perinatal hospital standards 2015 -...
TRANSCRIPT
2015
RevisionsapprovedbytheIPQICGoverningCouncilJune16,2015
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Standard Title SummaryI Organization Referstotheadministrationofahospital’sneonatal‐perinatalprograms.II ObstetricalUnitCapabilities Referstotheresourcesofequipment,supplies,andpersonnelneededforthe
deliveryunitwithinthehospital.III ObstetricPersonnel Describestheroles,responsibilities,andavailabilityofobstetricpersonnelinthe
perinatalprogram.IV ObstetricSupportPersonnel Describestheroles,responsibilities,andavailabilityoftheotherpersonnelin
theobstetricprogram.V ObstetricEquipment Referstotheavailabilityofspecificequipmentneededfortheobstetricprogram.VI ObstetricMedications Referstotheavailabilityofspecificmedicationsneededfortheobstetric
program.
DEFINITIONS
AttheSite:onstaffattheinstitutionBoard‐certified:MeansaphysiciancertifiedbyanAmericanBoardofMedicalSpecialtiesMemberBoardortheAmericanOsteopathicAssociation.Immediatelyavailable:Aresourceavailableonsiteassoonasitisrequested.In‐house/Onsite:PhysicallypresentinthehospitalPerinatalCenter:AhospitaldesignatedasaperinatalcentermustmeettheACOGandAAPguidelinesforaLevelIII/IVObstetricUnitandaLevelIII/IVNeonatalUnitandcarryouttheresponsibilitiesoutlinedintheIndianaCoordinatedPerinatalSystemsofCare.Programmaticresponsibility:Thewriting,reviewandmaintenanceofpracticeguidelines;policiesandprocedures;developmentofoperatingbudget(incollaborationwithhospitaladministrationandotherprogramdirectors);evaluationsandguidingofthepurchaseofequipment;planning,developmentandcoordinationofeducationprograms(in‐hospitaland/or
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outreachasapplicable);participationintheevaluationofperinatalcare;andparticipationofperinatalqualityimprovementandpatientsafetyactivities.Readilyavailable:Aresourceforconsultsandassistanceavailablewithinashorttimeafteritisrequested.30minutes:In‐housewithinthirty(30)minutes.(Exceptionsmayoccurforcircumstancesbeyondanindividual’scontrolsuchasextraordinaryweatherortrafficimpediments).
LevelsofCareChartKey
E EssentialrequirementforlevelofperinatalcenterO OptionalrequirementforlevelofperinatalcenterNA NotApplicable
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OBSTETRICALDEFINITIONS
LevelI
LevelIhospitalshaveperinatalprogramsthatprovidebasiccaretopregnantwomenandinfants,asdescribedbythesestandardsandasstatedinIndianaAdministrativeCode(IAC)Title410:Article15.LevelIfacilities(basiccare)providecaretowomenwhoarelowriskandareexpectedtohaveanuncomplicatedbirth.Thesehospitalsprovidedeliveryroomandnormalnewborncareforstableinfants≥350/7weeksgestation.LevelIfacilitieshavethecapabilitytoperformroutineintrapartumandpostpartumcarethatisanticipatedtobeuncomplicated.Maternitycareproviders,midwives,familyphysicians,orobstetrician–gynecologistsshouldbeavailabletoattendallbirths. Thesehospitalsdonotacceptmaternaltransportsfromhospitalswithobstetricalservices.LevelIILevelIIobstetricalserviceshaveperinatalprogramsthatprovidespecialtycaretopregnantwomenandinfants,asdescribedbythesestandards.LevelIIfacilities(specialtycare)providecaretoappropriatehigh‐riskpregnantwomen,bothadmittedandtransferredtothefacility.InadditiontothecapabilitiesofaLevelI(basiccare)facility,LevelIIfacilitiesshouldhavetheinfrastructureforcontinuousavailabilityofadequatenumbersofRNswhohavedemonstratedcompetenceinthecareofobstetricpatients(womenandfetuses).Thesehospitalsprovidedeliveryroomandacutespecializedcareforinfants≥1,500gramsAND≥320/7weeksgestation.Maternalcareislimitedtotermandpretermgestationsthatarematernalriskappropriate.AlthoughmidwivesandfamilyphysiciansmaypracticeinLevelIIfacilities,anattendingobstetrician–gynecologistshouldbeavailableatalltimes.Aboardcertifiedobstetricianhasresponsibilityforprogrammaticmanagementofobstetricalservices.Thesehospitalsmayreceivematernalreferralswithintheguidelinesoftheirlevel.LevelIII
LevelIIIhospitalshaveobstetricalprogramsthatprovidesubspecialtycareforpregnantwomenandinfants,asdescribedbythesestandards.DesignationofLevelIIIshouldbebasedonthedemonstratedexperienceandcapabilityofthefacilitytoprovidecomprehensivemanagementofseverematernalandfetalcomplications. Thesehospitalsprovideacutedeliveryroomandneonatalintensivecareunit(NICU)careforhigh‐riskmothersandinfants<1,500gramsOR<320/7weeksgestation.
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Maternalcarespanstherangeofnormaltermgestationcaretothemanagementofcomplexmaternalcomplicationsandprematurity.Thedirectorofthematernal–fetalmedicineserviceshouldbeaboard‐certifiedmaternal–fetalmedicinesubspecialist.Aboard‐certifiedobstetrician–gynecologistwithspecialinterestandexperienceinobstetriccareshoulddirectobstetricservices. LevelIIIobstetricalhospitalsacceptriskappropriatematernaltransports.Inacceptingmaternaltransportsthelevelofneonatalcarerequiredforananticipateddeliveryandcareoftheneonatemustbeinplace.
LevelIV
LevelIVfacilities(regionalperinatalhealthcarecenters)includethecapabilitiesofLevelI,LevelII,andLevelIIIfacilitieswithadditionalcapabilitiesandconsiderableexperienceinthecareofthemostcomplexandcriticallyillpregnantwomenthroughoutantepartum,intrapartum,andpostpartumcare.InadditiontohavingICUcareonsiteforobstetricpatients,aLevelIVfacilitymusthaveevidenceofamaternal–fetalmedicinecareteamthathastheexpertisetoassumeresponsibilityforpregnantwomenandwomeninthepostpartumperiodwhoareincriticalconditionorhavecomplexmedicalconditions.Amaternal–fetalmedicineteammemberwithfullprivilegesisavailableatalltimesforon‐siteconsultationandmanagement.Theteamshouldbeledbyaboard‐certifiedmaternal–fetalmedicinesubspecialistwithexpertiseincriticalcareobstetrics.Thedirectorofobstetricservicesisaboard‐certifiedmaternal–fetalmedicinesubspecialistoraboard‐certifiedobstetrician–gynecologistwithexpertiseincriticalcareobstetrics.Inacceptingmaternaltransportsthelevelofneonatalcarerequiredforananticipateddeliveryandcareoftheneonatemustbeinplace.
