Patton Post – March 2023

Racial and Ethnic Disparities in Pregnant and Postpartum Patients:

The lead article in Perspectives is rather complex in that it summarizes a January 17 Sentinel Event Alert #66 on racial and ethnic disparities in pregnant and postpartum patients. In addition it references a second document, Quick Safety #67 on Mental Health Conditions Causing Pregnancy Related Deaths.

The Sentinel Event Alert identifies the US as having the highest mortality rate for pregnant and postpartum patients among developed countries. There are references in the SE Alert with links and for this statistic it references a 17.4 mortality rate per 100,000 births in the US. This same reference displays a graphic with state-by-state mortality rates with Louisiana, Georgia, Indiana, and New Jersey having the highest mortality rates and California having the lowest.

The SE Alert also identifies some important ethnic comparisons from the CDC including:

• “Non-Hispanic black patients were 3 times more likely than white patients to die from pregnancy related causes.”
• “Native American pregnant patients were twice as likely to die than white pregnant patients.”
• “Black and Native American patients over the age of 30, have a mortality rate for pregnancy related causes that is 4-5 times higher than for white patients.”
• “Black pregnant patients with at least a college degree still have a mortality rate 5.2 times higher than white patients.”

The Sentinel Event Alert briefly discusses potential causes for these disparities and the Quick Safety provides a more in-depth analysis of mental health issues as a causative factor in a significant percentage of these deaths. The Quick Safety references another CDC data set that analyzed 36 state Maternal Mortality Review Committees analyses of just over 1,000 pregnancy related deaths and these committees identified almost 23% related to mental health conditions.

This is undoubtedly a complex issue, and you likely will want to have a team analyze these publications and data to determine how you might be able to enhance safety within your own patient population. We would also remind readers that the published Sentinel Event Alerts always contain recommendations for action, yet there is no standards-based mandate to implement each of these suggested actions.

There is however an expectation that accredited organizations will analyze the recommendations and implement those that might enhance safety for their particular organization, so you do want to document your careful analysis and some formal implementation efforts for those recommendations that are most meaningful to your organization.

Readers should also recall that TJC has new leadership standards in 2023 on reducing racial and ethnic healthcare disparities and these standards will become National Patient Safety Goals later this year. It is likely that this topic will be the subject of discussion by surveyors at the leadership and/or data use meetings.

If you provide maternal services, you will want to be able to address your analysis of these recommendations and more importantly your enhanced safety strategies as a result of your analysis. Organizations sometimes struggle to find a suitable issue to conduct the “proactive intensive analysis” TJC requires every 18 months. This may be an appropriate and meaningful issue to identify for potential analysis.

Collecting Data on Discrepancies Between Diagnoses:

This month’s Perspectives also mentions that some organizations have long-been confused about the Performance Improvement requirement to collect data on “all significant discrepancies between preoperative and post operative diagnoses.” The good news is TJC has posted a revision to PI.01.01.01, EP 4 that adds significant clarity to the requirement. The bad news is the older version that was confusing to some organizations may also have been unclear to surveyors because we can’t ever recall seeing this issue scored on a survey.

The newly revised version is both clearer and more specific and has been posted to the Joint Commission’s prepublication page on their website. The new version includes a note that states:

“The hospital’s medical staff determine which unexpected postoperative diagnoses are clinically significant. Examples may include, but are not limited to, the following:

• A preoperative pathology or cytology report interpreted as a malignancy, but no malignancy was found in the surgical specimen.
• A patient underwent surgery for acute appendicitis, but the appendix was normal in the postsurgical specimen.
• An operation was performed because of a presumed malignancy based on a radiology report, but no malignancy was found.”

Readers will want to work with their QAPI, medical staff, and surgery departments to ensure that there is a similar medical staff-developed definition for these discrepancies as well as an identification and PI reporting process to bring forward such discrepancies for analysis.

Titrations:

This month’s Consistent Interpretation column discusses MM.06.01.01, EP 3, which defines the verification process staff should go through just prior to medication administration. This EP has become one of the most frequently scored as a result of TJC’s focus on medication titrations.

