants, there is a consensus that PPD screening is recommended in the NICU during infant hospitalization. The goal of PPD screening in the NICU is to capture high-risk women who may otherwise go unscreened, to ultimately improve long-term infant outcomes. In an observational study performed at Children’s Hospital Los Angeles, mothers of infants admitted to the NICU were screened for PPD to determine the rate of postpartum depression, as well as identification of maternal or infant factors that increase risk for PPD (Trost et al., 2016). They found a positive PPD rate of twenty-eight percent (87/310) using the Edinburgh Postnatal Depression Scale (EPDS). This study identified low social support and history of past psychiatric diagnosis as maternal risk factors for a positive EPDS screen. The major infant risk factor that was found to increase incidence of a positive EPDS screen was neurodevelopmental morbidity, including mental retardation, cerebral palsy, epilepsy, hydrocephalus, craniosynostosis, and ventriculoperitoneal shunt (Trost et al., 2016). This study concludes that PPD screening during infant hospitalization captures high-risk women who are previously unscreened (Trost et al., 2016). Rationale This project was developed using the Plan-Do-Study-Act (PDSA) theoretical framework (see Figure 2). This is a four-stage process change model that is used to improve a process and carry out a change (Institute for Healthcare Changes, 2022). The “plan” phase involves identifying objectives, recruiting team members, creating roles and responsibilities, and making a timeline. In the “do” phase, the plan is executed, implementation is performed, and changes will hopefully be seen. In the “study” phase, the new process is evaluated, and it is determined if the process change was successful or if changes need to be made. Finally, in the “act” phase, process improvement changes occur and preparation for the next PDSA cycle occurs. This project will utilize the PDSA process change model to create a plan for 8 standardized postpartum depression screening in the NICU, implement the standardized screening, evaluate if the screening is effective in better identifying mothers with PPD, and improve the screening process based on the results in preparation for the next PDSA cycle. Specific Aims The purpose of this quality improvement (QI) project was identification of mothers of NICU infants, who are experiencing postpartum depression, through standardized interval screening, and refer them to mental health services, to prevent possible long term cognitive, behavioral, and emotional effects in infants of mothers who are experiencing PPD. The specific objectives of this project were 1) assess current screening methods in the NICU for PPD, current referral for positive screenings, and current documentation of PPD screening, 2) develop a workflow process for PPD screening, using a verified PPD screening tool, at specific intervals in the NICU, and determine who administers it, 3) implement the postpartum depression workflow process, 4) evaluate the feasibility, usability, and satisfaction of the postpartum depression workflow process, and 5) minimize the social determinants of health. Methods Context This QI project was conducted in a Level III NICU within suburban Utah. The patient population ranged from infants born at 22 weeks gestation to post-term, with some of these infants remaining hospitalized for months. These patients have a wide variety of diagnoses, ranging from respiratory distress, to hypoglycemia, to sepsis. The study population for this QI project included all mothers of hospitalized NICU infants. Pre-implementation data was provided by the NICU social work team. Postimplementation data was collected from February 2023 to April 2023. No mothers were excluded from data collection, regardless of their age, race/ethnicity, education level, or marital status. The participants of this QI project included advanced practice providers (APPs), social workers, health unit coordinators (HUCs), registered nurses, and mothers of hospitalized NICU infants. 