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2015
RevisionsapprovedbytheIPQICGoverningCouncilJune16,2015
RevisedIndianaPerinatalHospitalStandards
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
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outreachasapplicable);participationintheevaluationofperinatalcare;andparticipationofperinatalqualityimprovementandpatientsafetyactivities.Readilyavailable:Aresourceforconsultsandassistanceavailablewithinashorttimeafteritisrequested.30minutes:In‐housewithinthirty(30)minutes.(Exceptionsmayoccurforcircumstancesbeyondanindividual’scontrolsuchasextraordinaryweatherortrafficimpediments).
LevelsofCareChartKey
E EssentialrequirementforlevelofperinatalcenterO OptionalrequirementforlevelofperinatalcenterNA NotApplicable
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OBSTETRICALDEFINITIONS
LevelI
LevelIhospitalshaveperinatalprogramsthatprovidebasiccaretopregnantwomenandinfants,asdescribedbythesestandardsandasstatedinIndianaAdministrativeCode(IAC)Title410:Article15.LevelIfacilities(basiccare)providecaretowomenwhoarelowriskandareexpectedtohaveanuncomplicatedbirth.Thesehospitalsprovidedeliveryroomandnormalnewborncareforstableinfants≥350/7weeksgestation.LevelIfacilitieshavethecapabilitytoperformroutineintrapartumandpostpartumcarethatisanticipatedtobeuncomplicated.Maternitycareproviders,midwives,familyphysicians,orobstetrician–gynecologistsshouldbeavailabletoattendallbirths. Thesehospitalsdonotacceptmaternaltransportsfromhospitalswithobstetricalservices.LevelIILevelIIobstetricalserviceshaveperinatalprogramsthatprovidespecialtycaretopregnantwomenandinfants,asdescribedbythesestandards.LevelIIfacilities(specialtycare)providecaretoappropriatehigh‐riskpregnantwomen,bothadmittedandtransferredtothefacility.InadditiontothecapabilitiesofaLevelI(basiccare)facility,LevelIIfacilitiesshouldhavetheinfrastructureforcontinuousavailabilityofadequatenumbersofRNswhohavedemonstratedcompetenceinthecareofobstetricpatients(womenandfetuses).Thesehospitalsprovidedeliveryroomandacutespecializedcareforinfants≥1,500gramsAND≥320/7weeksgestation.Maternalcareislimitedtotermandpretermgestationsthatarematernalriskappropriate.AlthoughmidwivesandfamilyphysiciansmaypracticeinLevelIIfacilities,anattendingobstetrician–gynecologistshouldbeavailableatalltimes.Aboardcertifiedobstetricianhasresponsibilityforprogrammaticmanagementofobstetricalservices.Thesehospitalsmayreceivematernalreferralswithintheguidelinesoftheirlevel.LevelIII
LevelIIIhospitalshaveobstetricalprogramsthatprovidesubspecialtycareforpregnantwomenandinfants,asdescribedbythesestandards.DesignationofLevelIIIshouldbebasedonthedemonstratedexperienceandcapabilityofthefacilitytoprovidecomprehensivemanagementofseverematernalandfetalcomplications. Thesehospitalsprovideacutedeliveryroomandneonatalintensivecareunit(NICU)careforhigh‐riskmothersandinfants<1,500gramsOR<320/7weeksgestation.
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Maternalcarespanstherangeofnormaltermgestationcaretothemanagementofcomplexmaternalcomplicationsandprematurity.Thedirectorofthematernal–fetalmedicineserviceshouldbeaboard‐certifiedmaternal–fetalmedicinesubspecialist.Aboard‐certifiedobstetrician–gynecologistwithspecialinterestandexperienceinobstetriccareshoulddirectobstetricservices. LevelIIIobstetricalhospitalsacceptriskappropriatematernaltransports.Inacceptingmaternaltransportsthelevelofneonatalcarerequiredforananticipateddeliveryandcareoftheneonatemustbeinplace.
