Joint Commission issues latest Sentinel Event Alert on preventing maternal death

The Joint Commission issued its latest sentinel event alert on Tuesday about preventing maternal death. This alert is the first of 2010 and the 44th since The Joint Commission began issuing them in 1998. The alert highlights maternal death in the U.S. as a serious problem to which hospitals and caregivers should be paying more attention, although it is rare. Unfortunately, there seems to be few standard practices that these parties can take to prevent maternal death simply because the reasons that pregnant women may die are numerous and related to differing conditions of the patient. Maternal death is defined as death that occurs within 42 days of birth or termination of pregnancy.

The National Center for Health Statistics of the Centers for Disease Control and Prevention said that 13.3 mothers died per 100,000 live births in 2006. This number represents an increase when compared with rates of maternal death in earlier years. Although the increase may be due to more widespread reporting of maternal death, the issue is not one that is improving, according to the alert.

One of the reasons that researchers speculate the number of maternal deaths is climbing is the growing number of obese women who become pregnant. Obesity brings with it a host of related health issues, which could factor into the maternal death rate.

The Joint Commission recommends that hospitals comply with PC.02.01.19, which is where the 2009 National Patient Safety Goal requiring that hospital staff recognize and respond to changes in patient’s conditions was moved to for 2010. In addition, the alert provides the following specific actions:

• Educate caregivers to inform their female patients with underlying medical conditions such as high blood pressure, diabetes or morbid obesity, that if they become pregnant, they are putting their bodies at even greater risk. Additionally, offer them contraception and where to find preconceptual counseling.
• Identify specific protocols for how to handle changes in a pregnant woman’s vital signs, specifically for conditions such as hemorrhage and pre-eclampsia.
• Ensure that ED staff are aware that any woman who is admitted may be pregnant, whether she says so, appears so, or not. If staff are aware a woman is pregnant, they may prescribe different care.
• Refer those pregnant woman who have high risk conditions to experienced prenatal care providers
• Ensure pneumatic compression devices are available for women undergoing a Cesarean section and are at risk for a pulmonary embolism. Pregnancy is in itself a risk factor for pulmonary embolism and venous thromboembolism.
• Evaluate patients at risk for thromboembolism for the use of low molecular weight heparin for care after delivery

Do you think this SEA is one that your hospital will pay attention to?