La. Admin. Code tit. 48 § I-11505
Current through Register Vol. 50, No. 9, September 20, 2024
Section I-11505 - General Acute Care Hospital BedsA. General Information, Criteria and Standards1. Description a. General acute care hospital beds are those short-term acute care beds available for the overnight care of patients hospitalized for any of a variety of medical reasons.b. In Louisiana, general acute care hospital beds include but are not limited to: medical/surgical, obstetrics, pediatrics, intensive care/ coronary care, neonatal intensive care, pediatric intensive care, chemical dependency, hospital-based, Medicare certified skilled nursing beds and "swing" beds. All such types of hospital beds are included in the total bed complement of a hospital.2. Hospital Bed Need a. Determining how many general acute care hospital beds an area's population needs for proper health care is an important health planning function. An appropriate number of available beds, distributed equitably over the population, assures that the inpatient health care needs of the residents are met. Too many beds can mean higher costs and inefficient use of health care resources. Empty beds may inflate overall costs and encourage overutilization. Too few beds can mean waiting lists for admissions, reduced quality of care and unmet health care needs.b. Surpluses of general hospital beds are believed by many to contribute significantly to rising hospital care costs as the result of a decision-making process which is predicated on a distorted reimbursement mechanism. The rapid growth during the 1960's and 1970's of health insurance plans and of the federally-financed Medicare and Medicaid programs has created a health care system in which normal adverse market consequences of oversupply are felt primarily by third party payors rather than the hospitals themselves.c. In addition, reimbursement by third party payors makes patients, physicians and other health care practitioners less aware of the cost of treatment and thus removes the economic deterrents to excess use of hospital facilities. Another factor to consider is the benefit structure of most health insurance plans, which provides substantial coverage for hospitalization, while allowing minimal coverage for the cost of outpatient health care and often no coverage for preventive health care. Patients and their treating physicians may opt for hospitalization in lieu of outpatient treatment to assure that costs of diagnostic tests and minor surgical procedures are reimbursable by third party payors.3. Impact of Ruralness on Bed Need a. Small hospitals in rural areas where the patient population cannot support a large facility meet many of the health care needs of patients in the surrounding area. Rural hospitals offer emergency services and inpatient care for a variety of health conditions. However, more complicated health conditions and those requiring special treatments and diagnostic examinations are best treated in larger facilities where the patient population can support high technology equipment and highly specialized health care staff.b. Accessibility to health care services is a primary concern in planning and providing for the health care needs of sparsely populated areas of the state. Accessibility as related to general hospitals means that the majority of an area's residents are not more than 30 minutes travel time from a general hospital facility. Ensuring general hospital accessibility means that the hospital service need of an area's rural population may often best be met by the distribution of hospital beds over several small facilities rather than in one single larger facility.4. Service Area. The service area for all general acute care hospital beds is the health planning district in which the facility or proposed facility is or will be located.5. Resource Goals a. Bed Supply: 4.0 beds/1,000 population in Health Planning Districts one through six, and nine; 4.26/1,000 population in Health Planning Districts seven and eight. i. In determining the bed to population ratio for a proposal, Division of Policy, Planning and Evaluation will use population projections for the anticipated opening date (year) of the facility, which in no case shall exceed five years subsequent to the year in which the application is declared complete.ii. In Louisiana, the 65 + population is 9.6 percent of the overall population(1980 census figures). The only planning districts where the percentage of persons over 65 exceeds 9.9 percent are Planning Districts 7 and 8. There is, therefore, no adjustment to be made to the bed supply goal except in Planning Districts 7 and 8, where persons 65 + represent 11.8 percent of the population.iii. In the absence of state data, the national utilization rate of 34 percent (percentage of patient days utilized by persons age 65 +) is applied to the North Louisiana population age 65 + to determine the number of beds over 4.0 needed in that area to accommodate the disproportionately large population age 65 + . The North Louisiana population has 1.9 percent more persons age 65 + than the national average, so the national 1.36 65 + bed supply use rate is increased proportionately to 1.62 beds. This represents a .26 increase in the bed supply goal due to an increased number of persons age 65 + . The adjusted bed supply goal in North Louisiana (Planning District 7 & 8) is 4.26 beds per 1,000.iv. The bed supply standards stated above will be used to determine the need for all