New Joint Commission Requirements Likely to Boost Maternal Patient Safety

The maternal mortality rate in the U.S. has experienced a consistent and alarming increase in recent decades, driven in part by an increase in expecting mothers’ comorbidities such as obesity, hypertension, diabetes and cardiac disease.

In fact, the nation’s maternal mortality rate has more than doubled since 1987, up to 17.3 deaths per 100,000 live births, according to the U.S. Centers for Disease Control and Prevention (CDC). That number far exceeds the Healthy People 2020 goal of 11.4 deaths per 100,000 live births.

There is certainly opportunity for improvement, however. In a recent study, the CDC estimated that 60% of maternal deaths were preventable. The nation would comfortably meet the Healthy People 2020 goal if we could prevent those deaths.

Alana McGolrick

In addition to the rise in mothers’ comorbid conditions, another significant factor has contributed to the steady increase in maternal mortality: General disagreement on best approaches for managing maternal patients, from creating a single oxytocin checklist to detailing more complex processes for managing preeclampsia.

Part of the problem is that there is debate among clinical experts regarding the physiological parameter thresholds for various conditions, which has led to a situation in which treatment protocols across the country differ. Adding to the challenge, research has lagged on maternal early warning systems that could help clinicians recognize and respond to warning signs before a mother’s condition deteriorates.

Nonetheless, the outlook for decreasing the maternal mortality rate in the country has recently improved as a result of a recent initiative by the Joint Commission, which has developed 13 new elements of performance (EOPs) to help evaluate hospitals. Potentially beginning as soon as this month, all accredited hospitals that provide obstetric services must demonstrate compliance with these standards, which address two of the nation’s most frequent causes of maternal morbidity and mortality.

Although regular on-site surveys have recently been suspended by the Joint Commission due to the COVID-19 pandemic, hospital and health system leaders should begin reviewing the EOPs to ascertain where they stand today. Pandemic or no pandemic, adhering to evidence-based guidelines benefits both patients and providers in the form of better clinical outcomes.

Following is a brief review of the Joint Commission’s new EOPs that are designed to enhance safety for mothers and new-born babies.

Maternal hemorrhage requirements
Maternal hemorrhage is the focus of the first set of EOPs, and for good reason. Maternal hemorrhage is the leading cause of maternal deaths worldwide and is responsible for 11.2% of maternal deaths in the U.S. Data from the CDC also shows black women are two to three times more likely to experience issues with hemorrhaging than white women despite not being considered at higher risk for blood loss during delivery.

Common reasons for deaths by maternal hemorrhage clinicians missing or miscommunicating signs of active blood loss, underestimating the extent of blood loss, and a lack of standardized safety responses.

The Joint Commission has issued the following seven EOPs covering maternal hemorrhage:

• Use an evidence-based tool to determine maternal hemorrhage risk on admission to labor and delivery and postpartum: Assessing and discussing hemorrhage risk helps clinical teams identify higher-risk patients and be prepared.
• Create written evidence-based procedures for stage-based management of patients who experience maternal hemorrhage: These written procedures cover a variety of scenarios and should be developed by a multidisciplinary team that includes representation from obstetrics, anesthesiology, nursing, laboratory, and blood bank.
• Stock each obstetric unit with a standardized, secured, dedicated hemorrhage supply kit: Each kit must contain emergency hemorrhage supplies as determined by the organization, as well as the organization’s approved procedures for severe hemorrhage response.
• Deliver role-specific education about the organization’s hemorrhage procedure to all staff and providers who treat pregnant and postpartum patients: This education and training should be conducted at orientation, whenever changes to the processes or procedures occur, or every two years.
• Perform annual drills to determine system issues as part of on-going quality improvement efforts: Drills should include representation from each team identified in the organization’s hemorrhage response procedure and include a debriefing session after the drill is completed.
• Conduct reviews of hemorrhage cases: These reviews should evaluate the effectiveness of care, treatment, and services provided by the hemorrhage response team.
• Educate patients: At a minimum, hospitals should deliver education that helps patients recognize the signs and symptoms of postpartum hemorrhage that should prompt them to seek immediate care.

Severe hypertension/preeclampsia requirements
The second set of EOPs pertains to hypertensive crisis/preeclampsia, which is responsible for 6.8% of pregnancy-related deaths in the U.S., according to the CDC. Worldwide, preeclampsia is estimated to occur in 5 to 8% of all pregnancies.

While common symptoms of hypertension and preeclampsia include sudden edema, weight gain, headaches and visual disturbances, in many cases patients experiencing these conditions do not present with these symptoms. To help hospitals improve patient assessment of these conditions, the Joint Commission issued the following six EOPs:

1. Develop written evidence-based procedures for measuring blood pressure: At a high level, these procedures should cover standard blood pressure measurement best practices, including cuff size, proper patient positioning, and frequency of measurement.
2. Develop evidence-based procedures for managing patients with severe hypertension/preeclampsia: These procedures should include guidance on when to use continuous fetal monitoring, when to consider emergent delivery and when to consult additional experts and consider transfer to a higher level of care.
3. Provide role-specific education about the hospital’s evidence-based severe hypertension/preeclampsia procedure: Because the emergency department (ED) is often where post-partum patients with signs of severe hypertension present for care, hospitals should provide education to ED staff and providers.
4. Conduct annual severe hypertension/preeclampsia drills: These drills create an opportunity for organizations to practice skills and identify system issues in a controlled environment, with an eye toward process improvement in the future.
5. Review severe hypertension/preeclampsia cases: These reviews help organizations find errors and improve skills to ensure that patients are receiving the highest level of care.
6. Provide printed education to patients: Educational materials should include information on signs of severe hypertension/preeclampsia that alert patients to seek immediate care, as well as when to schedule a post-discharge follow-up appointment.

Enhancing maternal and fetal safety
Maternal hemorrhage and severe hypertension/preeclampsia have been responsible for too many deaths across the nation, but renewed focus on the problems could help us reverse the trend. Adherence to the Joint Commission’s new EOPs is likely to result in enhanced maternal and fetal safety and bring the U.S. closer to achieving the Healthy People 2020 goal of lower maternal mortality.

Alana McGolrick, DNP, RNC-OB, C-EFM, is Chief Nursing Officer of PeriGen, a company delivering innovative perinatal software solutions.