Depression screening, heart failure, nurse practitioner, quality improvement



  1. Wilhelm, Elizabeth A. B. DNP, FNP-BC


Background: About one in three patients with heart failure (HF) have depression. Comorbid HF and depression are associated with poor outcomes and increased health care burden. Clinical guidelines recommend routine depression screening in patients with HF.


Local Problem: Depression screening was not being systematically implemented in an outpatient cardiology clinic.


Methods: To create a sustainable process for a cardiology clinic to screen adults with chronic HF for depression, identify patients who have an elevated depression screening score and initiate an evidence-based treatment algorithm for patients with depressive symptoms.


Intervention: A nurse practitioner (NP)-led process improvement project administered the Patient Health Questionnaire (PHQ-9) tool to patients with HF. The score was reviewed by the NP and, if elevated, addressed with assessment and plan. Compliance was measured by the percentage of patients screened. Clinical impact was measured by percentage of patients with an elevated score with a documented treatment plan.


Results: Postimplementation results for four Plan-Do-Study-Act cycles were 38%, 68%, 72%, and 66%, respectively, with a total 63% of patients screened during the entire project. Twenty unique patients (13.2%) had elevated PHQ-9 scores; all had a documented treatment plan.


Conclusions: We demonstrated how a screening protocol and an accompanying treatment algorithm can be successfully implemented in an outpatient cardiology clinic. Elements of success included a standardized screening protocol, a clinical support algorithm for treatment/referral, an optimized electronic medical record, and a follow-up system for patients with significant depressive symptoms. Stakeholder engagement throughout the project informed iterative changes and provided direction for sustainability.