Antenatal Did Not Attend DNA Appointment Guideline April 2014

WOM/MAT/CLI/GUI/V1/2014/04
MATERNITY SERVICES GUIDELINE
Missed Appointments - Did not attend (DNA)
APPROVING COMMITTEE(S)
EFFECTIVE FROM
DISTRIBUTION
RELATED DOCUMENTS
STANDARDS
OWNER
AUTHOR/FURTHER INFORMATION
SUPERCEDED DOCUMENTS
REVIEW DUE
KEYWORDS
CONSULTATION
INTRANET LOCATION(S)
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Barts Health
Maternity
Date
11th April
Improvement
approved:
2014
Board
24th April 2014
All staff in the maternity service
Intranet
Booking guideline, Obstetric Ultrasound
guideline
CNST Clinical Risk Management Standards for
Maternity Service (2013-14) (Criterion 4.2)
Sandra Reading, Director of Nursing, Midwifery
& Governance for Women’s Health.
Debbie Twyman, Lead Midwife for Low Risk,
Whipps Cross University Hospital
Missed Appointments, Whipps Cross University
Hospital NHS Trust (2010)
Antenatal Care Booking and Missed
Appointment Guidelines, (2010) Barts and the
London NHS Trust
Maternity Booking and Missed Appointments
Guideline, (2011) Newham University Hospital
NHS Trust
April 2017
Antenatal, missed appointments and DNA.
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Maternity Improvement Board
Denise McEneaney - Consultant Midwife.
Royal London Hospital.
Barts and the London unit
(BLT)
Margaret Keenan - Clinical Lead Midwife for
Antenatal Services.
Mr. M. Hogg - Consultant Obstetrician and
Gynaecologist
WOM/MAT/CLI/GUI/V1/2014/04
Newham University Hospital
unit (NUH)
Whipps Cross University
Hospital (WX)
External Partner(s)
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Sonia Jabke - Clinical Lead Midwife for
Antenatal Services.
Mr. R. Maplethorpe -Consultant Obstetrician
and Gynaecologist
Mr. Gupta - Consultant Obstetrician and
Gynaecologist
Debbie Twyman - Clinical Lead Midwife for
Antenatal Services.
Not applicable
SCOPE OF APPLICATION
AND EXEMPTIONS
WOM/MAT/CLI/GUI/V1/2014/04
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Included in policy:
For the groups listed below, failure to follow the policy may result in investigation and
management action which may include formal action in line with the Trust's disciplinary or
capability procedures for Trust employees, and other action in relation to organisations
contracted to the Trust, which may result in the termination of a contract, assignment,
placement, secondment or honorary arrangement.
All Trust staff, working within or for the maternity service in whatever capacity
All agency staff, students midwives, student nurses and doctors in training
working within the maternity service
Exempted from policy:
The following groups are exempt from this policy
Non-maternity staff
WOM/MAT/CLI/GUI/V1/2014/04
TABLE OF CONTENTS
1
INTRODUCTION AND AIMS OF POLICY
Responsibilities of relevant staff group
2
FOLLOW UP OF WOMEN WHO FAIL TO ATTEND A CONSULTANT
ANTENATAL CLINIC APPOINTMENT
5
5
5
3
FOLLOW UP OF WOMEN WHO FAIL TO ACCESS MIDWIFERY CARE DURING
THE ANTENATAL PERIOD
6
Responsibilities
6
Objectives
6
Process
7
Documentation
7
4
MISSED ANTENATAL ULTRASOUND APPOINTMENTS
8
5
MISSED ANTENATAL DAY ASSESSMENT UNIT APPOINTMENTS (DAU)
8
6
MONITORING THE EFFECTIVENESS OF THIS POLICY
7 REFERENCES
Appendix 1: Antenatal Non-Attenders Flow Chart
Appendix 2: Change Log
Appendix 3 – Impact assessments
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9
10
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WOM/MAT/CLI/GUI/V1/2014/04
MISSED APPOINTMENTS
1
INTRODUCTION AND AIMS OF POLICY
1.1
Saving Mothers Lives (CEMACH 2007) identifies that around 20% of women
who died from direct or indirect causes missed more than four routine antenatal
appointments, did not seek care at all or actively concealed their pregnancies.
This delay denied them the opportunities that early maternity care provides for
mother, baby and family.
1.2
This guideline includes guidance on action to be taken when women fail to keep
any antenatal appointment in any care setting. Women who fail to attend their
appointments require follow up to ensure they are offered appropriate care.
1.3
Midwives have a responsibility to ensure that services are accessible to women
in the local community that women and their families are aware of the services
available to them and that women who do not attend for appropriate care are
followed up and given every reasonable opportunity to receive midwifery care.
