AH-TRIP

TPCH Social Work Department: Rebecca Averillo, Stroke Social Worker

TPCH Psychology Department: Ada Lo, Neuropsychologist

Stroke Mood Screening

Such a small component within the brain can have such a

large impact on quality of life

• It was identified that no formal processes existed at The Prince Charles Hospital to ensure stroke survivors received a formal mood screen during the acute stroke or rehabilitation phase, including appropriate intervention/referral where appropriate.

• The Prince Charles Hospital (TPCH) Rehabilitation and Acute Stroke Unit undergoes either an Acute Stroke or Rehabilitation stroke clinical audit (alternating each year). Within this audit, 40 charts are reviewed based on a complex audit process developed by the Stroke Foundation1.

• Performance data from these audits are provided by the Stroke Foundation. Audit results identified a gap in service and best practice stroke care.

1 Stroke Foundation. Clinical Guidelines for Stroke Management 2017. Retrieved from https://informme.org.au/Guidelines/Clinical-Guidel ines-for-Stroke-Management-2017

2Ml, H., & K, P. (2008). Part I: frequency of depression after stroke: an updated systematic review and meta-analysis of observational studies. - PubMed - NCBI. Retrieved from

https://www.ncbi.nlm.nih.gov/pubmed/25117911

Mood is frequently affected following a stroke. Depression is the most common mood disturbance with a meta-analysis of 61

observational studies finding almost one-third of patients with depression after stroke (Hackett et al, 2014)2.

• 0%

2009

• 16.2%

2011• 44.4%

2013

• 38%

2015

• 18%

2017

Percentage of stroke survivors who received a mood screen

What is the clinical problem?

• Depression is an important consequence of stroke that impacts on recovery yet often is not detected or is inadequately treated3.

• The consistently high proportion of stroke survivors with depression and other mood disorders emphasises the importance of screening and assessment for mood disturbance following stroke and specifically depression (Hackett et al, 2014).

• Where altered mood is suspected, formal screening should occur using a validated tool that is agreed upon within the local team. For people with communication and cognitive impairments, an observational tool may be more appropriate. Ideally this tool should capture both anxiety and depressive symptoms. A local site champion can be useful in the implementation process (Stroke Foundation, 2017).

1 Stroke Foundation. Clinical Guidelines for Stroke Management 2017. Retrieved from https://informme.org.au/Guidelines/Clinical-Guidel ines-for-Stroke-Management-2017

2Ml, H., & K, P. (n.d.). Part I: frequency of depression after stroke: an updated systematic review and meta-analysis of observational studies. - PubMed - NCBI. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25117911

3 Ml, H., & al., E. (n.d.). Interventions for preventing depression after stroke. - PubMed - NCBI. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/18646094

What is the evidence for mood screening post stroke?

• Psychotherapy appears to substantially reduce the risk of developing depression following stroke (81 fewer depression per 1000 patients treated), but may only be effective for patients without cognitive and communication difficulties who can actively participate in treatment (Hackett et al, 2008)3

• For stroke survivors, psychological strategies (e.g. problem solving, motivational interviewing) may be used to prevent depression. (Hackett et al, 2008)3

3 Ml, H., & al., E. (2008). Interventions for preventing depression after stroke. - PubMed - NCBI. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/18646094

What is the evidence surrounding interventions that may prevent depression

post stroke?

- Why do we do what we do? How do we know what we’re doing is ACTUALLY

best practice?

- What do you do if you find a gap in service provision?

__________________________________________

Consume, investigate, scope

• consume research to increase knowledge base – journal articles, professional guidelines

• investigate if others have already begun research in a desired field of interest. (No need to re-invent the wheel)

• scope out other professionals with knowledge in the desired field of interest

Initial steps to Stroke Mood Screening

• Undertook research into best practice patient care relating to stroke survivors. Clinical Guidelines for Stroke Management 2010

• Liaised with other professionals working within stroke across other HHSs to ascertain models of care that are currently in place

• Considered which professionals would be key stakeholders from TPCH with an interest in commencing mood screening

Evidence Based Practice – There’s a gap

in service, what now?