Specifically the EP requires staff to verify the product label and medication order, expiration date, examine for particulates, discoloration, or other loss of integrity, contraindications, that the medication is being administered at the proper time, in the prescribed dose, and by the correct route, and lastly that any concerns are discussed with the practitioner responsible for the treatment. We bolded the part of the EP that we see being scored most often as a result of the focus on titrations.

Prior to 2019 this EP was scored noncompliant much less often because it only required that the medication and its order match the product label. At that time the placeholder for scoring titration issues was PC.01.02.03, EP 3 for failure to perform reassessments as required. The Consistent Interpretation column this month sheds new light on how TJC is now carefully parsing the scoring on titration errors. They advise that surveyors score the MM standard is the medication order is not being followed. For example if a sedation titration should be adjusted if a certain RASS score is not being met. They also advise that the PC standard should be scored if there is a failure to document the physiologic parameter such as RASS when adjusting a sedation titration.

As luck would have it, the same day we saw this guidance published in Perspectives, we saw a 2023 survey report with both of these specific MM and PC standards scored noncompliant as a result of titrations. The MM standard was scored because a titration was adjusted even though a RASS score was documented that did not warrant an adjustment.

In addition the PC standards was scored noncompliant for another patient because a titration was adjusted and there was a failure to document any RASS score. The technical nuances of assigning fault to a specific EP, while interesting is likely not as important to our readers as is preventing either of these findings in your own organization. We continue to find sedation titrations most vulnerable to this type of scoring.

Blood pressure or pressor titrations are often better documented than sedation titrations which may be due to assistance by automated measurement and documentation systems which is not feasible with a RASS score. RASS requires staff to perform and document a specific and formal assessment. We do at times see gaps in policy requirements for RASS documentation that may account for some documentation gaps when staff are only recording RASS at a specific interval such as every 2 or 4 hours.

This interval-based documentation schedule may not align with assessments made at the time the titration needs to be adjusted. Another process gap we have seen is when staff assess the RASS as inadequate, adjust the titration rate, and then reassess and document the RASS is now where is should be, however the first assessment that was not on target is not documented. Organizations really need to think of the sedation titration documentation similar to pain medication.

With pain medication there is an assessment that indicates treatment is needed, followed by a reassessment after treatment to determine if the intervention was effective. Sedation titrations also need that assessment which indicates when an adjustment is needed, followed by a reassessment after the adjustment that documents if the target goal has been reached.

Discussion with ICU nurses during consults has identified many other clinical issues with sedation titrations such as observation of pain and blood pressure which may be resulting in titration rate adjustments outside of just the RASS parameter by itself. Unfortunately the authorization to change the rate may not be noted in the order details and the rationale why a change was made may also not be documented.

This month’s Consistent Interpretation column identified almost half of the hospitals surveyed last year received an RFI against this MM.06 standard. As there is also the potential for a “double ding” against the PC standard improvement of titration documentation is certainly warranted.

Getting timely documentation in an ICU setting may be difficult as urgent patient care needs take precedence, but organizations that have not yet considered TJC’s block charting option may want to give that another look. This would allow staff to “summarize” in a narrative note what adjustments took place and why during a 4-hour time block and avoid some of the minute-by-minute documentation gaps that are leading to RFIs.

Medication Compounding for Home Care:

There are 8 months to go until the implementation of the new chapter. By now everyone should have obtained a copy and begun to formally analyze the workload, training, and environmental requirements. We noted the In Sight column on the last page of this month’s Perspectives mentions that TJC is working on revising the Medication Compounding Chapter for its Home Care Accreditation Manual.

While this chapter is not applicable at this time in the hospital accreditation manual, we do find the content and EP format very helpful to understanding TJC’s focus and requirements for sterile compounding. Unfortunately this home care chapter is not available to hospitals who do not also have a home care program.

The In Sight column informs us that TJC is working on incorporating all the new requirements from the 2023 version of USP Chapter 797 into a standard and EP format, which will be published in the revised medication compounding chapter for home care. TJC usually posts such new content to its Prepublication page on its website, and we would encourage hospitals with and without home care to download this chapter when it becomes available.

While USP is written in a narrative format, TJC will publish standards with specific elements of performance which can sometimes make it clearer as to what the actual requirement is.