9 Implementation A self-reported pre-implementation and post-implementation survey was used to evaluate NICU caregivers’ knowledge, training, and barriers of PPD and PPD screening (see Appendix A). Current evaluation of PPD screening, and referral for positive screens was evaluated through retrospective chart review and discussion with social work. Following this, a workflow process was developed with the goal of implementing standardized PPD screening, at intervals recommended by the AAP. Pre-Implementation First, this QI project assessed NICU caregivers’ knowledge and barriers of implementation of PPD screening in the NICU through a survey. Surveys were distributed to the NICU caregivers, via REDCap (see Appendix A). The survey link was sent via email. The survey results were analyzed, to help guide the development of a PPD screening workflow process. An educational presentation regarding PPD screening within the NICU was created, that incorporated educational material to address knowledge deficits identified in the pre-survey. Workflow Process Development A new workflow process was developed to screen NICU mothers for PPD, using current evidence-based recommendations from the literature. The workflow process involved the determination of how to screen, when to screen, who would perform the screen, calculation of the screening, documentation of the screening, and what to do with a positive screen. A dot-phrase was created with assistance from iCentra experts for the APP group to easily document PPD screening results in the electronic medical record (EMR). The EPDS screening tools were printed and delivered to the NICU HUC team in both English and Spanish in preparation for implementation. Education An educational PowerPoint was created to highlight the importance of PPD screening for NICU mothers, potential consequences on childhood development related to PPD, signs and symptoms of PPD, as well as information about the new screening workflow (see Appendix B). This education was delivered to the NICU staff via email. In person education was also provided to the APP group to reinforce the 10 teaching provided via email. Additionally, an educational PowerPoint was created and presented to the Neonatal Nurse Practitioner students at the University of Utah, regarding the importance of Postpartum Mood Disorders and screening. Workflow Process Implementation The workflow process was implemented within the NICU. First, the APP group received the educational presentation regarding PPD and learned about the PPD screening process. The importance of PPD screening and referral was highlighted, and the APPs were taught how to document the PPD screening score in the EMR. The presentation also defined what the APP should do with a positive screen. Then, the HUCs were taught how and when to administer the screenings to mothers when they entered the unit to visit their infant. The HUCs then gave the completed screenings to the appropriate APP to document in the infant’s daily progress note using the dot phrase. If the screen was positive, the APP was to discuss with the social work team, so that social work could provide the mother with a referral to mental health services. Prospective Chart Review Prospective chart review was performed via the EMR on all NICU infants admitted from February 2023 to April 2023. These reviews were used to determine the prevalence of PPD, frequency of PPD screening documentation, and if appropriate referral was being made for positive screenings. Study of the Implementation To evaluate the impacts of implementation of the PPD screening workflow process in this QI project, prospective chart reviews were performed from February 2023 to April 2023. These chart reviews were used to determine if NICU APPs were accurately documenting PPD screening, if appropriate referral was being made by social work, and to determine if there was an increase in number of mothers being referred to mental health services compared to the pre-implementation period. Data was collected on all patients, regardless of age, race/ethnicity, education level, or marital status. 11 Measures A pre-survey was administered via REDCap to the APP group, nurses, patient care technicians, health unit coordinators, and social workers of the NICU. It included 11 questions (see Appendix A). The first two questions were demographic questions to assess years of NICU experience and role in the NICU. The next eight questions were to assess knowledge of PPD, comfort level discussing PPD with mothers, effects of PPD on childhood development, barriers to PPD screening in the NICU and documentation of PPD screening These questions were answered using a five-point Likert scale, with answers ranging from “strongly disagree” to “strongly agree”. Question ten was used to assess how many NICU caregivers had formal training in PPD, and was evaluated by “yes,” “no,” or “some.” The last question was a free text question, to assess perceived barriers to implementation of PPD screening. The EPDS was used as the tool to evaluate mothers for PPD. The EPDS is a validated tool that is used for assessing symptoms of PPD. It