Plan Do Study Act (PDSA) cycle

Implementation Phase

4 Safety & Quality Unit, RBWH, MNHHS. (2017). Quality improvement framework. Retrieved from http://hi.bns.health.qld.gov.au/medical/safety_and_quality/documents/quality-framework.pdf

• Initial discussions held with Ada Lo, TPCH Neuropsychologist, indicated that this was a topic that Psychology Department were keen to see progress forward. Tricia Rolls, Psychology Department Director, provided support to proceed with mood screening changes, despite possible increase in referrals to Psychology Department.

• Undertook broader liaison with other key stakeholders to ensure support. – John Deeth, Ward Nurse Unit Manager– Dr Ling Lan, Dr Tik Chan and Dr Kathryn Colebourne (Ward Consultants)– Caitlin Kearney, Neurology Coordinator– Allied Health multidisciplinary team

• Through consultation, Ada advised of previous research completed by Psychology Department relating to the identification of best practice mood screening validation tools for stroke survivors with/without communication difficulties.

Consultation with interested parties…

Implementation Phase – who is involved

Investigating and creating a flow process

8Mood and anxiety screening pathway v3 - 170303

In the event that severe depressive symptoms are identified, patients will be flagged with medical team with a view to refer patients to CL-Psych as per standard clinical practice.

Implementation Phase

9

Implementation Phase - documentation

Chart stickers

10

Implementation Phase

Documentation

continued…

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GERIATRIC DEPRESSION

SCALE(GDS-15)

(Affix patient identification label here)

URN:

Family Name:

Given Names:

Address:

Date of Birth: Sex: M F I

Date of Completion: / / Completed by:

Please choose the best answer for how you felt over the past week.

Yes No Score

1. Are you basically satisfied with your life?

2. Have you dropped many of your activities and interests?

3. Do you feel that your life is empty?

4. Do you often get bored?

5. Are you in good spirits most of the time?

6. Are you afraid that something bad is going to happen to you?

7. Do you feel happy most of the time?

8. Do you often feel helpless?

9. Do you prefer to stay at home, rather than going out and doing new things?

10. Do you feel you have more problems with memory than most?

11. Do you think it is wonderful to be alive now?

12. Do you feel pretty worthless the way you are now?

13. Do you feel full of energy?

14. Do you feel that your situation is hopeless?

15. Do you think that most people are better off than you are?

Total:

Note: Score of 6 or more is suggestive of depression and may require further clinical interview.

Social Work to support and review Est. review date: ___________

Referral to Moodcheck? No Yes date: ___________ initials: __________

Simple additions of Social

Work interventions to

existing validated screening

tools

Don’t forget to collect data for future purposes

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Support for future

business cases

Support for further

research

Identify further gaps,

trends

Implementation Phase

Implementation Phase

• After collaboration with all stakeholders, and support from the TPCH Social Work Department, it was decided that the Stroke Social Worker would conduct mood screens as per the new Stroke Mood Screen Pathway.

• All stroke survivors to receive formal mood screen via validation tool at day 7 post stroke with follow up review mood screens where required.

• Should stroke survivor be discharged home within 7 days, mood screen to be conducted prior to discharge.

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Outcomes

Dissemination!

Abstract accepted into the International Journal of Stroke

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Outcomes – the greater organisation

• With dissemination comes improved practice in other Hospital and Health

Services…better outcomes for stroke survivors and better patient care.

Social Workers from the RBWH and

PAH are currently considering

whether they can implement a similar

pathway

Social Workers from the RBWH and

PAH requested further information to

consider whether the pathway could

be implemented within their

Directorate.

Future consideration - further liaison with stroke units within other

hospitals across Queensland and beyond.

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Outcomes

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Conclusion

Future planning?• Evaluation still required to ascertain effectiveness of the

process – time constraints? Reliability? New research relating to validation tools post stroke?

• Data collection• Creation of a Work Unit Guideline?• Collaboration with other hospitals?

Consume research

Identify gaps in service

Collaborate with others

Investigate options to improve patient care utilising best practice research