Ohio Administrative Code|Rule 3701-7-08 | Level II service standards.

                                                
(A) Obstetric license. A level II
		  obstetrical service shall provide antepartum, intrapartum and postpartum care
		  for obstetrical patients, including:
(1) All low-risk
			 patients;
(2) All uncomplicated patients with
			 higher-risk conditions;
(3) Selected high-risk
			 patients as identified by the service, such as patients with:
(a) Severe preeclampsia; or
(b) Placenta previa with prior uterine surgery in which a
				placenta accreta has been ruled out by ultrasound or magnetic resonance
				imaging;
(4) The management of
			 unanticipated complications of labor and delivery; and
(5) The management of
			 emergencies.
(B) Obstetric transfer. A level II
		  obstetrical service shall transfer to a level III or level IV obstetric
		  service, as appropriate, of any pregnant woman for intrapartum
		  care:
(1) With a high-risk
			 condition beyond those designated by the service; or
(2) At less than
			 thirty-two weeks gestation or with a fetus expected to weigh less than one
			 thousand five hundred grams.
Exception: A level II obstetrical service may
			 provide care where an emergency medical condition exists as defined by the
			 Emergency Medical Treatment and Labor Act, 42 U.S.C. 1395dd (2012), and is
			 evidenced by the following:
(a) The mother is having contractions; and
(b) When, in the clinical judgment of a qualified
				obstetrical practitioner working under that practitioners scope of
				practice:
(i) There is inadequate
				  time to effect a safe transfer of the mother to an appropriate higher level
				  hospital before delivery; or
(ii) The transfer will
				  pose a threat to the health or safety of either the mother or the
				  fetus.
(C) When considering a woman's
		  condition and the likelihood of pregnancy-related complications, paragraphs (A)
		  and (B) of this rule do not preclude the admission of:
(1) A less than thirty
			 two weeks gestation pregnant woman to the maternity unit for care or services
			 for a non-obstetrical issue, but that may require monitoring of the health of
			 the mother, the fetus, or both;
(2) Women with
			 uncomplicated, complicated, and high-risk conditions for antepartum care where
			 labor is not imminent;
(3) Non-infectious
			 gynecologic patients; or
(4) Non-infectious female
			 surgical patients in accordance with policies and procedures approved by the
			 service's director.
(D) Neonatal license. A level II neonatal care service
		  shall provide intermediate and routine care to newborns, including
		  to:
(1) All low-risk
			 newborns;
(2) All uncomplicated
			 newborns;
(3) Newborns with selected complicated
			 conditions as identified by the service, such as newborns:
(a) With physiologic immaturity such as apnea of
				prematurity;
(b) With an inability to maintain body
				temperature;
(c) With an inability to take oral feedings;
(d) Who are moderately ill with problems that are expected
				to resolve rapidly and are not anticipated to need sub-specialty services on an
				urgent basis; and
(e) Who are convalescing from intensive care;
(4) Newborns requiring
			 mechanical ventilation for brief durations of less than twenty-four hours or
			 continuous positive airway pressure, except the twenty-four hour period may be
			 extended if the newborn is stable and improving, and the newborn does not
			 require numerous interventions for time periods nearing twenty-four hours over
			 the course of days; and
(5) Newborns requiring emergency
			 resuscitation or stabilization for transport.
(E) Newborn transfer. When a level II
		  obstetrical service cannot effect a timely transfer of a pregnant woman
		  pursuant to paragraph (B)(2) of this rule, the level II neonatal care service
		  shall transfer a newborn that is less than thirty-two weeks gestation or weighs
		  less than one thousand five hundred grams to a neonatal care service licensed
		  to provide the needed care unless all of the following conditions are
		  met:
(1) The level II neonatal
			 care service has in place a valid memorandum of agreement with one or more
			 neonatal care services licensed to provide the needed care providing for
			 consultation on the retention of the infant between the level II neonatal care
			 service attending physician and a neonatologist on the staff of that neonatal
			 care service licensed to provide the needed care;
(2) The consultation
			 with, and the concurrence of, the neonatologist on the staff of the neonatal
			 care service licensed to provide the needed care is documented by the level II
			 neonatal care service in the patient medical record and as otherwise may be
			 determined by the service. Such documentation shall be made available to the
			 director upon request; and
(3) The risks and
			 benefits to the newborn for both retention at the level II neonatal care
			 service and transfer of the newborn to a neonatal care service licensed to
			 provide the needed care are discussed with the parent, parents, or legal
			 guardian of the newborn and appropriately documented. Such documentation shall
			 be made available to the director upon request.
