Frequently Asked Questions V5 - IN.gov · Frequently Asked Questions ... Level III Perinatal Centers and Level IV hospitals must have obstetrical ... hospital to be a level three

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Indiana Perinatal Hospital Standards

Frequently Asked Questions

2013‐2015


TableofContentsStandard I: Organization ............................................................................................................................... 3

Standard II: Obstetric Unit Capabilities ......................................................................................................... 3

Standard III: Obstetric Personnel .................................................................................................................. 4

Standard IV: Obstetric Support Personnel .................................................................................................... 7

Standard V: Obstetric Equipment ................................................................................................................. 9

Standard VI: Obstetric Medications .............................................................................................................. 9

NEONATAL SECTION ................................................................................................................................... 10

Standard I: Organization ............................................................................................................................. 10

Definitions ................................................................................................................................................... 10

Standard VIII: Neonatal Personnel ............................................................................................................. 14

Standard IX: Neonatal Support Personnel .................................................................................................. 22

Standard X: Neonatal Equipment ............................................................................................................... 23

Standard XI: Neonatal Medications ............................................................................................................ 25

Standard XII: Universal Laboratory ............................................................................................................. 25

Standard XIII: Universal Education ............................................................................................................. 25

Standard XIV: Performance Improvement .................................................................................................. 26

Standard XV: Policies and Protocols ........................................................................................................... 26

General Questions: ..................................................................................................................................... 26


StandardI:Organization

StandardII:ObstetricUnitCapabilities2.4Thehospitalshallhavegeneticdiagnosticandcounselingservicesorpolicyforconsultationreferralsfortheseservicesinplace.Q1:Tomeetthisrequirement,doweneedtohaveawrittenpolicyandawrittenagreementwithsomeonewhodoesprovidetheseservices?ThisstandardisoptionalforLevel1.ItisexpectedforLevelsIIandIII.Ifthehospitaldoesnothaveitsowngeneticdiagnosticandcounselingservices,theremustbewrittenpolicytomakesuchreferralsandinformationonwheregeneticdiagnosticandcounselingservicesareavailable.Awrittenagreementisnotrequired.Q2:IsthisreferringtoinpatientsorpatientspostdeliveryafteraD&C?Thisisreferringtopregnantwomenwithriskfactors,postdeliveryandpostD&Casneeded.

Ifthereisaneedforcounselingduringnormalprenatalcare,thiswouldbeaddressedinthephysicianoffice.

2.5Thehospitalshallhavealaboratorycapableofperformingfetallungmaturitytests.Q1:Doesthismeanthatthetestresultsmustbeimmediatelyavailableordoyoujusthavetohavethecapabilityofperforming?ThisstandardisoptionalforLevel1.ItisexpectedforLevelsIIandIII.Testresultsdonothavetobeavailableimmediately.Q2:IsitOKtosendthetestout?YesQ3:Ifwehaveawrittenagreementwithalaboutsideofourhospitalthatiscapableofperformingthesetests24hoursadaywouldthatbesufficient?Yes2.6Thehospitalshallhaveafullrangeofinvasivematernalmonitoringavailabletothedeliveryarea,includingequipmentforcentralvenouspressureandarterialpressuremonitoring.


Q1:Pleaseclarifywhetherthelineshavetobeinsertedormaintained?ThisstandardisoptionalforLevelsIandII.ItisexpectedforLevelIII.Thestandardreferstounitcapabilitiesanddoesnotspecifywhoinsertsandmaintainsthelinesforinvasivemonitoring.2.10:Hospitalsofferingatrialoflaborforpatientswithapriorcesareandeliverymusthaveimmediatelyavailableappropriatefacilitiesandpersonnelwiththecapacityforanesthesia,cesareansection,andneonatalresuscitationcapabilityduringthetrialoflabor.Q1:Whatdoesthedefinitionof“immediatelyavailable”meanparticularlyintheanesthesiaarea?Immediatelyavailablemeansaresourceavailableonsiteassoonasitisrequested.

StandardIII:ObstetricPersonnel3.1Ataminimum,eachdeliveryhospitalmusthavethefollowingprimarydeliveryprovidersavailabletoattendalldeliverieswhenapatientisinactivelabor:

a) Obstetricprovider(OB‐GYN,SurgeonorFamilyPracticephysicianwithadditionaltraininginobstetrics)withappropriatetrainingandprivilegestoperformemergencycesareandeliveryshouldbeavailabletoattendalldeliveries.

b) Aproviderboard‐certifiedorboardeligibleinobstetrics/gynecologyormaternal‐fetalmedicineavailableatalltimes.

c) Aproviderboard‐certifiedorboardeligibleinobstetrics/gynecologyormaternal‐fetalmedicineonsiteatalltimes

Q.1:TheOBclinicisnextdoortotheFamilyBirthingCenterandisliterallylessthanoneminutedoortodoor.If,duringnormalclinichours,thephysiciandesignatedasthelaboristsawpatientsintheclinicwiththeunderstandingthefirstprioritywastheFamilyBirthingCenter,wouldthatmeetthestandardforimmediatelyavailable?Immediatelyavailablemeansaresourceavailableonsiteassoonasitisrequested.SincetheclinicandBirthingCenterareco‐located,itwouldappearitwouldmeetthedefinitionofimmediatelyavailable.Thelaboristmustmeetthestandardsidentifiedin3.1(a),3.1(b),and3.1(c)forthelevelofcarethehospitalisproviding.


3.2Aprovider(orproviders)board‐certifiedorboardeligibleinmaternal‐fetalmedicineshallbe:

a) Availableforconsultationon‐site,byphoneorbytelemedicineasneeded.b) Availableatalltimeseitheronsite,byphoneorbytelemedicinewithinpatient

privilegesc) Availableatalltimesforonsiteconsultationandmanagement

Q1:Wouldawrittenagreementwithanotherfacilitythatcanprovidethisservicebesufficient?Standard3.2aisexpectedforLevelsIandII.AninternalwrittenguidelineonwhentoobtainconsultationandawrittenMemorandumofUnderstandingwithaphysicianboard‐certifiedinmaternal‐fetalmedicineorahospitalwithamaternal‐fetalmedicinespecialistonstaffwouldbesufficientQ2a:Does3.2ameanthattheMFMhastobeinhouseorthatthepracticingOBhastheabilitytocalltheMFM24hoursaday?ForLevelsIandII,thepracticingOBmusthavetheabilitytoobtainconsultationatalltimes.

ForLevelIIIstandard3.2bisexpectedaswritten.Standard3.2bdoesnotapplytoLevelIVasaLevelIVhospitalmustadheretoStandard3.2c.Standard3.2cisrequiredforLevelIVandforLevelIIIifthehospitalisdesignatedasaPerinatalCenter.

Q2b:Or,ifthepatientisadmittedatourfacility,andtheOBdoctorhasconsultedbyphonewiththeMFM,cananappointmentbemadeforthepatienttoseetheMFMasanoutpatient?TheanswertothisquestiondependsontheconditionofthepatientandtheresultoftheconsultationbetweentheOBphysicianandtheMFMspecialist.Q3:Isitnecessaryforthehospitaltohaveamaternal‐fetalmedicinephysicianonthemedicalstaffinactivepracticeand,ifneeded,inhousewithin30minutesorcouldtheconsultationbebytelephone?ItisexpectedforLevelIIIandIVOBUnitsQ4:WhileACOGremoved“inhousewithin30minutes”theexpectationforalevelIIIandIVfacilityisthatanMFMwouldneedinpatientprivilegesforpurposesofmanagingthosepatients,iftheirconditionwarrantedit.Iftheexpectationisthattheydonotneedtomanagethepatienton‐site,wouldarrangingcoveragewithanMFMfromanothercitymeetthestandardiftheMFMhad“inpatientprivileges”butwasaminimumof2hoursaway.


Notethatstandard3.2bisoptionalforLevelII.ForLevelIIIHospitalswishingtobedesignatedasaPerinatalCenterandLevelIVhospitals,itisexpectedthattheMFMbeavailableonsiteatalltimesforimmediateconsultationandmanagementasindicatedinStandardIII.2(c).IfthereisnoMFMpresentthesehospitalswouldneedtoreferthehighriskpregnantwomantoanotherappropriatelevelhospitalorhirealocumtenensMFMtocovertheMFMduties.LevelIIIPerinatalCentersandLevelIVhospitalsmusthave obstetrical programs that provide subspecialty care for pregnant women and infants. Maternal care must

include management of complex maternal complications and prematurity. As written, thisstandardintendstoassuretimelyassessmentandinterventionforpregnantwomenwithrapidlydeterioratingclinicalstatusrelatedtounderlyingmedicalconditionsthatarenotroutinelyencounteredbyboard‐certifiedOB/GYNs,suchascardiovascularcollapse,respiratoryfailureandneurologiccompromise.