general acute care hospital beds, including but not limited to medical/surgical, obstetrics, pediatric, pediatric intensive care, neonatal intensive care and intensive care/coronary care beds. Medicare certified and Section 1122 approved rehabilitation and psychiatric hospital beds are not counted in determining the number of general acute care hospital beds. In determining bed supply, beds which are counted are (1) licensed but not Section 1122 approved beds which are in use or could be put into use within 24 hours*, (2) 1122 approved and licensed beds which are in use or could be put into use within 24 hours and (3) 1122 approved beds which are not yet licensed.v. Licensed hospital beds which are Medicare certified as skilled nursing beds are considered available for long term patients and not available for general acute care patients; therefore, such beds are not counted in determining the number of general acute care hospital beds and shall not be considered for the purposes of determining hospital occupancy.b. Occupancy Rate: General acute care hospitals shall maintain annual occupancy rates relative to the number of beds in the facility: 0- 49-50%
50- 99-60%
100-199-70%
200 + -75%
i. In determining occupancy rates, beds used in the calculations include: (1) licensed but not Section 1122 approved beds which are in use or could be put into use within 24 hours*, and (2) 1122 approved and licensed beds which are in use or could be put into use within 24 hours*. This calculation shall not include general acute care hospital beds which are Medicare certified as skilled nursing beds.ii. *Beds that can be brought into service within 24 hours shall be construed to mean the appropriate number of beds in rooms originally constructed and equipped as hospital rooms that either (1) have not been converted to other uses, or (2) retain all essential nonmovable equipment and connections necessary for patient care in accordance with licensing standards. Nonmovable equipment shall include equipment which can be removed only through reconstruction or rennovation.iii. For any additional general acute care hospital beds to be approved: (a). the bed to population ratio shall not exceed 4.0 or 4.26 beds per 1000 population (4.26/1000 for Health Planning District 7 and 8);(b). either optimal occupancy must be reached by all hospitals in all bed size categories or a 75 percent occupancy for the four most recent quarters of all hospitals in the health planning district must be attained.c. Adjustment i. An existing general acute care hospital which has operated at a level of 10 percent or more above its optimal occupancy, as determined by bed size category, for the four most recent quarters will be allowed to add a number of beds that would bring its occupancy down to the optimal occupancy level for its bed size. The occupancy rate for the 12 consecutive months shall be determined by Division of Policy, Planning and Evaluation from the four most recent quarters of data due to have been reported by the hospital to the Division of Licensing and Certification. B. Obstetrical Services 1. Description a. Institutional obstetrical services are those health-related services provided to pregnant women in specialized OB units in acute care hospitals. Services primarily involve health care during labor, delivery and post partum recovery; care and treatment of a medical condition (in a pregnant patient), related to or complicated by pregnancy; and special care rendered to the fetus during the prenatal period, during and immediately following labor and delivery. Institutional obstetrical services can also include health education and genetic counseling before and during the prenatal period, and performance of outpatient diagnostic examinations which may be necessary during the course of a pregnancy. Services rendered to newborns at delivery are a part of obstetrical unit services, although newborn nursery care, intermediate and intensive care services are considered neonatal services.b. Facilities providing obstetrical services can be categorized into three types according to the level of technology and the spectrum of services offered. The existence of neonatal nursery services at a level commensurate with the level and quantity of obstetrical services offered is essential to the continuity and overall quality of obstetrical services. i. Level I-A unit within a hospital designed to provide services for the uncomplicated maternity patient.ii. Level II-A unit within a hospital designed to provide a full range of maternal services for uncomplicated patients and the majority of complicated obstetrical problems.iii. Level III-A unit within a hospital designated to provide the full range of resources and expertise required for the management of any complication of pregnancy.c. Obstetrical units consist of postpartum beds, labor beds, recovery beds and delivery rooms, for both normal and cesarean deliveries.2. Location of OB Services a. Obstetrical beds in hospitals are often part of a unit providing a combination of obstetrical and gynecological services (OB/GYN services). If occupancy levels in the unit rise above a specified optimum level, elective gynecological admissions may be postponed or GYN patients may be transferred to available general medical and surgical beds. Utilization of obstetrical beds in frequently not as efficient as it could be because of the randomness of birth, the number of unscheduled deliveries, fluctuations in length of OB stays and