2 antenatal screening audit 2015 kate israel
TRANSCRIPT
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