By Alana McGolrick, DNP, RNC-OB, C-EFM
The steadily climbing maternal mortality rate in the U.S. has (appropriately) attracted a great deal of media attention over the last few years.
Figures from the Centers for Disease Control and Prevention (CDC) show that the rate has more than doubled since 1987, reaching an alarming high of 17.3 maternal deaths per 100,000 live births. That is well above the Healthy People 2020 goal of 11.4.
Worse, the CDC estimates that 60% of maternal deaths reviewed in a study were preventable. Stopping those would result in easily meeting and surpassing the Healthy People 2020 goal.
Many factors have contributed to the rise in maternal mortality, including the increase in complex comorbidities in expecting mothers such as diabetes, obesity, hypertension, and cardiac disease. There has also been disagreement on the best approach to manage maternal patients, from creating a single oxytocin checklist to detailing more complex processes for managing preeclampsia.
Clinical experts in maternal and fetal medicine have been unable to agree on the physiological parameter thresholds for various conditions, leading to a variety of treatment protocols across the country. Exacerbating it all is the limited success of research into maternal early warning systems that could overcome the common occurrence of clinicians failing to recognize or respond to clinical warning signs in a timely manner.
Fortunately, these issues have also captured the attention of The Joint Commission (TJC), which has added 13 new elements of performance (EP) for hospitals to be surveyed on, effective July 2020. All accredited hospitals providing obstetric (OB) services will be required to show evidence of compliance with these new standards, which cover two of the most common causes of maternal morbidity and mortality. While TJC has suspended all regular on-site surveys until further notice due to COVID-19, hospitals should review the new EPs to determine elements that could be easily implemented. Especially during a pandemic, following evidence-based and recommended protocols can greatly improve clinical outcomes for patients while ensuring staff have access to necessary resources and are trained appropriately.
The first set of EPs focuses on maternal hemorrhage, which is the leading cause of maternal deaths worldwide. CDC data shows it also accounts for 11.2% of pregnancy-related deaths in the U.S., and that 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. Typical causes include missed or inaccurately communicated signs and symptoms of active blood loss, underestimating the amount of blood loss, and the lack of a standardized response.
The second set of EPs focuses on maternal deaths from hypertensive crisis/preeclampsia, which accounts for 6.8% of pregnancy-related deaths in the U.S. It is estimated that preeclampsia can occur in 5%–8% of all pregnancies, and is responsible for 76,000 maternal and 500,000 infant deaths globally each year.
Following is a more detailed look at the new EPs TJC has implemented to reverse these trends and improve the safety and lives of both maternal and fetal patients.
TJC has issued seven EPs related to maternal hemorrhage, requiring:
- Performing a hemorrhage risk assessment using an evidence-based tool upon admission to labor and delivery (L&D) and postpartum care. This risk assessment can be performed on paper or (preferably) in the mother’s electronic medical record. Taking this initial step will allow the care team to prepare for those patients who may be at higher risk. The California Maternal Quality Care Collaborative (CMQCC) offers an excellent starting point in its OB Hemorrhage Toolkit V2.0.
- Development of written procedures for hemorrhage management. This is the EP that is likely to require the most work at the hospital. Fortunately, most of what is needed should already exist in an organization’s massive transfusion protocol or OB hemorrhage protocol. The goal is to standardize on an evidence-based approach to minimize delays and foster effective communication among team members. To comply, hospitals need to describe the med kit in detail, establish team members’ roles and responsibilities, and describe how to call the blood bank. Hospitals will also need to develop procedures to confirm how much blood is required and should be on-site, when to call for a consult, and when to transfer a hemorrhaging mother to a higher level of care if the facility is a critical access hospital or is unable to provide the higher level of care itself. Hospitals must also demonstrate that they have scripted how to communicate with patients and their families during an active blood loss event.
- Standardization of a hemorrhage supply kit. Here again, the CMQCC OB Hemorrhage Toolkit offers a great starting point as it lists all the required elements. Hospitals should have a crash cart dedicated to maternal hemorrhage that has all these elements on board, along with anything else the hospital and delivering clinicians prefer. This cart should be checked with the same frequency as regular crash carts and locked in a secure area. The number of carts/kits required depends on the patient population and the layout of the hospital. For example, if postpartum is on a different floor than L&D, there should be at least one cart on each floor. If a large number of L&D patients are admitted through the emergency department (ED), there should be a cart in the ED as well. Organizations with a high percentage of high-risk mothers might want to consider having more than one cart/kit available in these areas.
