The Joint Commission: Fewer Inductions, Fewer C-Sections, and Exclusive Breastfeeding

The Joint Commission* is the agency which accredits most hospitals in the USA. All of our clinical practice is done with an eye to Joint Commission requirements. These requirements are often housed in what the Joint Commission calls Core Measures, which are "bundles" of treatments that should happen for certain diseases. For us in emergency and critical care, these can be pretty strict. For instance, if your patient comes to the ER with a possible heart attack, you need to give aspirin immediately, run an EKG within five minutes, etc. It's important because these are documented life-saving treatments. If you skip any part of a bundle, you need explicit documentation justifying your decision. When the Joint Commission comes, they follow patients and inspect their charts from admission to discharge. If they don't like what they can see, they can fine you or remove your accreditation, which can then lead to Medicare not reimbursing your services or the state closing your doors.

I'm familiar with the Core Measures for medical patients, but I was surprised to learn that they exist for mother-baby care as well. The new Core Measures for Perinatal Care were released in January 2010 and they began collecting data on hospitals this month. I was additionally surprised at how forward-thinking they are, compared to how I picture obstetric care in this country. Here's what I gleaned from the measures (keep in mind that I don't work for or represent the Joint Commission!):

Measure 1: Elective Delivery. Their goal is reducing the rate of elective deliveries before 39 weeks.

...almost 1/3 of all babies delivered in the United States are electively delivered...compared to spontaneous labor, elective inductions result in more cesarean deliveries and longer maternal length of stay. The American Academy of Family Physicians (2000) also notes that elective induction doubles the cesarean delivery rate. Repeat elective cesarean sections before 39 weeks gestation also result in higher rates of adverse respiratory outcomes, mechanical ventilation, sepsis and hypoglycemia for the newborns

I think this is great, but obviously would like to see a reduction in elective deliveries after 39 weeks, but modern obstetrics is very afraid of 'overdue' births, without (as far as I can tell) very much evidence. However, inductions and c-sections before the 39 week mark are probably one of the major causes of birth complications and NICU admissions in this country, so this is probably a good start.

Measure 2: Cesarean Section. Their goal is cutting the c-section rate for first-time mothers who have no complications. This Measure is worded the strongest:

The removal of any pressure to not perform a cesarean birth has led to a skyrocketing of hospital, state and national cesarean section (CS) rates. Some hospitals now have CS rates over 50%. Hospitals with CS rates at 15-20% have infant outcomes that are just as good and better maternal outcomes (Gould et al., 2004). There are no data that higher rates improve any outcomes, yet the CS rates continue to rise. This measure seeks to focus attention on the most variable portion of the CS epidemic, the term labor CS in nulliparous women. This population segment accounts for the large majority of the variable portion of the CS rate, and is the area most affected by subjectivity.

I take "subjectivity" to mean "clinical decision-making lacking in evidence." This, again, is good, though limited (hopefully someday it will extend to an endorsement of VBACs for uncomplicated pregnancies).

Measure 5: Exclusive Breast Milk Feeding. This was the most interesting and surprising goal: Exclusive breast milk feeding during the newborn's entire hospitalization. It lists all the dozens of healthcare organizations which endorse exclusive breastfeeding, and it clarifies what counts as reasons for not exclusively breastfeeding:

Reasons for not exclusively feeding breast milk during the entire hospitalization are clearly documented in the medical record. These reasons are due to a maternal medical condition for which feeding breast milk should be avoided.

Exclusive breast milk feeding is defined as a newborn receiving only breast milk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines.

The mother's refusal to feed the newborn breast milk does not constitute a reason for not exclusively feeding breast milk. [bold emphasis theirs]

When determining whether there is a reason documented by a physician/APN/PA or CNM for not exclusely feeding breast milk, reasons must be explicitly documented (e.g., "mother is HIV positive - infant will not be breast fed") or clearly implied (e.g., "mother is currently abusing alcohol - infant will be fed formula"). If reasons are not mentioned in the context of infant feeding, do not make references (e.g., Do not assume that the infant is not receiving breast milk because of the medications the mother is currently taking).

They are also explicit on what medical conditions apply: HIV, active TB, galactosemia, etc. It also allows exemption for drugs which contraindicate breastfeeding.

Two other Core Measures (3 and 4) concern Antenatal Steroids (to avoid preterm labor) and Bloodstream Infections in Newborns which are important, but of more concern to the L&D and NICU clinical environment.

I'm excited by this, because in my clinical world, the Core Measures are important guides to our care, and by and large respected as things that have saved lives. I'm not sure how they are viewed in obstetrics. Hospital obstetrics seems much more dominated by physician's personal views than other parts of the hospital, and it's also much influenced by the outside clinical world: e.g., reducing elective inductions in the hospital will mean affecting how obstetricians practice with patients in their offices. And I heard a lot of "that's nice, but we'll see how it goes in the real world" regarding implementing the Baby-Friendly Hospital Initiative by L&D staff when I was in school. I also don't know how much leverage the Joint Commission has over obstetrics, compared to the leverage it has over the rest of us.

But it's exciting to read.



*It used to be called the Joint Commission on the Accreditation of Healthcare Organizations, or JCAHO—"jay-co" as we still call them. Now they're just The Joint Commission or TJC.