Section 15-8-90-04-405.03 - Perinatal Levels of CareLevel 1- Basic Care, Well Newborn Nursery
Neonatal Guidelines
1. Provide neonatal resuscitation at every delivery.2. Evaluate and provide postnatal care to stable term newborn infants.3. Stabilize and provide care for infants born at 35-37 weeks gestation who remain physiologically stable.4. Stabilize newborn infants who are ill and those born at less than 35 weeks gestation until transfer to a facility that can provide the appropriate level of care.5. Maintain a staff of providers including pediatricians, family physicians, nurse practitioners with newborn training, registered nurses with newborn training including being current with Neonatal Resuscitation Program Certification and S.T.A.B.L.E.Maternal Guidelines
1. Surveillance and care of all patients admitted to the obstetric service, with an established triage system for identifying high-risk patients who should be transferred to a facility that provides specialty or sub-specialty care.2. Capability to begin an emergency cesarean delivery within 30 minutes of the decision to do so.3. Mothers that are stable and likely to deliver before 35 weeks gestation or have a fetus that is likely to require specialty services and mothers who themselves are likely to require specialty services should be transferred prior to delivery, when possible.4. Proper detection and supportive care of known maternal conditions and unanticipated maternal-fetal problems that occur during labor and delivery.5. Care of postpartum conditions.6. Maintain a staff of providers certified to perform normal and operative vaginal deliveries and cesarean sections including obstetricians and family physicians with advanced training in obstetrics, providers certified to perform normal vaginal deliveries including certified nurse midwives, and registered nurses with training in labor and delivery, post-partum care or inpatient obstetrics. Hospital Resources
1. Availability of anesthesia, radiology, ultrasound, blood bank and laboratory services available on a 24-hour basis.2. Consultation and transfer agreement with specialty and/or subspecialty perinatal centers.3. Parent-sibling-neonate visitation.4. Data collection and retrieval.5. Quality improvement programs, maximizing patient safety.Level II- Specialty Care, Special Care Nursery
Neonatal Guidelines
1. Performance of all basic care services as described above.2. Provide care for infants born at more than 32 weeks and weighing more than 1500g who have physiological immaturity or who are moderately ill with problems that are expected to resolve rapidly and are not anticipated to need subspecialty services on an urgent basis.3. Provide care for infants convalescent care after intensive care.4. Provide mechanical ventilation for brief duration (less than 24 hours) and/or continuous positive airway pressure.5. Stabilize infants born before 32 weeks gestation and weighing less than 1500 grams until transfer to a Level III or Level IV neonatal intensive care facility.6. Maintain a staff of providers including those listed in Basic Care plus pediatric hospitalists, neonatologist, and neonatal nurse practitioners.7. Referral to a higher level of care for all infants when needed for pediatric surgical or medical subspecialty intervention.8. Level II nurseries must have equipment (e.g., portable x-ray machine, blood gas analyzer) and personal (e.g., physicians, specialized nurses, respiratory therapists, radiology technicians and laboratory technicians) to provide ongoing care of admitted infants as well as to address emergencies.Maternal Guidelines
1. Perform all basic maternal services listed above.2. Mothers that are stable and likely to deliver before 32 weeks gestation or have a neonate that is likely to require sub-specialty services, or mothers who themselves are likely to require sub-specialty services should be transferred prior to delivery, when possible.3. Access to maternal fetal medicine consultation and antenatal diagnosis technology including fetal ultrasound.Level III- Sub-specialty Care/Neonatal Intensive Care Unit
Neonatal Guidelines
1. Provision of all Level I and Level II services.2. Level III NICUs are defined by having continuously available personnel (neonatologists, neonatal nurses, and respiratory therapists) and equipment to provide life support for as long as necessary.3. Provide comprehensive care for infants born less than 32 weeks gestation and weighing less than 1500 grams and infants born at all gestational ages and birth weights with critical illness.4. Provide prompt and readily available access to a full range of pediatric medical subspecialists, pediatric surgical specialists, pediatric anesthesiologists or anesthesiologists with experience in neonatal surgical care and pediatric ophthalmologists, on site or by prearranged consultative agreements.5. Provide a full range of respiratory support and physiologic monitoring that may include conventional and/or high-frequency ventilation and inhaled nitric oxide.6. Perform advanced imaging with interpretation on an urgent basis, including computed tomography, MRI and echocardiography.7. Social and family support including social services and pastoral care.8. If geographic constraints for land transportation exist, the Level III facility should ensure availability of rotor and fixed-wing transport services to transfer infants requiring subspecialty intervention from other regions and facilities.9. Consultation and transfer agreements with both lower level referring hospitals and regional centers, including back-transport agreements.10. Prompt diagnosis and appropriate referral of all conditions requiring surgical intervention. Major surgery should be performed by pediatric surgical specialists (including anesthesiologists with pediatric expertise) on-site within the hospital or at a closely related institution, ideally in close geographic proximity if possible. Level III facilities should be able to offer complete care, management, and evaluation for high-risk neonates 24 hours a day. A neonatologist should be available either in-house or on-call with the capacity to be in-house in a timely manner, 24 hours a day.11. Level III facilities should maintain a sufficient volume of infants less than 1500 grams to meet professionally accepted guidelines to achieve adequate experience and expertise.12. Enrollment in the Vermont Oxford Network to report and monitor data regarding outcomes of infants born less than 32 weeks and weighing less than 1500 grams.13. Participation in and evaluation of quality improvement initiatives.Maternal Guidelines
1. Manage complex maternal and fetal illnesses before, during and after delivery.2. Maintain access to consultation and referral to Maternal-Fetal Medicine specialists.Level IV- Regional Care
Neonatal Guidelines
1. All level III capabilities listed above.2. Located within an institution with the capability to provide surgical repair of complex congenital or acquired conditions.3. Maintain a full range of pediatric medical subspecialists, pediatric surgical subspecialists and pediatric anesthesiologists at the site.4. Facilitate transport and provide outreach education including community taught NRP and S.T.A.B.L.E. classes.Maternal Guidelines
1. All level III capabilities listed above.2. Maintain a full range of surgical and medical specialists including Maternal-Fetal Medicine specialists at the site.3. Facilitate maternal transport and provide outreach education.15 Miss. Code. R. 8-90-04-405.03