contains 10 questions and can be completed within 10 minutes. An EPDS score of 10 or higher, and/or an answer of anything other than “never” on question 10, which refers to self-harm/suicidal ideation, was considered a positive screen and social work was notified to provide a mental health referral. It is available in both English (see Appendix C) and Spanish (see Appendix D). A post-survey was administered to the APP group, nurses, patient care technicians, HUCs, and social workers of the NICU, which included the same questions as the pre-survey. The purpose of this survey was to measure outcomes of implementation and the educational material provided. Feedback about the survey design and questions was sought from content experts, who provided validation that the content was accurate. Analysis Pre- and Post-Implementation Survey Responses from the completed pre- and post-surveys were compiled and analyzed. Descriptive statistics were applied to the demographic information and a Pearson Chi-Square test was used to evaluate the significance of the differences. Descriptive statistics were used to measure the changes between pre- 12 implementation and post-implementation scores. For the open-ended question, a content analysis was conducted. The words were read word for word and then summarized. Next, the summarized data were categorized and organized. Implementation Data Analysis Post-implementation data were gathered and organized. Descriptive statistics were used to analyze these findings. Then, a Pearson Chi-square test was used to evaluate the relationship of infant sex, maternal primary language, and gestation on the screening results. A Pearson Chi-square test was also used to evaluate if there was a statistical difference between the number of Spanish-speaking and Englishspeaking mothers who were screened for PPD and scored positively. Ethical Considerations This project was a quality improvement in nature and not subject to University of Utah institutional review board oversight. There were no conflicts of interest concerning this study. Results Survey The pre-implementation survey that addressed attitudes and barriers towards PPD screening was made available to NICU APP’s, registered nurses, health unit coordinators, patient care technicians, and social workers. Fifty-five surveys were completed, with the majority being registered nurses (n=32, 58%) (Table 1). The respondents had varying years of experience, with the majority having >20 years of experience (n=19, 34.5%). The post-implementation survey was completed by 21 NICU caregivers, with the majority being registered nurses (n=10, 47.6%). The majority of the post-implementation survey respondents had 5-10 years of experience (n=8, 38.1%). The demographic composition of the pre- and post-implementation groups were evaluated using the Pearson Chi-Square statistical analysis test. There was no statistical difference found in the years of experience and the NICU caregiver role, between the pre- and post-implementation survey. These results are presented within Table 1. Before education was performed, most respondents felt knowledgeable about the presenting signs and symptoms of PPD (n=37, 67.3%), agreed that screening is important and documentation in the EMR 13 should be done (n=44, 80%), and agreed that referral should be made for positive screens (n=50, 91%). Forty percent of caregivers admitted that they were not aware of the long-term effects that PPD can have on the child, the mother, and the maternal-child relationship (n=22, 40%). The majority of caregivers did not have any formal training in PPD (n=45, 82%), and felt that patient acuity level is a barrier to screening for and discussing PPD (n=45, 82%). After providing NICU caregivers with education, there was an increase in the percentage of respondents who felt knowledgeable about the signs/symptoms of PPD (n=17, 81%), agreed that screening for PPD is important (n=20, 95.2%), agreed that documentation of PPD screening should be done (n=18, 85.7%), and agreed that referral should be made for positive screens (n=20, 95.2%). There was also an increase in the percentage of NICU caregivers who felt knowledgeable about the long-term effects of PPD (n=12, 57.1%). These findings are reported in Table 2. An open-ended question at the end of the survey allowed respondents to comment with concerns they had about implementation of PPD screening in the NICU (Table 3). Eighty percent of NICU caregivers stated that they had no concerns regarding PPD screening in the NICU (n=44), and some even stated that they think PPD screening is necessary (n=3). The