the need to maintain OB beds in facilities that are reasonably accessible to residents of sparsely populated geographic areas. Mixing obstetric and gynecology patients is a primary method of improving bed utilization within an obstetric unit. Other methods include construction of "swing" units, which can be partitioned as part of either OB/ GYN or medical/surgical units as the demand requires, and regional sharing of obstetrical facilities.3. Regionalization of Services a. Regional planning is an important factor in the location of obstetrical units and is an essential element in evaluating the feasibility of existing and proposed OB units. In determining the need for OB services in a health planning district, critical factors include the population base and the requirements for prenatal and perinatal services that the population base will generate. In planning for these needs, optimal deployment of scarce resources (such as money and personnel) must be a goal secondary only to an acceptable quality of obstetrical services.b. An optimum occupancy level is conducive to high quality, efficiency and economy in hospital obstetrical care. The Perinatal Commission, because of the high risk nature of Louisiana's perinatal patients, recommends that a Level III regional Perinatal Center should serve an area with 6,000 to 10,000 births annually. A Level III regional OB and Perinatal Center with an annual rate of 6,000-10,000 live births can justify high technology equipment, better staffing and a more effective inservice program. As a result of these advantages, personnel in large obstetrical departments can maintain a higher level of proficiency in their duties, and the cost of highly specialized services may be spread over a larger population. The population base and the economic base must be adequate to support the large investment required for operation of a Level III regional facility.c. Since the numbers of perinatal patients who are gravely ill or at extremely high risk are not large, most complication is of pregnancies and abnormalities of the newborn can be properly managed in units staffed and equipped to provide moderately complex care.d. A concern in the regional approach to obstetrical care is the function of hospitals with small numbers of deliveries (Level I OB beds). In many instances, such hospitals must provide obstetrical services because of geographic, climatic and transportation factors which prevent patients from having access to fully staffed and equipped obstetrical facilties. An approach is to encourage the consolidation of multiple small obstetrical units into a larger service whenever such action is not impeded by geographic or other insurmountable problems. Another approach is to encourage Level I units to refer or transfer high risk obstetrical patients to Level II and III facilities.e. Regional planning is critical for obstetrical services. Institutions offering OB care should develop and maintain a network of communication and coordinate service delivery and facility planning. All obstetrical units should have linkages with intermediate and intensive care (Level II and III) neonatal units to assure that transportation and beds are available to infants who are in need of immediate transfer to neonatal special care units. However, maternal transport is encouraged in preference to neonatal transport when high risk situations can be predicted (approximately 50 percent of the time). The Guidelines for Perinatal Transportation, prepared by the Sub-Committee on Perinatal Transportation of the Louisiana Perinatal Commission, address specific procedures, staffing patterns, and equipment for the transportation of high risk mothers and neonates.f. Obstetrical units should also maintain communication with other obstetrical units in the health planning district so that resources, equipment and staff can best be utilized to meet the obstetrical care needs of the population. This is particularly necessary for appropriate referral, antenatal diagnosis and monitoring, counseling, scheduling of delivery, specialist attendance and monitoring of OB patients who are identified as having one or more antepartum high risk factors for perinatal and/or maternal mortality and morbidity.4. Costs and Length of Staya. One of the current issues related to institutional obstetrical services is cost containment. Costs of basic obstetrical services are increased by the length of the patient's stay and the number and type of special diagnostic examinations and medical procedures which may be required because of complications arising from the pregnancy and delivery. According to the Perinatal Commission, several studies have shown that cost of basic obstetrical services are increased with the level of care regardless of the needs of the patient. This factor is important since it is among patients with an essentially uncomplicated delivery where a reduction in the length of stay is most possible.b. Length of hospitalization for maternity patients (and other types of admissions) has been reduced substantially from the lengthy hospital stays of 50 years ago, when maternity patients were often "confined" in a hospital as long as two weeks after delivery. The reduced stays are in part due to the development of a theory that getting out of bed earlier helps recovery, and in part due to other changes in social and medical concepts concerning pregnancy and the post partum period.c. Since the mid 1970's there have been numerous projects begun