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STANDARDI.ORGANIZATION‐GOVERNINGBOARDRESPONSIBILITIES1.1Thehospital’sBoardofDirectors,administration,andmedicalandnursingstaffsshalldemonstratecommitmenttoitsspecificlevelperinatalcenterdesignationandtothecareofperinatalpatients.ThiscommitmentshallbedemonstratedbyaBoardresolutionthat:
a) ThehospitalagreestomeettheIndianaPerinatalSystemStandardsforitsspecificlevelofdesignationthroughits
commitmenttothefinancial,human,andphysicalresourcesandtotheinfrastructurethatisnecessarytosupportthehospital’slevelofcaredesignation.
b) ThehospitalagreestoconductinternalauditingandattestationusingscreeningformsprovidedbytheIndianaStateDepartmentofHealth(ISDH).OncetheISDHformiscompleted,itistobesignedbytheCEOtoverifythatinformationsubmittedistrueandaccurate.
c) Thehospitalassuresthatallperinatalpatientsshallreceivemedicalcarecommensuratewiththelevelofthehospital’sdesignation.
d) Thehospitalagreestoberesponsibleforcredentialing,licensingandtrainingofallneonatalandobstetricalstaffbasedonthehospital’sdesignatedlevelofcare.Thehospitalisalsoresponsibleforensuringthatallhealthcareworkersmaintaincurrentlicenses,registrationorcertification,andkeepdocumentationofthisinformationwiththeabilitytohavethematerialavailablewithinareasonableamountoftime.410IAC15‐1.4‐1
e) Thehospitalagreestohavewrittenmedicalstaffpoliciesandproceduretoaddressemergentneonatalandobstetricalemergencies,initiatingtreatmentandreferringwhenappropriate.Thehospitalwillbeabletoprovideimmediatelifesavingmeasuresandhavetheappropriatestaffreadilyavailabletocareforemergentneonatalandobstetricpatientneeds,includingtimelyassessment,stabilization,andtreatmentpriortotransfer.Transfersshouldbearrangedwhenneededalongwithcopiesofthepatients’recordsandtreatmentsprovidedtotheacceptingfacility410IAC15‐1.4‐1
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STANDARDII.OBSTETRICALUNITCAPABILITIES I II III IV2.1Thehospitalshalldemonstrateitscapabilityofprovidinguncomplicatedandcomplicatedobstetricalcarethroughwrittenstandards,protocols,guidelinesandtrainingincludingthefollowing:
a) Managingunexpectedobstetricalandneonatalproblems. E E E Eb) Providingfetalmonitoring,includinginternalscalpelectrodemonitoring. E E E Ec) Initiatinganemergentcesareandeliverywithinatimeintervalthatbest
incorporatesmaternalandfetalrisksandbenefitswiththeprovisionofemergencycare.
E E E E
d) Selectingandmanagingobstetricalpatientsatamaternalrisklevelappropriatetoitscapability. E E E E
e) Providingcriticalcareservicesappropriateforobstetricalpatients,asdemonstratedbyhavingacriticalcareunitandaboard‐certifiedcriticalcarespecialist,readilyavailableatalltimes.
NA NA E E
f) Assuringavailabilityofanesthesia,radiology,ultrasound,laboratory,andbloodbankservicesatalltimes E E E E
g) Determiningthelevelofcompetenceandqualificationsrequiredforstafftoassumeclinicalresponsibilityforneonatalresuscitation24hoursadayand7daysaweek.
E E E E
h) Initiatingmaternaltransportstoanappropriatelevel. E E E Ei) Havingawrittenplanforacceptinglevelbasedmaternaltransports O E E Ej) Havingwrittenplanforconsultationandtransferarrangements. E E E Ek) Havingprotocolsandcapabilitiesformassivetransfusion,emergency
releaseofbloodproducts(beforefullcompatibilitytestingiscomplete)andmanagementofmultiplecomponenttherapy.
E E E E
2.2Thematernityservicehasaccesstothehospital’slaboratoryservicesincluding24‐hourcapabilitytoprovidebloodgroup,Rhtype,cross‐matching,antibodytestingandbasicemergencylaboratoryevaluations,andeitherABO‐Rh‐specificorO‐Rh‐negativebloodandfreshfrozenplasmaandcryoprecipitateatthefacilityatalltimes.
E E E E
2.3HospitalshallfollowcurrentCDC/ACOGrecommendationsregardinginductionoflabor,GroupBstreptococci(GBS)treatment,andHIVtreatment. E E E E
2.4Thehospitalshallhavegeneticdiagnosticandcounselingservicesorpolicyfor O E E E
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STANDARDII.OBSTETRICALUNITCAPABILITIES I II III IVconsultationreferralsfortheseservicesinplace.
2.5Thehospitalshallhavealaboratorycapableofperformingfetallungmaturitytests. O E E E
2.6Thehospitalshallhaveafullrangeofinvasivematernalmonitoringavailabletothedeliveryarea,includingequipmentforcentralvenouspressureandarterialpressuremonitoring.
O O E E
2.7Thehospitalshallhavespecialequipmentneededtoaccommodatethecareandservicesneededforobesewomen. O E E E
2.8ThehospitalshallhaveappropriateequipmentandpersonnelavailableonsitetoventilateandmonitorwomeninlaboranddeliveryuntilsafelytransferredtoanICU
NA NA E E
2.9ThehospitalICUcollaboratesactivelywiththeMFMcareteaminthemanagementofallpregnantwomenandwomeninthepostpartumperiodwhoareincriticalconditionorhavecomplexmedicalconditions.ThehospitalICUco‐managesICUadmittedobstetricpatientswiththeMFMteam.
NA NA E E
2.10Hospitalsofferingatrialoflaborforpatientswithapriorcesareandeliverymusthaveimmediatelyavailableappropriatefacilitiesandpersonnelwiththecapacityforanesthesia,cesareansection,andneonatalresuscitationcapabilityduringthetrialoflabor.
E E E E
STANDARDIII.OBSTETRICPERSONNEL I II III IV3.1Ataminimum,eachdeliveryhospitalmusthavethefollowingprimarydeliveryprovidersavailabletoattendalldeliverieswhenapatientisinactivelabor:
a) Obstetricprovider(OB‐GYN,SurgeonorFamilyPracticephysicianwithadditionaltraininginobstetrics)withappropriatetrainingandprivilegestoperformemergencycesareandeliveryshouldbeavailabletoattendalldeliveries.
E NA NA NA
b) Aproviderboard‐certifiedorboardeligibleinobstetrics/gynecologyormaternal‐fetalmedicineavailableatalltimes NA E E E
c) Aproviderboard‐certifiedorboardeligibleinobstetrics/gynecologyor NA NA E E
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STANDARDIII.OBSTETRICPERSONNEL I II III IVmaternal‐fetalmedicineonsiteatalltimes
3.2Aprovider(orproviders)board‐certifiedorboardeligibleinmaternal‐fetalmedicineshallbe:
a) Availableforconsultationon‐site,byphoneorbytelemedicineasneeded. E E NA NAb) Availableatalltimeseitheronsite,byphoneorbytelemedicinewith
inpatientprivileges NA O E NA
c) Availableatalltimesforonsiteconsultationandmanagementwithfullprivileges NA NA O1 E
3.3Aproviderboard‐certifiedinobstetrics/gynecologywithexperienceandinterestinobstetricsshallbeamemberofthemedicalstaffandhaveresponsibilityforprogrammaticmanagementofobstetricalservices.
