Joint Commission Seeks to Reduce Maternal Deaths

By John Palmer

The Joint Commission has issued guidance and an alert to hospitals to help prevent what it calls a shocking number of women who die from largely preventable pregnancy complications.

The accreditation agency in October 2019 released Quick Safety Issue 51: Proactive Prevention of Maternal Death From Maternal Hemorrhage, published to help healthcare facilities respond to pregnancy-related complications and prevent pregnancy-related deaths.

The Joint Commission says that about 700 women die annually from these complications, stemming mostly from obstetric hemorrhage (excessive blood loss while giving birth). The accreditor notes that rates of maternal hemorrhage are increasing in developed countries, including the United States, leading to the need for increased attention to the problem.

As a result, the organization has introduced two new standards effective July 1, 2020 that hospitals will need to adhere to help address complications in maternal hemorrhage and severe hypertension/ preeclampsia. The new standards fall into the Provision of Care, Treatment, and Services chapter of The Joint Commission’s Comprehensive Accreditation Manual for Hospitals at PC.06.01.01 and PC.06.01.03.

“Recognizing all members of the health care team have vital roles in guiding women through their birth experience represents a challenge to some organizations,” The Joint Commission writes in the Quick Safety document. “Working as a team, with the end goal of safety for all who are touched by the birth experience, will help to improve the health and well-being of organizations, communities and the world.”

In addition, the rate of “hemorrhage-associated severe maternal morbidity,” which The Joint Commission defines as the need for blood transfusions requiring four or more units of packed red blood cells and/or ICU-level care during the birth process or immediate postpartum period, has apparently exceeded the morbidities associated with other obstetric or medical conditions that may result in complications requiring a higher level of care.

“Although common risk factors for postpartum hemorrhage are known, it is important to note that 20% of hemorrhages occur in women with no risk factors,” according to The Joint Commission. “All members of the obstetrical care team must maintain a constant readiness for this often-unpredictable emergency. Maintaining situational awareness and preoccupation with failure are cornerstones of high-reliability thinking and are critical components of care strategies in today’s fast-paced clinical care areas.”

Maternal hemorrhage is defined by the American College of Obstetricians and Gynecologists as a cumulative blood loss of at least 1,000 mL, or blood loss accompanied by signs or symptoms of hypovolemia. Within 24 hours after the birth process, up to 5% of obstetric patients will experience a postpartum hemorrhage. These preventable conditions cause 27% of maternal deaths worldwide and just over 11% of such deaths in the United States—making them worthy of greater public attention.

The Joint Commission reviewed a history of sentinel events for maternal death or severe maternal morbidity in the time period of 2010 through August 2019, and found that maternal hemorrhage was a causal factor in more than half (51%) of those events.

In addition, the Centers for Disease Control and Prevention (CDC) reported that 3,410 pregnancy-related deaths occurred in the United States from 2011 to 2015, and that the overall pregnancy-related mortality ratio during that time period was 17.2% pregnancy-related deaths per 100,000 live births.

The CDC also reported that cardiovascular conditions during pregnancy and birth were responsible for more than 33% of pregnancy-related deaths. Some of these conditions included the following:

• Cardiomyopathy (10.8%)
• Other cardiovascular conditions (15.1%)
• Cerebrovascular accidents (7.6%)

Additional leading causes of pregnancy-related death included other non-cardiovascular medical conditions (14.3%), infection (12.5%), and obstetric hemorrhage (11.2%), the CDC reported.

“According to the CDC, the rate of postpartum hemorrhage with procedures to control hemorrhage per 10,000 delivery hospitalizations increased from 4.3 in 1993 to 21.2 in 2014, with sharper increases in later years,” the Quick Safety alert notes. “The rate of postpartum hemorrhage with blood transfusions also increased noticeably over time, from 7.9 in 1993 to 39.7 in 2014.”

This Quick Safety alert is the latest in a recent series of alerts released by The Joint Commission. July 2019 saw the publication of Quick Safety Issue 50: Developing Resilience to Combat Nurse Burnout, produced to help healthcare facilities protect their nurses and other frontline staff from burnout.

According to the accreditor, of the 2,000 healthcare providers surveyed, more than 15% of all nurses reported feelings of burnout, with ER nurses at higher risk. A second survey in 2019 found that burnout is a top patient safety and quality concern in healthcare organizations.

In January 2019, The Joint Commission released Quick Safety Issue 47: De-Escalation in Healthcare, which noted that due to the increased violence in healthcare settings (active shooters, gang violence, etc.), frontline staff need to know de-escalation techniques and solutions to quell potential aggression.

The alert highlighted techniques such as communication, self-regulation, assessment, specific actions, and/or safety maintenance to reduce the potential for harm to patients, caregivers, and healthcare staff. In addition, the guide presented de-escalation models and workplace violence–related resources for use in staff training.

Recommendations to reduce maternal deaths

In Quick Safety 51, TJC recommends that hospitals follow a minimum of requirements to prepare for, respond to, and report any pregnancy-related hemorrhage incidents.

“Strategies to reduce morbidity and mortality from postpartum hemorrhage have included the use of standardized, comprehensive, obstetric safety bundles,” the alert recommends. “A patient safety bundle is a set of evidence-based recommendations for practice and care processes known to improve outcomes. Standardization and reduced variation have been shown to improve outcomes and quality of care.”

Some specific recommendations include the following:

• On all obstetric units, have a standardized, secured, and dedicated hemorrhage supply kit that must be stocked according to the hospital’s defined process and, at a minimum, contains emergency hemorrhage supplies as determined by the hospital and the hospital’s approved procedures for severe hemorrhage response.
• Provide immediate access to hemorrhage medications. Establish response teams. Know whom to call when help is needed.
• Provide role-specific staff education on your organization’s hemorrhage policies at regular intervals, including new employee orientation, whenever policy is changed, or every two years.
• Establish massive-transfusion emergency release protocols.
• Conduct multidisciplinary annual drills and debrief on hemorrhage response procedures.

Hospitals should have protocols for every single patient, including the following:

• Assess hemorrhage risk for every patient at different times—prenatal, on admission, or other appropriate times
• Provide education to the patient and family on signs and symptoms of postpartum hemorrhage while in the hospital and at home after discharge

They should also have protocols for response to every hemorrhage, including the following:

• Establish a standardized, obstetric hemorrhage emergency management plan
• Provide guidance on how to communicate with patients and families during and after the event

And after every incident, reporting and learning protocols should be in place, including the following:

• Establish a culture of huddles for high-risk patients and post-event debriefs to identify success and opportunities for improvement
• Conduct a multidisciplinary review of hemorrhages that meet established criteria to evaluate the effectiveness of treatment and services provided by the hemorrhage response team
• Monitor outcomes and process metrics via an organization-determined quality improvement committee

John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at johnpalmer@palmereditorial.com.