ForaLevelIIIthatisnotadesignatedPerinatalCenter,accessatalltimestoanMFMwithinpatientprivilegesonsite,byphoneorbytelemedicineisacceptableasindicatedinStandardIII.2(b)

3.7REVISEDAnesthesiaserviceshouldmeettheneedsofthepatientsserved,withinthescopeoftheserviceoffered,inaccordancewithacceptablestandardsofpractice,andunderthedirectionofaqualifiedphysician.a) Anesthesiaservicesshouldbeavailabletoprovidelaboranalgesiaandsurgical

anesthesia.b) Anesthesiaservicesshouldbeavailableatalltimestoprovidelaboranalgesia

andsurgicalanesthesia.c) Anesthesiaservicesshouldbeavailableatalltimesonsitetoprovidelabor

analgesiaandsurgicalanesthesia.d) Aproviderboard‐certifiedinanesthesiologywithspecialtrainingorexperience

inOBanesthesiashouldbeavailableforconsultatione) Aproviderboard‐certifiedinanesthesiologywithspecialtrainingorexperience

inOBanesthesiashallbeinchargeofOBanesthesiaservicesStandard3.7aisexpectedforLevelsI.Standard3.7band3.7disexpectedforLevelII.Standard3.7cand3.7eisexpectedforLevelsIIIandIV.Q1:Whatdefines“readilyavailabletothedeliveryareawhenapatientisinactivelabor?Readilyavailableisdefinedinthestandardsas“Aresourceforconsultsandassistanceavailablewithinashorttimeafteritisrequested.”Inthissituation,theremustbeaqualified


anesthesiaproviderwhocancometothedeliveryroomwithinashorttimeafterhe/sheisrequested.Related:Standard2.1(c)Thehospitalshalldemonstrateitscapabilityofprovidinguncomplicatedandcomplicatedobstetricalcarethroughwrittenstandards,protocols,guidelinesandtrainingincludingthefollowing:

c)Initiatinganemergentcesareandeliverywithinatimeintervalthatbestincorporatesmaternalandfetalrisksandbenefitswiththeprovisionofemergencycare

ThiswouldmeanthatalevelIhospitalshouldalsohaveaqualifiedanesthesiaprovideravailableforanemergentcesareandeliverywithinatimeintervalthatbestincorporatesmaternalandfetalrisksandbenefitswiththeprovisionofemergencycare.Q.2ThehospitalonlyhasaCRNAinthehospitalatnight.Isthatsufficientforthehospitaltobealevelthree.IgavethedocacopyofthestandardsandtheACOGbulletin.ThehospitalcanusetheCRNAbutwillneedtohaveanesthesiaservicesonsiteatalltimesasaback‐up. 3.11Thehospitalshallhaveappropriatelyqualifiedmedicalstafftoperformbasicinterventionalradiology,maternalechocardiography,computedtomography,magneticresonanceimagingandnuclearmedicineimagingwithinterpretation,detailedobstetricultrasonographyandfetalassessmentincludingDopplerstudiesavailableatalltimes.Q1:Whichtypesofproceduresarebeingreferredto?Thespecificprocedureswillnotbeidentifiedinthestandards.Examplesincludeuterinearteryembolizationtocontrolpost‐partumhemorrhageandabscessdrainage.Thephysicianwilldecidewhatisrequiredaccordingtothestatusofthepatient.StandardIV:ObstetricSupportPersonnel4.1Thehospitalshallhaveappropriatelyqualifiedpharmacypersonnelinadequate

numberstomeettheneedsofeachpatientinaccordancewiththecaresettingincluding:IAC15‐1.5‐7(3)(a)Registeredpharmacistavailablefortelephoneconsultation24hoursperdayand7daysperweek.


(b)Registeredpharmacistavailable24hoursperdayand7daysperweek.(c)Registeredpharmacistwithexperienceinperinatal/neonatalpharmacologyavailable24hoursperdayand7daysperweek.

Q1:Wehaveapharmaciston‐callduringthehoursthattheyarenotinthehospital‐isthisokay?ForLevelIhospital,theregisteredpharmacistmust,ataminimum,beavailablefortelephoneconsultation24hoursperdayand7daysperweek.ForaLevelIIhospital,aregisteredpharmacistmustbeavailable24hoursperdayand7daysperweek.Thismeansthepharmacistmustbeonsiteassoonasrequestedinordertodispenseanyneededmedicationinanemergencywithoutdelay.ForaLevelIIIhospital,aregisteredpharmacistmustbeavailable24hoursperdayand7daysperweek.Andthestandardsspecifythataregisteredpharmacistwithexperienceinperinatal/neonatalpharmacologybeavailable24hoursperdayand7daysperweek.Thepharmacistmustbeonsiteinordertodispenseanyneededmedicationimmediatelyinanemergency.4.3ThehospitalshallprovidelactationsupportperAWHONNandILCA

recommendation:a) LevelI:1.3FTEper1000deliveriesperyear

b) LevelII:1.6FTEper1000deliveriesperyear

c) LevelIIIandIV:1.9FTEsper1000deliveries

Q.1:IsitreallynecessaryforthehospitaltoprovidelactationsupportperAWHONNandILCArecommendations?Yes,thestandardwillstayaswrittenbecauseitreflectsthemostcurrentAWHONNrecommendations.ThehospitalmayseekcollaborativeagreementswiththelocalWICprogramorotherlocalresources.

Q2:ThisstandardindicatesIneed1.04FTEsforlactation.Icurrentlyhavea.5FTEfor

lactationbutalsohaveavailabilityforotherstaffmemberstohelpwithlactation.Thestaffreceivesyearlyeducationonlactationandhelpmotherswhenourlactationconsultisnotpresent.Dowehavetoemploy1.04FTE’splushaveextrastaffavailableorcanweemploy.5FTEandincludethestaffwehaveavailable?OrcanwesendsomeoftheRN’salreadyonstafftoadditionalclassestohelpfillthisneed?


ThehospitalwouldbeexpectedtoshowhowithasmettheFTEcriteria.ThehospitalcanusevarioussourcessuchasWICforlactationconsultants.

Q3:Howwasthenumberoflactationconsultantscalculated?

ThestandardreflectsthemostcurrentAWONNrecommendations.Q4:IsitanewstatestandardthatwehaveanIBCLCstaffmemberemployedinourdepartment?Standard4.3addressestherecommendedFTEsforlactationsupport.Werealizeitwilltakeanumberofyearsforallhospitalstoreachthisstandard.IndianaAWHONNandWICwillassistIndianainreachingthisgoalQ5:OurstaffhasbeenprovidedbreastfeedingeducationanddoesthatmeetcriteriaordowehavetohaveaLactationconsultantasperJointCommissionguidelines?Ifahospitalbelievestheircurrentbreastfeedingeducationisequivalenttothestandardstheywillneedtojustifythatinarequestforconsideration.

StandardV:ObstetricEquipment

5.2Thehospitalwillhavethefollowingequipmentavailableandthecapabilitytouseasindicated.n)FiberopticscopesforawakeintubationQ1:WedocurrentlyhaveaGlideScope®inourERdepartmentthatisaccessible.Doesthismeetthecriteriaforwhatyouarelookingfor?

Anyfiberopticscopeusedforawakeintubationwillmeetthisstandard.Video‐assistedlaryngoscopysystems,suchasGlideScope,canbeusedtofacilitatetraditionalorfiberopticintubation.Byitself,withoutfiberopticequipment,accesstoGlideScopealonewouldnotsatisfythisstandard.

StandardVI:ObstetricMedications6.2Thefollowingmedicationsshallbeinthedeliveryareaorimmediatelyavailable

tothedeliveryarea:a) Oxytocin(Pitocin)b) Methylergonovine(Methergine)


c) 15‐methylprostaglandinF2‐alpha(Carboprost,Hemabate,ProstinF2Alpha)

d) Misoprostole) ProstaglandinE2(Dinoprostone,Cervidil,ProstinE2)f) Narcoticsg) Antibioticsh) Magnesiumsulfatei) Naloxonej) Lorazepam

Q1:Whatis15‐methylprostaglandinF2?

15methylF2alphaprostaglandin,alsosoldasCarboprost,Hemabate,andProstinF2Alpha,isusedforthecontrolofpostpartumhemorrhage.Thisiscriticalforbirthingunitsincaseofemergency.