O E E NA
3.4Aproviderboard‐certifiedinmaternal‐fetalmedicineorboard‐certifiedinobstetrics/gynecologywithexpertiseincriticalcareobstetrics,shallbeamemberofthemedicalstaffandhaveresponsibilityforprogrammaticmanagementofhigh‐riskobstetricalservices.
NA O O2 E
3.5Aboard‐certifiednurse‐midwifewithobstetricalprivilegesmaybeamemberoftheobstetricalstaffincollaborationwithalicensedphysicianwithobstetricalprivileges.
0 0 0 O
3.6MedicalandSurgicalConsultantservicesmustbeavailablecommensuratewiththelevelofcareprovided.a) Establishedagreementwithahigher‐levelreceivinghospitalfortimely
transport,includingdeterminationofconditionsnecessitatingconsultationandreferral
E NA NA NA
b) MedicalandSurgicalconsultantsavailabletostabilize NA E E Ec) Fullcomplementofsubspecialistsavailableforinpatientconsultation
includingcriticalcare,generalsurgery,infectiousdisease,hematology,cardiology,nephrology,neurology,andneonatology.
NA NA E E
d) Adultmedicalandsurgicalspecialtyandsub‐specialtyconsultantsimmediatelyavailableatalltimesincludingthoseindicatedinLevelIIIand NA NA NA E
1ExpectedforhospitalswishingtobedesignatedasaPerinatalCenter2ExpectedforhospitalswishingtobedesignatedasaPerinatalCenter
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STANDARDIII.OBSTETRICPERSONNEL I II III IVadvancedneurosurgeryorcardiacsurgery.
3.7Anesthesiaserviceshouldmeettheneedsofthepatientsserved,withinthescopeoftheserviceoffered,inaccordancewithacceptablestandardsofpractice,andunderthedirectionofaqualifiedphysician.
E E E E
a) Anesthesiaservicesshouldbeavailabletoprovidelaboranalgesiaandsurgicalanesthesia. E NA NA NA
b) Anesthesiaservicesshouldbeavailableatalltimestoprovidelaboranalgesiaandsurgicalanesthesia. O E NA NA
c) Anesthesiaservicesshouldbeavailableatalltimesonsitetoprovidelaboranalgesiaandsurgicalanesthesia. O O E E
d)Aproviderboard‐certifiedinanesthesiologywithspecialtrainingorexperienceinOBanesthesiashouldbeavailableforconsultation O E NA NA
e)Aproviderboard‐certifiedinanesthesiologywithspecialtrainingorexperienceinOBanesthesiashallbeinchargeofOBanesthesiaservices O O E E
3.8Aproviderboard‐certifiedinanesthesiologyshallbeamemberofthemedicalstaffandhaveresponsibilityforprogrammaticmanagementofanesthesiaservices.
E E E E
3.9Thehospitalshallhaveappropriatelyqualifiedmedicalstaffavailabletoperformandinterpretobstetricultrasonographyatalltimes. E E E E
3.10Thehospitalshallhaveappropriatelyqualifiedmedicalstafftoperformandinterpretcomputedtomographyscans,magneticresonanceimagingwithinterpretationsformaternalandfetalassessment
NA E E E
3.11Thehospitalshallhaveappropriatelyqualifiedmedicalstafftoperformbasicinterventionalradiology,maternalechocardiography,computedtomography,magneticresonanceimagingandnuclearmedicineimagingwithinterpretation,detailedobstetricultrasonographyandfetalassessmentincludingDopplerstudiesavailableatalltimes.
O O E E
3.12Thehospitalshallhaveappropriatelyqualifiednursingpersonnelinadequatenumberstomeettheneedsofeachpatientinaccordancewiththecaresettingincluding:
E E E E
a) Aregisterednursewithdemonstratedtrainingandexperienceinthe E E E E
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STANDARDIII.OBSTETRICPERSONNEL I II III IVassessment,evaluationandcareofpatientsinlaborpresentatalldeliveries.
b) Aregisterednurseskilledintherecognitionandnursingmanagementofthecomplicationsoflaboranddeliveryreadilyavailableifneededtothelaboranddeliveryunitatalltimes.
E E E E
c) Anadvancepracticenurse(CNSorNP)withperinatalexperienceisavailabletothestafftofostercontinuousqualityimprovement,superviseeducationandparticipateinadministrativefunctions.
NA NA O3 E
d) Allnursesworkingwithantepartumpatientsathighriskshouldhaveevidenceofcontinuingeducationinmaternal‐fetalnursingandspecialtrainingandexperienceinthemanagementofwomenwithcomplexmaternalillnessesandobstetriccomplications.
NA NA E E
3.13Ahospitalprogramshallhavethefollowingnursingleadershipcapacity:a) Anon‐dutyregisterednursewhoseresponsibilitiesincludetheorganization
andsupervisionofantepartum,intrapartumandneonatalnursingservices E E E E
b) Adirectorofperinatalnursingserviceswhohasoverallresponsibilityforinpatientactivitiesintheobstetricareaandhasdemonstratedexpertiseinobstetriccare.
O E NA NA
c) Adirectorofperinatalnursingservices,masterspreparedoractivelyseekingamastersdegreewhohasoverallresponsibilityforinpatientactivitiesintheobstetricareaandhasdemonstratedexpertiseinobstetriccareaswellasinthecareofpatientsathighrisk..
NA NA E E
d) Aregisterednursewhoismasterspreparedorisactivelyseekingamastersdegreeshouldbeonstafftocoordinateeducation. NA NA E E
3.14Atleastonepersoncapableofinitiatingneonatalresuscitationshallbepresentateverydelivery. E E E E
3ExpectedforhospitalswishingtobedesignatedasaPerinatalCenter
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STANDARDIV.OBSTETRICSUPPORTPERSONNEL I II III IV4.1Thehospitalshallhaveappropriatelyqualifiedpharmacypersonnelin
adequatenumberstomeettheneedsofeachpatientinaccordancewiththecaresettingincluding:IAC15‐1.5‐7(3)
E E E E
a) Registeredpharmacistavailablefortelephoneconsultation24hoursperdayand7daysperweek. E NA NA NA
b) Registeredpharmacistavailable24hoursperdayand7daysperweek. O E E Ec) Registeredpharmacistwithexperienceinperinatal/neonatal
pharmacologyavailable24hoursperdayand7daysperweek. NA O E E
4.2The hospital shall have at least one registered dietitian or nutritionist who has special training in perinatal nutrition and can plan diets that meet the special needs of both women and neonates at high risk
O E E E
4.3ThehospitalshallprovidelactationsupportperAWHONNandILCArecommendation:a) LevelI1.3FTEper1000deliveriesperyear E NA NA NAb) LevelII1.6FTEper1000deliveriesperyear NA E NA NAc) LevelIII/IV1.9FTEsper1000deliveries NA NA E E
4.4ThehospitalshallhavealicensedsocialworkerorRNCaseManagerwithexperienceinpsychosocialassessmentandinterventionwithwomenandtheirfamiliesreadilyavailabletotheperinatalservice.