1.4
All midwives / health professionals should be aware:
 The increased risk to women and their pregnancy of frequent nonattendance for midwifery care.
 The relevant guidelines and for appropriate follow up of non-attendees.
1.5
Non attendance of antenatal appointments has a strong correlation with poor
maternal and neonatal outcomes. It is essential that a proactive and innovative
approach is taken by all maternity staff to support early and regular contact with
maternity services. Women will usually attend if they understand the reason for
the appointment and at a time that is manageable to them.
1.6
All women booking for maternity care at Bart’s Health who fail to attend for
antenatal appointments will be contacted either by phone or letter by a midwife
or clerical support to investigate their non attendance.
Responsibilities of relevant staff group
It is the responsibility of all staff groups to document when a woman fails to attend any
appointment during the antenatal period, detailing the type of appointment missed.
2
FOLLOW UP OF WOMEN WHO FAIL TO ATTEND A CONSULTANT
ANTENATAL CLINIC APPOINTMENT
2.1
Women who fail to attend a Consultant Obstetrician’s Antenatal Clinic
appointment should be followed up to ensure they are offered appropriate care.
Non-attendance is a known risk factor for poor outcomes.
2.2
All booked appointments should be recorded on the electronic booking system.
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WOM/MAT/CLI/GUI/V1/2014/04
2.3
All case notes should be available at the time of the appointment.
2.4
At the end of the clinic women who have not attended need to be followed up
by a midwife. Before further appointments are sent out all written or electronic
records need to be checked to establish any possible reason for the nonattendance e.g. miscarriage, delivery, transfer to another hospital or change of
address. A new appointment should be sent out at the next available
designated consultant appointment.
2.5
After a second consecutive non-attendance the notes/records and alert register
are checked and confirmation of the woman’s contact details should be
obtained from the General Practitioner’s (GP’s) surgery. If there is no obvious
reason for the non-attendance then a follow-up of non-attendance form is sent
out to the woman’s community midwife to contact and visit the woman to
ascertain the reason for non-attendance and take appropriate action and
arrange further appointment as required. The community midwife should return
the completed non-attendance form to the antenatal clinic within 14 working
days. Antenatal clinic midwives will update their records and hospital notes with
this information.
3
FOLLOW UP OF WOMEN WHO FAIL TO ACCESS MIDWIFERY CARE
DURING THE ANTENATAL PERIOD
Responsibilities
3.1
Midwives are responsible for ensuring that services are accessible to women in
the local community; that women and their families are aware of the services
available to them, and that women who do not attend for appropriate care are
followed up and given every reasonable opportunity to receive midwifery care.
All midwives must provide care that is safe and effective for women and their
families.
3.2
All women who do not attend a midwifery appointment are followed up to
ensure appropriate midwifery care has been/will be received.
3.3
All women who are not at home for an agreed visit will be followed up to ensure
appropriate care has been/will be received.
3.4
All women will be made aware of the importance of antenatal and postnatal
care for the health and wellbeing of themselves and their babies.
Objectives
3.5
Midwives will be aware of the increased risk to women and their babies of
frequent non-attendance for midwifery care.
3.6
Midwives should be aware of the guidelines for appropriate follow up of nonattendees.
3.7
Midwives should offer women reasonable access to midwifery care in the
community.
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WOM/MAT/CLI/GUI/V1/2014/04
3.8
Midwives should ensure that women who do not present for care are identified,
clear records kept and alternative access to care offered.
3.9
Where a woman is identified as not accessing appropriate midwifery care,
midwives should communicate with all relevant agencies, (GP, Hospital,
Midwives, Midwifery supervisors, Health Visitors, Child Protection team, Social
Services).
Process
If a woman fails to make herself available for an initial booking appointment:
3.10
Midwives should review records, contact GP or hospital to confirm that the
pregnancy is still ongoing. Check if address correct. If the woman has preschool/school age children, midwives should liaise with health visitor and/or
school nurse.
3.11
Midwives should contact the woman and arrange an alternative appointment.
3.12
Where telephone contact cannot be made a further appointment should be sent
by post.
3.13
If a women fails to be available for a second appointment a further letter should
be sent encouraging the women to contact the midwives.
3.14
If a woman fails to contact the midwives, the midwife responsible for
coordinating her care should arrange to visit the woman’s home and offer to
discuss when it would be appropriate for her to complete the booking process.
3.15
If the named midwife fails to gain access at this point, she should: contact the
woman’s GP explaining her concerns; contact the Community Team Leader to
inform of concerns; discuss the case with her Supervisor of Midwives; refer the
woman to the consultant obstetric unit.
3.16
Midwives should keep accurate records of contacts made and appointments
offered within the community midwife team office. Copies of letters should be
included in a woman’s hospital notes.