remainder of the respondents had concerns about implementing PPD screening for a variety of reasons. Some felt that PPD screening is the responsibility of the social work team (n=5, 9%), and others had concerns about increasing their current workload (n=3, 5%), lack of education regarding PPD (n=2, 4%), and feeling uncomfortable discussing PPD with mothers (n=1, 2%). Electronic Medical Record Review Prior to implementation, there was no use of a standardized, verified PPD screening tool to evaluate mothers of NICU infants for PPD. Post-implementation, there were 18 mothers screened for PPD, using the EPDS. Of these, sixty-one percent were performed at one month of infant age (n=11), thirty-three percent were performed at two months (n=6), five percent were performed at four months (n=1), and zero percent were performed at six months (n=0). These findings are presented in Table 4. These results were analyzed using measures of central tendency, with a mean screening time of one-anda-half months postpartum, and a median of one month postpartum. 14 Data was collected in the post-implementation period on how many mothers were identified as having a positive EPDS score. Of the 18 screenings completed, twenty-two percent were positive (n=4). The social work team was notified of these findings. The scores of the completed EPDS screenings ranged from 0-16. Descriptive statistics were used to analyze the scores. Of the 18 completed EPDS screens, the mean score was 5.9, with a standard deviation of 4.3. There was no standardized documentation process for PPD screening in the NICU prior to implementation of the PPD screening workflow process. In the post-implementation period, the EMRs were reviewed to evaluate for compliance of documentation in the APP daily progress note. Of the 18 total completed screenings, thirty-three percent were accurately documented in the infants EMR using the dot phrase (n=6). These findings are presented in Table 4. The EPDS screens were evaluated to determine if there was a statistical significance between the infants’ gender and screening results, as suggested in the literature. In addition, it was evaluated whether single or multiples had a statistical impact on the screening results. Of the 18 EPDS screenings, nine were of mothers of male infants, and nine were mothers of female infants. Of the four positive screenings, three were mothers of male infants. However, a chi square test found no statistical difference between the gender and result of the screening (χ2 (1) =1.29, p= .25). There were two mothers of multiples in the sample, one of twins, and one of triplets. The mother of the twins scored positively on her one-month EPDS screen. However, a chi square test found no statistical difference between single and multiples and EPDS screening results (χ 2 (1) =1.0045, p= .32). These results are presented in Table 5. Regarding the social determinants of health, EPDS screens were evaluated to determine the numerical difference between completed English and Spanish screens. There were twelve EPDS screens completed in English (66.6%), and six EPDS screens completed in Spanish (33.3%). A chi square test found no statistical difference between the number of Spanish-speaking and English-speaking mothers who were screened for PPD and scored positively (χ2 (1) =0.42, p= .52). These results are presented in Table 5. 15 Discussion Summary Postpartum depression surveillance screening in the NICU is recommended in the current literature and is thought to be beneficial. The aim of this project was to create and implement a PPD screening workflow and referral process for mothers of hospitalized NICU infants, to increase identification and treatment of PPD. Compared to pre-implementation data, there was a clinically significant increase in the number of mothers screened for PPD. There was also a clinically significant increase in the number of mothers identified as positive for PPD. The findings of this QI project will be disseminated to the NICU staff at this institution. Further emphasis on the importance of PPD screening is required in the NICU to create successful practice change and continuation of this screening process. Education on postpartum mood disorders and screening/referral should be implemented within the Neonatal Nurse Practitioner DNP educational curriculum. Future projects may convert this workflow process into a clinical practice guideline, as well as implement the PPD screening workflow process throughout the healthcare system. Although this project had a small sample size and only identified four mothers with PPD, there were