E E E E
4.5Thehospitalshallhaveatleastonestaffmemberwithexpertiseinbereavementresponsibleforthehospital’sbereavementactivities,includingasystemicapproachtoensuringthatindividualsinneedreceivetheappropriateservices.
OE
E
E
4.6Aregisterednurseshallsuperviselicensedpracticalnursesandotherlicensedpatientcarestaffwhodemonstrateknowledgeandclinicalcompetenceinthenursingcareofwomen,fetuses,andnewbornsduringlabor,delivery,andthepostpartumandneonatalperiods.
E E E E
4.7Bloodbanktechniciansshallbeimmediatelyavailable24hoursaday. O E E E
STANDARDV.OBSTETRICEQUIPMENT I II III IV5.1Thehospitalshallhaveequipmentforperforminginterventionalradiology O O E E
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STANDARDV.OBSTETRICEQUIPMENT I II III IVservicesforobstetricalpatients.
5.2Thehospitalwillhavethefollowingequipmentavailableandthecapabilitytouseasindicated.:a) Non‐stressandstresstesting E E E Eb) Ultrasonography E E E Ec) UltrasonographywithDopplerCapability O O E Ed) Portableobstetricultrasonographyequipment,withtheservicesof
appropriatesupportstaff,shallbeavailableinthedeliveryarea O E E E
e) ComputedTomography O E E Ef) MagneticResonanceImaging NA O E Eg) NuclearMedicineImaging NA O E Eh) Amniocentesis O E E Ei) Cardioversion/defibrillationcapabilityformothers E E E Ej) Resuscitationequipmentformothers E E E Ek) Adultbagandmasksystemscapableofdeliveringacontrolled
concentrationofoxygen E E E E
l) Orotrachealtubes,endotrachealtubesinarangeofsizesforadultintubation E E E E
m) Wallsuctionandaspirationequipment E E E En) Laryngoscopes E E E Eo) Bloodpressurecuffsinfullrangeofsizes,formanualandmachineuse E E E Ep) Pulseoximeter E E E Eq) Arterialbloodgasmachine E E E Er) Fiberopticscopesforawakeintubation E E E Es) Arteriallinekits NA O E Et) Centralvenouslinekits NA O E Eu) Invasivehemodynamicmonitoringequipment NA NA E Ev) Adultechocardiographyequipment NA NA E Ew) Individualoxygen,airO2blendedandhumidifiedcapability,andsuction
outlets E E E E
x) Emergencycallsystem E E E E
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STANDARDVI.OBSTETRICMEDICATIONS I II III IV6.1Allemergencyresuscitationmedicationsandequipmentneededtoinitiateand
maintainresuscitationshallbepresentinthedeliveryareainaccordancewithAdvancedCardiacLifeSupport(ACLS),NeonatalResuscitationProgram.
E E E E
6.2Thefollowingmedicationsshallbeinthedeliveryareaorimmediatelyavailabletothedeliveryarea:a) Oxytocin(Pitocin) E E E Eb) Methylergonovine(Methergine) E E E Ec)15‐methylprostaglandinF2(Prostin) E E E Ed)Misoprostol E E E Ee)Carboprosttromethamine(Hemabate) E E E Ef)Narcotics E E E Eg)Antibiotics E E E Eh)Magnesiumsulfate E E E Ei)Naloxone E E E E
j)Lorazepam E E E E
NEONATALSECTION‐DEFINITIONS THESESTANDARDSREFLECTTHEREVISEDAAPPOLICYSTATEMENTONLEVELSOFNEONATALCARE20124
LevelIHospitalshaveneonatalprogramsthatprovideabasiclevelofcaretoinfantswhoarelowrisk,asdescribedbythesestandards.Thesehospitalsprovidenormalnewborncareforinfants≥350/7weeksgestationwhoarephysiologicallystable.Theymusthavethecapabilitiestoperformneonatalresuscitationateverydeliveryandtoevaluateandprovideroutinepostnatalcareforhealthynewborninfants.LevelIhospitalsmustbeabletostabilizenewborninfantswhoarelessthan35weeksofgestationorwhoareilluntiltheycanbetransferredtoafacilityatwhichspecialtyneonatalcareisprovided.Board
4TheAAPCommitteeonFetusandNewbornsissuedthePolicyStatementonLevelsofNeonatalCareonAugust27,2012.www.pediatrics.org/cgi/doi/10.1542/peds.2012‐1999PEDIATRICS(ISSNNumbers:Print,0031‐4005;Online,1098‐4275).
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certifiedpediatriciansorfamilyphysicianswithprivilegesfornewbornresuscitationsupervisetheseunits.Theseneonatalunitsdonotprovidepediatricsubspecialtyorneonatalsurgicalspecialtyservices.Thesehospitalsdonotreceiveprimaryinfantormaternalreferrals.LevelIIHospitalshaveneonatalprogramsthatprovidespecialtycaretoinfants,asdescribedbythesestandards.Thesehospitalsmusthavetheabilitytoprovidecareforstableormoderatelyillinfants≥1,500gramsAND≥320/7weeksgestationwithproblemsthatareexpectedtoresolverapidlyandnotanticipatedtoneedsubspecialty‐levelservicesonanurgentbasis.Thesehospitalsmusthavetheabilitytoprovideassistedconventionalventilationorcontinuouspositiveairwaypressureorbothforbriefdurations,generallylessthan24hours.LevelIInurseriesmusthavetheabilitytostabilizeinfantsbornbefore32weeksgestationandweighinglessthan1500gramsuntiltransfertoaneonatalintensivecarefacility.LevelIInurseriesmusthaveequipmentandpersonnelcontinuouslyavailabletoprovideongoingcareaswellastoaddressemergencies.Thesehospitalsdonotreceiveprimaryinfanttransports.Thehospitalshallhaveawrittenplanforacceptingortransferringmothersorneonatesas“backtransports”forongoingconvalescentcare,includingcriteriaforacceptingthepatientandpatientinformationontherequiredcase.Theseneonatalunitsaresupervisedbyaboard‐certifiedpediatrician,andhaveprearrangedconsultativeagreementswithalevelIIIorIVcenter.LevelIII
Hospitalsprovidesubspecialtycareforinfantsasdescribedbythesestandards.ThesehospitalsprovideacuteandcomprehensiveNICUcareforinfantswhoarebornat<32weeksgestationand<1500gramsatbirth,orhavemedicalorsurgicalconditionsregardlessofgestationalageorweight.DesignationofLevelIIIcareshouldbebasedonclinicalexperienceasdemonstratedbylargepatientvolume,increasingcomplexityofcare,andavailabilityofpediatricmedicalsubspecialistsandpediatricsurgicalspecialists5.Pediatricsurgicalspecialists(includinganesthesiologistswithpediatricexperience)should
5AccordingtotheAAPpolicystatement“Althoughlittledebateexistsontheneedforadvancedneonatalservicesforthemostimmatureandsurgicallycomplexneonates,ongoingcontroversiesexistregardingwhichfacilitiesarequalifiedtoprovidetheseservicesandwhatisthemostappropriatemeasureforsuchqualification.Theseissuesare,ingeneral,basedontheneedforcomparisonoffacilityexperience(measuredbypatientvolumeorcensus),location(inborn/outborndeliveries,regionalperinatalcenter,orchildren’shospital)orcase‐mix(includingstillbirths,deliveryroomdeaths,andcomplexcongenitalanomalies).”ThereisanexpectationthatthenextreviewoftheAAPLevelsofNeonatalCarepolicystatementwillindicateappropriatepatientvolumeforeachlevelofneonatalcare.
