Antenatal Screening Audit 2015

Kate Israel

Antenatal & Newborn Screening Coordinator

Chelsea and Westminster Hospital

Aim

Demonstrate the quality of the antenatal screening programmes by assessing the level of compliance with Trust guidelines

Identify:

• if the processes for explaining, offering and documenting the results of antenatal screening are working

• if the management of screen positive results is robust

Method (documentation)

201 randomly selected maternity notes reviewed between 1st Apr 14 and 31st Mar 15 (min 10/month)

Criteria:

• ‘Screening tests for you and your baby’ leaflet received and discussed

• Each antenatal screening test explained and offered

• If consented to screening a result is in the notes

Results

NSC leaflet Downs syndrome screening Anomaly scan Hep B, HIV, Syphilis & rubella Sickle cell & thalassaemia

Leaflet given

Screening discussed

Explained

Offered

Result in notes

Explained

Offered

Result in notes

Scan gestation 18+0- 20+6

Explained Offered

Result in notes

Explained Offered Result in

notes

Missing data: 22 19 5 7 18

8 declined 6 6

10 5 N/A

5 5 N/A

2 2 4 2 2 4

Comments:

All missing Down syndrome screening results accounted for and low risk.

Screening is also explained and

offered by sonographer. Consent is documented on the scan report.

All missing anomaly scan reports reviewed electronically and NAD. 5 notes reviewed prior to anomaly scan – all

women had planned appts.

Anomaly scan is also explained and offered by sonographer. Consent is documented on scan report.

3 women were offered scans within timeframe and

rearranged their appts. 2 women were referred late. Therefore 100% were offered anomaly scan appointments 18+0 - 20+6 weeks gestation

All missing results on accounted for and NAD on lastword

The 4 women with missing

results had had multiple antenatal appointments with

midwives and/or obstetricians.

All missing results on accounted for and NAD on lastword

The 4 women with missing results

had had multiple antenatal appointments with midwives

and/or obstetricians.

Complete data:

179/201 182/201 196/201 194/201 175/193 195/201 195/201 186/196 191/196 199/201 199/201 197/201 199/201 199/201 197/201

% compliance 89.0% 90.5% 97.5% 96.5% 90.6% 97.0% 97.0% 94.9% 97.4% 99.0% 99.0% 98.0% 99.0% 99.0% 98.0%

2014 results 85.5% 89.1% 90.1% 97.0% 91.9% 92.3% 92.3% 95.8% 96.2% 99.5% 99.5% 99.1% 99.5% 99.5% 98.6% 2013 results: 85.0% N/A 92.8% 89.9% 86.9% 90.0% 90.0% 93.9% 89.5% 95.7% 97.8% 95.7% 96.4% 97.8% 95.7%

Results

0

10

20

30

40

50

60

70

80

90

100

Down screening Fetal anomaly Infectious diseases SC&T

% c

om

plia

nce

wit

h g

uid

elin

e

Explained Offered Results

Method (screen positive)

Reviewed all screen positive results 1st Apr 14 - 31st Mar 15 (except rubella). Criteria:

• Time taken by lab to inform specialist midwife

• Women informed within 2 working days

• Follow up compliant

Additional criteria included:

• Appointment timeframe (FASP, hep B & syphilis)

• Partner testing uptake (SC&T)

• Letter sent (rubella)

Results

0 20 40 60 80 100

Care plan documented

Prenatal diagnosis explained and offered

Partner testing accepted

Partner testing explained & offered

Results received & informed within 2 working days

Results received & attempt to contact within 2 working days

Timeframe from sample taken to result received

Sickle cell & thalassaemia screen positive audit results

% compliance with guidelines

Conclusion

Overall, a high level of compliance with Trust guidelines which incorporate the screening programmes standards

• Key improvements identified

• Action plan implemented

• Repeat audit next year

Action plan Recommendation Actions Lead Timeframe

Share audit findings & recommended actions Present to Maternity Clinical Effectiveness Committee Present to ANNB steering group

Kate Israel Oct 15

100% of women to have documented receipt of the screening for you & your baby leaflet 100% of women to have documented explanation, offer of & if accepted a result for each screening programme in maternity notes

Email audit results to core antenatal clinic & community midwives Include in annual screening updates, in addition to e-learning, for

antenatal clinic & community midwives Continue to involve midwives in the monthly maternity notes audit

Kate Israel Oct 15

SC&T laboratory to inform specialist midwife of screen positive results in <= 5 working days

Liaise with SC&T laboratory lead & share audit results Laboratory to improve systems to ensure that the specialist

midwife is informed of additional tests

Kate Israel Jun 15

Improve documentation of antenatal rubella susceptibility letter being sent to women & GPs

Develop and implement an action plan with the antenatal clinic and community midwifery leads

Sarah Dermont Sept 15

Ensure rubella screen positive women have a documented offer of MMR vaccine prior to discharge

Develop and implement an action plan with the maternity inpatient ward lead and matron.

Sarah Dermont Sept 15

Ensure that the electronic prescription chart is completed for MMR

Develop and implement an action plan with the maternity inpatient ward lead and matron.

Sarah Dermont Sept 15

Cotinuous audit of antenatal screening documentation

Continue monthly audit of a minimum of 10 sets of antenatal maternity notes & maintain the audit database

Kate Israel Jun 15

Continuous audit of screen positive result management

All screening programmes have screen positive databases managed by the appropriate specialist midwife which are used to continuously monitor & audit all aspects of the pathway

Kate Israel Sarah Dermont Julia Baker

Jun 15