CLINICAL GUIDELINE

MANAGEMENT OF BLOOD SPOT SCREENING IN THE Register No: 08065

NEWBORN Status: Public

Developed in response to: National Screening Committee

Contributes to CQC Outcome No: 11, 12

Consulted With: Individual/Body: Date:

Anita Rao/ Clinical Director for Women’s, Children’s Division April 2018
Alison Cuthbertson
Vidya Thakur Consultant for Obstetrics and Gynaecology
Dr Hassan Consultant Paediatrician
Alison Cuthbertson Associate Director of Midwifery/Nursing
Paula Hollis Lead Midwife Acute Inpatient Services
Chris Berner Lead Midwife Clinical Governance
Angela Woolfenden Lead Midwife Community Services; Named Midwife Safeguarding
Sarah Iskander Antenatal Clinic Midwife
Sarah Moon Specialist Midwife Guidelines and Audit
Professionally Approved By:
Anita Rao Lead Consultant for Obstetrics and Gynaecology April 2018

Version Number 5.0

Issuing Directorate Women’s and Children’s
Ratified by DRAG Chair’s Action
Ratified on 18th June 2018
EMG Sign Off Date July 2018
Implementation Date 16th July 2018
Next Review Date May 2021
Author/Contact for Information Emma Neate, Antenatal Newborn Screening Co-ordinator
Policy to be followed by (target staff) Midwives, Obstetricians
Distribution Method Intranet and Website.
Related Trust Policies (to be read in 04071 Standard Infection Prevention
conjunction with) 04072 Hand Hygiene
04272 Maternity Care
08045 Guideline for Amniocentesis for Antenatal Diagnosis
08046 Guideline for Interpreting and Acting on CVS sample and
Amniocentesis Results
06031 Receiving and Acting on Test Results in Maternity by both
Hospital and Community

Document Review History:

Review No: Reviewed by: Issue Date:
1.0 L. Collins, S Pilgrim, August 2008
2.3 Kathleen Bird - Additional Referral Form November 2008
3.0 Nicola Leslie February 2012
3.1 Lyn Collins and Nicky Leslie – clarification to point 4.0; Expanded May 2012
Newborn Screening Pilot (16/07/12 – 19/07/13)
4.0 Nicola Leslie, Antenatal Newborn Screening Co-ordinator March 2015
5.0 Emma Neate – Full review 16th July 2018

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INDEX

1. Purpose
2. Equality and Diversity
3. Aim
4. Information for parents
5. Research
6. Declining Screening
7. Screening accepted timeframe for screening well babies
8. Completing Bloodspot Documentation
9. Completing Bloodspot – Collecting the sample
10. After taking the blood spot sample
11. Special Circumstances: Babies born preterm or cared for in Neonatal Unit
12. CHT Screening for Preterm Infants
13. Repeat Samples
14. Avoidable Repeats
15. Failsafe Processes
16. Receiving Results
17. Staff and Training
18. Infection Prevention
19. Audit and Monitoring
20. Guideline Management
21. Communication
22. References
23. Appendices

Appendix A - A Summary of Screening Conditions

Appendix B - Northgate Failsafe System
Appendix C - Standard Operating Procedure for Newborn Bloodspot Screening for
Babies Born in Area
Appendix D - Standard Operating Procedure for Newborn Bloodspot Screening for
Babies Born Out of Area

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1.0 Purpose

1.1 To give guidance to all medical and nursing staff on the latest procedures for blood spot
screening.

1.2 To ensure all infants are screened as per the national protocol and blood spot screening
is repeated as necessary.

2.0 Equality and Diversity

2.1 Mid Essex Hospital Services NHS Trust is committed to the provision of a service that is
fair, accessible and meets the needs of all individuals.

3.0 Aim

3.1 Newborn blood spot (NBS) screening identifies babies who may have rare but serious
conditions. The UK National Screening Committee (UK NSC) recommends that all
babies are offered screening for (See Appendix A for Summary of Conditions, Appendix
C, D for processes) –
 Sickle cell disease (SCD),
 Cystic fibrosis (CF),
 Congenital hypothyroidism (CHT)
Six inherited metabolic diseases (IMDs):
 Phenylketonuria (PKU),
 Medium-chain acyl-CoA dehydrogenase deficiency (MCADD),
 Maple syrup urine disease (MSUD),
 Isovaleric acidaemia (IVA),
 Glutaric aciduria type 1(GA1)
 Homocystinuria (pyridoxine unresponsive) (HCU).