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performallproceduresinnewborninfants.Pediatricophthalmologyservicesandanorganizedprogramforthemonitoring,treatment,andfollow‐upofretinopathyofprematurityshouldbereadilyavailableinLevelIIInurseries.TheneonatalunitsaresupervisedbyBoard‐certifiedneonatologistsandoffercontinuousavailabilityofneonatologists.Neonatalunitsprovideafullrangeofrespiratorysupportthatmayincludeconventionalventilation,and/orinhalednitricoxide,and/orhigh‐frequencyventilationifsuitableequipmentandproperlytrainedpersonnelareavailable.Pediatricmedicalsubspecialtyservicesmaybeprovidedonsiteorconsultationmaybeprovidedatacloselyrelatedinstitutionwhichallowsforemergencytransportwithinareasonabletimebetweeninstitutions.Pediatricsurgicalandanesthesiologysubspecialistsmaybeonsiteoratacloselyrelatedinstitutiontoperformmajorsurgeries.Neonatalcarecapabilityincludesadvancedimaging,withinterpretationonanurgentbasisthatincludescomputedtomography,magneticresonanceimaging,andechocardiography.LevelIIIperinatalhospitalsacceptrisk‐appropriatematernalandneonataltransports.Thehospitalshallhaveawrittenplanforacceptingortransferringmothersorneonatesas“backtransports”forongoingconvalescentcare,whichincludescriteriaforacceptingthepatientandpatientinformationontherequiredcase.LevelIVHospitalsprovidecomprehensivesubspecialtyneonatalcareservices,asdescribedbythesestandards.ThesehospitalsprovideacuteNICUcareforinfantsofallbirthweightsandgestationalages.Inaddition,theneonatologistsassistinthemanagementoffetuseswhoareextremelyprematureorhavecomplexproblemsthatrendersignificantriskofpreterm,delivery,andpostnatalcomplications.TheneonatalunitsaresupervisedbyBoard‐certifiedneonatal‐perinatalsubspecialistsandoffercontinuousavailabilityofneonatologists.Advancedmodesofneonatalventilationandlife‐supportareprovided,includinghighfrequencyventilation,inhalednitricoxideand/orextracorporealmembraneoxygenation(ECMO).Theseneonatalunitsprovideafullrangeofmedicalpediatricsubspecialtyservices.Additionally,afullrangeofpediatricsubspecialtysurgicalservicesandpediatricanesthesiologistsareavailableatthesite,includingpediatriccardio‐thoracicopen‐heartsurgeryandpediatricneurosurgery.LevelIVperinatalhospitalsacceptmaternalandneonataltransports.Thesehospitalsfacilitatetransportandprovideoutreacheducation.
TheAAPPolicyStatementonLevelsofNeonatalCare,August27,2012.www.pediatrics.org/cgi/doi/10.1542/peds.2012‐1999
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STANDARDVII.NEONATALUNITCAPABILITIES I II III IV
7.1Thehospitalshalldemonstrateitscapabilityofprovidingneonatalcarethroughwrittenstandards,protocols,guidelines,andtraining,thatincludethefollowing:
a) ProvidingresuscitationandstabilizationofunexpectedneonatalproblemsaccordingtothemostcurrentNeonatalResuscitationProgram(NRP)guidelines.
E E E E
b) Selectingandmanagingneonatalpatientsataneonatalrisklevelappropriatetoitscapability.
E E E E
c) Managingallneonatalpatientsincludingthoserequiringadvancedmodesofneonatalventilationandlife‐support;pediatricsubspecialtyservices;andpediatricsubspecialtysurgicalservicesatthesiteoracloselyrelatedinstitutionbyprearrangedconsultativeagreement.
NA NA E NA
d) Managingallneonatalpatientsincludingthoserequiringadvancedmodesofneonatalventilationandlife‐support;pediatricmedicalsubspecialtyservices;andpediatricsubspecialtysurgicalservicessuchaspediatriccardio–thoracicopen‐heartsurgeryandpediatricneurosurgerywithintheinstitution.
NA NA NA E
7.2Thehospitalshallhaveequipmentforperforminginterventionalradiologyservicesforneonatalpatients.
NA NA O E
7.3Thefollowingmedicationsshallbeimmediatelyavailabletotheneonatalunits:
a) Antibiotics,anticonvulsants,andemergencycardiovasculardrugs. E E E Eb) Surfactant,prostaglandinE1. O 0 E E
7.4HospitalshallfollowcurrentCDC/AAP/ACOGrecommendationsrelatedtothecareofthenewbornincludingbutnotlimitedtosuchareasas:GroupStreptococci,HIV,positioning,circumcision.
E E E E
STANDARDVIII.NEONATALPERSONNEL I II III IV8.1Thehospitalshallhaveappropriatelyqualifiedneonatalmedicalstaff
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STANDARDVIII.NEONATALPERSONNEL I II III IVpersonnel,availableaslistedbelowforeachlevelofcare.a) Thehospitalshallhaveconsultingrelationshipsinplacewitha
pediatriccardiologist,asurgeonandanophthalmologistwhohasexperienceandexpertiseinneonatalretinalexamination.
O E NA NA
b) Thehospitalshallhaveaccesstopediatricophthalmologyservices NA O E Ec) Thehospitalshallhaveavailabilitytoperformstatandroutinecardiac
echoandEEGs24hoursadayand7daysaweek,andavailableinterpretationforstatcardiacechowithin1hourandforroutinestudieswithin24hours.
NA O E E
d) Thehospitalshallhavepromptandreadilyavailableaccesstoafullrangeofpediatricmedicalsubspecialists,pediatricsurgicalspecialists,anesthesiologistswithpediatricexperience,andpediatricophthalmologistsatthesiteoratacloselyrelatedinstitutionbyprearrangedconsultativeagreement.
