Joint Commission Maternal Safety Guidelines

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In an effort to improve maternal mortality rates in the United States, the Joint Commission has introduced new requirements to address complications in the area of maternal hemorrhage and hypertension. The SOGH Quality and Safety Committee has compiled these pearls and examples to assist our members and their hospitals in fulfilling the requirements of the Joint Commission. The hyperlinks are examples submitted by Committee members that can be adopted for use at your own hospital. We hope this helps to improve the health and safety of patients, in addition to meeting the regulatory requirements.

PC.06.01.01: Reduce the Likelihood of Harm Related to Maternal Hemorrhage

Risk Assessment
PPH Risk Assessment on Admission

CMQCC OB Hemorrhage Risk Factor Assessment.

Situational Awareness
Hemorrhage Risk Category Indicator on Labor Board ex. red, yellow, green/high, medium, low

PPH Risk Assessment Stoplight

Complete an assessment using an evidence-based tool for determining maternal hemorrhage risk on admission to postpartum

JC Guidance
Because the risk of maternal hemorrhage may change after delivery, a hemorrhage risk assessment must be completed during admission to both the labor and delivery and postpartum units.

CMQCC OB Hemorrhage Risk Factor Assessment
See "Ongoing risk assessment"

  • The use of evidenced-based tool that includes an algorithm for identification and treatment of hemorrhage
  • The use of an evidence-based set of emergency response medications(s) that are immediately available on the obstetric unit
  • Required response team members and their roles in the event of severe hemorrhage
  • How the response team and procedures are activated
  • Blood bank plan and response for emergency release of blood products and how to initiate the organizations’s massive transfusion protocol
  • Guidance on when to consult additional experts and consider transfer to a higher level of care
  • Guidance on how to communicate with patients and families during and after the event
  • Criteria for when a team debrief is required immediately after a case of severe hemorrhage

JC Guidance

  • Written procedures and evidence-based tools for managing postpartum hemorrhage patients
    must include clinical guidance from organizations
    such as, but not limited to, AWHONN, ACOG, and
    NAHQ.
  • At minimum, the written procedure must include
    feedback from anesthesiology, blood bank, laboratory,
    nursing, and obstetrics.

MLC 4 Obstetric Hemorrhage Management

OB Hemorrhage Protocol

AWHONN QBL

QBL Worksheet
(QBL Worksheet Credit: Jaimee Robinson, MSN, RN, RNC-OB, C-EFM)

ACOG Hemorrhage Checklist

Management of Obstetrical Hemorrhage

QBL Worksheet

CMQCC Obstetric Hemorrhage Emergency Management Plan
See stages of hemorrhage
OB Hem Emergency Management Plan Flow Chart
OB Hem Emergency Management Plan Table Chart


Table 3 in ACOG's 2017 PB on PP Hemorrhage.

See Blood Product Replacement

ACOG MTP

CMQCC Debrief Tool

ACOG Debrief Tool

Debrief Tool

  • Emergency hemorrhage supplies as determined by the organization
  • The organization’s approved procedures for severe hemorrhage response

Hemorrhage Cart Pics

  • Obstetric Providers/RNs
  • Anesthesiology Providers
  • ED Providers/RNs

JC Guidance

  • Doesn’t have to be completed until 12/31/2021.
  • Staff and providers must be educated to ensure that they can accurately measure blood pressures, recognize severe hypertension/preeclampsia, and provide evidence-based treatments to lower
  • Role-specific education is required so that providers receive only the information they need about their role during a HDP crisis

Additional ?/Details

  • Using Joint Commission requirement to engage leadership who will be highly motivated to mandate trainings
  • e-learning modules (ex. Relias/Lippincott for management of hemorrhage)
  • Management of Hemorrhage part of nurse educator led orientation for new nurses
  • Grand rounds, Dept meetings, M&M, small group discussions for updates to guidelines
  • Education can include videos vs live sessions vs virtual sessions

JC Guidance

  • Drills must occur within one year of the standards’ effective date (12/31/2021) and take place on the unit
  • Hospitals determine how many drills to perform based on staff proficiency
  • Drills must include representation from each department listed in the hemorrhage response procedure (All depts must participate; however, 100% staff participation is not required).
  • Hospitals should present lessons learned from drills to the entire team.

ODHCSEAC EMOB Postpartum Hemorrhage

Multidisciplinary Training

•Virtual drills including table-top discussions
•Assign roles, run scenarios
•In person, in the LDR to include where maternials and meds are located and any barriers to getting them
•Participants are not currently covering a shift so high acuity of unit does not stop the drill, additional few slots if people who are working want to join and have time
•Pre and post test questions
•Virtual sim as part of new nurse/provider orientation

•2 sims per month, one of which is either HTN or hemorrhage to complete these requirements but allow additional drills, as well
•In addition to regular monthly drills, twice yearly multidisciplinary sessions that include the blood bank and anesthesia. Requires leadership buy in
•Education board highlighting current drills and new changes
•Participants are currently covering a shift so sometimes unit acuity does cause challenge

•Noel Mannequin which includes specific hemmorhage modules

•Once per month drills that include anesthesia
•Use EMR test patient so the drill includes placing orders in EMR
•Involve hospital code team and the blood bank for true multidisciplinary event

JC Guidance

  • Hospitals should establish criteria that automatically generate a quality improvement review.
  • Hospitals should establish a process to disseminate key findings and improvement opportunities to all pertinent staff and providers

Additional ?/Details

  • Automatic triggers for review of cases include -Transufsion of > 4 units of RBCs -Return to OR
  • Working on automating the debrief and making it more frequent so it does not feel punitive MC
  • Automatic Referral to multidisciplinary committee for any PPH – >1000cc for vaginal delivery – >1500 for C/S VT
  • All cases from M&M go to monthly peer review multidisciplinary committee

 

EP 7: Provide education to patients (and their families including the designated support person whenever possible). At minimum, education includes:

  • Signs and symptoms of postpartum hemorrhage during hospitalization that alert the patient to seek immediate care
  • Signs and symptoms of postpartum hemorrhage that alert the patient to seek immediate care

JC Guidance

  • Hospitals must have a process verifying that patient received education about hemorrhage
  • Clear instructions should be provided to patients and/or support persons on whom to call when immediate care is needed or when to seek emergency care.