Q2:WecarryHemabatebutdon’tcarrythe15‐methylprostaglandinF2Prostininourpharmacy

Hemabate is a form of 15-methyl prostaglandin F2-alpha and meets this standard.

Q3: Is Carboprost an appropriate substitute for Prostin?

Carboprost, Hemabate, and Prostin F2 Alpha are forms of 15-methyl prostaglandin F2-alpha used to control postpartum hemorrhage.

Dinoprostone, Cervidil and Prostin E2 are all forms of prostaglandin E2 which is used for cervical ripening and labor induction.

NEONATALSECTION

StandardI:Organization

DefinitionsLevelIIHospitalshaveneonatalprogramsthatprovidespecialtycaretoinfants,asdescribedbythesestandards.Thesehospitalsmusthavetheabilitytoprovidecareforstable


ormoderatelyillinfants≥1,500gramsAND≥320/7weeksgestationwithproblemsthatareexpectedtoresolverapidlyandnotanticipatedtoneedsubspecialty‐levelservicesonanurgentbasis.Thesehospitalsmusthavetheabilitytoprovideassistedconventionalventilationorcontinuouspositiveairwaypressureorbothforbriefdurations,generallylessthan24hours.LevelIInurseriesmusthavetheabilitytostabilizeinfantsbornbefore32weeksgestationandweighinglessthan1500gramsuntiltransfertoaneonatalintensivecarefacility.LevelIInurseriesmusthaveequipmentandpersonnelcontinuouslyavailabletoprovideongoingcareaswellastoaddressemergencies.Thesehospitalsdonotreceiveprimaryinfanttransports.Thehospitalshallhaveawrittenplanforacceptingortransferringmothersorneonatesas“backtransports”forongoingconvalescentcare,includingcriteriaforacceptingthepatientandpatientinformationontherequiredcase.Theseneonatalunitsaresupervisedbyaboard‐certifiedpediatrician,andhaveprearrangedconsultativeagreementswithalevelIIIorIVcenter.Q1:AsaLevel2Nursery,canIacceptatransferinfromaLevel1facility?Asstatedabove,LevelIInurseriesdonotusuallyreceiveprimarytransportsofillnewborns.However,afterconsultationwiththeiraffiliatedLevelIIIorLevelIVcenter,theymayreceivetransportsfromLevelIofinfantsbornat32weeksofgestationorlaterandweighing1500gramsormorewithproblemsthatareexpectedtoresolverapidlyandarenotanticipatedtoneedsubspecialtyserviceonanurgentbasis.LevelIII

Hospitalsprovidesubspecialtycareforinfantsasdescribedbythesestandards.ThesehospitalsprovideacuteandcomprehensiveNICUcareforinfantswhoarebornat<32weeksgestationand<1500gramsatbirth,orhavemedicalorsurgicalconditionsregardlessofgestationalageorweight.DesignationofLevelIIIcareshouldbebasedonclinicalexperienceasdemonstratedbylargepatientvolume,increasingcomplexityofcare,andavailabilityofpediatricmedicalsubspecialistsandpediatricsurgicalspecialists1.Pediatricsurgicalspecialists(including

1AccordingtotheAAPpolicystatement“Althoughlittledebateexistsontheneedforadvancedneonatalservicesforthemostimmatureandsurgicallycomplexneonates,ongoingcontroversiesexistregardingwhichfacilitiesarequalifiedtoprovidetheseservicesandwhatisthemostappropriatemeasureforsuchqualification.Theseissuesare,ingeneral,basedontheneedforcomparisonoffacilityexperience(measuredbypatientvolumeorcensus),location(inborn/outborndeliveries,regionalperinatalcenter,orchildren’shospital)orcase‐mix(includingstillbirths,deliveryroomdeaths,andcomplexcongenitalanomalies).”ThereisanexpectationthatthenextreviewoftheAAPLevelsofNeonatalCarepolicystatementwillindicateappropriatepatientvolumeforeachlevelofneonatalcare.TheAAPPolicyStatementonLevelsofNeonatalCare,August27,2012.www.pediatrics.org/cgi/doi/10.1542/peds.2012‐1999


anesthesiologistswithpediatricexperience)shouldperformallproceduresinnewborninfants.Pediatricophthalmologyservicesandanorganizedprogramforthemonitoring,treatment,andfollow‐upofretinopathyofprematurityshouldbereadilyavailableinLevelIIInurseries.TheneonatalunitsaresupervisedbyBoard‐certifiedneonatologistsandoffercontinuousavailabilityofneonatologists.Neonatalunitsprovideafullrangeofrespiratorysupportthatmayincludeconventionalventilation,and/orinhalednitricoxide,and/orhigh‐frequencyventilationifsuitableequipmentandproperlytrainedpersonnelareavailable.Pediatricmedicalsubspecialtyservicesmaybeprovidedonsiteorconsultationmaybeprovidedatacloselyrelatedinstitutionwhichallowsforemergencytransportwithinareasonabletimebetweeninstitutions.Pediatricsurgicalandanesthesiologysubspecialistsmaybeonsiteoratacloselyrelatedinstitutiontoperformmajorsurgeries.Neonatalcarecapabilityincludesadvancedimaging,withinterpretationonanurgentbasisthatincludescomputedtomography,magneticresonanceimaging,andechocardiography.LevelIIIperinatalhospitalsacceptrisk‐appropriatematernalandneonataltransports.Thehospitalshallhaveawrittenplanforacceptingortransferringmothersorneonatesas“backtransports”forongoingconvalescentcare,whichincludescriteriaforacceptingthepatientandpatientinformationontherequiredcase.Q.1:TheIndianaStandardssay,“DesignationofLevelIIIcareshouldbebasedonclinicalexperienceasdemonstratedbylargepatientvolume,increasingcomplexityofcare,andavailabilityofpediatricmedicalsubspecialistsandpediatricsurgicalspecialists5.”Doesthismeansomeonewillbemonitoringourpatientvolume?Asthefootnotestates,“AccordingtotheAAPpolicystatement“Althoughlittledebateexistsontheneedforadvancedneonatalservicesforthemostimmatureandsurgicallycomplexneonates,ongoingcontroversiesexistregardingwhichfacilitiesarequalifiedtoprovidetheseservicesandwhatisthemostappropriatemeasureforsuchqualification.Theseissuesare,ingeneral,basedontheneedforcomparisonoffacilityexperience(measuredbypatientvolumeorcensus),location(inborn/outborndeliveries,regionalperinatalcenter,orchildren’shospital)orcasemix(includingstillbirths,deliveryroomdeaths,andcomplexcongenitalanomalies).”ThereisanexpectationthatthenextreviewoftheAAPLevelsofNeonatalCarepolicystatementwillindicateappropriatepatientvolumeforeachlevelofneonatalcare.TheAugust,2012LevelsofNeonatalCareGuidelinesfromtheAAPdonotincludepatientvolumeasacriteriaforassigninglevel,nordotheIndianaStandards,atthistime.Q2:WillweloseourNICUIIIstatusifwedonothave24/7inhousecoverageofOB,

anesthesia/CRNAoraneonatologist?Canwelookatqualitydatatoshowweareabovequalitymeasureswiththeresourceswehavenow?Allofphysiciansareon‐calland


mustbeinhousewithin30minutes.Mostlivewithin10minutesofthehospital.Dotheprovidershavetobeinhouseorcantheybereadilyavailable?

Standard8.1statesthat“Thehospitalshallhaveappropriatelyqualifiedneonatalmedicalstaff.”Standard8.1d)statesthatthehospitalshallhavepromptandreadilyavailableaccesstoafullrangeofpediatricmedicalsubspecialists,pediatricsurgicalspecialists,anesthesiologistswithpediatricexperience,andpediatricophthalmologistsatthesiteoratacloselyrelatedinstitutionbyprearrangedconsultativeagreement.“ThisisrequiredforalevelIIINICU.Readilyavailableisdefinedasaresourceforconsultsandassistanceavailablewithinashorttimeafteritisrequested.

Standard8.9statesthataboard‐certifiedprovideroranactivecandidateforBoardcertificationinneonatologyshallbeavailabletobepresentin‐housewithin30minutes.ThisisarequirementforLevelIIIandIVNICUs.Within10minuteswouldseemtomeetboththeserequirements.Incertainsituationstheremaybeaneedtoallowvariabilityfromthestandardssuchaswhengeographicalcoverageisnecessaryforacertainpartofthestate.Thesesituationswillbediscussedduringtheapplicationandsitevisitprocess.HospitalswillbeexpectedtoshowthattheymeetrelevantqualitygoalsifthereisareasontovaryfromtheStandards.Q3:IfweloseourlevelIIINICUstatus,willwehavetosendourmomsthatmightdeliverto

anotherhospitalwithalevelIIINICU?Q.4CanahospitalhaveaLevel2OBandLevelINICU?Thatwouldmeanthehospitalcould

acceptmothers>32weeks,butwouldnotqualifytokeepbabiesknowingthattheywouldhavetotransferallthosebabiesout.