For the small number of babies affected, early detection, referral and treatment can help
to improve their health and prevent severe disability or even death. Without early
treatment, the conditions screened for can result in:

 SCD - severe pain, life-threatening infections and anaemia (symptoms can be

present even with treatment)
 CF - poor weight gain, frequent chest infections and reduced life expectancy
(symptoms can be present even with treatment)
 CHT - permanent, serious physical problems and learning disabilities
 PKU - permanent brain damage and serious learning disabilities
 MCADD - serious illness and possible death
 MSUD - coma, permanent brain damage and possible death
 IVA - coma, permanent brain damage and possible death
 GA1 - coma and neurological damage
 HCU - learning difficulties, eye problems, osteoporosis, blood clots or strokes

For further information on all aspects of the newborn blood spot screening programme -
www.gov.uk/topic/populationscreening-programmes/newborn-blood-spot.

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4.0 Information for Parents

It is important to offer parents an informed choice about screening for their baby, to gain
consent and to prepare them for the blood sampling procedure. Babies that move into an
area and are eligible for screening should be offered screening as soon as possible.

 At or prior to antenatal booking, women are given a copy of the ‘Screening tests
for you and your baby’ booklet. This includes a section on newborn blood spot
screening.

 Ensure the booklet is in the appropriate language for the parents. Translated
versions are available from www.gov.uk/government/publications/screeningtests-
for-you-and-your-baby-description-in-brief or from the Antenatal Screening office
in Antenatal Clinic at Broomfield Hospital.

 If the required language is not available, an interpreter should be arranged to

discuss screening, the use of friends and family is not recommended practice.

 If there is a family history of PKU or MCADD, it is advantageous to take a

sample earlier as part of standard clinical practice. The PKU and MCADD
sample can be taken 24-48 hours after birth, with the reason being clearly
stated on the card. The Screening should be made aware of this family as
soon as possible in pregnancy and a plan of care put into place following
delivery.

 A healthcare professional should offer screening and record the parents’ decision
at least 24 hours before the screening is performed, documented in the babies
postnatal notes that newborn blood spot screening has been discussed and
recommended.

5.0 Research

 Parents should be asked if they wish to be contacted about research linked to the
screening programme.
Information is available at www.nhs.uk/Conditions/pregnancy-
andbaby/Pages/newborn-blood-spot-cards.aspx

 If a parent does not wish to be contacted about future research on their baby’s
newborn bloodspot screening sample, ‘No research contact’ should be recorded
clearly on the blood spot card.

 Ensure parents are aware that patient identifiable information may be stored by the
NHS Sickle Cell and Thalassaemia Screening Programme.

6.0 Screening Declined

The healthcare professional responsible for ensuring that screening has been offered
should:
 Record each condition declined and the reason (if stated) in the Child Health record
book / maternity notes (if applicable).

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  Parents can decline screening for SCD, CF and CHT individually but the six IMDs can
only be declined as a group.

 If screening is declined for all conditions, complete the blood spot card as described
in section 2 (add the reason for the decline if stated) and send marked ‘Decline – all
conditions’ to the laboratory without the blood spot sample.

 If screening is declined for only one or some of the conditions arrange for the
bloodspot sample to be taken. The bloodspot card should be completed and marked
‘Decline – XX’ (where XX is the condition(s) declined – add the reason for the decline
if stated).

 Inform the Screening team at Broomfield (01245 513433 or email

antenataland.newbornscreening@nhs.net ) of any declined screening (if baby is
under 28 days of age); this will allow for failsafe processes to be and systems to be
updated; also notify Child Health, GP and health visitor.

 Ensure parents are informed that screening can be performed up to one year of age,
up to day 56 for Cystic Fibrosis screening. If they decided to have screening within
this time they should contact their GP or Health Visitor to arrange screening.

7.0 Screening Accepted / Timeframe for Screening for Well Babies

 Record the parents’ screening decision as ‘consent’ and their decision about future
research contact in the Child Health record book and in the babies hospital notes.