NA O E NA
e) Thehospitalshallmaintainafullrangeofpediatricmedicalsubspecialists,pediatricsurgicalsubspecialists,andanesthesiologistswithpediatricexperienceatthesite.
NA O O E
f) Thehospitalshallbelocatedwithinaninstitutionwiththecapabilitytoprovideon‐sitepediatricsurgicalcareofcomplexcongenitaloracquiredconditions.
NA NA NA E
8.2Aproviderboard‐certifiedinpediatricsorfamilymedicineshallbeamemberofthemedicalstaff,haveprivilegesforneonatalcare,andhaveresponsibilityforprogrammaticmanagementforneonatalunitservices.
E NA NA NA
8.3Aproviderboard‐certifiedinpediatricsorinneonatal‐perinatalmedicineshallbeamemberofthemedicalstaff,haveprivilegesforneonatalcare,andhaveresponsibilityforneonatalunitservices.
O E NA NA
8.4Aprovider(s)board‐certifiedinneonatal‐perinatalmedicineshallbeamemberofthemedicalstaffandhavefull‐timeresponsibilityforneonatalspecialcareorintensivecareunitservices.
NA O E E
8.5Thehospitalshallhaveprearrangedconsultativeagreementswithaboard‐certifiedneonatologist24hoursaday.
E E NA NA
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STANDARDVIII.NEONATALPERSONNEL I II III IV8.6NeonatalResuscitationProgram(NRP)trainedprofessional(s)shallbe
immediatelyavailabletothedeliveryandneonatalunits.E E E E
8.7Aproviderwhohascompletedpostgraduatepediatrictraining,anursepractitioner,familyphysicianorphysicianassistantwithprivilegesforneonatalcareappropriatetothelevelofthenurseryshallbeavailablewhenaninfantrequiresLevelIIneonatalservicessuchasFiO2>40%,assistedventilation,orcardiovascularsupport.
NA E NA NA
8.8APediatricianwhohascompletedpediatricresidencytraining,anursepractitionerorphysicianassistantwithadequateNICUtrainingandexperience,withprivilegesforneonatalcareappropriatetothelevelofthenursery,shallbephysicallypresentin‐house24hoursadayandassignedtothedeliveryareaandneonatalunitsandnotsharedwithotherunitsinthehospital.
NA O E E
8.9Aboard‐certifiedprovideroranactivecandidateforboard‐certificationinneonatologyshallbeavailabletobepresentin‐housewithin30minutes.
NA O E E
8.10Thehospitalshallhave: a)Aprearrangedwrittenplanwithaneurodevelopmentalfollow‐upclinic
orneurodevelopmentalpractice.O O E NA
b)Aneurodevelopmentalfollow‐upclinicorpractice O O O E8.11Thehospitalshallhaveaprovideronthemedicalstaffwithprivilegesfor
providingcriticalinterventionalradiologyservicesforneonatalpatients.O O O E
8.12Thehospitalshallhaveappropriatelyqualifiedneonatalpersonnelinadequatenumberstomeettheneedsofeachpatientinaccordancewiththecaresetting:
a) Aregisterednursewithdemonstratedtrainingandexperienceintheassessment,evaluationandcareofnormalnewbornsatalltimes.
E E E E
b) Aregisterednurseskilledintherecognitionandnursingmanagementoftheneonatewithcomplicationsontheunitatalltimes.
NA E NA NA
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STANDARDVIII.NEONATALPERSONNEL I II III IVc) Anadvancepracticenurse(CNSorNP)withperinatalexperienceis
availabletothestafftofostercontinuousqualityimprovement,superviseeducationandparticipateinadministrativefunctions.
NA NA O6 E
d) Allnursesworkingwithneonatesathighriskshouldhaveevidenceofcontinuingeducationinneonatalnursingandspecialtrainingandexperienceinthemanagementofneonateswithcomplexillnessesandneonatalcomplications
NA NA E E
8.13Thehospitalshallhaverespiratorytherapistswhoare: a) Experiencedinthedeliveryofcontinuouspositiveairwaypressure
and/ormechanicalventilationorbothreadilyavailable.NA E E E
b) SkilledinneonatalventilatorcareandmanagementassignedtotheNICUandnotsharedwithotherunitswhenanypatientisreceivingassistedpositivepressureventilation,high‐frequencyventilation,and/orinhalednitricoxide24hoursaday.
NA NA E E
8.14Ahospitalprovidingneonatalsurgicalservicesshallhavenursesonstaffwithspecialexpertiseinperioperativemanagementofneonates.
NA NA E E
8.15ThehospitalshallprovidelactationsupportperAWHONNandILCArecommendation:a) LevelI1.3FTEper1000deliveriesperyear
b) LevelII1.6FTEper1000deliveriesperyear
c) LevelIIIandIV1.9FTEsper1000deliveries
E E E E
8.16Thehospitalshallhaveafull‐timeInternationalBoardCertifiedLactationConsultantwithexperienceinlactationsupportforthemotherofapreterminfant.
NA O E E
8.17ThehospitalshallhavealicensedsocialworkerorRNCaseManager,withexperienceinpsychosocialassessmentandinterventionwithwomenandtheirfamilieswhois:
6ExpectedforhospitalswishingtobedesignatedasaPerinatalCenter
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STANDARDVIII.NEONATALPERSONNEL I II III IVa) Readilyavailable E E E Eb) Dedicatedtotheperinatalservice. O O E E
8.18ThehospitalshallhavePhysicalTherapistand/orOccupationalTherapist,withadditionalContinuingEducationUnitsintheareaofneonatalcare,asamemberoftheinterdisciplinarycareteam.
NA O E E
8.19ThehospitalshallhaveaSpeechTherapist,withadditionalContinuingEducationUnitsintheareaofneonatalcare,asamemberoftheinterdisciplinarycareteam.
NA O E E
8.20Thehospitalshallhavequalifiednursingleadershipinaccordancewiththecaresetting:
a) Nursingcareshouldbeundertheleadershipofaregisterednurse E NA NA NAb) Nursingcareshouldbeundertheleadershipofaregisterednursewith
demonstratedexpertiseinobstetriccare,neonatalcareorboth O E NA NA
c) Nursingcareshouldbeundertheleadershipofaregisterednurse,masterspreparedoractivelyseekingamastersdegree,withexperienceandtraininginneonatalnursing,aswellasinthecareofpatientsathighrisk.
O O E E
8.21Aregisterednursewhohasbeeneducatedandmasterspreparedoractivelyseekingamastersdegree,shouldbeonstafftocoordinateeducation.
O O E E
8.22Ahospitalperinatalprogramshallhaveat least one registered dietitian or nutritionist who has special training in perinatal nutrition and can plan diets that meet the special needs of neonates at high risk
O O E E
8.23Thehospitalshallhaveappropriatelyqualifiedpharmacypersonnelinadequatenumberstomeettheneedsofeachpatientinaccordancewiththecaresettingincluding:IAC15‐1.5‐7(3)
E E E E
a)Registeredpharmacistavailablefortelephoneconsultation24hoursperdayand7daysperweek.