AhospitalcanhaveahigherlevelfortheirneonatalunitthanfortheOBunit.Howevera

hospitalcannothaveahigherOBunitthanneonatalunit.AsstatedintheObstetrical

Definitionsonpage4oftheRevisedPerinatalHospitalStandards(6‐16‐15),“These

hospitals{LevelIIObstetrical)mayreceivematernalreferralswithintheguidelinesof

theirlevel.Thesehospitalsprovidedeliveryroomandacutespecializedcareforinfants

≥1,500gramsAND ≥320/7weeksgestation.Maternalcareislimitedtotermand

pretermgestationsthatarematernalriskappropriate.”ForLevelsIIIandIV,the

ObstetricalDefinitionsstateonpage5,“Inacceptingmaternaltransportsthelevelof

neonatalcarerequiredforananticipateddeliveryandcareoftheneonatemustbein


place.”Everyeffortshouldbemadetosendthemother‐fetaldyadtotheriskappropriate

levelofcareforthepregnantwomanandinfantpriortodelivery.

StandardVII:NeonatalUnitCapabilities7.2Thehospitalshallhaveequipmentforperforminginterventionalradiologyservicesforneonatalpatients.Q.1:Pleaselisttheproceduresaninterventionalradiologistwouldbeexpectedtoperform.ThisstandardisnotapplicableforLevelsIandII,optionalforLevelIIIandexpectedforLevelIV.Theprocedureswillnotbelisted.Theydependontheclinicalsituationandthephysician’sassessmentofwhatisrequiredforthepatient.

StandardVIII:NeonatalPersonnel8.1Thehospitalshallhaveappropriatelyqualifiedneonatalmedicalstaffpersonnel,availableaslistedbelowforeachlevelofcare.(a)Thehospitalshallhaveconsultingrelationshipsinplacewithapediatriccardiologist,asurgeonandanophthalmologistwhohasexperienceandexpertiseinneonatalretinalexamination.Q1:Doesthisrequireawrittenplan/actualcontractswithreceivingphysicians/facilities?Wehave2PediatricgroupsandanindependentpracticingPediatrician.Onegroupusesprimarilyonehospitalandtheothergroupusesanotherhospital.Theyhavegoodworkingrelationshipswiththosehospitalsandhavenoissueswithmakingreferrals.Isthissufficientordoweneedawrittenplan(anddoyouhaveanexampleofone)?Ofcoursetheyalwaysaskthepatientiftheyhaveapreferencebeforemakingarrangements.ThisstandardisoptionalforLevelIandexpectedforLevelII.ItisnotapplicabletoLevelIIIorIVbecausetheyareexpectedtohavethesesubspecialistsatthesite.ItwillbeexpectedforLevelIIthattherebeaMemorandumofUnderstandingwiththesesubspecialiststhattheywillprovideconsultationservicesasneededforthehospital.Thisdoesnothavetobeacontract.Thisstandardreferstopediatricsubspecialists,notgeneralpediatricians.8.1(e)thehospitalshallmaintainafullrangeofpediatricmedicalsubspecialists,pediatricsurgicalsubspecialistsandanesthesiologistswithpediatricexperienceatthesite.


Q.1:ThelevelofcarechartkeystatesO=optionalrequirementforlevelofperinatalcenter.Whatisitreferringtoasaperinatalcenter?Thenicu?Wedonothavethisavailableatourhospital,butwehaveveryeasyaccesstosubspecialistsinoursystem.Ifahospitalhasself‐declaredasLevelIIorIIInursery,maintainingafullrangeofpediatricmedicalsub‐specialistsandanesthesiologistswithpediatricexperienceisoptional.Ifthehospitalwasself‐declaringataLevelIV,thiswouldbeanessentialrequirement.8.5Thehospitalshallhaveprearrangedconsultativeagreementswithaboardcertifiedneonatologist24hoursaday.

Q.1Wecurrentlyhaveaffiliationwithanotherhospitalthatmightbeabletoprovideavailabilitytohaveaneonatologistavailableifweneedthem.Wecurrentlydoconsultoverthephonewiththeneonatologistbeforetransferringournewbornsthatneedfurthermedicalcareorwouldtheyhavetophysicallybeavailabletoseeanewborn?

Standard8.5isexpectedforLevelsIandII.Theneonatologistdoesnothavetobephysicallypresent;however,thereshouldbeawrittenagreementwiththeotherhospitalthataboardcertifiedneonatologistwillbeavailableforconsultation24hoursaday.

8.8APediatricianwhohascompletedpediatricresidencytraining,anursepractitionerorphysicianassistantwithadequateNICUtrainingandexperience,withprivilegesforneonatalcareappropriatetothelevelofthenursery,shallbephysicallypresentin‐house24hoursadayandassignedtothedeliveryareaandneonatalunitsandnotsharedwithotherunitsinthehospital.Clarification:Standard8.8isnotapplicableforLevelIandoptionalforLevelII.ItisexpectedforLevelsIIIandIV.Q.1CanthisNPbeaFamilyNP?SomeonethathasNICUexperienceandisgrantedprivilegesbythehospital.ANICURNthatreturnedtoschoolforFamilyNursePractitioner?AccordingtoGPC7,“Neonatalnursepractitionersmanageacaseloadofneonatalpatientsincollaborationwithaphysician,usuallyapediatricianorneonatologist.NursepractitionerscaringforneonatesintheNICUmustdemonstratecompletionofaformalneonataleducationalprogramandnationalcertificationasaneonatalnursepractitioner.Anyadvancedpracticeregisterednursecaringforneonatesmustdemonstratecompletionofaformalneonataleducationalprogramthatincludesaminimumof200neonatal‐specificdidactichoursandatleast600supervisedclinicalhoursinthecareoftheat‐riskand


criticallyillnewborninLevelII,LevelIII,orlevelIVNICUs.NursepractitionerswhoarenoteducatedasneonatalnursepractitionersandareworkingasnursingpractitionersintheNICUarefunctioningbeyondtheirscopeofpractice.TheNPmustbegrantedappropriateprivilegesbythehospitalmedicalstaff.8.9Aboard‐certifiedprovideroranactivecandidateforboard‐certificationinneonatologyshallbeavailabletobepresentin‐housewithin30minutes.Clarification:Standard8.9isnotapplicableforLevelIandoptionalforLevelII.ItisexpectedforLevelsIIIandIV.8.12Thehospitalshallhaveappropriatelyqualifiedneonatalpersonnelinadequatenumberstomeettheneedsofeachpatientinaccordancewiththecaresetting:a) Areadilyavailable,in‐houseregisterednursewithdemonstratedtrainingand

experienceintheassessment,evaluationandcareofnormalnewbornsatalltimes;

b) Aregisterednurseskilledintherecognitionandnursingmanagementoftheneonatewithcomplicationsontheunitatalltimes;

c) AnAdvancedPracticeNurse(AClinicalNurseSpecialist(CNS)orNursePractitioner(NP))withperinatalexperienceisavailabletothestafftofostercontinuousqualityimprovement,superviseeducationandparticipateinadministrativefunctions.

d) Allnurseswithneonatesathighriskshouldhaveevidenceofcontinuingeducationinneonatalnursingandspecialtrainingandexperienceinthemanagementofneonateswithcomplexillnessesandneonatalcomplications.

