Perinatal Hospital Standards 2015 - IN.govsecure.in.gov/isdh/files/Perinatal_Hospital_Standards_2015.pdfRevised Indiana Perinatal Hospital Standards Revised 6.16.15 Page 6 STANDARD

2015

RevisionsapprovedbytheIPQICGoverningCouncilJune16,2015

RevisedIndianaPerinatalHospitalStandards


Revised6.16.15 Page2

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



outreachasapplicable);participationintheevaluationofperinatalcare;andparticipationofperinatalqualityimprovementandpatientsafetyactivities.Readilyavailable:Aresourceforconsultsandassistanceavailablewithinashorttimeafteritisrequested.30minutes:In‐housewithinthirty(30)minutes.(Exceptionsmayoccurforcircumstancesbeyondanindividual’scontrolsuchasextraordinaryweatherortrafficimpediments).

LevelsofCareChartKey

E EssentialrequirementforlevelofperinatalcenterO OptionalrequirementforlevelofperinatalcenterNA NotApplicable



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.



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.



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



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



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



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



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



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



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



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



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).



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.



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



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



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



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



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



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



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



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



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



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.



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



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



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

Documents

Perinatal Hospital Standards 2015 - IN.govsecure.in.gov/isdh/files/Perinatal_Hospital_Standards_2015.pdfRevised Indiana Perinatal Hospital Standards Revised 6.16.15 Page 6 STANDARD