by Rob Durkee, MHA, RN, FACHE
Accreditation Advisor

Each year in the U.S., approximately 700 women die as a result of pregnancy-related complications, according to a report recently published by the Centers for Disease Control and Prevention. The leading complications, maternal hemorrhage and severe hypertension/preeclampsia, make up 21.4% of all reported pregnancy-related deaths. Fortunately, they can be treated with early detection.

To that end, The Joint Commission will implement new standards Jan. 1, 2021 that aim to improve the quality and safety of care provided to women during all stages of pregnancy and postpartum. The standards are specifically related to early detection of life-threatening, pregnancy-related conditions, and to enabling hospital staff to mount rapid and coordinated treatment of women who experience severe hypertension/preeclampsia or maternal hemorrhage.

With the nation and world rightly focused on the COVID-19 response, there may be less attention to preparation for implementation of the perinatal safety standards. However, when the COVID-19 response moves into a less acute phase, organizations should conduct a gap analysis to determine whether their current processes comply with the new standards, and if not, work to correct any identified gaps. Here’s a summary of what hospitals are expected to have in place when the new standards go into effect.  


Organization must develop a procedure by a multidisciplinary team comprising obstetrics, anesthesiology, nursing, laboratory and, for those working with hemorrhage patients, a blood bank. Teams working to ensure preeclampsia patient health will need to include a staff member from pharmacy. All staff and providers who treat pregnant and postpartum women must receive role-specific training about the hospital’s evidence-based hypertension/preeclampsia procedure as well as the hospital’s hemorrhage procedure.  Minimally, this should occur at orientation, whenever changes to the procedure occur or every two years. Because patients often present to the emergency department regardless of the hospital’s ability to provide labor and delivery services, training should also be provided to ED staff.


In addition to education, organizations must conduct drills at least annually to determine systems issues as well as issues related to the hemorrhage response as part of ongoing quality efforts. Drills should include representation of all disciplines identified in the hospital’s hemorrhage response procedures.  A team debrief is required after the drill. The Joint Commission has clarified that an actual event does not take the place of the annual drill requirement.


OB postpartum units must review cases in accordance with the criteria established by the hospital to evaluate the effectiveness of the hemorrhage response team during the event. They must also provide education to patients and their families during hospitalization to include, in the case of a hemorrhage patient, the designated support person whenever possible. For hypertension patients, at a minimum, education includes signs and symptoms of severe hypertension/preeclampsia that alert the patient to seek immediate care and signs for when to schedule a post-discharge follow-up appointment. For hemorrhage patients, education must include the signs and symptoms of postpartum hemorrhage that might occur after discharge so that the patient is alerted for when to seek immediate care.

Evidence-based procedures: maternal hemorrhage

As described in Johns Hopkins Nursing Evidence-Based Practice: Models and Guidelines, an evidence-based procedure integrates the best available scientific evidence with the best available experiential (patient and practitioner) evidence. Evidence Based Practice (EBP) considers internal and external influences on practice and encourages critical thinking in the judicious application of such evidence to the care of individual patients, a patient population, or a system.

In addition to training, drills and review, upon admission to both labor and delivery and the postpartum unit, each patient must be assessed for hemorrhage risk using an evidence-based tool. Both the American College of Obstetricians and Gynecologists (ACOG) and the Association Women’s Health, Obstetric and Neonatal Nurses (AWHONN) have evidence-based tools available.

Hospitals must have a written, EBP for stage-based management of pregnant and postpartum patients who experience maternal hemorrhage. The procedure must be developed with help of a blood bank, and it must include:

  • Use of an evidence-based tool, with an algorithm, to identify and treat hemorrhage.
  • Use of evidence-based emergency response medications that are immediately available in the unit.
  • An outline of the roles and responsibilities of response team members.
  • A description of how the response team is activated.
  • A blood bank plan and plan for emergency release of blood products, to include how to activate the hospital’s massive-transfusion protocol.
  • Guidance on when to consult additional experts, consider transfer to a higher level of care and how to communicate with families during and after an event.
  • Criteria for when a team debriefing is required immediately after a case of severe hemorrhage.

Each OB unit must have a standardized, secured, and dedicated hemorrhage kit, which contains, at a minimum, emergency hemorrhage supplies as determined by the hospital and the approved procedures for a severe hemorrhage response.

Evidence-based procedures: hypertension/preeclampsia

Organizations should develop written, EPBs for measuring and remeasuring blood pressure to include criteria that identify patients with severely elevated blood pressure and also criteria that is specific to pregnant and postpartum patients who experience severe hypertension. Guidelines are available at ACOG.

The procedure must be developed by a multidisciplinary team referred to above, plus a representative from the organization’s pharmacy department. The EBP should include:

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

Many organizations have long-since implemented safety measures related to these potential medical emergencies involving pregnant women and those in the postpartum period. Reviewing the new standards and filling any gaps should further strengthen the quality and safety of care.

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About the author. In his role as accreditation advisor for Vizient, Rob Durkee provides accreditation and regulatory services to member organizations. He conducts compliance assessments, coaching during TJC surveys, and delivers educational presentations on accreditation and CMS compliance topics.

Published: August 21, 2020