LevelIV
LevelIVfacilities(regionalperinatalhealthcarecenters)includethecapabilitiesofLevelI,LevelII,andLevelIIIfacilitieswithadditionalcapabilitiesandconsiderableexperienceinthecareofthemostcomplexandcriticallyillpregnantwomenthroughoutantepartum,intrapartum,andpostpartumcare.InadditiontohavingICUcareonsiteforobstetricpatients,aLevelIVfacilitymusthaveevidenceofamaternal–fetalmedicinecareteamthathastheexpertisetoassumeresponsibilityforpregnantwomenandwomeninthepostpartumperiodwhoareincriticalconditionorhavecomplexmedicalconditions.Amaternal–fetalmedicineteammemberwithfullprivilegesisavailableatalltimesforon‐siteconsultationandmanagement.Theteamshouldbeledbyaboard‐certifiedmaternal–fetalmedicinesubspecialistwithexpertiseincriticalcareobstetrics.Thedirectorofobstetricservicesisaboard‐certifiedmaternal–fetalmedicinesubspecialistoraboard‐certifiedobstetrician–gynecologistwithexpertiseincriticalcareobstetrics.Inacceptingmaternaltransportsthelevelofneonatalcarerequiredforananticipateddeliveryandcareoftheneonatemustbeinplace.
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STANDARDI.ORGANIZATION‐GOVERNINGBOARDRESPONSIBILITIES1.1Thehospital’sBoardofDirectors,administration,andmedicalandnursingstaffsshalldemonstratecommitmenttoitsspecificlevelperinatalcenterdesignationandtothecareofperinatalpatients.ThiscommitmentshallbedemonstratedbyaBoardresolutionthat:
a) ThehospitalagreestomeettheIndianaPerinatalSystemStandardsforitsspecificlevelofdesignationthroughits
commitmenttothefinancial,human,andphysicalresourcesandtotheinfrastructurethatisnecessarytosupportthehospital’slevelofcaredesignation.
b) ThehospitalagreestoconductinternalauditingandattestationusingscreeningformsprovidedbytheIndianaStateDepartmentofHealth(ISDH).OncetheISDHformiscompleted,itistobesignedbytheCEOtoverifythatinformationsubmittedistrueandaccurate.
c) Thehospitalassuresthatallperinatalpatientsshallreceivemedicalcarecommensuratewiththelevelofthehospital’sdesignation.
d) Thehospitalagreestoberesponsibleforcredentialing,licensingandtrainingofallneonatalandobstetricalstaffbasedonthehospital’sdesignatedlevelofcare.Thehospitalisalsoresponsibleforensuringthatallhealthcareworkersmaintaincurrentlicenses,registrationorcertification,andkeepdocumentationofthisinformationwiththeabilitytohavethematerialavailablewithinareasonableamountoftime.410IAC15‐1.4‐1
e) Thehospitalagreestohavewrittenmedicalstaffpoliciesandproceduretoaddressemergentneonatalandobstetricalemergencies,initiatingtreatmentandreferringwhenappropriate.Thehospitalwillbeabletoprovideimmediatelifesavingmeasuresandhavetheappropriatestaffreadilyavailabletocareforemergentneonatalandobstetricpatientneeds,includingtimelyassessment,stabilization,andtreatmentpriortotransfer.Transfersshouldbearrangedwhenneededalongwithcopiesofthepatients’recordsandtreatmentsprovidedtotheacceptingfacility410IAC15‐1.4‐1
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STANDARDII.OBSTETRICALUNITCAPABILITIES I II III IV2.1Thehospitalshalldemonstrateitscapabilityofprovidinguncomplicatedandcomplicatedobstetricalcarethroughwrittenstandards,protocols,guidelinesandtrainingincludingthefollowing:
a) Managingunexpectedobstetricalandneonatalproblems. E E E Eb) Providingfetalmonitoring,includinginternalscalpelectrodemonitoring. E E E Ec) Initiatinganemergentcesareandeliverywithinatimeintervalthatbest
incorporatesmaternalandfetalrisksandbenefitswiththeprovisionofemergencycare.
