4 mmr audit – louise frost
TRANSCRIPT
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?