 The blood spot sample should be taken on day 5* for all babies regardless of medical
condition, medication, milk feeding and prematurity. *In exceptional circumstances the
sample can be taken between day 5 and day 8.

 For the purpose of screening, day of birth is day 0

8.0 Completing Bloodspot – Documentation

 The baby’s NHS number on the blood spot card is mandatory. Use of a bar-
coded label is recommended; this saves time in data entry and minimises
transcription errors.

 NHS number bar-coded labels should be generated at the point of notification of birth
and given to parents with the Child Health Record book on transfer from hospital to
home or before, so that they are available for blood spot screening.

 Do not delay screening movers in if not registered with a GP – the Child Health
Department can generate an NHS number.

 Check expiry date on the front of the blood spot card.

 When completing the blood spot card, care must be taken to place the card on a
clean surface.

 Complete the details on the blood spot card at the time of sampling. Use of a bar-
coded label is recommended.
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  When using a bar-coded label it is important that the information is accurate
and complete:
ensure that no sections of the barcode or text are cut off or missing
check with the parents that all details on the label are correct and make any
necessary changes
do not use incomplete / unreadable labels. Instead, complete the details on the
blood spot card using block capital letters.

apply one label to each sheet of the blood spot card at the time of sampling (do not
apply in advance of the test)

 Use block capital letters to complete all fields on the blood spot card that are
not
included on the bar-coded label.

 Further information on bar-coded labels can be found at -

www.gov.uk/government/publications/barcodelabels-quality-assurance-in-newborn-
blood-spotscreening

 If label is not available:

Ensure all fields are completed using block capital letters.

 For all cards:

Record the maternity organisation code in the ‘PCT’ field.

 Record any of the following in the ‘comments’ box on the blood spot card:
baby’s known medical condition
family history relevant to the conditions screened for
reason for sample if not taken on day 5-8 (for example, pretransfusion, preterm
CHT)

 Check the completed blood spot card with the parents and make any necessary
changes.

9.0 Completing Bloodspot – Collecting the Sample

 To take a newborn blood spot sample you will need:

NHS Screening Programmes’ booklet ‘Screening tests for you and your baby’
baby’s NHS number (use of a bar-coded label is recommended)
blood spot card and glassine envelope
personal child health record (PCHR) and babies hospital records
water for cleansing
non-sterile protective gloves
age-appropriate, automated incision device* (manual lancets must not be used)
sharps box
cotton wool/gauze
hypoallergenic spot plaster (if required)
prepaid/stamped addressed envelope (first class) (if not using a courier)

 Sample takers should check that consent for screening has been obtained and
recorded.

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  Recommend comfort measures for the baby.
 Ensure the baby is cuddled and in a secure position for taking the sample –
swaddling the
 Baby may reduce pain/discomfort.
 Engaging the baby through face-to-face contact, voice and touch may be
beneficial.
 Suggest the baby is breast feeding during the heel prick as an analgesic.
 An alternative to breast feeding is to offer expressed breast milk, non-nutritive
sucking
solution.
 Whilst there is no evidence that formula feed has analgesic properties, parents
may comfort formula-fed babies with a feed during the procedure.

 Clean the heel by washing thoroughly with plain water using cotton wool/gauze. The
water should not be heated and the baby’s foot should not be immersed.

 If faecal matter cannot be removed from the foot with water, use a mild, unperfumed
soap to clean away the faecal matter and then rinse the foot thoroughly.

 Do not use alcohol or alcohol wipes.

 The heel should be completely dry before taking the sample.

 Soft paraffin solutions such as Vaseline® should not be used for heel punctures

 Wash hands and apply gloves

 Ensure the baby is warm and comfortable.

 Warming of the foot is not required.

 Obtain the sample using an age-appropriate automated incision device (different

lancets are available for different ages).

 There is some evidence that an arch-shaped incision device is more effective in

providing a good quality sample, reducing the number of heel punctures per sample,
the time taken to complete the sample, bruising, the time the baby cried, and the need
to repeat the sample.

 Manual lancets must not be used.

 For full-term and preterm infants, the external and internal limits of the calcaneus are
the preferred puncture site. This is marked by the shaded areas in Figure 1. Skin
puncture must be no deeper than 2mm.