E E E E
d) Selectingandmanagingobstetricalpatientsatamaternalrisklevelappropriatetoitscapability. E E E E
e) Providingcriticalcareservicesappropriateforobstetricalpatients,asdemonstratedbyhavingacriticalcareunitandaboard‐certifiedcriticalcarespecialist,readilyavailableatalltimes.
NA NA E E
f) Assuringavailabilityofanesthesia,radiology,ultrasound,laboratory,andbloodbankservicesatalltimes E E E E
g) Determiningthelevelofcompetenceandqualificationsrequiredforstafftoassumeclinicalresponsibilityforneonatalresuscitation24hoursadayand7daysaweek.
E E E E
h) Initiatingmaternaltransportstoanappropriatelevel. E E E Ei) Havingawrittenplanforacceptinglevelbasedmaternaltransports O E E Ej) Havingwrittenplanforconsultationandtransferarrangements. E E E Ek) Havingprotocolsandcapabilitiesformassivetransfusion,emergency
releaseofbloodproducts(beforefullcompatibilitytestingiscomplete)andmanagementofmultiplecomponenttherapy.
E E E E
2.2Thematernityservicehasaccesstothehospital’slaboratoryservicesincluding24‐hourcapabilitytoprovidebloodgroup,Rhtype,cross‐matching,antibodytestingandbasicemergencylaboratoryevaluations,andeitherABO‐Rh‐specificorO‐Rh‐negativebloodandfreshfrozenplasmaandcryoprecipitateatthefacilityatalltimes.
E E E E
2.3HospitalshallfollowcurrentCDC/ACOGrecommendationsregardinginductionoflabor,GroupBstreptococci(GBS)treatment,andHIVtreatment. E E E E
2.4Thehospitalshallhavegeneticdiagnosticandcounselingservicesorpolicyfor O E E E
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STANDARDII.OBSTETRICALUNITCAPABILITIES I II III IVconsultationreferralsfortheseservicesinplace.
2.5Thehospitalshallhavealaboratorycapableofperformingfetallungmaturitytests. O E E E
2.6Thehospitalshallhaveafullrangeofinvasivematernalmonitoringavailabletothedeliveryarea,includingequipmentforcentralvenouspressureandarterialpressuremonitoring.
O O E E
2.7Thehospitalshallhavespecialequipmentneededtoaccommodatethecareandservicesneededforobesewomen. O E E E
2.8ThehospitalshallhaveappropriateequipmentandpersonnelavailableonsitetoventilateandmonitorwomeninlaboranddeliveryuntilsafelytransferredtoanICU
NA NA E E
2.9ThehospitalICUcollaboratesactivelywiththeMFMcareteaminthemanagementofallpregnantwomenandwomeninthepostpartumperiodwhoareincriticalconditionorhavecomplexmedicalconditions.ThehospitalICUco‐managesICUadmittedobstetricpatientswiththeMFMteam.
NA NA E E
2.10Hospitalsofferingatrialoflaborforpatientswithapriorcesareandeliverymusthaveimmediatelyavailableappropriatefacilitiesandpersonnelwiththecapacityforanesthesia,cesareansection,andneonatalresuscitationcapabilityduringthetrialoflabor.
E E E E
STANDARDIII.OBSTETRICPERSONNEL I II III IV3.1Ataminimum,eachdeliveryhospitalmusthavethefollowingprimarydeliveryprovidersavailabletoattendalldeliverieswhenapatientisinactivelabor:
a) Obstetricprovider(OB‐GYN,SurgeonorFamilyPracticephysicianwithadditionaltraininginobstetrics)withappropriatetrainingandprivilegestoperformemergencycesareandeliveryshouldbeavailabletoattendalldeliveries.