several strengths associated with this QI project. First, a workflow process for standardized interval PPD screening was created, which is recommended by the literature and AAP guidelines. NICU caregivers, including the APP group, received education on PPD which may help to increase recognition of signs and symptoms in mothers affected by PPD. Additionally, many NICU caregivers informally reported their appreciation of the implementation of this QI project, emphasizing how necessary this screening process is. The ease of this screening and documentation process was another strength of this project. Interpretation The pre-implementation survey highlighted that the NICU staff agree with the importance of PPD screening and documentation in the NICU. Ninety-three percent (n=51) stated that they agree or strongly agree with the screening process. However, upon implementation, there was a lack of compliance in 16 documentation of PPD screening. Further evaluation is warranted to determine the disconnect between the staff knowledge and clinical practice. The post-implementation data was gathered over a two-month period and therefore had a small sample size. This QI project positively identified four mothers with PPD after implementation of the PPD screening workflow process, out of 18 total mothers who were screened. The findings of this QI project were compared to similar projects that had larger sample sizes. In one QI project by Brownlee (2022), one-hundred and four mothers were screened for PPD using the EPDS screening tool. Twenty-seven of these mothers scored positively, which resulted in a positive PPD screening rate of 26% (Brownlee, 2022). In another study performed by the Children’s Hospital of Los Angeles, a positive maternal PPD rate of 28% (87/310) was found using the EPDS screening tool (Trost et al., 2016). These two studies yielded a similar positive PPD screening rate to this QI project despite having larger sample sizes. Another QI project with a smaller sample size similar to this QI project by Vaughn & Hooper (2020) identified a 43% positive PPD screening rate defined by an EPDS score >10. The difference in positive PPD screening rates between these projects is likely due to the small sample sizes. Continued data collection of this QI project would be beneficial to provide more generalizable results. PPD screening is performed at minimal additional cost for mothers of NICU infants. The only ongoing cost is the printing of EPDS screenings and chart labels. NICU caregivers were educated via electronic means, with an expectation of reviewing the material during regular working hours. Therefore, no additional paid education time was necessary for this QI project. Limitations One limitation in this QI project was use of samples from one single NICU. Due to the similarities in diagnoses within this NICU, it is difficult to generalize these findings to all NICU settings. An increase in prevalence of PPD may be found in a Level IV NICU, which includes a longer average length of hospitalization, increased morbidity and mortality, and more complex diagnoses, such as congenital heart disease, genetic disorders, and infants requiring surgical intervention. 17 Due to lack of time during the implementation process, this QI project had a small sample size. Continuation of data collection is recommended to obtain more accurate results. Because of this, it is difficult to generalize these findings throughout all NICUs. Other limitations of this project included lack of compliance in the documentation process, lack of comfort among nurses regarding the topic of PPD and lack of mental health support within the hospital itself. Continuing to educate the NICU caregivers and emphasize the importance of the screening process may help to increase compliance of screening documentation in future PDSA cycles. Conclusions Routine standardized maternal PPD screening should be implemented within all NICU settings using a verified screening tool. Postpartum mood disorders and mental health issues should not be the sole responsibility of obstetricians or primary care providers/pediatricians, as these mood disorders can have major negative consequences on infants. Mothers with infants admitted to the NICU are at an increased risk for developing a postpartum mood disorder. The prolonged hospitalization of some infants within the NICU creates an ideal setting for screening and referral of PPD, if needed. However, continued data collection is required to determine the benefits of implementation of this screening process. If successful, this screening process should be implemented and standardized throughout all NICUs within this institution. 