Joint Commission Releases First Sentinel Event Alert for 2010: Prevention of Maternal Death

By: LMcBride

Whether your facility is accredited by The Joint Commission (TJC) or another accrediting body, there should be an interested in reducing risks of maternal death. The U.S. government’s Healthy People 2010 initiative set a target of 3.3 maternal deaths per 100,000 live births, but according to the CDC’s (TJC, 2010) most recent statistics there are 13.3 maternal deaths per 100,000 live births. Further, U.S. Department of Health and Human Services (USDHHS), Health Resources and Services Administration (HRSA) (2008) released disparities of care based on ethnicity for maternal deaths for the year 2005 indicating that if you are non-Hispanic Black woman your rate is 39.2 per 100,000 live births which is three (3) times more than the rate of non-Hispanic White women (11.7 per 100,000 live births) and more than four (4) times the rate among Hispanic women (9.6 per 100,000 live births). TJC (2010) indicates the greatest risk is among women who present with high blood pressure, diabetes and/or obesity.

What can hospitals do to prevent maternal deaths? TJC (2010) has suggested the following actions:

1. Educate physicians and other clinicians who care for women with underlying medical conditions about the additional risks that could be imposed if pregnancy were added; how to discuss these risks with patients; the use of appropriate and acceptable contraception; and pre-conceptual care and counseling. Communicate identified pregnancy risks to all members of the health care delivery team.
2. Identify specific triggers for responding to changes in the mother’s vital signs and clinical condition and develop and use protocols and drills for responding to changes, such as hemorrhage and pre-eclampsia. Use the drills to train staff in the protocols, to refine local protocols, and to identify and fix system problems that would prevent optimal care.
3. Educate emergency room personnel about the possibility that a woman, whatever her presenting symptoms, may be pregnant or may have recently been pregnant. Many maternal deaths occur before the woman is hospitalized or after she delivers and is discharged. These deaths may occur in another hospital, away from the woman’s usual prenatal or obstetric care givers. Knowledge of pregnancy may affect the diagnosis or appropriate treatment.
4. Refer high-risk patients to the care of experienced pre-natal providers with access to a broad range of specialized services.
5. Make pneumatic compression devices available for patients undergoing Cesarean section who are at high risk for pulmonary embolism.
6. Evaluate patients who are at high risk for thromboembolism for low molecular weight heparin for post partum care.

References:
Health Resources and Services Administration (HRSA). (2008). Women’s health USA 2008: Maternal mortality. HRSA website. Rockville, Maryland: U.S. Department of Health and Human Services (USDHHS). Retrieved January 31, 2010: http://mchb.hrsa.gov/whusa08/hstat/mh/pages/234mm.html
The Joint Commission (TJC). (2010). Issue 44, January 26, 2010: Preventing maternal death. The Joint Commission website. Retrieved January 31, 2010: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_44.htm