Q.1Instandard“c”above,Whatistheirspecificrole/function?IstheNNPtofunctionasaCNS?IstheretobededicatedNNPorCNSthatfunctionsasaCNS?WehavehadanopenNICUCNSpositionforoverayearwithnoqualifiedcandidatesapplying.IsthisshortagewhytheabovecallsforaCNSorNNP?Standard8.12c)isExpectedforLevelsIIIandIVnurseries,optionalforLevelIIandnotapplicableforLevelIIngeneralGuidelinesforPerinatalCare,7thEdition(GPC7)states“anadvancedpracticeregisterednurseshouldbeavailabletothestaffforconsultationandsupportonnursingcareissues(intheNICU)(pp32‐33)TheGPC7includesinthecategoryofadvancedpracticeregisterednurses:neonatal,perinatal,andwomen’shealthclinicalnursespecialistandtheneonatalandwomen’shealthnursepractitioner.Anadvancedpracticeregisterednurseisprepared,accordingtonationallyrecognizedstandards,bythecompletionofaneducationalprogramofstudyandsupervisedpracticebeyondthelevelofbasicnursing.AsofJanuary1,


2000,thispreparationmustincludetheattainmentofamaster’sdegreeinthenursingspecialty.Nurseswithoutagraduatedegreewhoenteredtheprofessionbeforetheyear2000,butarecredentialedadvancedpracticeregisterednursesorcertificate‐prepared(non‐graduate)nursepractitioners,shouldbeallowedtomaintaintheirpracticeandareencouragedtocompletetheirformalgraduateeducation.Nationallyrecognizedcertificationexaminationsexistforeachcategoryofadvancedpracticenursing.Credentialingisnowrequiredonanationallevelandisnolongergovernedbyindividualstates.Inregardto8.12c),GPC7statesthat“theclinicalnursespecialistisaregisterednursewithamaster’sdegreewho,throughstudyandsupervisedpracticeatthegraduatelevel,hasbecomeanexpertinthetheoryandpracticeofneonatal,perinatal,andwomen’shealthnursing.Responsibilitiesoftheclinicalnursespecialistincludefosteringcontinuousqualityimprovementinnursingcareanddevelopingandeducatingstaff.Theclinicalnursespecialistmodelsexpertnursingpractice,participatesinadministrativefunctionswithinthehospitalsetting,servesasaconsultantexternaltotheunit,andappliesandpromotesevidence‐basednursingpractice.”Consideringtheroleoftheneonatalnursepractitioner(NNP)definedbyGPC7below,theNNPcouldfunctionintheroleoftheCNSdescribedin8.12c).However,theNNPcouldnotmanageafullcaseloadofpatientsandcovertheresponsibilitiesdefinedin8.12cQ.2CantheNNPswhomanageafullcaseloadsofpatientscrosscoverforstandard“c”aboveordotheyneedtobe“dedicated”toaspecificrole?Standard8.12d)isnotapplicableforLevelIandLevelIIandexpectedforLevelsIIIandIV.TheGPC7statesthat“aneonatalorwomen’shealthnursepractitionerisaregisterednursewhohastheclinicalexpertiseinneonatalorwomen’shealthnursing,hasamaster’sdegreeorhascompletedaneducationalprogramofstudyandsupervisedpracticeinthespecialty;andhasacquiredsupervisedclinicalexperienceinthemanagementofpatientsandtheirfamilies.Usingtheiracquiredknowledgeofpathophysiology,pharmacology,andadvancedassessment,nursepractitionersexerciseindependentjudgmentintheassessmentanddiagnosisofpatientsandintheperformanceofcertainprocedures.Theydevelopaplanofcare,providetreatment,andevaluateoutcomes,Similartotheclinicalnursespecialist,anursepractitioneralsomaybeininvolvedineducation,administration,consultation,andresearch. Consideringtheroleoftheneonatalnursepractitioner(NNP)definedbyGPC7above,theNNPcouldfunctionintheroleoftheCNSdescribedin8.12c).However,theNNPcouldnotmanageafullcaseloadofpatientsandcovertheresponsibilitiesdefinedin8.12c).TheNNPwouldneedtobededicatedtorolein8.12c).OneNNPcouldnotberesponsibleforbothroles.Ifthereareenoughappropriatelyqualifiedneonatalpersonnelinadequatenumberstomeet


theneedsofeachpatientinaccordancewiththeLevelIIIsetting,itisoptionaltohaveanNNPinthepatientcarerole.Q.3ANNPworks32hoursaweek;24hoursofwhichisdedicatedtomanagingacaseloadofneonatalpatients,and8hours(weekly)isdedicatedtodevelopmentofstaffeducation,policyrevisions,qualityimprovementinitiatives,skilllabs…..andit’swrittenintoherjobdescriptionassuch,statingthatinadditiontomanagingacaseloadofneonatalpatientsshewillhavexnumberofhoursdedicatedtodevelopmentofstaffeducation,andqualityimprovementinitiatives……wouldthatmeetthisstandard?ThisquestionimpliesthattheNNPismanagingacaseloadofneonatalpatientsandalsofulfillingthedutiesofcoordinatingstaffeducationasstatedinStandard8.21.Standard8.21isoptionalforlevelsIandII.ItisexpectedforLevelsIIIandIV.Iftheratiooftimeavailableforpatientcareandstaffeducationmeetstheneedsofadequatepatientcareandstaffeducationconsiderationwillbegiventothisarrangement.8.13Thehospitalshallhaverespiratorytherapistswhoare:(a)Experiencedinthedeliveryofcontinuouspositiveairwaypressureand/ormechanicalventilationorbothreadilyavailable.(b)SkilledinneonatalventilatorcareandmanagementassignedtotheNICUandnotsharedwithotherunitswhenanypatientisreceivingassistedpositivepressureventilation,high‐frequencyventilation,and/orinhalednitricoxide24hoursaday.Q1:Does8.13(b)includeCPAP,SIPAPandBIPAP?Ordoesitrefertoinfantsontheventilator?WearetryingtoincreaseourrespiratoryFTE’stofitalevel3NICUsoneedtomakesurewearereadingthestandardappropriately.Q2:Willyoupleaseclarifythestandardbelowasitrelatestonon‐invasivepositivepressureventilation?Doesthisalsocountasmeetingthisstandard8.13.BandinsodoingrequireRTstobeinNICU‘andnotsharedwithotherunits’?‘Skilledinneonatalventilatorcareandmanagementassignedtothe

NICUandnotsharedwithotherunitswhenanypatientisreceivingassistedpositivepressureventilation,high‐frequencyventilation,and/orinhalednitricoxide24hoursaday.’

Standard8.13isexpectedforLevelsII,IIIandIV


AnRTskilledandexperiencedinallmethodsofthedeliveryofcontinuouspositiveairwaypressureand/orassistedconventionalmechanicalventilationorboth,mustbereadilyavailable.ForLevelII,thisRTcouldbesharedwithotherunits.BydefinitionaLevelIInurserywillonlybeprovidingassistedconventionalventilationorcontinuouspositiveairwaypressureorbothforbriefdurations,generallylessthan24hours.Standard8.13(b)isexpectedforLevelIIIandIVAnRTskilledinallmethodsofthedeliveryofcontinuouspositiveairwaypressureaswellasneonatalventilatorcareandmanagementmustbeassignedtotheNICUandnotsharedwithotherunitswhenanypatientisreceivingassistedpositivepressureventilation(includingCPAP,BPAPorSIPAP),high‐frequencyventilation,and/orinhalednitricoxide24hoursaday.Forinfectioncontrolpurposesifababyisonanyformofpositivepressureventilation,anRTdedicatedtothatunitmustbeassignedtothatunitonly.IftheRTisalsotheonegoingondeliveriesthatwouldbeacceptablebecauseitisconsideredafunctionoftheunit.TheRTmustnotbesomeonewhoisrotatingthroughdifferentunitsofthehospital.8.15ThehospitalshallprovidelactationsupportperAWHONNandILCArecommendation:

a) LevelI1.3FTEper1000deliveriesperyear

b) LevelII1.6FTEper1000deliveriesperyear

c) LevelIIIandIV1.9FTEsper1000deliveries

Q.1IstheaboveLCFTEs(intheneonatalstandardssection)inadditiontotheLCFTEsprovidedinOB?No,thelactationconsultantstandardreferstothenumberofdeliveriesornumberofmaternal‐infantdyads.Q.2ifOBunitdoes3,000deliveriesayear,theabovewouldcallfor5.7FTEsfortheOBarea.Dothese5.7FTEsalsocovertheNICU?YesQ.3Ifthe5.7FTEsisforbothareas,whatistheallocationofFTEstotheNICU?TheallocationfortheICUwoulddependonthenumberofadmissionstotheICU.Q.4.IsthereareasonwhytherecommendedLCsfortheNICUisnotbasedontheNICUaveragedailycensusoradmissionsperyear?IsthereanopportunitytohavethislookedatandarecommendationmadespecifictoNICU?