18 Acknowledgements I would like to thank Jenny Hearne, DNP, NNP-BC, my project chair, who was so supportive and encouraging throughout this entire project. Thank you for all your guidance as I navigated through this QI project. I would also like to thank Julieanne Schiefelbein, DNP, MAPPSC, MA, ENM, NNP-BC, CPNP, NPT-C and Jenn Anker, MSW, LCSW, PMH-C for their expertise and assistance with implementation of this project. To all the Neonatal DNP faculty, thank you for pouring your souls into this program and supporting me more than I could ask for. I would not be where I am today without the education you have provided me with. To my classmates, I could not have done this without you all. I am excited for us to transition into the role of brand-new Neonatal Nurse Practitioners together. To my family and friends who were there for me throughout this entire program, I cannot thank you enough. I would not have been able to achieve this dream of mine without your continued support and words of encouragement. 19 References Brownlee, M. (2022). Screening for Postpartum Depression in a Neonatal Intensive Care Unit. Advances in Neonatal Care, 22(3), E102–E110. https://doi.org/10.1097/ANC.0000000000000971 Earls, M., Yogman, M. W., Mattson, G., & Rafferty, J. (2019). Incorporating recognition and management of perinatal depression into pediatric practice. Pediatrics (Evanston), 143(1), 1. https://doi.org/10.1542/peds.2018-3259 Institute for Healthcare Improvement. (2022). Science of Improvement: Testing Changes. https://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx #:~:text=The%20Plan%2DDo%2DStudy%2D,used%20for%20action%2Doriented%20learning. Kersten-Alvarez, L.E., Hosman, C. M., Riksen-Walraven, J. M., Doesum, K. T. M. van, Smeekens, S., & Hoefnagels, C.C. (2012). Early school outcomes for children of postpartum depressed mothers: Comparison with a community sample. Child Psychiatry and Human Development, 43(2), 201– 218. https://doi.org/10.1007/s10578-011-0257-y Liu, X., Wang, S., & Wang, G. (2021). Prevalence and Risk Factors of Postpartum Depression in Women: A Systematic Review and Meta-analysis. Journal of Clinical Nursing. https://doi.org/10.1111/jocn.16121 Mughal, S., Azhar, Y., & Siddiqui, W. (2022, October 7). Postpartum Depression. National Institute of Health; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519070/ Raza, S. K., & Raza, S. (2022, June 27). Postpartum Psychosis. National Institute of Health; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK544304/ Ryan, D., & Kostaras, X. (2005). Psychiatric disorders in the postpartum period. British Columbia Medical Journal, 47(2), 100–102. Shovers, S. M., Bachman, S. S., Popek, L., & Turchi, R. M. (2021). Maternal postpartum depression: risk factors, impacts, and interventions for the NICU and beyond. Current Opinion in Pediatrics, 33(3), 331–341. https://doi.org/10.1097/MOP.0000000000001011 20 Suhana Yahya, N.F., Teng, N. I., Das, S., & Juliana, N. (2021). Postpartum depression among Neonatal Intensive Care Unit mothers and its relation to postpartum dietary intake: A review. Journal of Neonatal Nursing: JNN, 27(4), 229–237. https://doi.org/10.1016/j.jnn.2020.09.005 Trost, M.J., Molas-Torreblanca, K., Man, C., Casillas, E., Sapir, H., & Schrager, S. M. (2016). Screening for maternal postpartum depression during infant hospitalizations. Journal of Hospital Medicine, 11(12), 840–846. https://doi.org/10.1002/jhm.2646 Varma, J.R., Nimbalkar, S. M., Patel, D., & Phatak, A. G. (2019). The Level and Sources of Stress in Mothers of Infants Admitted in Neonatal Intensive Care Unit. Indian Journal of Psychological Medicine, 41(4), 338–342. https://doi.org/10.4103/IJPSYM.IJPSYM_415_18 Vaughn, A., & Hooper, G. L. (2020). Development and Implementation of a Postpartum Depression Screening Program in the NICU. Neonatal Network, 39(2), 75–82. https://doi.org/10.1891/07300832.39.2.75 21 Tables Table 1 Demographics of Health Care Professional Completing Knowledge Questions regarding Postpartum Depression Screening Survey Pre & Post-implementation Survey Х2(df) Health Care Professional Pre-Implementation Post(n=55) Implementation n % (n=21) n % Years of NICU Experience 1.3024 (4) 0-4 13 23.6% 3 14.3% 5-10 15 27.3% 8 38.1% 11-15 6 10.9% 2 9.5% 16-20 2 3.6% 1 4.8% >20 19 34.5% 7 33.3% Role in the NICU 0.7489 (3) Registered Nurse 32 58.2% 10 47.6% Health Unit Coordinator 2 3.6% 1 4.8% Neonatal Nurse Practitioner 16 29.1% 8 38.1% Other 5 9.1% 2 9.5% p .861 .861 22 Table 2 Knowledge Questions Results Questions Knowledgeable about signs/symptoms