 For infants who have had repeated heel punctures, the areas marked in Figure 2 may
also be used. When using the whole plantar surface, an automated incision device
with a penetrative depth of no more than 1mm is recommended.

 Avoid posterior curvature of the heel.

 Allow the heel to hang down to assist blood flow.

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 Before activation place the automated incision device against the heel in accordance
with manufacturer’s instruction.

Figure 1 Figure 2

 For full-term and preterm infants For infants who have had repeated heel punctures
these sites are also suitable for infants up to a year of age.

 Good quality blood spots are vital to ensure that babies with rare but serious
conditions are identified and treated early.

 The aim is to fill each circle on the blood spot card, using a single drop of blood for
each circle

 Wait for the blood to flow and a hanging drop to form.

 Allow one spot of blood to drop onto each of the circles on the blood spot card.

 Do not allow the heel to make contact with the card as this can prevent blood from
soaking through to the back of the card.

 There is no need to discard the first drop.

 Do not squeeze the foot in an attempt to increase blood flow.

 Allow the blood to fill the circle by natural flow, and seep through from front to back of
the bloodspot card.

 Fill each of the four circles completely.

 Always ensure that the sample is applied to the front of the card and not the back.

 Spots that exceed the dotted lines on the filter paper are acceptable provided that a
single drop of blood has been used.

 Do not compress or apply pressure to the bloodspots (for example when sealing the
postage envelope).

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 If the blood flow ceases:
 The congealed blood should be wiped away firmly with cotton wool or gauze.

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  Gently ‘massage’ the foot, avoid squeezing, and drop the blood onto the blood spot
card.

 If the baby is not bleeding, a second puncture is necessary:

 The second puncture should be performed on a different part of the same foot or on
the other foot.

 When sample collection is complete, wipe excess blood from the heel and apply
gentle
pressure to the wound with cotton wool or gauze.

 Apply a hypoallergenic spot plaster if required and remind the parent to remove the
plaster in a few hours.

10.0 After Taking the Blood Spot Sample

 It is important that the laboratory receives the blood sample promptly to ensure that
screen positive babies are seen quickly. Parents also need to know when to expect
the results. This will help to reduce their concerns about the results, as well as
provide an additional safety net in following up missing results.

 Allow blood spots to air-dry away from direct sunlight or heat before placing in the
glassine envelope – take care to avoid contamination.

 There is currently no evidence to support an optimal drying time but taking the sample
at the beginning of the visit will allow for a longer drying time.

 Despatch the blood spot card in the prepaid/stamped addressed envelope (first class)
on the same day (if not using a courier). If not possible, despatch within 24 hours of
taking the sample.

 Despatch should not be delayed in order to batch blood spot cards together for
postage. If a post box is used, ensure it is one that is emptied daily (Monday to
Saturday).

 Before sending the sample –

All bloodspots taken within Broomfield Hospital / Chelmsford Community Team

MUST be taken to the Screening office based in Antenatal Clinic for checking of
cards prior to sending to GOSH.
All bloodspots taken within St Peter’s / WJC birth centres / community area, to
be double checked for accuracy of information and sample sufficiency. Cards
must be signed by the two staff checking the cards prior to sending – this will
help reduce the risk of avoidable repeat samples.

 In exceptional circumstances that may delay samples reaching the laboratory in time,
for example postal strikes, severe weather disruptions the Maternity Screening team
will arrange courier service for samples to reach the laboratory for screening.

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  Record date, method, blood spot card serial number and location of sample despatch;
this will enable an audit trail if samples are lost in the post.

 Record that the sample has been taken in the Child health Record book and baby’s
hospital notes.

 Record and notify the baby’s screening status on discharge / transfer notifications.

 Inform parents that they will receive the results within six weeks. If the baby screens
positive for a condition the parents will be contacted sooner.

 Inform parents how they will receive the results - via the health visitor; ensure that
parents know to contact their health visitor if results are not received within six weeks.

11.0 Special Circumstances: Babies Born Preterm or Cared for in Neonatal Unit

11.1 Some babies will be in hospital when their blood spot sample is due to be taken - Babies
who are cared for in neonatal units including babies born less than 32 weeks (less than
or equal to 31 weeks + 6 days) and those who experience multiple blood spot samples
taken from the heel.

