Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 640 - REGIONALIZED PERINATAL HEALTH CARE CODE › Appendix O - Level III Resource Checklist

Current through Register Vol. 48, No. 28, July 12, 2024
Level III Resource Checklist
Briefly describe institutional
				compliance:
The Level III hospital shall provide all of the services
				outlined for Level I and Level II general, intermediate and special care, as
				well as diagnosis and treatment of high-risk pregnancy and neonatal problems.
				Both the obstetrical and neonatal services shall achieve Level III capability
				for Level III designation.
Level III General Provisions
1. The hospital shall provide documentation of participation in
				Continuous Quality Improvement (CQI) implemented by the Administrative
				Perinatal Center.
RECOMMENDATIONS:
2. The hospital shall provide documentation of health care
				provider participation in Joint Morbidity & Mortality Reviews.
RECOMMENDATIONS:
3. The hospital shall have the following clinical laboratory
				resources available:
Microtechniques for hematocrit and blood gases
				within 15 minutes; glucose, blood urea nitrogen (BUN), creatinine, blood gases,
				routine urine analysis, electrolytes and coagulation studies, complete blood
				count, routine blood chemistries, type & cross, Coombs test, bacterial
				smear within one hour; and capabilities for bacterial culture and sensitivity
				and viral culture.
RECOMMENDATIONS:
4. The hospital shall ensure that experienced radiology
				technicians are immediately available in the hospital with professional
				interpretation available 24 hours a day. Ultrasound capability shall be
				available 24 hours a day with additional ultrasound availability on the OB
				floor and staff knowledgeable in its interpretation.
RECOMMENDATIONS:
5. The hospital shall provide blood bank technicians
				immediately available in the hospital for blood banking procedures and
				identification of irregular antibodies. Blood components shall be readily
				available.
RECOMMENDATIONS:
6. The hospital shall ensure that personnel skilled in
				phlebotomy and IV placement in newborns are available 24 hours a day.
RECOMMENDATIONS:
Level III Standards
1. The Level III hospital shall provide documentation of a
				policy requiring health care professionals, in both obstetrics and pediatrics,
				to obtain consultation from or transfer of care to the maternal-fetal medicine
				or neonatology sub-specialists as outlined in the standards for Level
				II.
RECOMMENDATIONS:
2. The Level III hospital shall accept all medically eligible
				Illinois residents. Medical eligibility is to be determined by the obstetrical
				or neonatal director or his/her designee based on the Criteria for High-Risk
				Identification (Guidelines for Perinatal Care, American Academy of Pediatrics
				and American College of Obstetricians and Gynecologists).
RECOMMENDATIONS:
3. The Level III hospital shall provide or facilitate emergency
				transportation of patients referred to the hospital in accordance with
				guidelines for inter-hospital care of the perinatal patient (Guidelines for
				Perinatal Care, American Academy of Pediatrics and American College of
				Obstetricians and Gynecologists). If the Level III hospital is unable to accept
				the patient referred, the Administrative Perinatal Center shall arrange for
				placement at another Level III hospital or appropriate Level II or Level II
				hospital with Extended Neonatal Capabilities.
RECOMMENDATIONS:
4. The Level III hospital that elects not to provide all of the
				advanced level services shall have established policies and procedures for
				transfer of these mothers and infants to a hospital that can provide the
				service needed as outlined in the letter of agreement.
RECOMMENDATIONS:
5. The Level III hospital shall have a clearly identifiable
				telephone number, facsimile number and/or other electronic communication,
				either a special number or a specific extension answered by unit personnel, for
				receiving consultation requests and requests for admissions. This number shall
				be kept current with the Department and with the Regional Perinatal
				Network.
RECOMMENDATIONS:
6. The Level III hospital shall provide and document continuing
				education for medical, nursing, respiratory therapy, and other staff providing
				general, intermediate and intensive care perinatal services.
RECOMMENDATIONS:
7. The Level III hospital shall provide caesarean section
				decision-to-incision within 30 minutes.
RECOMMENDATIONS:
8. The hospital shall provide data relating to activities and
				shall comply with the requirements of the State Perinatal Reporting
				System.
RECOMMENDATIONS:
9. The medical co-directors of the Level III hospital shall be
				responsible for developing a system ensuring adequate physician-to-physician
				communication. Communication with referring physicians of patients admitted
				shall be sufficient to report patient progress before and at the time of
				discharge.
RECOMMENDATIONS:
10. The hospital shall provide documentation of the capability
				for continuous electronic maternal-fetal monitoring for patients identified at
				risk with staff available 24 hours a day, including physicians and nursing, who
				are knowledgeable of electronic fetal monitoring use and interpretation. Staff
				shall complete a competence assessment in electronic maternal-fetal monitoring
				every two years.