3.17
If a woman fails to make herself available for subsequent antenatal care the
above actions should be repeated.
3.18
The case should be discussed with the relevant specialist midwife.
Documentation
3.19
Good communication is vital between the multidisciplinary team to ensure
everyone involved is aware that the woman is not accessing antenatal care.
Each time a woman fails to attend an antenatal appointment, the midwife
involved in the care is responsible for ensuring that this is documented in the
maternal records. A Missed Appointment Proforma should be completed for
each appointment missed.
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WOM/MAT/CLI/GUI/V1/2014/04
4
4.1
MISSED ANTENATAL ULTRASOUND APPOINTMENTS
If any obstetric ultrasound appointment is missed, midwife sonographer or
midwife working in the antenatal clinic (ANC) will investigate to see if the
woman has:



miscarried
given birth or is a hospital inpatient
moved out of area or is still registered with the same GP
has an appointment elsewhere or has changed her appointment
4.2
If none of the above is applicable the midwife sonographer/antenatal clinic
midwife will contact the woman by telephone or send a further appointment by
letter.
4.3
If a woman does not attend an ultrasound department appointment the
sonographer informs the Antenatal Clinic, and the antenatal clinic midwife will
contact the woman as above.
4.4
All missed appointments and actions taken should be documented in the
hospital maternal records.
5
MISSED ANTENATAL DAY ASSESSMENT UNIT APPOINTMENTS (DAU)
5.1
If any woman fails to attend a DAU appointment the midwife running the DAU is
responsible for contacting the woman and rearranging the appointment.
5.2
If the woman needs to be reviewed the same day and the DAU midwife is
unable to make contact within working hours, the Delivery Suite co-ordinator
must be informed and follow up arranged. This should be documented in the
DAU diary.
5.3
If contact with the woman is not possible the midwife in DAU will need to inform
original referrer to follow up.
5.4
All missed appointments and actions taken should be documented in the
hospital notes.
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WOM/MAT/CLI/GUI/V1/2014/04
6
MONITORING THE EFFECTIVENESS OF THIS POLICY
Issue being monitored
Monitoring
method
Responsibility
Frequency Reviewed by
and actions
arising
followed up by
Process for ensuring that Audit
any women who miss any
type of antenatal
appointment are followed
up including the
responsibilities of health
care professionals
Lead Midwife
for Low Risk
Annual
Women’s
Quality,
Assurance and
Safety
Committee
Documentation of the Audit
follow up process for
women who miss any
type
of
antenatal
appointment including the
fact that the women are
seen.
Lead Midwife
for Low Risk
Annual
Women’s
Quality,
Assurance and
Safety
Committee
7 REFERENCES
Confidential Enquiry into Maternity and Child Health, (CEMACH) (2007). Saving
Mother’s Lives 2003-2005.
Confidential Enquiry into Maternal Deaths (CEMD) (1997-1999 & 2000-2002). Why
Mothers Die.
Nursing and Midwifery Council (NMC) (2009) Record Keeping: Guidance for Nurses and
midwives, Nursing and Midwifery Council. Available at www.nmc-uk.org
Nursing and Midwifery Council (NMC) (2010) The Code: Standards of Conduct,
Performance and Ethics for Nurses and Midwives. Nursing and Midwifery Council.
Available at www.nmc-uk.org
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Appendix 1: Antenatal Non-Attenders Flow Chart
DNA Hospital Midwife /
Consultant/Ultrasound
Appointment
DNA Community Midwife
Appointment
Check written and electronic
records to confirm still pregnant,
not delivered or transferred to
other hospital or changed address.
Confirm woman still pregnant via
GP and hospital and check correct
address
Contact woman to arrange further
appointment via phone or letter
Send repeat appointment
and contact Community
Midwife by letter
2nd Consecutive DNA
Send further letter
encouraging the woman
to contact the midwives
If a woman fails to contact
midwives. Midwife to arrange a
home visit.
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Check notes/electronic
system as before. Contact
GPs surgery to confirm
contact details and check if
any reason for DNA
Check electronic system for any
changes, send non-attender letter to
community midwife to contact/visit
woman. (Letter to be returned within
14 working days in order to update
records)
WOM/MAT/CLI/GUI/V1/2014/04
Appendix 2: Change Log
Change Log – Maternity Service Risk Management Strategy
Substantive changes since
previous version
Reason for Change
Author & Group(s)
approving
change(s)
New Policy
Merger of three policies
Debbie Twyman,
Lead Midwife for
Low Risk – Whipps
Cross University
Hospital and
Maternity
Improvement Board
Appendix 3 – Impact assessments
Equalities impact checklist - must be completed for all new policies
Microsoft Word 97 2003 Document
Organisational impact checklist - must be completed for all new policies
Microsoft Word 97 2003 Document
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