E NA NA NA
b) Aproviderboard‐certifiedorboardeligibleinobstetrics/gynecologyormaternal‐fetalmedicineavailableatalltimes NA E E E
c) Aproviderboard‐certifiedorboardeligibleinobstetrics/gynecologyor NA NA E E
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STANDARDIII.OBSTETRICPERSONNEL I II III IVmaternal‐fetalmedicineonsiteatalltimes
3.2Aprovider(orproviders)board‐certifiedorboardeligibleinmaternal‐fetalmedicineshallbe:
a) Availableforconsultationon‐site,byphoneorbytelemedicineasneeded. E E NA NAb) Availableatalltimesonsite,byphoneorbytelemedicinewithinpatient
privileges NA O E NA
c)Availableatalltimesforonsiteconsultationandmanagement NA NA O1 E3.3Aproviderboard‐certifiedinobstetrics/gynecologywithexperienceand
interestinobstetricsshallbeamemberofthemedicalstaffandhaveresponsibilityforprogrammaticmanagementofobstetricalservices.
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‐specialtyconsultantsimmediatelyavailableatalltimesincludingthoseindicatedinLevelIIIandadvancedneurosurgeryorcardiacsurgery.
NA NA NA E
1ExpectedforhospitalswishingtobedesignatedasaPerinatalCenter2ExpectedforhospitalswishingtobedesignatedasaPerinatalCenter
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STANDARDIII.OBSTETRICPERSONNEL I II III IV3.7Anesthesiaserviceshouldmeettheneedsofthepatientsserved,withinthe
scopeoftheserviceoffered,inaccordancewithacceptablestandardsofpractice,andunderthedirectionofaqualifiedphysician.
E E E E
a) Anesthesiaservicesshouldbeavailabletoprovidelaboranalgesiaandsurgicalanesthesia.
E E E E
b) Aproviderboard‐certifiedorboardeligibleinanesthesiologywithspecialtrainingorexperienceinobstetricsshallbereadilyavailableforconsultation.
O E NA NA
c) Aproviderboard‐certifiedorboardeligibleinanesthesiologywithspecialtrainingorexperienceinobstetricsshallbeavailableatalltimesonsite. 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) Aregisterednursewithdemonstratedtrainingandexperienceintheassessment,evaluationandcareofpatientsinlaborpresentatalldeliveries. E E E E
b) Aregisterednurseskilledintherecognitionandnursingmanagementofthecomplicationsoflaboranddeliveryreadilyavailableifneededtothelaboranddeliveryunitatalltimes.
E E E E
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STANDARDIII.OBSTETRICPERSONNEL I II III IVc) Anadvancepracticenurse(CNSorNP)withperinatalexperienceisavailabletothe
stafftofostercontinuousqualityimprovement,superviseeducationandparticipateinadministrativefunctions.
NA NA E 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
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 E
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STANDARDIV.OBSTETRICSUPPORTPERSONNEL I II III IVc) 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
servicesforobstetricalpatients. O O E E
5.2Thehospitalwillhavethefollowingequipmentavailableandthecapabilitytouseasindicated.:a) Non‐stressandstresstesting E E E Eb) Ultrasonography E E E Ec) UltrasonographywithDopplerCapability O O E Ed) Portableobstetricultrasonographyequipment,withtheservicesof O E E E
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STANDARDV.OBSTETRICEQUIPMENT I II III IVappropriatesupportstaff,shallbeavailableinthedeliveryarea
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:
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STANDARDVI.OBSTETRICMEDICATIONS I II III IVa) 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 THESESTANDARDSREFLECTTHEREVISEDAAPPOLICYSTATEMENTONLEVELSOFNEONATALCARE20123
LevelIHospitalshaveneonatalprogramsthatprovideabasiclevelofcaretoinfantswhoarelowrisk,asdescribedbythesestandards.Thesehospitalsprovidenormalnewborncareforinfants≥350/7weeksgestationwhoarephysiologicallystable.Theymusthavethecapabilitiestoperformneonatalresuscitationateverydeliveryandtoevaluateandprovideroutinepostnatalcareforhealthynewborninfants.LevelIhospitalsmustbeabletostabilizenewborninfantswhoarelessthan35weeksofgestationorwhoareilluntiltheycanbetransferredtoafacilityatwhichspecialtyneonatalcareisprovided.Boardcertifiedpediatriciansorfamilyphysicianswithprivilegesfornewbornresuscitationsupervisetheseunits.Theseneonatalunitsdonotprovidepediatricsubspecialtyorneonatalsurgicalspecialtyservices.Thesehospitalsdonotreceiveprimaryinfantormaternalreferrals.