at hospitals across the nation to encourage OB patients with normal deliveries to leave the hospital soon after birth. Maternity day care units, providing a home-like environment, with husbands allowed to stay during labor and delivery, and with discharge within 24 hours of delivery, have been established partly in response to the women's movement and partly to reduce hospital costs.d. The Perinatal Commission does not recommend early discharge (less than 24 hours after delivery) for uncomplicated deliveries unless provisions are made for appropriate follow-up of the mother and neonate on an out-patient basis. At the present time the public health nursing system in the state is not adequate to meet the needs of a follow-up system for non-private patients.e. It has been noted that patients choosing maternity day care services have primarily been those without insurance coverage, who personally feel the financial impact of longer hospital stays. Because the motivation for shorter OB stays seems to be predominantly financial, a number of programs exist in which rebates and other benefits are offered by insurance companies to women who leave the hospital within 24 hours of an uncomplicated delivery.f. Among the alternatives to traditional hospital deliveries are deliveries by certified nurse-midwives at alternative birthing centers or at home. The Perinatal Commission is vigorously opposed to home deliveries and also recommends that alternative birthing centers should come under the same vigorous standards and guidelines as hospital based obstetrical units.g. According to the Perinatal Commission, the combination of private and charity beds into one overall plan is a desired goal, but is not realistic in present day Louisiana. Any plan for Perinatal Care in Louisiana must take full recognition that the charity and private systems operate separately, and that patients do not easily cross over This is especially true for charity patients in need of more intensive care who cannot find access (financial or physicial) into the private system that may have high technology beds available. As the charity system becomes more deluged by perinatal patients seeking services, the number of patients requiring high technological obstetrical and/or neonatal care will increase. The charity system cannot now adequately handle these high risk situations and private hospitals are reluctant to participate because of inadequate reimbursement. An improved reimbursement strategy will be necessary to allow patients to more easily cross over from the charity to private systems in order to meet the medical needs of this population.5. Resource Goals a. Note: Proposals for obstetrical services that include an increase in general acute care hospital beds must meet the resource goals for both obstetrical services (1-12 below) and general acute hospital beds. Proposals for obstetrical services that do not include an increase in general acute care hospital beds must meet the resource goals for obstetrical services (2-12) below).b. Obstetrical beds are considered general acute care hospital beds; therefore, the need for such beds is determined in accordance with the standards for general acute care hospital beds.c. The Level I Unit must be able to provide emergency medical services competently. There must be a well-defined, efficient regional system of communication, consultation, and transport between the Level I Unit and other levels of care.d. Level II units shall provide a full range of maternal services for uncomplicated patients and the majority of complicated obstetrical problems.e. A Level II Obstetrical Service must be located in the same facility as a Level II or Level III Neonatal Unit.f. Level III units must be able to provide the full range of resources and expertise required for the management of any complication of pregnancy. The Level III Obstetrical Unit should serve an area with approximately 6,000-10,000 deliveries per year. The unit should provide care for normal patients, preferably with an obstetrical base of greater than 1,500 inborn deliveries annually. The Level III Unit must be equipped to manage all types of maternal-fetal illnesses. They must be able to provide a full range of resources 365 days a year for the management of complicated perinatal conditions. This includes personnel and facility resources available continously in the medical, nursing, and ancillary health areas. The Level III Obstetrical Unit should be physically contiguous to the Level III Neonatal Unit.g. In areas where two or more Level I units exist in close proximity, attention should be given to consolidation of obstetric services.h. The average annual length of stay should not exceed current acceptable obstetrical practices.i. Obstetrical services should be planned on a regional basis with linkages among obstetrical services and neonatal services. New obstetrical services should be located a distance of at least 30 miles from the nearest obstetrical unit.j. All obstetrical units should have procedures for obtaining and effecting consultation and patient transfers between Level I, II and III units. Obstetrical facilities should have arrangements for referrals to services offered by physicians, acute care facilities, social service agencies, community mental health centers, public health and welfare agencies, and providers of home health care.k. Hospital OB units should have a minimum of two delivery rooms. The ratio of delivery rooms to deliveries should be