RECOMMENDATIONS:
11. The Level III hospital, in collaboration with the
				Administrative Perinatal Center, shall establish policies and procedures for
				the return transfer of high-risk mothers and infants to the referring hospital
				when they no longer require the specialized care and services of the Level III
				hospital.
RECOMMENDATIONS:
12. The Level III hospital shall provide suitable backup
				systems and planning to prevent and respond to a sudden power outage, oxygen
				system failure, and interruption of medical grade compressed air
				delivery.
RECOMMENDATIONS:
13. The Level III hospital shall provide or develop a referral
				agreement with a follow-up clinic to provide neuro-developmental services for
				the neonatal population. Hospital policies and procedures shall describe the
				at-risk population and the referral procedure to be followed for enrolling the
				infant in developmental follow-up. Infants shall be scheduled for assessments
				at regular intervals. Neuro-developmental assessments shall be communicated to
				the primary physicians. Referrals shall be made for interventional care in
				order to minimize neurological sequelae. A system shall be established to
				track, record and report neuro-developmental outcome data for the population,
				as required to support network CQI activities.
RECOMMENDATIONS:
14. Neonatal surgical services shall be available 24 hours a
				day.
RECOMMENDATIONS:
Level III Resource Requirements
1. The Level III hospital shall provide documentation that
				obstetrical activities shall be directed and supervised by a full-time
				subspecialty obstetrician certified by the American Board of Obstetrics and
				Gynecology in the subspecialty of maternal-fetal medicine or a licensed
				osteopathic physician with equivalent training and experience and certification
				by the American Osteopathic Board of Obstetricians and Gynecologists. The
				director of obstetric services shall ensure the back-up supervision of his or
				her services by a physician with equivalent credentials.
RECOMMENDATIONS:
2. The Level III hospital shall provide documentation that
				neonatal activities shall be directed and supervised by a full-time
				pediatrician certified by the American Board of Pediatrics Sub-Board of
				Neonatal/Perinatal Medicine or a licensed osteopathic physician with equivalent
				training and experience and certification by the American Osteopathic Board of
				Pediatricians/Neonatal-Perinatal Medicine. The director shall ensure the
				back-up supervision of his or her services by a physician with equivalent
				credentials.
RECOMMENDATIONS:
3. The Level III hospital shall provide documentation that an
				administrator/manager with a master's degree shall direct, in collaboration
				with the medical directors, the planning, development and operation of the
				non-medical aspects of the Level III hospital and its programs and
				services.
RECOMMENDATIONS:
4. The Level III hospital shall provide documentation that the
				obstetric and newborn nursing services are directed by a full-time nurse
				experienced in perinatal nursing with a master's degree.
RECOMMENDATIONS:
5. The Level III hospital shall provide documentation that half
				of all neonatal intensive care direct nursing care hours are provided by
				registered nurses who have had two years or more nursing experience in a Level
				III NICU. All NICU direct nursing care hours shall be provided or supervised by
				licensed registered nurses who have advanced neonatal intensive care training
				and documented competence in neonatal pathophysiology and care technologies
				used in the NICU. All nursing staff working in the NICU shall have yearly
				competence assessment in neonatal intensive care nursing.
RECOMMENDATIONS:
6. The Level III hospital shall provide documentation that
				obstetrical anesthesia services, under the supervision of a board-certified
				anesthesiologist with training in maternal, fetal and neonatal anesthesia, are
				available 24 hours a day. The director of obstetric anesthesia shall ensure the
				back-up supervision of his or her services when he or she is
				unavailable.
RECOMMENDATIONS:
7. The Level III hospital shall provide documentation that
				pediatric-neonatal respiratory therapy services are directed by a full time
				licensed respiratory care practitioner with a bachelor's degree.
RECOMMENDATIONS:
8. The Level III hospital shall provide documentation that the
				respiratory care practitioner responsible for the NICU has at least three years
				of experience in all aspects of pediatric and neonatal respiratory care at a
				Level III Neonatal Intensive Care Unit and completion of the
				neonatal/pediatrics specialty examination of the National Board for Respiratory
				Care.
RECOMMENDATIONS:
9. The Level III hospital shall provide documentation that
				respiratory care practitioners with experience in neonatal ventilatory care
				staff the NICU according to the respiratory care requirements of the patient
				population, with a minimum of one dedicated neonatal licensed respiratory care
				practitioner for newborns on assisted ventilation, and with additional staff
				provided as necessary to perform other neonatal respiratory care
				procedures.
RECOMMENDATIONS:
10. The Level III hospital shall provide documentation that a
				physician for the program assumes primary responsibility for initiating,
				supervising and reviewing the plan for management of distressed infants in the
				delivery room. Hospital policies and procedures shall assign responsibility for
				identification and resuscitation of distressed neonates to individuals who are
				both specifically trained and immediately available in the hospital at all
				times. Capability to provide neonatal resuscitation in the delivery room may be
				satisfied by current completion of a neonatal resuscitation program by medical,
				nursing and respiratory care staff or a rapid response team.