3TheAAPCommitteeonFetusandNewbornsissuedthePolicyStatementonLevelsofNeonatalCareonAugust27,2012.www.pediatrics.org/cgi/doi/10.1542/peds.2012‐1999PEDIATRICS(ISSNNumbers:Print,0031‐4005;Online,1098‐4275).
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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,andavailabilityofpediatricmedicalsubspecialistsandpediatricsurgicalspecialists4.Pediatricsurgicalspecialists(includinganesthesiologistswithpediatricexperience)shouldperformallproceduresinnewborninfants.Pediatricophthalmologyservicesandanorganizedprogramforthemonitoring,treatment,andfollow‐upofretinopathyofprematurityshouldbereadilyavailableinLevelIIInurseries.TheneonatalunitsaresupervisedbyBoard‐certifiedneonatologistsandoffercontinuousavailabilityofneonatologists.Neonatalunitsprovidea4AccordingtotheAAPpolicystatement“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
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fullrangeofrespiratorysupportthatmayincludeconventionalventilation,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.STANDARDVII.NEONATALUNITCAPABILITIES I II III IV
7.1Thehospitalshalldemonstrateitscapabilityofprovidingneonatalcarethroughwrittenstandards,protocols,guidelines,andtraining,thatincludethefollowing:
a) ProvidingresuscitationandstabilizationofunexpectedneonatalproblemsaccordingtothemostcurrentNeonatalResuscitation
E E E E
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STANDARDVII.NEONATALUNITCAPABILITIES I II III IV
Program(NRP)guidelines.b) Selectingandmanagingneonatalpatientsataneonatalrisklevel
appropriatetoitscapability.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
personnel,availableaslistedbelowforeachlevelofcare.
a) Thehospitalshallhaveconsultingrelationshipsinplacewithapediatriccardiologist,asurgeonandanophthalmologistwhohasexperienceandexpertiseinneonatalretinalexamination.
O E NA NA
b) Thehospitalshallhaveaccesstopediatricophthalmologyservices NA O E E
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STANDARDVIII.NEONATALPERSONNEL I II III IVc) 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
8.6NeonatalResuscitationProgram(NRP)trainedprofessional(s)shallbeimmediatelyavailabletothedeliveryandneonatalunits.
E E E E
8.7Aproviderwhohascompletedpostgraduatepediatrictraining,anursepractitioner,familyphysicianorphysicianassistantwithprivilegesforneonatalcareappropriatetothelevelofthenurseryshallbeavailable
NA E NA NA
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STANDARDVIII.NEONATALPERSONNEL I II III IVwhenaninfantrequiresLevelIIneonatalservicessuchasFiO2>40%,assistedventilation,orcardiovascularsupport.
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
c) Anadvancepracticenurse(CNSorNP)withperinatalexperienceisavailabletothestafftofostercontinuousqualityimprovement,superviseeducationandparticipateinadministrativefunctions.
NA NA E E
d) Allnursesworkingwithneonatesathighriskshouldhaveevidenceofcontinuingeducationinneonatalnursingandspecialtrainingandexperienceinthemanagementofneonateswithcomplex
NA NA E E
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STANDARDVIII.NEONATALPERSONNEL I II III IVillnessesandneonatalcomplications
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:
a) 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
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STANDARDVIII.NEONATALPERSONNEL I II III IV8.20Thehospitalshallhavequalifiednursingleadershipinaccordancewith
thecaresetting:
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 pediatric expertise who can work to continually review their systems and processes of medication administration to ensure that patient care policies are maintained.