 Babies admitted to neonatal units are likely to have multiple blood samples taken.

 Blood spot screening should be coordinated with other tests when possible.

 Venepuncture or venous / arterial sampling from an existing line can be used to

collect the blood spot sample onto the card. This is providing the sample is not
contaminated with EDTA/heparin and the line is cleared of infusate.

 Do not use heparinised capillary tubes.

 Babies less than five days of age should have a single circle blood spot sample
taken on
admission / prior to blood transfusion for the routine screening test for SCD. This
should be on a separate blood spot card marked ‘Pretransfusion’.

 The pre-transfusion blood spot card should be stored with the baby’s medical records
in line with local protocols and despatched to the newborn screening laboratory
together with the routine day 5 sample if the baby has received a blood transfusion in
the interim.

 The pre-transfusion blood spot card can be discarded appropriately if the baby has
not received a blood transfusion.

 If the baby is transferred to another unit before the day 5 sample has been taken,
ensure the pre-transfusion blood spot card accompanies the infant. Details of
newborn sampling should be documented and included in transfer information.

 The routine blood spot sample (four spots) should be taken on day 5* for all babies
regardless of medical condition, medication, milk feeding and prematurity.

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  For the purpose of screening, day of birth is day 0 (some information systems
record day of birth as day 1, which could cause the sample to be taken on the
incorrect day). *In exceptional circumstances the sample can be taken between day 5
and day 8.

 When a baby has had a blood transfusion, either intrauterine or in the newborn
period, an interval of at least three clear days is required between the transfusion and
the routine blood spot sample for CF, CHT and the IMDs.

 For intrauterine transfusion count day of birth as date of transfusion.

 However, in the event of multiple blood transfusions, even if it has not been at least
three clear days since the last transfusion, a routine blood spot sample should be
sent by day 8 at the latest regardless. In this scenario, a repeat sample will be
needed at least three clear days after the last transfusion.

 The date of the last blood transfusion before the blood spot must be recorded on the
blood spot card and on discharge / transfer notifications.

 If a baby who has been transfused has not had a pre-transfusion sample taken, the
laboratory will forward the routine day 5 sample to the DNA laboratory for analysis as
a failsafe. Additional costs for this will be incurred by the trust.
Further information is available at www.gov.uk/government/publications/dna-testsfor-
transfused-babies-sickle-cell-andthalassaemia-screening

 Inform parents of any outstanding screening tests, and record this in the PCHR and
maternity/professional record. Advise parents which healthcare professional will be
responsible for completing the blood spot screening for their baby and approximately
when it will occur.

 Provider organisations should ensure failsafe arrangements for notifying screening

status when the care of babies is transferred. This includes babies who are
transferred in the neonatal period. The screening status of the baby is to be recorded
on an auditable IT system and in the discharge/transfer documentation.

12.0 CHT Screening for Preterm Infants

 Babies born at less than 32 weeks (less than or equal to 31 weeks + 6 days) require a
second blood spot sample to be taken in addition to the day 5 sample (counting day
of birth as day 0).

 These babies are to be tested when they reach 28 days of age (counting day of birth
as day 0) or day of discharge home, whichever is the sooner.

 Complete the details on the blood spot card as recording ‘CHT preterm’ on the blood
spot card.

 Write the gestational age on the card.

 If the baby is being discharged home before 28 days of age, write ‘discharged
home’ on bloodspot card.

 Two spots on the blood spot card should be filled with blood.
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  The responsibility for taking each sample lies with the healthcare professional that is
responsible for clinical care at the time the bloodspot sample is due.

 In babies who are transferred to another Trust for care before they reach 28 days of
age, the responsibility for completing screening is transferred the Trust providing care
for the baby.

 Record all blood spot samples taken in baby’s hospital records, on transfer
documentation, Child Health record book and on Newborn Bloodspot Northgate System
(Failsafe system).

13.0 Repeat Samples

13.1 The Screening Team or Failsafe Officer will contact the midwife or team responsible and
arrange a repeat blood sample to be taken. All repeat samples must be taken within
72 hours.

 Informed consent must be taken for all repeat samples. Parents should be informed of
the reason for the repeat.