Standard8.15isbasedonthecurrentrecommendationsoftheInternationalLactationConsultantAssociation(ILCA)andAssociationforWomen’sHealth,Obstetric&NeonatalNurses(AWHONN).TheIPQICwillreviewstandardsonaregularbasisandwillacceptspecificrecommendationsforupdates.8.18ThehospitalshallhavePhysicalTherapistand/orOccupationalTherapist,withadditionalContinuingEducationUnitsintheareaofneonatalcare,asamemberoftheinterdisciplinarycareteam.Q.1:HowmanyCEUswillberequired?ThenumberofCEUswillnotbeprescribed.Q2.Thestandardsaystheyneed“continuingeducationunitsintheareaofneonatalcare.”Ourquestionis:arethereacertainnumberofcreditsrequiredeachyear?ThisstandardisnotapplicableforLevelI,optionalforLevelIIandexpectedforLevelsIIIandIV.ThenumberofCEUswillnotbeprescribed.Hospitalswillberesponsibletoensurestaffisqualified.8.19ThehospitalshallhaveaSpeechTherapist,withadditionalContinuingEducationUnitsintheareaofneonatalcare,asamemberoftheinterdisciplinarycareteam.Q.1:HowmanyCEUswillberequired?ThisstandardisnotapplicableforLevelI,optionalforLevelIIandexpectedforLevelsIIIandIV.ThenumberofCEUswillnotbeprescribed,butshouldincludeevaluationandmanagementofneonatalfeedingandswallowingdisorders.Hospitalswillberesponsibletoensurestaffisqualified.8.20Thehospitalshallhavequalifiednursingleadershipinaccordancewiththecaresetting: a)Nursingcareshouldbeundertheleadershipofaregisterednurse (ExpectedforLevelI,NotapplicableforLevelsII,III,andIV) b)Nursingcareshouldbeundertheleadershipofaregisterednursewithdemonstratedexpertiseinobstetriccare,neonatalcareorboth (OptionalforLevelI,ExpectedforLevelII,NotapplicableforLevelsIIIandIV) c)Nursingcareshouldbeundertheleadershipofaregisterednurse,masterspreparedoractivelyseekingamastersdegreewithexperienceandtraininginneonatalnursing,aswellasinthecarepatientsathighrisk.


(OptionalforLevelsIandII,ExpectedforLevelsIIIandIV)Q.1:Ifthedirectorcurrentlydoesnothaveanadvanceddegree,whattimeframewouldhe/shebegiventobeenrolledinaprogramandhowlonguntilcompletionwouldberequired?Standard8.20referstoanadministrative/managementposition.Thisisthetypeofsituationthatwillrequirearequestforconsiderationorcorrectiveactionplan.

Q2:TheCNOisthedirectorandisabouttoobtainaBSNdegreeinacoupleofmonths.TheOBmanager(myself)hasanASNdegreewith17yearsofexperienceinobstetricsandneonatalcare.NeithertheCNOnorIhaveaMSNdegree.However,dowemeetthecredentialsforacriticalaccesshospitalthatyouarelookingfor?WhatactionsneedtohappensinceobviouslyobtainingaMSNisnotaquickthingtofix?

Thisisthetypeofsituationthatwillrequirearequestforconsiderationorcorrectiveactionplan.TheIndianaHospitalPerinatalStandardsarethesameforCriticalAccessHospitalsastheyareforotherdeliveringhospitals.8.21Aregisterednursewhohasbeeneducatedandmasterspreparedoractivelyseekingamastersdegree,shouldbeonstafftocoordinateeducation.Q.1:ThisstandardappearstobeinconsistentwithStandard8.20Standard8.21referstoaneducational/trainingposition.ItisoptionalforLevelsIandII.ItisexpectedforLevelsIIIandIV.Standard8.20referstoanadministrative/managementposition.ItisoptionalforLevelIandexpectedforLevelsII,III,andIV.

Q2:Pleasedefinewhatismeantby“ahospitalperinatalprogram”whichrequiresaregisterednursewithadvancedneonatalexperienceandamaster’sdegreeidentifiedforstaffeducationasstatedinsection8.21.Whatdoestheperinatalprogramrefertoand,ifmorethan1personisresponsibleforstaffeducation,doeshavingatleastoneofthesemembersmasterspreparedmeetthecriteria??

Ingeneral,theterm”hospitalperinatalprogram”referstotheadministrationandoperationofhospitalunitswhichprovideobstetricalandneonatalcare.TheIndianaHospitalPerinatalStandardswerewrittenwithanObstetricalandaNeonatalSection.Insomestandards,theterm“hospitalperinatalprogram”appliestoeithertheObstetricalortheNeonatalsection


suchasinStandard8.21,where“hospitalperinatalprogram”referstothehospital’sneonatalcareunit.Thestandardindicatesthatatleastoneregisterednursewithadvancedneonatalexperienceandamaster’sdegreemustbeidentifiedforstaffeducation.

Q.3Currently,wehaveone0.8NetworkeducatorFTE(32hoursweek)for3hospitals(2SCN,1NICU).Wouldthismeetthisstandard?ORTomeetthisstandarddoestheeducatorneedtobeonsite/dedicatedtotheNICUstaffforeducation?Ifso,isthereaspecifiedFTErequired?Examplespecificnumberofeducatorhours/FTEper#ofbeds/nursingFTEs?Standard8.21referstoaneducational/trainingposition.AnFTEnurseeducatorisoptionalforLevelsIandII.ItisexpectedforLevelsIIIandIV.TheexpectationisthatoneFTEwillbededicatedtoaLevelIIIorLevelIVnursery.IfSCNmeansSpecialCareNurseryoraLevelIInursery,theFullTimeeducational/trainingpositionisnotnecessaryatLevelII.Thereisnospecifiednumberofeducatorhours/FTEper#ofbedsorpernursingFTEsatthistime.ItwouldbeappropriateforanFTEnurseeducatorassignedtoaLevelIIItobeavailableforeducationofLevelIIorLevelIunitsassumingtheeducational/trainingneedsoftheLevelIIInursingstaffaremet.

StandardIX:NeonatalSupportPersonnel9.1Portableultrasonographyfornewborns,withtheservicesofappropriatesupportstaff,shallbeavailabletotheneonatalunits.

Q1:Wedonotcurrentlydoultrasoundsoninfantsexceptforabdominalultrasounds.WehaveanaffiliationwithalargerhospitalinLouisvillethathavepediatricradiologiststhatcouldreadourultrasoundsifweareabletoconsultthemwhenneededandwouldneedtohaveanagreementwiththehospital.Wouldthatworktomeettheexpectationandavailability?

Standard9.1isoptionalforLevelIandexpectedforLevelsII‐IV.Itisnecessarytohavetheportableultrasonographymachineonsite.Itwouldbeacceptabletohaveanagreementwithapediatricradiologistwhocouldreadtheultrasoundimmediatelyifitweresentelectronicallyorusingtelemedicinetechnology.

9.5Thehospitalshallhaveapediatriccardiaccatheterizationlaboratoryandappropriatestaff.Q1:IsittrulyexpectedthatahospitalmusthaveapediatriccardiaccathlabtobeconsideredLevelIII?


No,thisstandardisoptionalforLevelIIIandexpectedforLevelIV.

StandardX:NeonatalEquipment

10.2Thehospitalshallhaveallofthefollowingequipmentandsuppliesimmediately

availableforexistingpatientsandforthenextpotentialpatient:a) O2analyzerb) stethoscopec) intravenousinfusionpumpswithappropriatedruglibrariesd) radiantheatedbedindeliveryroomandavailableintheneonatalunitse) oxygenhoodwithhumidityf) pediatricbagandmaskscapableofdeliveringacontrolledconcentrationof

oxygentotheinfantg) orotrachealtubesh) aspirationequipmenti) laryngoscopej) umbilicalvesselcathetersandinsertiontrayk) cardiacmonitorl) pulseoximeterm) phototherapyunitn) Dopplerbloodpressureforneonateso) cardioversion/defibrillationcapabilityforneonatesp) resuscitationequipmentforneonatesq) individualoxygen,airO2blendedandhumidifiedcapability,andsuction

outletsformothersandneonatesr) emergencycallsystems) bowelbags

Q1a:WhatexactlydotheywantforDopplerbloodpressuresforneonates?Wehavetheabilitytotakebloodpressuresonnewbornsbutwerenotsureifthis(standard)wantedmoreinvasivemonitoringtobeavailable.Q1b:Wecurrentlytakebloodpressuresafterdeliveryonallpatientswithabloodpressuremachine.DoesthismeettheDopplerbloodpressuresyouarelookingfor?

ADopplerbloodpressureunitforneonatesisanoninvasivedevicewhichautomaticallymeasuressystolicBP,diastolicBP,meanarterialpressure,andheartrate;itdisplaysthevaluesonalighteddigitaldisplayandprintsthemonarecorder.TheDopplerbloodpressuremeasurementismoreaccurate,especiallyinsmallneonates.Dopplerultrasoundisnotthe


samething.TheDopplerbloodpressureunitisexpectedequipmentforalllevelsofneonatalcre.