O O E E
STANDARDIX.NEONATALSUPPORTPERSONNEL I II III IV9.1Portableultrasonographyfornewborns,withtheservicesofappropriate
supportstaff,shallbeavailabletotheneonatalunits.O E E E
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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) pulseoximeterb) phototherapyunitc) Dopplerbloodpressureforneonatesd) cardioversion/defibrillationcapabilityforneonatese) resuscitationequipmentforneonatesf) individualoxygen,airO2blendedandhumidifiedcapability,and
suctionoutletsformothersandneonatesg) emergencycallsystemh) bowelbags
E E E E
a) O2analyzer b) stethoscope
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STANDARDX.NEONATALEQUIPMENT I II III IVi) intravenousinfusionpumpswithappropriatedruglibraries j) radiantheatedbedindeliveryroomandavailableintheneonatal
units
k) oxygenhoodwithhumidity l) pediatricbagandmaskscapableofdeliveringacontrolled
concentrationofoxygentotheinfant
m) orotrachealtubes n) aspirationequipment o) laryngoscope p) umbilicalvesselcathetersandinsertiontray q) cardiacmonitor r) pulseoximeter
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
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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
resuscitation,conductclinicaldrillstohelpstaffprepareforhighrisk,highcomplexityeventswithlowrateofoccurrence
Conductdrilldebriefingstoevaluateteamperformanceandidentifyareasforimprovementforhighriskevents Educatenurses,residents,nursemidwivesanddeliveringphysicianstousestandardizedterminologyto
communicateallcategoriesoffetalheartratemonitortracings. Identifyspecifictriggersforrespondingtochangesinthemother’s,fetus’sornewborn’svitalsignsandclinical
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STANDARDXIII.EDUCATIONconditionanddevelopanduseprotocolsanddrillsforrespondingtochangessuchaspreeclampsia,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.
13.4ThePerinatalteammember:
Acquiresknowledgeandexperiencesthatreflectcurrentevidencedbasedpracticeinordertomaintainskillsandcompetenceappropriateforhisorherspecialtyarea,role,andpracticesetting.
Participatesinandmaintainsprofessionalrecordsofeducationalactivitiesrequiredtoprovideevidenceofcompetency.
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STANDARDXIII.EDUCATION Maintainslicensureandcertificationasmandatedbystatelicensingboards,healthcarefacilitiesandaccrediting
agencies. Maintainscertificationwithinthespecialtyareaofpracticeasappropriate,asamechanismtodemonstrate
specialknowledge. Participatesinlifelonglearning,includingeducationalactivitiesrelatedtoevidencebasedpractice,knowledge
acquisition,safetyandprofessionalissues. Hasknowledgeofrelevantpracticeparametersandguidelinesofotherorganizationsthatfocusonthedeliveryof
healthcareservicestowomenandnewborns.13.5Thehospitalshallhaveawrittenplanforassuringregisterednurse/patientratiosaspercurrentGuidelinesForPerinatal
Care,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
neonatalpatientsappropriatetothelevelofcarerenderedatitsfacility.15.2Thehospitalshallhaveobstetricalandneonatalresuscitationprotocols.15.3Thehospitalmedicalstaffcredentialingprocessshallincludedocumentationofcompetencytoperformobstetricaland
neonatalinvasiveproceduresappropriatetoitsdesignatedlevelofcare.15.4Thehospitalshallhaveawrittenplanforacceptingortransferringmothersorneonatesas“backtransports”forongoing
convalescentcare,includingcriteriaforacceptingthepatientandnecessarypatientinformation.
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STANDARDXV.POLICIESANDPROTOCOLS15.5Thehospitalshallhavepoliciesthatallowfamilies(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 NeonatalOrientationEducationProgram GuidelinesforProfessionalRegisteredNurseStaffingforPerinatalUnits StandardsforPerinatalNursingPracticeandCertificationinCanada
CDCCenterforDiseaseControlwww.cdc.govIndianaCodeArticle15HospitalLicensureRules.Rule1.4.GoverningBoardResponsibilities.410IAC15‐1.4‐aGoverningBoard.
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STANDARDXV.POLICIESANDPROTOCOLSIndianaMothersMilkBankwww.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