The Joint Commission's Perinatal Core Measure Set, published in April 2010, consists of 5 indicators.
PC-01 Elective Delivery.
Patients with elective vaginal deliveries or elective cesarean sections at >37 and <39 weeks of gestation completed
PC-02 Cesarean Section.
Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section
PC-03 Antenatal Steroids.
Patients at risk of preterm delivery at 24-32 weeks of gestation receiving antenatal steroids prior to delivering preterm newborns
PC-04 Healthcare-Associated Bloodstream Infections in Newborns.
Staphylococcal and Gram-negative septicemias or bacteremias in high-risk newborns
PC-05 Exclusive Breastmilk Feeding.
Exclusive breastmilk feeding during the newborn's entire hospitalization
Number of non-NICU term babies exclusively breastfed.
Frequently Asked Questions about PC-05 Exclusive Breastmilk Feeding
FAQ #1 Who would they like data on?
The Joint Commission wants to know how many non-NICU term babies without a contradication to breastfeeding were exclusively breastfed during the time period measured.
FAQ #2 What is the definition of exclusive breastfeeding?
The Joint Commission defines exclusive breastmilk feeding as a newborn receiving only breast milk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals or medicine.
Sweetease (24% oral sucrose) used as pain relief in newborns is not a reason to designate a baby as not exclusively breastfed.
Expressed breast milk and donor milk count as breast milk.
FAQ #3 What babies fit into the contraindication to breastfeeding group?
Acceptable maternal medical conditions for which breast milk feeding should be avoided include:
HIV infection, illegal substance abuse or alcohol abuse, certain medications (examples: prescribed cancer chemotherapy, radioactive isotopes), galactosemia, active untreated tuberculosis, HTLV Type I or II, active herpes simplex virus with breast lesions, active untreated varicella.
A baby can be excluded from the total sample for several reasons: admission to the NICU; the mother has a contraindication to breastfeeding; the baby requires parenteral infusion, has experienced death, requires a length of stay >120 days, or is enrolled in a clinical trial.
FAQ #4 What about a mother who is eligible to breastfeed but she doesn't want to?
The mother's refusal to breastfeed does not constitute a reason for not exclusively feeding breast milk.
FAQ #5 What is the desired outcome?
The Joint Commission wants to see an increase in the rate of exclusive breastfeeding over time.
FAQ #6 Are there any resources to help us with this?
Yes, the United States Breastfeeding Committee has develped a toolkit to assist sites in obtaining this information: The Toolkit.
Also view: Implementing The Joint Commision Perinatal Care Core Measure on Exclusive Breast Milk Feeding
FAQ #7 I am feeling a little overwhelmed! Where do we begin?
Keep in mind that you are not alone. Many maternity facilities don't collect annual feeding data at all, let alone exclusive breastfeeding rates. To start, figure out a way to collect your data. If you find your exclusivity rate is low, don't panic - we are all in the same boat! Pull out your mPINC survey and work to improve that score. Optimal mother baby practices will drive your breastfeeding rates up. Information about the CDC mPINC survey can be found on this www.motherbabysummit.com website.
FAQ #8 How many babies should we audit?
Hospitals who choose to sample can do so quarterly or monthly. Hospitals must also decide whether to sample mothers or newborns and follow the guidelines as explained in The Joint Commission's Specification Manual.
Quarterly sample sizes*:
Monthly sample sizes*:
*As seen in The Joint Commission's Specification Manual. Check their website for additional information and conditions.
FAQ #9 What about non-term infants?
They should be excluded.The Join Commission specifies that exclusive rates be collected on term infants (37-42 weeks gestation): "The Joint Commission is looking specifically at the number of exclusively breast milk-fed term infants as a proportion of all term infants," from page 2 of Implementing The Joint Commision Perinatal Care Core Measure on Exclusive Breast Milk Feeding. In other words, non-NICU babies outside of 37-42 weeks gestation (36 weeks or lower, 43 weeks or higher) should not be counted in exclusive rates.
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To read more take a look:
The Joint Commission's Breastfeeding Policy 2010
The Joint Commission’s Perinatal Care Measure Set Overview
United States Breastfeeding Committee Toolkit:
Implementing TJC Perinatal Care Core Measure on Exclusive Breast Milk Feeding
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