Toclarify,theBloodPressuredevice(s)usedfornewbornsisactuallyanoscillometricdevice(s).WhentheBPislow,DopplertechnologycanbeusedtodetectapulseandsometimesthesystolicBP.

Q1c:Asalevel2nurserydoIneedtohaveaDopplerforbloodpressurereadings?

Q1d:ExactlywhatisneededtoqualifyfortheDopplerBloodFlowDeviceforneonates?

ThecommonlyusedBPdevice(s)fornewbornsisanoscillometricdevice(s);thesemeasuremeanBPandextrapolatesystolicanddiastolic.WhenBPislow,dopplertechnologycanbeusedtodetectapulseandsometimesthesystolicBP.

LevelsI,II,IIIandIVnurseriesareexpectedtohaveanoscillometricdevice(s)tomeasurebloodpressureinaneonate.

LevelsIIIandIVnurseriesareexpectedtohavetheabilitytomeasurebloodpressurecontinuouslyanddirectlythroughtheuseofelectricaltransducersandcatheters.

ChockVY,WongRJ,HintzSR,StevensonDK.Biomedicalengineeringaspectsofneonatalmonitoring.InMartinRJ,FanaroffAA,WalshMC(eds)FanaroffandMartin’sNeonatal‐PerinatalMedicineDiseasesoftheFetusandInant2011ElsevierSt.Louis,MO:580‐582.

Q2a:Towhatextentdoweneedcardioversion/defibrillationcapabilitiesforneonates?IwanttoclarifywhatequipmentisexpectedtobeavailableattheLevel1facilitiestoperformtheseproceduresiftheneedarises.

Q2b:AlsotheCardioversion/defibrillationcapableonneonates’requirement.Wedonotcardiovertordefibrillateanynewborns.WeonlyfollowingtheNRPguidelinesinregardstoresuscitation.LevelsIandIIareexpectedtohaveequipmenttoimplementtheNeonatalResuscitationProgram(NRP).Thiswouldnotincludecardioversionordefibrillationequipmentfornewborns.LevelsIIIandIVareexpectedinadditiontohavethenecessaryequipmenttoperformcardioversionordefibrillationonneonates.Q3:Whatspecificallyisabowelbag?Bowelbagsareusedtoprotectthenewborn’sintestinesinacaseofGastroschisisorOmphalocele,birthdefectsintheabdominalwallthatallowtheintestinesandsometimes


stomachtositoutsideoftheabdomen.Thebowelbagisasterilebagthatpreventstemperatureloss,fluidlossandinfectionuntilthebabycanreceivesurgerytocorrectthedefect.Thelowerhalfoftheinfant(includingtheintestine)isplacedintoasterilebowelbag,feetfirst,uptotheleveloftheunder‐arms.ThisisarareoccurrencebutthereareanumberofcasesinIndianaeachyear.Allbirthingunitsshouldbepreparedforanyproblemsthatcouldariseatlaboranddelivery.Eachhospitalshouldhaveatleast2sterilebowelbagsincaseofunforeseenbirthproblems.

StandardXI:NeonatalMedications

StandardXII:UniversalLaboratory

StandardXIII:UniversalEducation13.4ThePerinatalteammember:

Acquiresknowledgeandexperiencesthatreflectcurrentevidencedbasedpracticeinordertomaintainskillsandcompetenceappropriateforhisorherspecialtyarea,role,andpracticesetting.

Participatesinandmaintainsprofessionalrecordsofeducationalactivitiesrequiredtoprovideevidenceofcompetency.

Maintainslicensureandcertificationasmandatedbystatelicensingboards,healthcarefacilitiesandaccreditingagencies.

Maintainscertificationwithinthespecialtyareaofpracticeasappropriate,asamechanismtodemonstratespecialknowledge.

Participatesinlifelonglearning,includingeducationalactivitiesrelatedtoevidencebasedpractice,knowledgeacquisition,safetyandprofessionalissues.

Hasknowledgeofrelevantpracticeparametersandguidelinesofotherorganizationsthatfocusonthedeliveryofhealthcareservicestowomenandnewborns.


Q1:Thisstandardstatesthattheperinatalteamwillmaintaincertificationwithinthespecialtyareaofpractice.Itisnotreasonabletoexpect100%ofthestafftobecertifiedbutcertainlyapercentageofthestaffisreasonable.Eachhospitalwillberesponsibletoensurestaffisqualified.

StandardXIV:PerformanceImprovement

StandardXV:PoliciesandProtocols

GeneralQuestions:Q1:Doesa“prearrangedconsultativeagreement”havetobewritten?AprearrangedconsultativeagreementshouldbeawrittenMemorandumofUnderstandingbetweenthehospitalandconsultantthatserviceswillbeprovidedasneeded.Itdoesnothavetobeacontract.Withafewexceptionsforemergencies,prearrangedconsultativeagreementscanbeperformedbyusingtelemedicinetechnologyand/ortelephoneconsultation.Q2:Doesa“closelyrelatedinstitution”meanwithinacertaingeographicalarea?Therelationshipdoesnothavetobegeographic.Ifgeographicconstraintsforlandtransportationexist,theLevelIIIfacilityshouldensureavailabilityofrotorandfixed‐wingtransportservicestoquicklyandsafelytransferinfantsrequiringsubspecialtyintervention.“Closelyrelated”referstoalevelofcloseaffiliationorcollaborationthatassuresachievementandmaintenanceoftheappropriatelevelofcare.ThereshouldbeawrittenMemorandumofUnderstandingbetweenthehospitalsthatthepertinentserviceswillbeprovidedasneeded.Q3:Whatisthetimelinetocorrectanydeficiencies?Thereareatleasttwosituationsduringthecertificationprocesswheretimetocorrectdeficienciesmaybegranted.Inthefirstcase,iftheapplicationisnotcomplete,thehospitalwillbegivenastatedtimetocompletetheapplication.TheexacttimehasnotbeendeterminedbytheISDHyet.Thesecondsituationmayoccurafterasitevisitofthehospitaldoesnotmeettherequirementsforthelevelofcareitappliedfor.Aletterwillbesenttothehospitalaskingforarevisionoractionplantomeettherequiredstandardandtheletterwillstatethetimelineforrevision.Q4.CanwebeaLevelIIIOBandaLevelIINeonatalunit?


AhospitalcanhaveahigherlevelfortheirneonatalunitthanfortheOBunit.HoweverahospitalcannothaveahigherOBunitthanneonatalunit.AsstatedintheObstetricalDefinitionsonpage4oftheRevisedPerinatalHospitalStandards(6‐16‐15),“Thesehospitals{LevelIIObstetrical)mayreceivematernalreferralswithintheguidelinesoftheirlevel.Thesehospitalsprovidedeliveryroomandacutespecializedcareforinfants≥1,500gramsAND ≥320/7weeksgestation.Maternalcareislimitedtotermandpretermgestationsthatarematernalriskappropriate.”ForLevelsIIIandIV,theObstetricalDefinitionsstateonpage5,“Inacceptingmaternaltransportsthelevelofneonatalcarerequiredforananticipateddeliveryandcareoftheneonatemustbeinplace.”Everyeffortshouldbemadetosendthemother‐fetaldyadtotheriskappropriatelevelofcareforthepregnantwomanandinfantpriortodelivery.Q.5:Areanydeficienciesallowedordowehavetometeverystandard?Theexpectationisthatthehospitalwillmeetthestandardsindicatedforthelevelofcareitappliesfor.Incertainsituationstheremaybeaneedtoallowvariabilityfromthestandardssuchaswhengeographicalcoverageisnecessaryforacertainpartofthestate.HospitalswillbeexpectedtoshowthattheymeetrelevantqualitygoalsifthereisareasontovaryfromtheStandards.Thesesituationswillbediscussedduringtheapplicationandsitevisitprocess.Q6:Whatphysicianssitonthecommitteerecommendingthechanges?TheTaskForcethatdevelopedtheIndianaPerinatalHospitalStandardswasmadeupofneonatologists,maternal‐fetalmedicinespecialists,obstetricians,pediatricians,familyphysicians,hospitaladministrators,certifiedlactationconsultants,women’shealthnursingandrepresentativesfromtheIndianaHospitalAssociation,IndianaPerinatalNetwork,IndianaMarchofDimes,IUCenterforWomen’sHealthandIndianaFamilyHealthCouncilandtheIndianaStateDepartmentofHealth.TheStandardswereacceptedbytheGoverningCounciloftheIndianaPerinatalQualityImprovementCollaborativeinFebruary,2013.MembersoftheGoverningCouncilrepresenttheIndianaChapterAmericanAcademyofPediatrics,IndianaChapterAmericanCollegeofObstetrics&Gynecology,IndianaChapterAssociationofWomen’sHealthObstetric&NeonatalNurses,IndianaAcademyofFamilyPhysicians,IndianaHospitalAssociation,IndianaMarchofDimes,IndianaMinorityHealthCoalition,IndianaPerinatalNetwork,IndianaPrimaryHealthCareAssociation,IndianaRuralHealthAssociation,IndianaStateMedicalAssociation,IndianaUniversitySchoolofMedicine,DepartmentofPublicHealth,IndianaStateDepartmentofHealthMaternalChildHealth,IndianaStateDepartmentofHealthOfficeofPrimaryCare,IndianaDepartmentofInsurance,IndianaOfficeofMedicaidPolicy&Planning,andaConsumerMember.