one for every 1,000 births. Every obstetrical unit performing deliveries should have the ability to perform cesarean sections in an appropriately equipped delivery room or surgical suite. One labor bed should be provided for each 250-350 deliveries performed annually.l. Obstetrical services should be available to all residents in need of such services regardless of their ability to pay. m. Level I, II, and III units should meet standards and guidelines for licensure developed by the Perinatal Commission. C. Pediatric Beds 1. Definition/Description a. Inpatient pediatric services are distinguished and treated separately from general or adult inpatient services because of the special needs of children to age 21.b. Changes have occurred in the delivery of pediatric services as diagnosis and treatment of diseases have become more sophisticated. Advances in biomedical research and the behavioral sciences have enabled pediatricians to deal with more diseases in a more precise manner in their own offices, or on an outpatient basis, rather than to hospitalize children. As a result of this trend, and of the generally declining birth rate, children have proportionately fewer hospitalizations and shorter hospital stays than adults. Infants spend more time in the hospital than older children, and children in low income families are more likely to be hospitalized than children in middle and high income families.2. Related Issues a. Inpatient services should be organized and coordinated with other services within the same facility, and should be appropriately linked with other facilities in terms of working relationships, shared services, and agreements. Internal and external coordination are essential for the delivery of high quality, cost effective pediatric inpatient care. Note all hospitals can or should provide all services to all children; each community and hospital must evaluate the extent of pediatric inpatient services needed, and he capability for providing the services.b. Regionalization, in its broadest sense, implies the development within a geographical area of a coordinated, cooperative system of health care which promotes efficiently, avoids unnecessary duplication, improves access to health care, achieves greater equity, enhances quality, and responds to consumer needs. The concentration in regional centers of pediatric inpatient services (including complex and expensive equipment and facilities and highly skilled personnel) would assure that children have access to needed services.c. Unnecessary duplication of services should be avoided; however, because children have different hospital needs than adults, services which appear to be similar and duplicative to adult services may be necessary to provide optimal care for hospitalized infants and children. The proper care of a hospitalized child cannot be given simply by adopting adult inpatient philosophy, programs, or standards. The National Guidelines for Health Planning, published by DHEW, recognize that two main differences exist: the need for hospitalized children to remain close to home, and the need for regulations providing different occupancy rates.3. Resource Goals a. Note: Proposals for pediatric services that include an increase in general acute care beds must meet resource goals for both pediatric services (1-3 below) and general acute care hospital beds. Proposals for pediatrics services that do not include an increase in general acute hospital beds must meet the resource goal for pediatric services. (2-3 below).b. Pediatric beds are considered general acute care hospital beds; therefore, the need for such beds shall be determined in accordance with the standards for general acute care hospital beds.c. Pediatric units in urban areas should maintain a minimum of 20 beds.d. Pediatric units should be accessible. New pediatric services should be located a distance of at least 30 miles from the nearest facility providing pediatric beds/services. D. Pediatric Intensive Care Units 1. Resource Goals a. Bed supply: Pediatric intensive care unit beds are considered general acute care hospital beds and the need for such beds is determined in accordance with the standards for general acute care hospital beds. E. Neonatal Intensive Care Unit (NICU) Beds 1. Commission on Perinatal Care a. The Commission on Perinatal Care was established by an act of the legislature of the state of Louisiana in 1978 in Section 2018, title 40 of the Louisiana Revised Statutes of 1950. This act established the Commission on Perinatal Care within the Bureau of Personal Health Services, the Office of Preventive and Public Health Services of the Department of Health and Human Resources, and charged the Commission with certain functions, duties and services which include but are not limited to: i. Development of a plan for upgrading perinatal are of Louisiana.ii. Development of criteria for the classification of Level I, II and III centers and development of licensing standards for state-wide certification of obstetrical and neonatal units.iii. Investigation, review, and study of all maternal deaths occurring within the State for the purpose of reducing the risk and incidence thereof.b. In the past six years, the commission has accomplished these goals and developed a state-wide plan as well as criteria for classification of Level I, II, and III centers. The Perinatal Commission is composed of practicing physician representatives from all parts of the state, representatives of the medical schools, major health societies and gubernatorial appointees. The expertise of the commission members, the written perinatal plan for the state of Louisiana, and the neonatal and obstetrical guidelines were used as resources in the State Health Plan.c. Over the past six years, the Commission on Perinatal Care has reviewed Louisiana's statistics on perinatal health with statistics of previous years and with national statistics. The commission has viewed the problems of increased perinatal morbidity and mortality in our state as both a social as well as a medical problem. The commission, after due consideration, decided that the national guidelines could not easily or correctly be applied to Louisiana because of the high rate of prematurity, increased numbers of non-whites births, the large number of hospitals delivering less than 1500 babies per year, and other logistic and social problems that are unique to our state. Moreover, the Commission has been extremely aware of the dual nature of the medical system in our state, with the charity and private hospital systems working in isolation rather than in cooperation. This is especially evident in the perinatal health field.d. One theme consistently reiterated by the Perinatal Commission has been the voluntary aspect of regionalization of perinatal care. The commission believes that all hospitals should be encouraged to reach their highest level of care without regard for other need standards. The commission is also opposed to drawing lines georgraphically or requiring physicians to have certain referral patterns for high risk patients. The commission is opposed to any midwives other than Certified Nurse Midwives (CNM).e. The Perinatal Commission has worked on coordinating efforts for transport of high risk patients and communication among physicians caring for perinatal patients. A standard transport form is used by a large majority of hospitals in the state, thus standardizing and documentating medical problems of referred perinatal care patients. The commission recommends that patients be referred and moved to the most appropriate facility, allowing financial and physical access to the best medical care possible to meet the needs of the patient. The patient should not be denied access to care because of economic or transportation deficits.2. Louisiana Perinatal Foundation. The Louisiana Perinatal Foundation, a free-standing and completely independent foundation, serves as a source of funds for the advancement of quality perinatal care and a consequential improvement in the overall health of the people of Louisiana. The foundation is composed of concerned individuals and corporations who wish to assist in improving obstetrical and neonatal care. The main activity of the foundation is the support of educational and research owned and controlled by the community at large.3. Definitions a.Birth (live)-a birth that shows any sign of life after delivery.b.Birth Rate-the number of live births per 1,000 population.c.Infant Death-death of an infant under 365 days of age.d.Low Birth Weight-less than 2500 grams at birth.e.Low Birth Weight Percentage-the number of low birth weight births per 100 live births.f.Maternal Death-a death attributable to complications of pregnancy, childbirth or the peurperium.g.Neonate-an infant less than 28 days of age.h.Neonatal Death-death occurring to a child under 28 days of age.i.Perinatal-pertaining to or occurring in the period shortly before and after birth, generally considered to begin with completion of twenty-eight weeks of gestation and variously defended as ending one to four weeks after birth.j.Perinatal Care-preventive and curative, direct and indirect services offered to maternal and neonatal patients.4. Description a. Neonatal intensive care units provide highly specialized medical care to the small percentage of infants who are born with or develop serious health impairments during the first weeks of life. Respiratory distress and asphyxia are the two most common conditions indicating the need for transfer of a newborn to a NICU. Other conditions which might indicate the transfer of a newborn to a NICU would be prematurity, significant congenital malformation, genetic disorder, intrapartum complications or injuries, or other disease or illness.b. Neonatal intensive care consists primarily of higher sophisticated life-support systems, monitoring and intensive care techniques which compensate for the infants's lack of full or normal development. The most common technologies are respirators and positive pressure breathing devices for treatment of respiratory distress syndrome (RDS) which is responsible for nearly 20 percent of all neonatal deaths in the U.S. According to the Perinatal Commission, half of all neonatal deaths result from respiratory distress syndrome or its complications.c. The hospital facilities delivering neonatal care are classified into three groups, depending on the sophistication and scope of the services provided. These levels of care and the definition of each are in accordance with standards and guidelines for Neonatal Intensive Care Units developed by the Commission on Perinatal Care. i.Level I Newborn Unit-a unit within a hospital designed to provide services for the normal newborn infant.ii.Level II Neonatal Unit-a unit within a hospital designed to provide a full range of neonatal services for uncomplicated patients and certain types for neonatal illnesses except those requiring consultation and facilities not available at that level.iii.Level III Neonatal Unit-a specialized unit within a hospital specifically designed to provide a full range of health services to the high-risk neonate and which meets the guidelines established for the Level III unit with the exception of the transportation and out-reach education programs.d. Unfortunately, neonatal services in may hospitals do not reflect the three defined levels of care. Factors such as the rapid advancement of medical technology, the rising costs of medical equipment, and training requirements for medical personnel have led to a diversity of neonatal services provided at various hospitals in the same region. As a result, the services provided in different hospitals classified at the same level can vary considerably, making a standard level of care difficult to determine in practice. According to the Perinatal Commission, although the standard of care does vary in hospitals classified at the same level, through adherence to guidelines and extensive education, neonatal services in hospitals should reflect the designated level of care. The American Academy of Pediatrics states that there is "considerable diversity of opinion about the definition of Level II (Neonatal) units and the functions these units should perform." Morever, the American Academy of Pediatrics Committee on the Fetus and the Newborn considers it undesirable for Level II units to provide neonatal cardiology and certain surgical procedures (subspecialist). The committee's final observation was that "the continued development of Level II (neonatal) units in both urban and rural locations throughout the country is essential, particularly for hospitals in which more than 1,000 infants are born annually." Dr. Auld, a Neonatologist, suggests that all community hospitals should approach the standards of care required for Level II units.e. The increase in the overall birth rate in Louisiana since 1974 (from 17.5/1,000 in 1974 to 19.4/1,000 in 1980), caused mainly by a larger percentage of women of childbearing ages, has resulted in an increase in the number of ill newborns requiring special neonatal are. Continued increases in the overall number of births and in the number of newborns needing special care will expand the need for neonatal intensive care. It is extremely important to consider certain factors which have increased the Louisiana mortality rate, such as weight specific mortalities, almost 25 percent of births are to women who are not married, and a high percentage of birth are to teenage mothers. Not only does Louisiana have more infants born less than 2500 grams, but the state has more very low births weight infants, less than 1500 grams. If the number of infants in certain weight categories (i.e. 500-1,000 grams, 1,000-1,500 grams, etc.) are compared to other states, Louisiana's mortalities by weight specific groups are average for this country. The problem is that the state is higher than the national average of infants born in the low birth weight categories. Thus the goal in this area should be to decrease low birth weight infants by improving prenatal care and family planning.5. Regionalization of NICU's a. Health professionals nationwide and in Louisiana are in basic agreement that the best care can be given to critically ill newborns if NI-CU's are planned and developed on a regional basis, with a few adequately staffed and qualified units meeting the needs of the population of planning districts rather than a large number of units within many different hospitals. As affirmed by the American Academy of Pediatrics, properly conducted, early transfer of ill newborns to a qualified NICU results in better care than attempts to maintain them in inadequate units. This regionalized concept necessitates the development of level II and III units of sufficient size located in medical facilities which have available specialty staff. The availability of subspecialty consultative services and highly sophisticated equipment is necessary for Level III units.b. Regionalized planning also requires appropriate linkages between neonatal units and obstetrical services, with communication and transportation systems. The majority of transport in this state are done by ground and fixed wing. Approximately 75 percent of all transports are done by ground ambulance and 25 percent by air. Of the air transport, almost 90 percent is done by fixed wing and probably less than 10 percent by helicopter. There is a state-wide transport system operative among a number of private institutions, but the charity system does not have an organized transport system. The major factor in limiting access to existing neonatal intensive care units is not the lack of transportation but the lack of financial resources to move charity patients into private institutions and pay for these services.c. The Guidelines for Perinatal Transportation, prepared by the sub-committee on Perinatal Transportation of the Louisiana Perinatal Commission, provide specific guidelines regarding procedures, staffing patterns, and equipment for the transportation of high risk mothers and neonates.6. Costs of NICU Services a. The costs of neonatal intensive care are directly related to birthweight and prematurity-the lower the weight and/or the earlier the births, the higher the costs of care. The U.S. Congressional Office of Technology Assessment estimates that in 1978, the mean cost per patient in NICU (Level III) was $8,000 with an average length of stay of 13 days. It can be roughly estimated that for each dollar spent on neonatal intensive care over $4 is saved in future costs.b. Another issue related to the cost of neonatal intensive care is the number of NICU patients whose costs cannot be borne by the family because of insufficient resources and lack of health insurance coverage for the newborn. Over 50 percent of low birthweight infants in Louisiana are born to blacks, who have a lower income level and who experience a high rate of births to unmarried women. Another factor contributing to the overall tendency of ill newborns to be born into families with limited resources is the high incidence of low birthweight babies among females under age 20. In the U.S. in 1978, 66.5 percent of low birthweight babies were born to females under 20 years of age.c. The costs of caring for ill newborns, therefore, are often either left to be assumed by the hospital facilities and ultimately absorbed by other patients, or borne by state and federal taxpayers.d. In terms of terminating care for hopelessly ill newborns, the Baby Doe law in the state of Louisiana plays a more important role than ethical or economic considerations. This law allows for very little leeway in parent or physician intervention that would shorten the suffering of a hopelessly and terminally ill neonate. The Perinatal Commission has discussed the present Baby Doe law as it now exists, and is opposed to its present wording.7. Resource Goals a. Note: Proposals for neonatal intensive care services that include an increase in general acute care beds must meet resource goals for both neonatal intensive care services (1-9 below) and general acute care hospital beds. Proposals for neonatal intensive care services that do not include an increase in general acute hospital beds must meet the resource goals for neonatal intensive care services (2-below).b. Neonatal intensive care unit beds are considered general acute care hospital beds; therefore, the need for such beds is determined in accordance with the standards for general acute care hospital beds.c. Level I Newborn Units shall provide services for normal newborn infants.d. Level I Newborn Units shall have an active relationship with a Regional Center for the support of in-service education, patient and service consultation, and general support of newborn services.e. Level II Neonatal Units shall provide a full range of neonatal services for uncomplicated patients and certain types of neonatal illnesses except those requiring consultation and facilities not available at that level.f. Level II units shall be located in hospitals delivering more than 1,000 infants annually.g. Level III Neonatal Units shall serve approximately 6,000 10,000 deliveries per year. These units must provide care for normal patients, preferably with an obstetrical base greater than 1,500 inborn deliveries annually.h. The Regional Level III Neonatal Unit should have as a minimum 20 neonatal special care beds.i. Neonatal care shall be planned on a regional basis with linkages to obstetrical services.j. Level I, II, and III units shall meet the standards and guidelines for licensure developed by the Perinatal Commission. NOTE: The Perinatal Commission has recognized that there is no shortage of neonatal intensive care beds in the private sector in the state of Louisiana. The shortage is in the charity system. With the advent of Medicaid target rates and Diagnostic Related Group prospective payment system, the access to private care beds for indigent perinatal patients will become even more limited in the next few years. The limited access to intensive care for the high risk mother and neonates in the charity sector will be one of the most difficult problems facing the state over the next 6 years.
E. Intensive Care Unit (ICU)/Coronary Care Unit (CCU)1. Description a. An intensive care/coronary care unit is defined as a unit in which especially intense surgical and medical care can be given to patients in the first few days after suffering from acute myocardial infarction (heart attack).b. ICU's are used to support surgical patients postoperatively, to keep accident victims alive until surgery can be performed, and to enable premature infants to survive the first few days of life where neonatal intensive care units are not available. They also play a large part in the treatment of burns when the victims are critically ill and cannot undergo surgery until the crisis is over. The objectives of an ICU are the initiation of resuscitation, the administration of electrolytes and fluids, and the prevention of contamination and cross-infection.c. As an aid to the main task of keeping the patient alive, ICU's are commonly equipped with a number of monitoring devices; these are designed to keep the medical and nursing staff informed of the status of the patient's heart by displaying his ECG in various ways. An ICU will commonly have facilities for inserting pacemakers in cases where arrhythmias occur, and catheterization of the heart for diagnostic purposes.2. Resources Goals a. Bed Supply: ICU/CCU unit beds are considered general acute care hospital beds and the need for such beds is determined in accordance with the standards for general acute hospital beds.La. Admin. Code tit. 48, § I-11505
Promulgated by the Department of Health and Human Resources, Office of Management and Finance, LR 13:246 (April 1987).AUTHORITY NOTE: Promulgated in accordance with P.L. 93-641 as amended by P.L. 96-79, and R.S. 36:256(b).