- Delivery of role-specific staff and provider education about the organization’s OB hemorrhage procedures. For the care team to function optimally in an emergency, everyone must know the procedures to follow in the event of a hemorrhage. This education should be delivered during orientation, when there are changes in procedures, and every two years. Ensuring readiness in this way will make an impressionable impact on maternal outcomes.
- Conducting hemorrhage drills. Just as in the military, multidisciplinary simulation of emergency events is essential to uncovering gaps in education or procedures as well as improving staff response time and recognition of a worsening condition. Drills should be conducted annually at a minimum.
- Performing OB hemorrhage case reviews. A standardized approach to assessment of the response team and effectiveness of treatment in actual situations is an invaluable tool for gathering key information that can improve future patient experiences. With this information, hospitals can address process gaps and confirm optimal best practices that will help reduce maternal morbidity and mortality rates.
- Providing patient and family education. Patients and their families are often forgotten elements of the care team, yet their understanding of issues is vital. At a minimum, education should include the signs and symptoms of postpartum hemorrhage during hospitalization and instructions on when to seek care as well as signs and symptoms for when to seek immediate care. Research shows that discharge education suffers from alarming inconsistencies, misinformation, and healthcare provider subjective bias. As a result, patients often leave the hospital misinformed, undereducated, and unappreciative of the high-risk nature of their medical condition. A checklist tool greatly reduces these inconsistencies so clinicians can provide better patient education.
It is not uncommon for maternal patients to present without the common signs and symptoms of hypertension or preeclampsia, such as sudden edema or weight gain, headaches, and visual disturbances. To combat this and improve patient assessment, TJC has issued six EPs for this condition, requiring:
- Detailing within the policy and procedure steps for accurately measuring and remeasuring maternal blood pressure. Taking blood pressure properly is usually learned in the first weeks of nursing school, but in the clinical setting, it’s often done incorrectly. Following the proper, written procedure will lead to more accurate blood pressure assessments and data interpretation, which is extremely valuable for diagnosing a patient who is suffering from severely elevated blood pressure or preeclampsia. Conversely, inaccurate measurement can lead to a mother not receiving proper treatment and being discharged unknowingly with elevated blood pressure that is potentially fatal. The recommended procedure can be found in the CMQCC preeclampsia toolkit.
- Development of a policy and procedure for managing maternal patients with severe hypertension/preeclampsia. This may be the most difficult and time-consuming EP to implement because several factors must be addressed, including:
- Creation of an evidence-based set of emergency response medications that are stocked and immediately available on the OB unit
- Use of seizure prophylaxis
- Guidance on when to use continuous fetal monitoring
- Guidance on when to consider emergent delivery
- Criteria for when a team debrief is required
- Delivery of staff and provider education on maternal severe hypertension/preeclampsia. This carries the same rationale and requirements as #4 in the OB hemorrhaging discussion. Special attention should be paid to staff education surrounding magnesium sulfate due to its high-risk medication label. Understanding the pathophysiology of eclampsia, the rationale for magnesium sulfate as seizure prevention, and the risk of maternal cerebral events is critical to the care of at-risk patients.
- Conducting OB severe hypertension/preeclampsia drills. This carries the same rationale and requirements as #5 in the OB hemorrhaging discussion.
- Performing OB severe hypertension/preeclampsia case reviews. This carries the same rationale and requirements as #6 in the OB hemorrhaging discussion.
- Delivery of patient and family education. This is similar to #7 in the OB hemorrhaging discussion, but also offers an opportunity to get creative. For example, staff can wear t-shirts that say, “Got headaches?” as a reminder to patients to report them. Magnets in the discharge package that look like drops of blood can be a reminder to look for active, bright red bleeding. Anything hospitals can do to draw the attention of patients and families to these high-risk situations is an added benefit.
Reversing the trend
Maternal hemorrhage and severe hypertension/preeclampsia are pervasive issues in America today, leading to far too many maternal morbidity and mortality events. But both are eminently fixable. Following TJC’s new EPs isn’t just a requirement for accreditation—it’s also the right thing to do. Together, we won’t just meet the Healthy People 2020 goals, we can greatly exceed them.
Alana McGolrick is chief nursing officer of PeriGen, a company delivering innovative perinatal software solutions.