E NA NA NA
b)Registeredpharmacistavailable24hoursperdayand7daysperweek.
NA E E E
c)Ahospitalperinatalprogramshallhavepharmacy personnel with O O E E
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STANDARDVIII.NEONATALPERSONNEL I II III IVpediatric expertise who can work to continually review their systems and processes of medication administration to ensure that patient care policies are maintained.
STANDARDIX.NEONATALSUPPORTPERSONNEL I II III IV9.1Portableultrasonographyfornewborns,withtheservicesofappropriate
supportstaff,shallbeavailabletotheneonatalunits.O E E E
9.2Computedtomography(CT)capability,withtheservicesofappropriatesupportstaff,shallbeavailableoncampus.
O O E E
9.3Magneticresonanceimaging(MRI)capability,withtheservicesofappropriatesupportstaff,shallbeavailableoncampus.
O O E E
9.4Neonatalechocardiographyequipmentandexperiencedtechnicianwithinterpretationbypediatriccardiologistshallbeimmediatelyavailable.
O O E E
9.5Thehospitalshallhaveapediatriccardiaccatheterizationlaboratoryandappropriatestaff.
O O O E
9.6Portablex‐rayequipment,withtheservicesofappropriatesupportstaff,shallbeavailabletotheneonatalunits.
E E E E
9.7Bloodbanktechniciansshallbepresentin‐house24hoursaday. O E E E
STANDARDX.NEONATALEQUIPMENT I II III IV10.1Thehospitalshallobtainandmaintaincurrentequipmentand
technology,asdescribedinthesestandards,tosupportoptimalneonatalcareforthelevelofcareofthehospitalsdesignation.
E E E E
10.2Thehospitalshallhaveallofthefollowingequipmentandsuppliesimmediatelyavailableforexistingpatientsandforthenextpotentialpatient:
a) O2analyzer E E E Eb) stethoscope E E E Ea) intravenousinfusionpumpswithappropriatedruglibraries E E E E
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STANDARDX.NEONATALEQUIPMENT I II III IVb) radiantheatedbedindeliveryroomandavailableintheneonatal
unitsE E E E
c) oxygenhoodwithhumidity E E E Ed) pediatricbagandmaskscapableofdeliveringacontrolled
concentrationofoxygentotheinfantE E E E
e) orotrachealtubes E E E Ef) aspirationequipment E E E Eg) laryngoscope E E E Eh) umbilicalvesselcathetersandinsertiontray E E E Ei) cardiacmonitor E E E Ej) pulseoximeter E E E Ek) phototherapyunit E E E El) Dopplerbloodpressureforneonates E E E Em) cardioversion/defibrillationcapabilityforneonates E E E En) resuscitationequipmentforneonates E E E Eo) individualoxygen,airO2blendedandhumidifiedcapability,and
suctionoutletsformothersandneonatesE E E E
p) emergencycallsystem E E E Eq) bowelbags E E E E
STANDARDXI.NEONATALMEDICATION I II III IV11.1Thefollowingmedicationsshallbeimmediatelyavailabletotheneonatal
units:
a)antibiotics,anticonvulsants,andemergencycardiovasculardrugs E E E E
b)surfactant,prostaglandinE1 O O E E
11.2Emergencymedications,aslistedintheNeonatalResuscitationProgramoftheAmericanAcademyofPediatrics/AmericanHeartAssociation(AAP/AHA),shallbeimmediatelyavailableinthedeliveryareaandneonatalunits
E E E E
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JOINTSTANDARDSAPPLYUNIVERSALLY
STANDARDXII.LABORATORY12.1Theprogrammaticleadersoftheperinatalserviceinconjunctionwiththehospitallaboratoryleaderswillagreeon
processingandreportingtimestoensurethattheseareappropriateforsamplesdrawnfromobstetricandneonatalpatientswithspecificconsiderationfortheacuityofthepatientandtheintegrityofthesamples.
12.2Thehospitallaboratoryshalldemonstratethecapabilitytoimmediatelyreceiveprocessandreporturgent/emergentobstetricandneonatallaboratoryrequests.
12.3Thehospitallaboratoryshallhaveaprocessinplacetoreportcriticalresultstotheobstetricandneonatalservices.12.4ThehospitalshallhaveavailabletheequipmentandtrainedpersonneltoperformaPulseOximetryassessmentandnewbornhearingscreeningpriortodischargeonallinfantsbornatortransferredtotheinstitutionasrequiredbytheStateofIndianaUniversalNewbornHearingScreening,Diagnosis,andInterventionGuidelines.(410IAC3)
12.5Thehospitalshallhavemolecular,cytogenic,andbiochemicalgenetictestingavailableorwrittenpolicyforconsultationandreferralinplace.
12.6AllhospitalsperformingpointofcarelaboratorytestingwillfollowtherulesestablishedbyCLIAandIndianaAdministrativeCode.
STANDARDXIII.EDUCATION13.1Thehospitalshallhaveidentifiedminimumcompetenciesforobstetricalclinicalstaff,nototherwisecredentialed,thatare
assessedpriortoindependentpracticeandonaregularbasisthereafter.13.2Thehospitalshallprovidecontinuingeducationprogramsforphysicians,nurses,andancillarymembersoftheperinatal
teamconcerningthetreatmentandcareofobstetricalandneonatalpatients. Conductteamtraininginperinatalareastoteachstafftoworktogetherandcommunicateeffectively Providelactationandbreastfeedingeducationforallmembersoftheperinatalteam. Forhighriskeventssuchasshoulderdystocia,emergencycesareandelivery,maternalhemorrhageandneonatal
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STANDARDXIII.EDUCATIONresuscitation,conductclinicaldrillstohelpstaffprepareforhighrisk,highcomplexityeventswithlowrateofoccurrence
Conductdrilldebriefingstoevaluateteamperformanceandidentifyareasforimprovementforhighriskevents Educatenurses,residents,nursemidwivesanddeliveringphysicianstousestandardizedterminologyto
communicateallcategoriesoffetalheartratemonitortracings. Identifyspecifictriggersforrespondingtochangesinthemother’s,fetus’sornewborn’svitalsignsandclinical
conditionanddevelopanduseprotocolsanddrillsforrespondingtochangessuchaspreeclampsia,hemorrhage,orneonatalshock.