 Unavoidable repeat samples may be required from a few babies due to -

 Prematurity,
 Borderline thyroid stimulating hormone (TSH) results,
 Inconclusive CF screening
 Having received a blood transfusion.

 These samples should be taken as soon as possible or at the age directed by the
screening laboratory (GOSH).

 Ensure that the ‘repeat sample’ box is ticked on the blood spot card.

 A one week interval between samples is recommended for borderline TSH results.

 Take a four-blood spot sample and mark the blood spot card ‘CHT borderline’.

 A repeat requested because of an inconclusive CF result should be taken as close to day

21 as possible this would be performed by GOSH.

14.0 Avoidable Repeats

 If poor quality blood spots are received, or the fields on the blood spot card are not
completed fully and accurately, Great Ormond Street (GOSH) will request an ‘avoidable
repeat’ sample.

 Avoidable repeat samples can cause anxiety for parents, distress to babies and delays in
the screening process. This could lead to a baby missing CF screening because it can
only be screened up to eight weeks or to delayed identification and treatment of an
affected baby.

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  Avoidable repeats are also a waste of healthcare resources (each repeat costs the NHS
around £100). In some cases, parents may refuse to consent to a repeat – this means
that the baby will have incomplete screening.

 Newborn screening laboratories in England follow a national, evidence-based consensus

on blood spot quality, with standardised acceptance and rejection criteria.

 To ensure that an avoidable repeat sample is not requested, sample takers are advised
to obtain four good quality blood spots and complete all fields on the blood spot
card accurately.

 Laboratories may also request a repeat sample due to any of the following -
Too young for reliable screening
Too soon after transfusion (less than 72 hours)
Insufficient sample
Inappropriate application of blood
Compressed, damaged or contaminated sample
Day 0 and day 5 sample on same blood spot card
Possible faecal contamination
Incomplete or inaccurate data on the blood spot card, for example no/inaccurate NHS
number, no/inaccurate date of sample or no/inaccurate date of birth
expired blood spot card used
more than 14 days in transit, too old for analysis
damaged in transit
sickle – too premature for testing

14.1 When a repeat sample is requested for any of the above reasons, the sample should be
taken within 72 hours of the receipt of the request (unless ongoing transfusions).

15.0 Failsafe Processes

 All newborn blood spot samples are tracked by the Northgate Failsafe System to
ensure receipt of the sample at GOSH. The Northgate Failsafe System (Appendix B)
allows communication between GOSH, Child Health and the Antenatal Screening
Office. The Failsafe Officer will complete documentation on the Northgate Failsafe
System to inform GOSH and Child Health when a blood sample has been obtained
and posted.

 The Failsafe Officer will review Northgate System daily and update individual babies
status regarding screening e.g. repeat requested, repeat taken with date, sample sent
and if a delay in the process.

 Any requests received from either Great Ormond Street (GOSH) or Mid Essex PCT
Child Health Department are sent via the Screening Office and the date of receipt is
recorded along with the subsequent action. This will provide an audit trail in the
absence of electronic tracking and records. The Northgate Failsafe System has an
alert system that indicates any blood samples that are outstanding.

 If any requests for a repeat blood spot sample for infants over 10 days old is received,
an urgent referral is either made to the Community Midwife or the Community
Paediatric Nursing Team - Tel 01245 513008 (Mon-Fri 9-5).

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  Failsafe for Repeat samples - The Screening Team or Failsafe Officer will contact
the midwife or team responsible and arrange a repeat blood sample to be taken. All
repeat samples must be taken within 72 hours.

 Before sending the sample –

All bloodspots taken within Broomfield Hospital / Chelmsford Community Team MUST
be taken to the Screening office based in Antenatal Clinic for checking of cards prior
to sending to GOSH.
All bloodspots taken within St Peter’s / WJC birth centres / community area, to be
double checked for accuracy of information and sample sufficiency. Cards must be
signed by the two staff checking the cards prior to sending – this will help reduce the
risk of avoidable repeat samples.

 In exceptional circumstances that may delay samples reaching the laboratory in time,
for example postal strikes, severe weather disruptions the Maternity Screening team
will arrange courier service for samples to reach the laboratory for screening.

16.0 Receiving Results

 A letter is generated by Child Health to the parents if all five results are negative.

