MMR vaccination audit

April 2014 – March 2015

Louise Frost

Antenatal & Newborn Screening Coordinator Princess Royal University Hospital

Aim

• To identify all women

who are Rubella non

immune and uptake

of MMR vaccination

Cohort identification

• Maternity system download booking data

which identifies cohort

• Manual input SC&T and infectious diseases

results – cross check laboratory spreadsheet

(failsafe process)

• Identified Rubella non-immune

• Set-up a separate spreadsheet including

delivered date & MMR vaccination date

Data collection

• 225 women identified as

Rubella non-immune

• 154 vaccinated

• 12 declined

• 25 miscarried/ transferred

out

• 30 no documentation in

hospital records

(1 woman pregnant)

• 4 unable to locate records

Review of maternity system documentation or hospital

records:

GP information

• Letters sent to GP informing

them of women who are

susceptible and to offer MMR

vaccination:

– Miscarried

– Transferred care

– Declined

– No documentation of

vaccination / missed

– No records

– Note input on maternity

system for women who is

pregnant

MMR vaccination uptake

Vaccinated 77%

Declined 6%

No documentation 17%

Difficulties

• Timely cross check – admin support

• Access to hospital records - offsite

• Lack of knowledge regarding vaccination

• True declines

Action plan

• Training regarding MMR

vaccination

– Face to face new starters

– e-learning mandatory

– ward talks

– Email memo

– safety briefing

• Improve documentation of

vaccination in hospital

records & maternity system

(Badgernet)

• Audit form implementation

• Guideline updated cross

site

Thank you

Any questions?