Revised Perinatal Hospital Standards 6 - IN.gov of Care Chart Key E Essential requirement for level...

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) 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



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



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



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



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:



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).



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



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



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



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



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



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



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



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



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



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



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.



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.



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.



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

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