 If any of the results are positive, the GP is informed by GOSH, with clinical specialist
appointments arranged.

17.0 Staff and Training

 All staff undertaking blood spot screening will be trained by experienced staff prior to
undertaking the procedure.

 Training in taking samples will be recorded as part of the induction process and staff
member’s yearly appraisal.

18.0 Infection Prevention

18.1 All staff should follow Trust guidelines on infection prevention by ensuring that they
effectively ‘decontaminate their hands’ prior to undertaking blood spot screening.

18.2 All staff should ensure that they follow Trust guidelines on infection control, using Aseptic
Non-Touch Technique (ANTT) when carrying out procedures i.e.
obtaining blood spot samples.

18.3 MEHT Infection prevention guidelines for bodily fluids and disposal of sharps should be
adhered to as per protocol.

19.0 Audit and Monitoring

19.1 Audit of compliance with this guideline will be considered on an annual audit basis in
accordance with the Clinical Audit Strategy and Policy (register number 08076), the
Corporate Clinical Audit and Quality Improvement Project Plan and the Maternity annual
audit work plan; to encompass national and local audit and clinical governance
identifying key harm themes. The Women’s and Children’s Clinical Audit Group will
identify a lead for the audit.

19.2 As a minimum the following specific requirements will be monitored:

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  Designated lead for antenatal screening in the maternity service
 Antenatal screening tests, which follow the UK National Screening Committee
guidance
 System for ensuring that appropriate tests are undertaken within appropriate
timescales
 System for ensuring that appropriate tests are undertaken when patients book late
 Process for the review of the results
 Process for reporting all results to patients
 Process for reporting results to other relevant healthcare professionals
 Process for ensuring that women with screen positive test results are referred and
managed within appropriate timescales
 Maternity service’s expectations for staff training, as identified in the training
needs analysis
 Process for audit, multidisciplinary review of results and subsequent monitoring of
action plans

19.3 A review of a suitable sample of health records of patients to include the minimum
requirements as highlighted in point 19.2 will be audited. A minimum compliance 75% is
required for each requirement. Where concerns are identified more frequent audit will be
undertaken.

19.4 The findings of the audit will be reported to and approved by the Multi-disciplinary Risk
Management Group (MRMG) and an action plan with named leads and timescales will be
developed to address any identified deficiencies. Performance against the action plan will
be monitored by this group at subsequent meetings.

19.5 The audit report will be reported to the monthly Directorate Governance
Meeting (DGM) and significant concerns relating to compliance will be entered on the
local Risk Assurance Framework.

19.6 Key findings and learning points from the audit will be submitted to the Patient Safety
Group within the integrated learning report.

20.0 Guideline Management

21.1 As an integral part of the knowledge, skills framework, staff are appraised annually to
ensure competency in computer skills and the ability to access the current approved
guidelines via the Trust’s intranet site.

21.2 Quarterly memos are sent to line managers to disseminate to their staff the most
currently approved guidelines available via the intranet and clinical guideline folders,
located in each designated clinical area.

21.3 Guideline monitors have been nominated to each clinical area to ensure a system
whereby obsolete guidelines are archived and newly approved guidelines are now
downloaded from the intranet and filed appropriately in the guideline folders. ‘Spot
checks’ are performed on all clinical guidelines quarterly.

21.4 Quarterly Clinical Practices group meetings are held to discuss ‘guidelines’. During this
meeting the practice development midwife can highlight any areas for further training;
16
 possibly involving ‘workshops’ or to be included in future ‘skills and drills’ mandatory
training sessions.

22.0 Communication

22.1 A quarterly ‘maternity newsletter’ is issued and available to all staff including an update
on the latest ‘guidelines’ information such as a list of newly approved guidelines for staff
to acknowledge and familiarise themselves with and practice accordingly.