Additional ?/Details

•AWHONN PostBirth Warning Signs
•After visit summary
•In hospital education invluding EMI videos patients are required to watch on warning signs and when to return to the hospital

Council on Patient Safety in Women’s Health Care

AWHONN Post Birth Warning Signs
*Also available in multiple languages

PC.06.01.03: Reduce the likelihood of harm related to maternal severe hypertension/preeclampsia

JC Guidance

  • Use evidence-based instructions when measuring blood pressure to obtain an accurate measurement. To ensure accuracy, use the proper size cuff and ensure corrrect cuff posoition; also, know when to retake a blood pressure measurement.
  • Develop clear instructions for what to do for an abnormal blood pressure measurement. Instructions may include, but are not limited to, when to retake blood pressure, what to do if the measurement remains elevated, and what to instruct the patient.

Safety Action Series

Accurate Blood Pressure Measurement

  • The use of an evidence-based set of emergency response medications that are stocked and immediately available on the obstetric unit
  • The use of seizure prophylaxis
  • Guidance on when to consult additional experts and consider transfer to higher level of care
  • Guidance on when to use continuous fetal monitoring
  • Guidance on when to consider emergent delivery
  • Criteria for when a team debrief is required


JC Guidance

  • Written procedures must include clinical, evidencebased guidance from organizations such as, but not limited to, AWHONN, ACOG, and NAHQ.
  • At minimum, the written procedure must include feedback from anesthesiology, emergency department, laboratory, nursing, obstetrics, and pharmacy.
  • Hospitals must have a plan to obtain expert consults as needed and guidance related to emergent deliveries.
  • The plan should list items staff must do or obtain for patients at high risk for seizure; these items may include padded bed rails, quiet/private room, and magnesium sulfate.

Hypertensive Disorders in Pregnancy

Hypertensive Emergency Checklist

Hypertensive Disorders of Pregnancy

Recommendations for Fetal Monitoring

Pre-eclampsie with Severe Feature Debrief Form

Preeclampsia Debrief Form

UH OB Network Debriefing Tool

  • Obstetric Providers/RNs
  • Anesthesiology Providers
  • ED Providers/RNs

JC Guidance

  • Doesn’t have to be completed until 12/31/2021.
  • Staff and providers must be educated to ensure that they can accurately measure blood pressures, recognize severe hypertension/preeclampsia, and provide evidence-based treatments to lower
  • Role-specific education is required so that providers receive only the information they need about their role during a HDP crisis

Hypertensive Disorders in Pregnancy

  • Using Joint Commission requirement to engage leadership who will be highly motivated to mandate trainings
  • e-learning modules (ex. Relias/Lippincott for management of hypertension)
  • Management of Hypertension part of nurse educator led orientation for new nurses
  • Grand rounds, Dept meetings, M&M, small group discussions for updates to guidelines
  • Education can include videos vs live sessions vs virtual sessions
  • Drills must occur within one year of the standards’ effective date (12/31/2021) and take place on the unit
  • Hospitals determine how many drills to perform based on staff proficiency
  • Drills must include representation from each department listed in the hemorrhage response procedure (All depts must participate; however, 100% staff participation is not required).
  • Hospitals should present lessons learned from drills to the entire team.

Pre-eclampsia Scenario

The Role of Medical Simulation

LDEclampsia Scenario B

LDEclamspia Scenario A

ODHCSEAC EMOB Postpartum PreEclampsia

  • Hospitals should establish criteria that automatically generate a quality improvement review.
  • Hospitals should establish a process to disseminate key findings and improvement opportunities to all pertinent staff and providers

Automatic QA triggers include eclampsia, transfer to higher level of care including ICU

AIM Safety Bundle for Severe HTN in Pregnancy

A workbench report in EPIC is pulled from current inpatients with diagnosis of HTN and looks for any patient who has at least one severe range HTN episode in the last 24-48 hours

Patient charts are manually reviewed who were coded with a HTN diagnosis-this database is from the Maternal Data Center of Washington state

  • Signs and symptoms of severe hypertension/preeclampsia during hospitalization that alert the patient to seek immediate care
  • Signs and symptoms of severe hypertension/preeclampsia after discharge that alert the patient to seek immediate care

JC Guidance

  • Educational materials must be provided to patients in a hard-copy and electronic format (as applicable).
  • Hospitals must have a process verifying that pt. received education about HDP

Preeclampsia Early Recognition Tool

Council on Patient Safety in Women’s Health Care

AWHONN Post Birth Warning Signs
*Available in multiple languages

"Every patient with hpyertensive disease of pregnancy receives blood pressure cuff on discharge with instructions on when to seek care

Obstetric Blood Pressure Log

Post Birth Warning Signs

Automatic follow up appointment in 2-7 days standing order for oral nifedepine which is available to the post-partum RN at the post-partum clinic for patients who meet criteria for HTN in the severe range. They are able to give the medication to the patient before they send the patient to the OBED