RECOMMENDATIONS:
11. The Level III hospital shall provide documentation that a
				board-certified or active candidate obstetrician is present and available in
				the hospital 24 hours a day. Maternal-fetal medicine consultation shall be
				available 24 hours a day.
RECOMMENDATIONS:
12. The Level III hospital shall provide documentation that a
				board-certified neonatologist, active candidate neonatologist or a pediatrician
				receiving postgraduate training in a neonatal-perinatal medicine fellowship
				program accredited by the Accreditation Council of Graduate Medical Education
				is present and available in the hospital 24 hours a day to provide care for
				newborns in the NICU.
RECOMMENDATIONS:
13. The Level III hospital shall provide documentation that
				neonatal surgical services are supervised by a board-certified surgeon or
				active candidate in pediatric surgery appropriate for the procedures performed
				at the Level III hospital.
RECOMMENDATIONS:
14. The Level III hospital shall provide documentation that
				neonatal surgical anesthesia services under the direct supervision of a
				board-certified anesthesiologist with extensive training or experience in
				pediatric anesthesiology are available 24 hours a day.
RECOMMENDATIONS:
15. The Level III hospital shall provide documentation that
				neonatal neurology services, under the direct supervision of a board-certified
				or active candidate pediatric neurologist, are available for consultation in
				the NICU 24 hours a day.
RECOMMENDATIONS:
16. The Level III hospital shall provide documentation that
				neonatal radiology services, under the direct supervision of a board-certified
				radiologist with extensive training or experience in neonatal radiographic and
				ultrasound interpretation, are available 24 hours a day.
RECOMMENDATIONS:
17. The Level III hospital shall provide documentation that
				neonatal cardiology services, under the direct supervision of an active
				candidate pediatrician or a pediatrician board- certified by the American Board
				of Pediatrics Sub-Board of Pediatric Cardiology, are available for consultation
				24 hours a day. In addition, cardiac ultrasound services and pediatric cardiac
				catherization services by staff with specific training and experience shall be
				available 24 hours a day.
RECOMMENDATIONS:
18. The Level III hospital shall provide documentation that a
				board-certified or active candidate ophthalmologist with experience in the
				diagnosis and treatment of the visual problems of high-risk newborns
				(retinopathy of prematurity) is available for appropriate examinations,
				treatment and follow-up care of high-risk newborns.
RECOMMENDATIONS:
19. The Level III hospital shall provide documentation that
				pediatric sub-specialists with specific training and extensive experience or
				subspecialty board certification or active candidacy (when applicable) are
				available 24 hours a day, including, but not limited to, pediatric urology,
				pediatric otolaryngology, neurosurgery, pediatric cardiothoracic surgery and
				pediatric orthopedics appropriate for the procedures performed at the Level III
				hospital.
RECOMMENDATIONS:
20. The Level III hospital shall provide documentation that
				genetic counseling services are available for inpatients and outpatients, and
				the hospital shall provide for genetic laboratory testing, including, but not
				limited to, chromosomal analysis and banding, fluorescence in situ
				hybridization (FISH), and selected allele detection.
RECOMMENDATIONS:
21. The Level III hospital shall designate at least one person
				to coordinate the community nursing follow-up referral process, to direct
				discharge planning, to make home care arrangements, to track discharged
				patients, and to ensure appropriate enrollment in a developmental follow-up
				program. The community nursing referral process shall consist of notifying the
				follow-up nurse in whose jurisdiction the patient resides of discharge
				information on all patients. The Illinois Department of Human Services will
				identify and update referral resources for the area served by the unit.
RECOMMENDATIONS:
22. The Level III hospital shall establish a protocol that
				defines educational criteria necessary for commonly required home care
				modalities, including, but not limited to, continuous oxygen therapy,
				electronic cardio-respiratory monitoring, technologically assisted feeding and
				intravenous therapy.
RECOMMENDATIONS:
23. The Level III hospital shall provide documentation that one
				or more full-time licensed medical social workers with perinatal/neonatal
				experience are dedicated to the Level III hospital.
RECOMMENDATIONS:
24. The Level III hospital shall provide documentation that one
				registered pharmacist with experience in perinatal pharmacology is available
				for consultation on therapeutic pharmacology issues 24 hours a day.
RECOMMENDATIONS:
25. The Level III hospital shall provide documentation that one
				dietitian with experience in perinatal nutrition is available to plan diets and
				education to meet the special needs of high-risk mothers and neonates in both
				inpatient and outpatient settings.
RECOMMENDATIONS: