Ill. Admin. Code tit. 77, pt. 640, app O
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.
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2. The hospital shall provide documentation of health care provider participation in Joint Morbidity & Mortality Reviews.
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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.
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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.
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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.
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6. The hospital shall ensure that personnel skilled in phlebotomy and IV placement in newborns are available 24 hours a day.
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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.
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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).
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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.
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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.
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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.
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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.
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7. The Level III hospital shall provide caesarean section decision-to-incision within 30 minutes.
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8. The hospital shall provide data relating to activities and shall comply with the requirements of the State Perinatal Reporting System.
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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.
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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.
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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.
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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.
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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.
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14. Neonatal surgical services shall be available 24 hours a day.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Ill. Admin. Code tit. 77, pt. 640, app O