of PPD Strongly Disagree Disagree Neutral Agree Strongly Agree Comfort level discussing PPD with mothers Strongly Disagree Disagree Neutral Agree Strongly Agree Knowledgeable about effects of PPD Strongly Disagree Disagree Neutral Agree Strongly Agree Understand the importance of screening Strongly Disagree Disagree Neutral Agree Strongly Agree Patient acuity level is a barrier Strongly Disagree Disagree Neutral Agree Strongly Agree Importance of documentation of PPD screening in EMR Strongly Disagree Disagree Neutral Agree Strongly Agree Mental Health Referrals should be performed Pre-Implementation (n=55) n % Post-Implementation (n=21) n % 1 6 11 33 4 1.8% 10.9% 20% 60% 7.3% 0 1 3 13 4 0% 4.8% 14.3% 61.9% 19% 2 12 16 18 7 3.6% 21.8% 29.1% 32.7% 12.7% 0 1 6 8 6 0% 4.8% 28.6% 38.1% 28.6% 2 20 14 16 3 3.6% 36.4% 25.5% 29.1% 5.5% 0 3 6 6 6 0% 14.3% 28.6% 28.6% 28.6% 0 2 2 21 30 0% 3.6% 3.6% 38.2% 54.5% 0 0 1 10 10 0% 0% 4.8% 47.6% 47.6% 2 4 4 33 12 3.6% 7.3% 7.3% 60% 21.8% 0 3 2 12 4 0% 14.3% 9.5% 57.1% 19% 0 2 9 30 14 0% 3.6% 16.4% 54.5% 25.5% 0 1 2 8 10 0% 4.8% 9.5% 38.1% 47.6% 23 Strongly Disagree Disagree Neutral Agree Strongly Agree Formal training in PPD and Effects of PPD Yes No Some *See Appendix A for full survey. 0 0 5 22 28 0% 0% 9.1% 40% 50.9% 0 0 1 9 11 0% 0% 4.8% 42.9% 52.4% 3 45 7 5.5% 4 81.8% 14 12.7% 3 19% 66.6% 14.3% 24 Table 3 NICU Health Care Professionals Perceived Concerns to Utilization & Implementation of PPD Screening Categories of Concerns No Concerns Feel as though it is a social work responsibility Feel as though they have limited education regarding PPD Concerned that it will add to an already busy workload Feel uncomfortable discussing PPD Pre-Implementation n =55 (%) n % 44 80% 5 9.1% Post-Implementation n = 21 n % 15 71.4% 3 14.3% 2 3.6% 1 4.8% 3 5.4% 2 9.5% 1 1.8% 0 0% 25 Table 4 EPDS Screening Results Post-implementation (n=18) n % Infant Sex Male Female EPDS Total Score Positive screen (score ≥10) Negative screen (score <10) Gestation Singleton Multiple Months Postpartum 1-month 2-months 4-months 6-months Documented Screen Yes No Language of EPDS Screen English Spanish 9 9 50% 50% 4 14 22.2% 77.8% 16 2 88.8% 11.1% 11 6 1 0 61.1% 33.3% 5.5% 0% 6 12 33.3% 66.6% 12 6 66.6% 33.3% 26 Table 5 Relationship of Infant’s Sex, Maternal Primary Language & Gestation on Screening Results Infant’s Sex Male Female Primary Language English Spanish Gestation Single Multiple Post-implementation (n=18) Positive (n=4) Negative (n=14) χ 2 (df) p 3 1 6 8 1.29 (1) .25 3 1 8 6 0.42 (1) .52 3 1 13 1 1.00 (1) .31 27 Figures Figure 1 Hormonal Changes 28 Figure 2 The Plan-Do-Study-Act Process Change Model 29 Appendix A Postpartum Depression Screening Survey How many years of NICU experience do you have? a. 0-4 b. 5-10 c. 11-15 d. 16-20 e. >20 What is your role in the NICU? a. Registered Nurse b. Health Unit Coordinator/Patient Care Technician c. Neonatal Nurse Practitioner d. Other I feel knowledgeable about the presenting signs and symptoms of postpartum depression. a. Strongly disagree b. Disagree c. Neutral d. Agree e. Strongly Agree I feel comfortable discussing postpartum depression with mothers of infants hospitalized in the NICU. a. Strongly disagree b. Disagree c. Neutral d. Agree e. Strongly Agree I feel knowledgeable about the effects of postpartum depression on childhood development (both physical & psychological). a. Strongly disagree b. Disagree c. Neutral d. Agree e. Strongly Agree I understand the importance of screening for postpartum depression in the NICU setting. a. Strongly disagree b. Disagree c. Neutral d. Agree e. Strongly Agree Patient acuity level is a potential barrier to postpartum depression screening and discussing postpartum depression with mothers. a. Strongly disagree b. Disagree c. Neutral d. Agree 30 e. Strongly Agree Documentation of postpartum depression screening in the EMR is important. a. Strongly disagree b. Disagree c. Neutral d. Agree e. Strongly Agree Mental health referrals should be performed and prioritized in mothers of NICU infants who screen positive on the Edinburgh Postnatal Depression Scale. a. Strongly disagree b. Disagree c. Neutral d. Agree e. Strongly Agree Have you had any formal training in postpartum depression and its effects? a. Yes b. No c. Some Please list concerns that you have related to the implementation of postpartum depression screening in the NICU. If you have no concerns, type N/A. 31 Appendix B Education of PPD and Training regarding Project Implementation Appendix C Edinburgh Postnatal Depression Scale- English 32 Appendix D Edinburgh Postnatal Depression Scale- Spanish 33