M Level II Resource Checklist

Section 640.APPENDIX M   Level II Resource Checklist Level II Resource Checklist Briefly describe institutional compliance: The Level II hospital shall provide all of the services outlined for Level I general care. 1.         The hospital shall provide continuing education for medical, nursing, respiratory therapy and other staff who provide general perinatal services, with evidence of a yearly competence assessment appropriate to the population served. RECOMMENDATIONS: 2.         The hospital shall provide documentation of participation in Continuous Quality Improvement (CQI) implemented by the Administrative Perinatal Center. RECOMMENDATIONS: 3.         The hospital shall provide documentation of the health care provider’s risk assessment and consultation with a maternal-fetal medicine sub-specialist or neonatologist as specified in the letter of agreement  and hospital’s policies and procedures, and transfer to the appropriate level of care. RECOMMENDATIONS: 4.         The hospital shall provide documentation of the availability of trained personnel and facilities to provide competent emergency obstetric and newborn care. RECOMMENDATIONS: 5.         The hospital shall maintain a system of recording admissions, discharges, birth weight, outcome, complications and transports to meet the requirement to support CQI activities described in the hospital’s letter of agreement with the Administrative Perinatal Center.  The hospital shall comply with the reporting requirements of the State Perinatal Reporting System. RECOMMENDATIONS: 6.         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: 7.         The hospital shall have the capability of performing caesarean sections within 30 minutes of decision to incision. RECOMMENDATIONS: 8.         The hospital shall have experienced blood bank technicians immediately available in the hospital for blood banking procedures and identification of irregular antibodies. Blood component therapy shall be readily available. RECOMMENDATIONS: 9.         The hospital shall have general anesthesia services on call and available under 30 minutes to initiate C-section. RECOMMENDATIONS: 10.       The hospital shall have experienced radiology technicians immediately available in the hospital with professional interpretation available 24 hours a day. Ultrasound capability shall be available 24 hours a day.  In addition, Level I ultrasound and staff knowledgeable in its use and interpretation shall be available 24 hours a day. RECOMMENDATIONS: 11.       The hospital shall have the following clinical laboratory resources available: Micro-techniques 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 1 hour; and capabilities for bacterial culture and sensitivity and viral culture. RECOMMENDATIONS: 12.       The hospital shall designate a physician to assume primary responsibility for initiating, supervising and reviewing the plan for management of distressed infants.  Policies and procedures shall assign responsibility for the identification and resuscitation of distressed neonates to individuals who have successfully completed a neonatal resuscitation program and are both specifically trained and immediately available in the hospital at all times. RECOMMENDATIONS: 13.       The hospital shall ensure that personnel skilled in phlebotomy and IV placement in newborns are available 24 hours a day. RECOMMENDATIONS: 14.       Social worker services shall be provided by one social worker, with relevant experience and responsibility for perinatal patients, and available through the hospital social work department. RECOMMENDATIONS: 15.       The hospital shall ensure that protocols for discharge planning, routine follow-up care, and developmental follow-up are established. RECOMMENDATIONS: 16.       The hospital shall ensure that a licensed respiratory care practitioner with experience in neonatal care is available 24 hours a day. RECOMMENDATIONS: 17.       The hospital shall ensure that a dietitian with experience in perinatal nutrition is available to plan diets to meet the needs of mothers and infants. RECOMMENDATIONS: 18.       The hospital shall ensure that staff physicians and consultants are aware of standards and guidelines in the letter of agreement. RECOMMENDATIONS: 19.       The hospital shall provide documentation of health care provider participation in Joint Mortality and Morbidity reviews.