22.2 Approved guidelines are published monthly in the Trust’s Focus Magazine that is sent via
email to all staff.

22.3 Approved guidelines will be disseminated to appropriate staff quarterly via email.

22.4 Regular memos are posted on the guideline notice boards in each clinical area to notify
staff of the latest revised guidelines and how to access guidelines via the intranet or
clinical guideline folders

23.0 References

Public Health England (2016) Guidelines for Newborn Blood Spot Sampling, PHE
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment
_data/file/511688/Guidelines_for_Newborn_Blood_Spot_Sampling_January_2016.pdf

17
Appendix A

18
19
20
 Appendix B

Northgate Failsafe System

21
 Appendix C

STANDARD OPERATING PROCEDURE FOR

NEWBORN BLOODSPOT SCREENING FOR BABIES BORN IN AREA

Live Birth (Day 0)

Screening Tests for you and your baby leaflet given to parents and discussion regarding
screening at least 24 hrs before test

Day 5-8 Blood spot screening to be performed with consent, Irrespective of Gestational Age or milk feeds

DECLINE ACCEPT
Complete Blood spot Complete Form, take sample
form and send to GOSH Document in notes, Child Health Record book and log date of test, Sample double
in prepaid envelope, checked for accuracy before sending to GOSH
ensure clear Send to GOSH in prepaid envelope
documentation that
screening has been GOSH receives sample
declined
Inform Screening team,
GP/Health Visitor of
declined screening
Unable to test missing/incorrect/ inadequate sample Sample Tested

Screening team to update

Northgate Failsafe Screening Team review of Northgate Failsafe System – sample seen as
system of declined requiring a repeat
screening

Still receiving care Not under Maternity care to inform the community
Parents to be informed from Maternity Unit paediatric nurse
that if they choose to
have screening it can be
performed up to one year
of age Inform ward, community team / birthing centre of the need to repeat and for
what reason

Missing
Borderline /incorrect data Expired Card / Taken Missing/Incorrect Inadequate
Result - Inform – Inform too early / data – Inform sample – Inform
parents of the parents of the Contaminated Inform parents of the parents of the
need to repeat, need to repeat, parents of the need to need to repeat, need to repeat,
Repeat sample Repeat sample repeat, Repeat sample Repeat sample & Repeat sample &
& send to & send to & send to GOSH send to GOSH send to GOSH
GOSH GOSH

Positive Screen/ Further Sample Tested Result‘s

investigation, parents available -
contacted by GOSH NAD

Result to
Review by appropriate team for
Child Health
investigations / Actions
Department
22
 Appendix D

STANDARD OPERATING PROCEDURE FOR

NEWBORN BLOODSPOT SCREENING FOR BORN OUT OF AREA

Alive

<10 days Child >10 days Inform community >1 year No

Health Services paediatric nurse Action
Notified

Check bloodspot
<5 days follow in >5 days check blood spot performed/ result
area procedure performed

No Yes – No Further No Result/Not Result – No further action

Action Performed

National Pre-Screening leaflet at

least 24 hrs before test

Bloodspot Test performed.

If > 8wk too late for CF testing

DECLINE ACCEPT
1. Complete form 1. Complete Form
2. Send to GOS in prepaid envelope 2. Document in notes, red book and log
3. Inform GP/HV date of test
3. Send to GOS in prepaid envelope

GOS – Document on system

GOS Sample received

< 17 Days
Unable to test missing/incorrect/ Sample Tested
Child Health document inadequate sample
decline on system

Child Health
1st Request Notified

23
 1st Request Child Health
Notified

Under 10 days to be actioned by >10 days to inform the

hospital or community midwife. community paediatric nurse

Missing Inadequate Repeat test Missing/Incorrect data Inadequate Repeat

/incorrect data – and send to GOS – complete GOS test and send to GOS
complete &
return to GOS

Sample Tested Result

Data Sample Not Received

Positive Screen/
Negative/ No Further investigation
Further Action

Appropriate team for

Result to Child investigations / Actions
Health Department
Child Health
Notified
Result to Child
Health Department

Under 10 days to be nd
2 Request
actioned by hospital or
community midwife. >10 days to inform the
community paediatric
nurse

24
 Child Health
Notified

nd
2 Request

Under 10 days to be
>10 days to inform the
actioned by hospital or Babies <32
community paediatric
community midwife. weeks TSH
nurse
screening @
29 days

Missing/ Incorrect data Inadequate repeat test

completed & returned to send to GOS
GOS

May be done Out of Area

prior to
Sample discharge on
Not Tested NNU if earlier
Received 3rd Request

For repeat blood spot tests

contact the paediatric
Director of community nurse if
Public necessary
Health

25