Professor Linda Worrall-Cartera
Dr Karen Pagea, Dr Steve Bunkerb
Professor Patricia Davidsonc
Associate Professor Andrew MacIsaacd
Dr Mike Salzbergd
Dr Bridget Hamiltond
Dr Karen-leigh Edwarde
Professor Robert Cumminsf
Professor David Thompsong
a St Vincent’s/ACU National Centre for Nursing Research, St Vincent’s Public Hospital, Melbourne
b Medibank Private
c Curtin University of Technology
d St Vincent’s Public Hospital, Melbourne
e La Trobe University
f Deakin University
g Leicester University
beyondblue Victorian Centre of Excellence
Project completion year
This study aimed to improve depression and anxiety screening in people with coronary heart disease (CHD) using a ward-based clinical pathway. Stage 1 involved two steps: a retrospective medical record audit of 147 participants to provide baseline data and the development of a Clinical Pathway by a multidisciplinary group that included cardiac nurses, cardiologists, GPs and representatives from a liaison psychiatry service, a health education service and a cardiac rehabilitation service. Medical records from a 12-month period were randomly examined for current screening and referral practices in people over 18 years admitted with a primary diagnosis of acute coronary syndrome, or heart failure decompensation, or for a percutaneous coronary intervention. The Clinical Pathway screened people for depression/anxiety and described the actions required for people at moderate/high risk for these conditions.
In Stage 2 the Clinical Pathway was implemented in two cardiac wards over a four-month period, with project team members providing coordination, follow-up, education and motivation. There were seven specialty education sessions on depression and CHD, covering 53 nursing staff. A follow-up telephone survey with ten patients asked whether their emotional well-being was discussed and assessed during the admission.
The medical record audit showed that screening and referral for depression/anxiety was infrequent, even in the face of documented depressive symptomatology. No clinical, validated depression and anxiety assessment tool existed for clinical staff. When screening did occur, it involved a non-validated psychological component of a falls risk assessment tool (63 participants, 43 per cent). There were 18 referrals, more often to pastoral care and/or social work than to mental health services. The study found 32 people (22 per cent) were noted to have significant mood changes possibly indicative of depression, but only four of these were referred for follow-up.
When the Clinical Pathway was implemented, there was a significant improvement in the formal assessment of depressive symptoms. Over the 18 weeks, 201 people with CHD who would not normally have been screened for depression/anxiety were assessed using a validated instrument (the 5-item Cardiac Depression Scale). The Clinical Pathway also identified 110 patients (55 per cent) with moderate/high risk of depression. The Clinical Pathway empowered nurses by providing quantitative evidence on CHD patients at risk of depression/anxiety and a formalised process to document this. Afterwards, 77 per cent of nurses surveyed reported routinely screening for depression/anxiety. Compared to baseline, almost twice as many nurses were screening CHD patients and using a validated tool to do so.
Of people at moderate/high risk of depression (n = 110):
- 89 per cent (99 participants) had the risk score documented in their medical history
- 88 per cent (98 participants) had discussions with clinicians regarding the risk score
- 84 per cent (93 participants) had their risk score communicated formally to the medical team.
There was a significant increase in referrals for follow-up of emotional health: 45 people were referred to primary care; eight were offered referral to inpatient psychiatry (only three accepted this); six people who were referred had discussions with cardiac rehabilitation coordinators; and seven people indicated they already had a mental health plan through their GP.
As a secondary outcome, the educational sessions increased nurse knowledge and awareness of depression in people with CHD. Before the sessions, only 14 nurses indicated they had a good understanding of this, but one to two months later the figure had risen to 24, while the number of nurses reporting limited knowledge decreased from 25 to six. Additionally, the profile of the consultant psychiatric liaison service increased on the cardiac wards and a referral barrier was identified, in that only doctors, not nurses, could make referrals.
Implications for policy, practice and further research
Nurses in acute cardiac wards should, as a core competency, develop the skills to discuss emotional health with patients and make recommendations for follow-up. Many nurses are skilled in assessing emotional well-being, but their skills are often unrecognised and underutilised. Processes should be developed to harness these skills via appropriate use of tools and mentoring.
Research is needed to evaluate, longitudinally, the effectiveness of the Clinical Pathway and identify barriers to service provisions, including mapping longer-term outcomes of referrals to primary or community healthcare services and investigating why patients decline referral to mental health services.
It is not known whether emotional needs differ between people admitted for cardiac surgery and those admitted for medical management. Knowing this would determine the appropriateness of screening for depression/anxiety in different cardiac populations and could identify the optimal time for screening.