Maternal Patient SafetyThe Joint Commission Makes it a Priority
ALANA MCGOLRICK, DNP RNC -OB, C-EFM
CHIEF NURSING OFFICER, PERIGEN
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DisclaimerThis presentation includes information from The Joint Commission and other sources (designated on the slides). The following studies were not conducted by PeriGen.
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About PeriGenComprehensive labor and delivery patient safety platform incorporating PeriGen’s NICHD-validated Artificial Intelligence decision support tools.
Leveraging evidence-based medicine with 50 peer-reviewed publications: American Journal of Obstetrics and Gynecology, Becker’s, Journal of Healthcare Information Management.
PeriWatch Vigilance ® is an early warning system that works with an existing EFM to quickly & consistently identify patients who may be developing a potentially worsening condition.
330 clients nationally
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Our PresenterDr. Alana McGolrick
DNP, RNC-OB, C-EFM
PeriGen Chief Nursing Officer
With significant perinatal experience, Dr. McGolrick leads PeriGen's efforts to expand and enhance clinical education, customer outcomes and publishing.
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Clinical ConsultantKaren Kolega (“KK”)
MSN-CNL, RNC-OB, C-EFM
PeriGen Clinical Consultant
Karen is a clinical subject matter expert for PeriGen’s obstetrical software. Her expertise in Obstetric practices, regulations and hospital operations improves prospective client engagement, adoption, and implementation.
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AgendaBackground
Significance
Problem
The Joint Commission Accreditation Manual Additions
Obstetric Hemorrhage
Severe Hypertension/Pre-eclampsia
PeriWatch Vigilance® Demonstration
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Objectives
At the conclusion of this program, the participant will be able to:1. Demonstrate knowledge and understanding of The Joint Commission new elements of
performance.
2. Describe the strategies to achieve compliance with the new elements of performance.
3. Identify one performance improvement opportunity that you may implement at your hospital.
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Background
40-50 % of maternal deaths have been deemed potentially preventable deaths
Most preventable events are preceded by vital sign changes
Maternal morbidity rates have more than doubled in the United States since 1998
Causal factors are commonly related to a delayed response to clinical warning signs
(MacDorman et. al., 2016; Mhyre et al., 2014; Morton et al., 2019; Shields et al., 2016)To learn more about PeriGen, please visit PeriGen.com
Maternal Mortality Trends
(https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html)
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Poll QuestionAre you currently participating in a local, state or national maternal safety collaborative?
1. Yes
2. No
3. Unsure
4. Plan to participate in the future
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Poll QuestionIf yes, which collaborative are your partnering with?
1. AIM
2. CMQCC
3. AWHONN
4. State specific collaborative
5. Other
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Significance
Medical complexity of the pregnant patient
Failure to standardize national obstetric patient safety standards
Limited research exists on maternal early warning systems
(Arora et al., 2016; Carle et al., 2013; Cole, 2014; Mhyre et al., 2014; Shields et al., 2016)
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(https://www.cdc.gov/mmwr/volumes/68/wr/mm6818e1.htm)
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The Problem
Potentially preventable
maternal morbidity & mortality
Inaccurate assessment
Misinterpretation
Communication delay
Lack of standardization
Escalation of care
Complex comorbidities
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Poll QuestionHave you experienced an adverse outcome that was related to any of the following causative factors? ‘check all that apply’
1. Underappreciation of patient status
2. Failure to recognize worsening condition
3. Delay in care
4. Reluctance to escalate situation
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Accreditation Manual Additions
• PC.06.01.01
• Reduce the likelihood of harm related to maternal hemorrhage
• Elements of Performance 1-7
Provision of Care, Treatment, and Services
• PC.06.01.03
• Reduce the likelihood of harm related to maternal severe hypertension/preeclampsia
• Elements of Performance 1-6
Provision of Care, Treatment, and Services
(https://www.jointcommission.org/r3_report_24_pc_standards_for_maternal_safety/)
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Obstetric Hemorrhage
Leading cause of maternal death worldwide
Major component of severe complications
Racial disparities indicating an alarming gap
Failure to recognize excessive blood loss
Delayed interventions
(Callaghan, Creanga, & Kuklina, 2012; CMQCC, 2015, Seachrist et al., 2019)
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Elements of Performance1. Maternal hemorrhage risk assessment upon admission
2. Written procedures for stage-based maternal hemorrhage management*
3. Standardized hemorrhage supply kit
4. Staff and provider maternal hemorrhage education
5. Obstetric hemorrhage drills
6. Obstetric hemorrhage case reviews
7. Patient and family education
(https://www.jointcommission.org/r3_report_24_pc_standards_for_maternal_safety/)
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Obstetric Risk Assessment
(https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit)
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Massive Transfusion Protocol
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Obstetric Hemorrhage Supply Kit
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(https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit)
Case Review
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(Callaghan et al., 2014, Geller et al, 2014, Kilpatrick et al., 2014)
Patient and Family Education (Suplee et al., 2016)
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Hypertension Crisis & Pre-eclampsia
One of the leading causes of maternal mortality
Contributing factor to pregnancy complications
Historically focus has not been on BP control
ACOG Practice Bulletin 202, Volume 133, No. 1 January 2019
Initiate aspirin therapy for high risk maternal patients
Postpartum patients continue to be at risk
(ACOG, 2019)
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Elements of Performance 1. Policy and procedure for accurate measuring and remeasuring maternal blood pressure
2. Policy and procedure for managing maternal patients with severe hypertension/preeclampsia*
3. Staff and provider maternal severe hypertension/preeclampsia education
4. Obstetric severe hypertension/preeclampsia drills
5. Obstetric severe hypertension/preeclampsia case reviews
6. Patient and family education
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How to accurately
measure blood pressure
(https://www.cmqcc.org/resources-tool-kits/toolkits/preeclampsia-toolkit)
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Policy and Procedure Designed to guide clinical practice
Provide specific steps to care for patients within the hospital
Evidenced based practice
Supported by established standards
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Magnesium SulfateT W O M A I N G O A L S – M A N A G E M E N T O F P R E E C L A M P S I A A N D P R E V E N T I O N O F S E I Z U R E S
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Case Review
(https://www.cmqcc.org/resources-tool-kits/toolkits/preeclampsia-toolkit)
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Patient and Family Education
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(Suplee et al., 2016)
PeriWatch Vigilance® Demonstration
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PeriWatch Vigilance®• PeriWatch Vigilance is an OB Early Warning System, not a documentation system
• Aggregates data from your fetal monitor and EMR, it analyzes that data and gives it back to you with actionable notifications and information
• Quality improvement tool; does not send information back to the permanent medical record
• Goal: Provide the caregivers with timely notifications of potentially worsening conditions so you can assess the patient, intervene as appropriate and potentially avoid a delay in care
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Poll QuestionDo you feel that the tools and references presented today will be helpful with achieving compliance with the new elements of performance?
1. Yes
2. No
3. Not sure
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SummaryUnacceptable maternal morbidity and mortality rates
One adverse outcome is too many
Share resources
Be empowered
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1. Yes, I’m not a customer & would be interested learning more!
2. Yes, I am a customer & want to see what’s new!
3. Yes, I’d like to talk with the webinar speaker.
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Thank You
Hosting a repeat webinar on December 10th – 3pm EST◦ https://attendee.gotowebinar.com/register/4588480128912253196?source=December+10th
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ReferencesAvailable upon request
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