Joint Commission New Maternal Infectious Disease Requirements

PUBLISHED: Jan 23, 2018
Relevant to: Critical Access Hospitals, Hospitals

As StayAlert! has previously reported, The Joint Commission recently issued three new Elements of Performance (EPs) related to maternal status assessment and documentation that are effective as of July 1, 2018 for TJC-accredited hospitals and critical access hospitals with labor and delivery services.

The intention of these new EPs is to help provide early identification of mothers who are at risk for transmitting certain infections to their newborns so that both the mother and newborn can be treated as necessary.

Provision of Care, Treatment and Services standard PC.01.02.01 requires the organization to assess and reassess patients. The new EPs require:

  • Organizations to document or assess the current maternal status of infectious diseases, such as human immunodeficiency virus (HIV), hepatitis B, Group B streptococcus (GBS), and/or syphilis.
  • Promote patient safety and quality of care of the mother and newborn upon arrival and admission to labor and delivery.
  • Document information in the newborn’s medical record after delivery if the mother tests positive for HIV, hepatitis B, GBS, and/or syphilis.

In conjunction with announcing these new EPs, TJC released a new R3 Report, Maternal Infectious Disease Status Assessment and Documentation Standards for Hospitals and Critical Access Hospitals, which provides background and rationale for the new requirements.

According to TJC, a mother’s status of human immunodeficiency virus (HIV), hepatitis B, Group B streptococcus (GBS), and/or syphilis should be assesed upon admission to the labor and delivery unit and documented in the mother’s medical record. If there has not been testing of these conditions during the prenatal period or disease status is unknown, the hospital should test for these diseases and record the results in the medical record. A positive test result should also be documented in the newborn’s medical record.

Follow the link bellow to read the R3 report is its entirety.

Included with today’s notice are example polices related to these new requirements.

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