13.3.Ahospitalthatacceptsmaternaland/orneonatalprimarytransportsshallprovidethefollowingtothereferringhospital/providers:a) Guidanceonindicationsforconsultationandreferralofpatientsathighrisk.b) Informationaboutalternativesourcesforspecializedcarenotprovidedbytheacceptinghospital.c) Guidanceonthepre‐transportstabilizationofpatients.d) Feedbackonthepre‐transportcareofpatients.e) Clearcommunicationbetweensendingandreceivingpersonnel.f) Oncethepatienthasreachedthereceivinghospital,informationregardingthepatient’scondition,andcaregiven
duringtransportshouldbesentbacktothereferringproviderandreferringhospitalstaff.g) Regularlyscheduledconferenceswithreferralandreceivinghospitalsthatmayincludethefollowingtopics:
Reviewofmajorperinatalconditions,theirmedicalandnursingmanagement. Reviewoffetalmonitoring,includingmaternal‐fetaloutcomes,towardagoalofstandardizingnomenclatureand
patientcare. Reviewofperinataloutcomesandcomplications. Reviewofpatientandreferringprovidersatisfactiondata,complaintsandcompliments.
h) Perinataloutreacheducationprovidedjointlybyneonatalandobstetricphysicians,nurses,APN’s,PA’sandotherperinatalstaff.Responsibilitieswouldinclude: Assessreferralhospitaleducationalneeds. Plancurricula. Teach,implementandevaluateprograms. Analyzeanduseperinataldata. Providepatientfollow‐uptoreferringcommunitypersonnel. Maintaininformativeworkingrelationshipswithcommunitypersonnelandoutreachteammembers.
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STANDARDXIII.EDUCATION13.4ThePerinatalteammember:
Acquiresknowledgeandexperiencesthatreflectcurrentevidencedbasedpracticeinordertomaintainskillsandcompetenceappropriateforhisorherspecialtyarea,role,andpracticesetting.
Participatesinandmaintainsprofessionalrecordsofeducationalactivitiesrequiredtoprovideevidenceofcompetency.
Maintainslicensureandcertificationasmandatedbystatelicensingboards,healthcarefacilitiesandaccreditingagencies.
Maintainscertificationwithinthespecialtyareaofpracticeasappropriate,asamechanismtodemonstratespecialknowledge.
Participatesinlifelonglearning,includingeducationalactivitiesrelatedtoevidencebasedpractice,knowledgeacquisition,safetyandprofessionalissues.
Hasknowledgeofrelevantpracticeparametersandguidelinesofotherorganizationsthatfocusonthedeliveryofhealthcareservicestowomenandnewborns.
13.5Thehospitalshallhaveawrittenplanforassuringregisterednurse/patientratiosaspercurrentGuidelinesForPerinatalCare,orAssociationofWomen’sHealth,Obstetric,andNeonatalNurses(AWHONN)nursepatientratios.
STANDARDXIV.PERFORMANCEIMPROVEMENT14.1Thehospitalshallhaveamultidisciplinarycontinuousqualityimprovementprogramforimprovingmaternaland
neonatalhealthoutcomesthathasinitiativestopromotepatientsafetyincludingsafemedicationpractices,UniversalProtocoltopreventproceduralerrors,andeducationalprogramstoimprovecommunicationandteamwork.
14.2Thehospitalstaffshallconductinternalperinatalcasereviewsthatincludeallmaternal,intrapartumfetalandneonataldeaths,andallmaternalneonataltransports.
14.3Thehospitalshallutilizeamultidisciplinaryforumtoconductperiodicperformancereviewsofperinatalprogram.Thisreviewshallincludeareviewoftrends,alldeaths,alltransfers,allverylowbirthweightinfants,problemidentificationandsolution,issuesidentifiedfromthequalitymanagementprocess,andsystemsissues.
STANDARDXV.POLICIESANDPROTOCOLS15.1Thehospitalshallhavewrittenpoliciesandprotocolsfortheinitialstabilizationandcontinuingcareofallobstetricaland
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STANDARDXV.POLICIESANDPROTOCOLSneonatalpatientsappropriatetothelevelofcarerenderedatitsfacility.
15.2Thehospitalshallhaveobstetricalandneonatalresuscitationprotocols.15.3Thehospitalmedicalstaffcredentialingprocessshallincludedocumentationofcompetencytoperformobstetricaland
neonatalinvasiveproceduresappropriatetoitsdesignatedlevelofcare.15.4Thehospitalshallhaveawrittenplanforacceptingortransferringmothersorneonatesas“backtransports”forongoing
convalescentcare,includingcriteriaforacceptingthepatientandnecessarypatientinformation.15.5Thehospitalshallhavepoliciesthatallowfamilies(includingsiblings)tobetogetherinthehospitalfollowingthebirthof
aninfantandthatpromoteparentalinvolvementinthecareoftheneonateincludingcareoftheneonateintheNICU(exceptionscanbemadeundercertaincircumstances).
15.6AllhospitalsshallhaveanappropriatenewbornscreeningprograminplaceaccordingtoFederalandStateLaw.15.7Allhospitalsshallhaveinplacepoliciesandprotocolstoaddressemergencypreparednessfortheobstetricandneonatal
areas.15.8Thehospitalshallhavewrittenpoliciesandproceduresonlocalanesthesia(IAC410:15‐1.6‐1,f,2)
ResourcesAmericanAcademyofPediatricswww.aap.org
GuidelinesforPerinatalCare7thEdition PerinatalContinuingEducationProgram NeonatalResuscitationProgram GuidelinesforAirandGroundTransportofNeonatalandPediatricPatients LevelsofNeonatalCare:CommitteeonFetusandNewbornPediatrics;originallypublishedonlineAugust27,2012
http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012‐1999
AmericanAssociationofCriticalCareNurses(AACN)www.aacn.orgAmericanCollegeofNurseMidwives(ACNM)www.midwife.orgAmericanCongressofObstetriciansandGynecologistswww.acog.org
CurrentGuidelinesforPerinatalCareAssociationofPerioperativeRegisteredNurseswww.aorn.orgAssociationofWomen’sHealthObstetric&NeonatalNurses(AWHONN)www.awhonn.org
FetalHeartRateMonitoringProgram PerinatalOrientationEducationProgram
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STANDARDXV.POLICIESANDPROTOCOLS NeonatalOrientationEducationProgram GuidelinesforProfessionalRegisteredNurseStaffingforPerinatalUnits StandardsforPerinatalNursingPracticeandCertificationinCanada
CDCCenterforDiseaseControlwww.cdc.govIndianaCodeArticle15HospitalLicensureRules.Rule1.4.GoverningBoardResponsibilities.410IAC15‐1.4‐aGoverningBoard.IndianaMothersMilkBankwww.immilkbank.orgIndianaPerinatalNetwork(IPN)www.indianaperinatal.orgIndianaStateDepartmentofHealth(ISDH)www.in.gov/isdhInternationalLactationConsultantsAssociation(ILCA)www.ilca.orgHealthstreamwww.healthstream.comMarchofDimeswww.marchofdimes.comNationalAssociationofNeonatalNurses(NANN)www.nann.orgNICHDEuniceKennedyShriverNationalInstituteofChildHealthandHumanDevelopmentwww.nih.gov/about/almanac/organization/nichd.htmOccupationalHealthandSafetyAdministration(OSHA)www.osha.govPeri‐factsUniversityofRochesterwww.urmc.rochester.edu/ob‐gyn/education/peri‐factsSugar&SafeCare,Temperature,Airway,BloodPressure,LabWork,EmotionalSupport(S.T.A.B.L.E.)Programwww.stableprogram.orgTheJointCommissionwww.jointcommission.org