TheIndianaStateDepartmentofHealthandtheIndianaPerinatalQualityImprovementCollaborativearecommittedtoassistingeveryhospitalreachthelevelofperinatalcareitwantstoprovide.QuestionsregardingthestandardsmaybesubmittedtoArtLogsdon,AssistantCommissionerforHealthandHumanServicesatalogsdon1@isdh.in.gov.

Q9:Pleasedefinewhatismeantby"ahospitalperinatalprogramIngeneral,theterm”hospitalperinatalprogram”referstotheadministrationandoperationofthehospitalunitswhichprovideobstetricalandneonatalcare.TheIndianaHospitalPerinatalStandardswerewrittenwithanObstetricalandaNeonatalSection.Insomestandards,theterm“hospitalperinatalprogram”appliestoeithertheObstetricalortheNeonatalsectionsuchasinStandard8.21,where“hospitalperinatalprogram”referstothehospital’sneonatalcareunit.Q10:IfalevelIInurseryhasababyonavent.for18hours,extubatesandthenadaylatertiresoutandhastogobackonavent.orCPAPwouldthebabyneedtobetransferredtoalevelIIInurseryatthattimeordoesthe“24hour”positivepressureguidelineforlevelIInurseriesstartover?Ifthebabyisfailingextubationthenitneedstobetransferred.Forapracticethatwantedtotrialextubationdailyinthesebabiesyoucouldtheoreticallydraganew24hoursoutindefinitely.MoreovertheinfantlikelywouldstillexceedtheCPAPandoroxygenlimitstobeimprovingby24hours.Q11:Doesyourmedicalstaff(sectionleaders)havetheauthority/accountabilitytosetordefinebestpractice?Bestpracticesarebasedonstandardsfromnationalorganizationsnotestablishedbyeachhospital'smedicalstaff.Hospitalstaffcanandshouldconveywhatarebestpracticesthathavebeenestablishedbytherelevantprofessionalorganizations

Q12:Areallstandardsweightedthesame?Mustallbemettopass?Yes,allstandardsthatapplytothelevelofcarethatahospitalisapplyingformustbemettopass.Therearecertainstandardsthatpertainmoretosafetythanothers.Ex.FTEsforlactationconsultantsvs.24/7coverage.Theplanistolookatprocesses.Therewillbenowaivers,butalternativestoachieveoutcomeswillbeconsidered.Therewillbeanappealsprocess.

Q13:Wehavea2hospitalsystem–oneplanstobeaLevel3andoneplanstobeaLevel2–howwillwebesurveyed?Eachhospitalwillbesurveyedseparately.Twohospitals=twosurveys.Wewouldexpectthemtosharebinderinformationthatisapplicabletobothplaces.


Q14:WillLevel3sbelimitedbygeographyandifso,howwillthatbedetermined?Eachhospitalwillapplyforwhateverlevelofcaretheywishtopursue.TheISDHwillplacenorestrictionsonahospital'slevelofcareapplication.

Q15:ForLevel1hospitals,willpatientsthatdon’tmeetdefinitionof“lowrisk”betransferredouttohigherlevelhospital(includingsmokers,highbloodpressure,etc)?Thegoalisforwomenandbabiestoreceiveserviceinariskappropriatehospital.ThisiswherePerinatalCentersupportwillcomeinaswell.IfLevelIcanmanagecircumstancesthroughconsultation,thatwillwork.

Q16:Howareyouaddressingthestandardofaffiliationwithaperinatalcenterforhospitalsonstatebordersthatdon’ttransfertoIndy?ThereisnoexpectationthatalltransferswillgotoIndianapolis.(ex.BorderhospitalsthattransfertoLouisville,Cincinnati,Chicago).Indianahasnocontroloverhospitalsinotherstates.TheISDHnursesurveyorswilllookatagreementsIndianahospitalsmakewithoutofstatehospitalstoensuretheirappropriatenessforthesafetyandqualityofcareforthenewborn.

Q17:IfweapplyasLevel1,butwemeetthecriteriaforaLevel2,willthesurveyreflectthat?Allhospitalsreceiveadetailedreportthatreflectswhichstandardsaremetandwhatleveltheyqualifyfor.E

Q17:Willhospitalsbeassignedtoaperinatalcenter?Allhospitalswillneedtobealignedwithaperinatalcenterbutitwon’tbeassigned.Hospitalswilldecidewhichperinatalcenterwithwhichtoalign.Theymayhaveagreementswithmorethanone.WeknowIndiana’sstructurewillbemoresystemicornetwork‐basedthangeographical.

Q18:DoesanyonehavesamplecontractsorMOUsbetweenthevariouslevels?Theresponsibilitiesthatwillneedtobeaddressedinthecontract/agreementwereidentifiedinthePerinatalCenterDocument.TheSystemsImplementationcommitteepurposelydidnotdevelopatemplatecontractorMOUsinceallhospitalsystemswillneedtonegotiatethedetailsandpersonalizefortheirsystem.Weknowsomehavedesignedtheirownalready.Thenursesurveyorsreportthathospitalshavebeenwillingtosharewhattheyhavedeveloped.

Q19:Haveyouseencommongapsinthevolunteersurveyssofarthatcanbeshared?ThefollowingarecommongapsinObstetricsStandards:


StandardII:ObstetricalUnitCapabilitieso Writtenplanforacceptinglevel‐basedmaternaltransportso Geneticdiagnostic&counselingservicesorpolicyforconsultation/referrals

StandardIII:ObstetricPersonnelo Board‐certifiedorboardeligibleOB/GYNorMFMonsiteatalltimes(LevelIII

OB’s)o NursingLeadership:PerinatalDirectors&Educatorsbeingmasterspreparedor

activelyseekingmasters.(LevelIIIfacilities)o Advancedpracticenurses(CNSorNP)forLevelIIIfacilities

StandardIV:ObstetricalSupportPersonnel:o LactationsupportperAWHONNandILCArecommendations

StandardXV:Policies&Protocols:o Writtenplanfortransferringmothersas“backtransports”

ThefollowingarecommongapsinNeonatalStandards: StandardVIII:NeonatalPersonnel

o Consultingrelationshipsinplacewithpediatriccardiologist,asurgeonandanophthalmologist.(LevelIInurseries)

o 24/7“in‐house”neonatalcoverage(LevelIIInurseries)o Prearrangedconsultativeagreementswithneonatologists24/7(LevelI&II

nurseries)o RTnotsharedwithotherunitswhenanypatientisreceivingassistedPPV,HFOV,

and/orNO24hrsadayo NursingLeadership:PerinatalDirectors&Educatorsbeingmasterspreparedor

activelyseekingmasterso Advancedpracticenurses(CNSorNP)forLevelIIIfacilities

StandardXV:PoliciesandProtocolso Writtenplanforacceptingortransferringneonatesasbacktransports.

Q20:Somefacilitiesuse“manager”andothersuse“director”todescriberesponsibility.Willthisbeconsideredwhengaugingstandardattainment?Thetermitselfisnottheissue.Surveyorswilllookforoversightresponsibilityandwillunderstandorganizationalchartforclarificationrelatedtothestandards.

Q21:Docriticalaccesshospitalsneedtogothroughthelevelsofcarecertificationprocess?Allhospitalsofferingobstetricserviceswillneedtogothroughthecertificationprocess.

Documents

Frequently Asked Questions V5 - IN.gov · Frequently Asked Questions ... Level III Perinatal Centers and Level IV hospitals must have obstetrical ... hospital to be a level three