Joint Commission Issues New Maternal Infectious Disease Requirements

By on 7:18 AM

The Joint Commission is implementing three new elements of performance (EPs) pertaining to maternal infectious disease identification and prevention, according to an R3 Report.

The EPs, which take effect July 1, 2018, are applicable to all Joint Commission-accredited hospitals and critical access hospitals that provide obstetric services, specifically labor and delivery. The Joint Commission stated that the EPs are "…designed to improve the identification of mothers upon admission to labor and delivery who are at risk for transmitting certain infectious diseases to their newborns so that the mother and/or the newborn can be treated promptly to prevent harm."

The EPs are part of standard PC.01.02.01 in the Provision of Care (PC) chapter of the hospital accreditation manual. They are as follows:

EP 14: For [critical access] hospitals that provide obstetric services: Upon admission to labor and delivery, the mother's status of the following diseases (during the current pregnancy) is documented in the mother's medical record:
  • Human immunodeficiency virus (HIV)
  • Hepatitis B
  • Group B streptococcus (GBS)
  • Syphilis
EP 15: For [critical access] hospitals that provide obstetric services: If the mother had no prenatal care or the disease status is unknown, testing for the following diseases are performed and the results documented in the mother's medical record:
  • HIV
  • Hepatitis B
  • GBS
  • Syphilis
Note: Because GBS test results may not be available for 24-48 hours, organizations may elect not to perform this test but instead administer prophylactic antibiotics to the mother.

EP 16: For [critical access] hospitals that provide obstetric services: If the mother tests positive for HIV, hepatitis B, GBS or syphilis when tested in labor and delivery, that information is also documented in the newborn's medical record after delivery.

"The requirements will help improve maternal and neonatal health in Joint Commission accredited hospitals and critical access hospitals across the country," said Kathy Clark, MSN, RN, associate project director specialist, Division of Health Care Quality Evaluation, The Joint Commission, in a news release. "If left undiagnosed or untreated, infectious diseases can be extremely dangerous and even life-threatening, so it is critical that testing and treatment for both the woman and baby is completed according to clinical practice guidelines."

Phenelle Segal, RN, CIC, FAPIC

Phenelle Segal, RN, CIC, FAPIC, is the founder and president of Infection Control Consulting Services LLC (ICCS). Phenelle has more than 30 years' experience providing customized comprehensive infection control and prevention services to healthcare facilities nationwide. Her services focus on assisting hospitals, ambulatory surgery centers, dental office and oral surgery practices, doctor's offices, nursing homes and other organizations with implementing and maintaining an infection control program that: complies with The Joint Commission, AAAHC, Centers for Medicaid and Medicare Services (CMS) and other regulatory agencies; respond to situations of noncompliance; and improve the processes for reducing risk.