§640.APPENDIX L. Level I Resource Checklist

Level I Resource Checklist

Briefly describe institutional compliance:

 

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.

 

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2.         The hospital shall provide documentation of participation in Continuous Quality Improvement (CQI) implemented by the Administrative Perinatal Center.

 

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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.

 

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4.         The hospital shall provide documentation of the availability of trained personnel and facilities to provide competent emergency obstetric and newborn care. 

 

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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. 

 

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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.

 

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7.         The hospital shall have the capability of performing caesarean sections (C-sections) within 30 minutes of decision-to-incision.

 

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8.         The hospital shall have blood bank technicians on call and available within 30 minutes for performance of routine blood banking procedures.

 

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9.         The hospital shall have general anesthesia services on call and available under 30 minutes to initiate C-section.

 

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10.       The hospital shall have radiology services available within 30 minutes.

 

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11.       The hospital shall have the following clinical laboratory resources available:

 

Microtechniques for hematocrit, within 15 minutes; glucose, blood urea nitrogen (BUN), creatinine, blood gases, routine urine analysis, 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.

 

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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.   

 

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13.       The hospital shall be responsible for assuring that staff physicians and consultants are aware of standards and guidelines in the letter of agreement.

 

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14.       The hospital shall provide documentation of health care provider participation in Joint Mortality and Morbidity reviews.

 

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(Source:  Added at 35 Ill. Reg. 2583, effective January 31, 2011)