(F) Informed consent. When discussing
		  transfer of a pregnant woman or a newborn to another facility in accordance
		  with this rule, the transferring service shall document and provide the patient
		  or patient's legal guardian with:
(1) The recommendations
			 from any consultations with a higher-level service;
(2) The risks and
			 benefits associated with the patient's transfer or retention;
			 and
(3) Any other information
			 required by the hospital's policies and procedures.
(G) In the event the patient or
		  patient's legal guardian refuses transfer to a recommended hospital, the
		  service shall document the refusal of transfer and provide treatment to the
		  patient or patients in accordance with hospital policies and procedures. The
		  service shall update the patient or patient's legal guardian as the
		  patient's condition warrants.
(H) Written service plan. Each provider
		  shall, using licensed health care professionals acting within their scopes of
		  practice, develop a written service plan for the care and services to be
		  provided by the service. The written service plan shall be based on the
		  "Guidelines for perinatal care" or other applicable professional
		  standard and address, at minimum:
(1) The selected
			 high-risk conditions for which care will be provided based on the:
(a) Patient population;
(b) Acuity of patients;
(c) Volume of patients; and
(d) Competency of staff;
(2) Criteria for
			 determining those conditions that can be routinely managed by the
			 service;
(3) Admission to the
			 service;
(4) Discharge from the
			 service;
(5) Patient care in accordance with
			 accepted professional standards;
(6) Referrals for obtaining public
			 health, dietetic, genetic, and toxicology services not available
			 in-house;
(7) Minimum competency requirements for
			 staff in accordance with recognized national standards and ensure that all
			 staff are competent to perform services based on education, experience and
			 demonstrated ability;
(8) Administration of blood and blood
			 products;
(9) Provision of
			 phototherapy;
(10) Provision of respiratory
			 therapy;
(11) Unit-based surgeries and surgical
			 suite-based surgeries;
(12) Post-mortem
			 care;
(13) A formal education program for staff,
			 including, at minimum: 
(a) The neonatal resuscitation program. The service shall
				ensure all labor and delivery registered nurses and any other practitioner
				likely to attend to a neonate at a high risk delivery receive training in the
				neonatal resuscitation program; and
(b) A post resuscitation program. The service shall ensure
				individuals caring for newborns receive training in a post resuscitation
				program to include, at minimum:
(i) The identification
				  and treatment of signs and symptoms related to hypoglycemia, hypothermia, and
				  pneumothorax;
(ii) Blood pressure (normal ranges, factors that can impair
				  cardiac output);
(iii) Lab work, including perinatal and postnatal risks
				  factors and clinical signs of sepsis;
(iv) Principles of
				  assisted ventilation, continuous positive airway pressure, positive pressure
				  ventilation, assisting and securing endo-tracheal tube insertion, and chest
				  x-rays;
(v)  Emotional support to
				  parents with sick infants; and
(vi) Quality improvement
				  to identify problems and the importance of debriefing to evaluate care in the
				  post-resuscitation period; and
(c) Ongoing continuing education;
(14) Provision of care by direct care
			 staff to individuals in other areas of the hospital, including, but not limited
			 to the emergency department and the intensive care unit;
(15) Risk assessment of obstetric and
			 neonatal patients to ensure identification of appropriate consultation
			 requirements for or referral of high-risk patients;
(16) Follow-up services to patients or
			 referral of patients for appropriate follow-up;
(17) Education for mothers regarding
			 personal care and nutrition, newborn care and nutrition, and newborn
			 feeding;
(18) Infection control, consistent with
			 current infection control guidelines issued by the United States centers for
			 disease control and prevention;
(19) Consultation for or referral of both
			 obstetric and neonatal transports;
(20) Criteria for the acceptance of both
			 obstetric and neonatal transports from other services, which may include the
			 reverse transport of newborns who otherwise do not meet the level II
			 gestational age and weight restrictions, based on demonstrated capability to
			 provide the appropriate services;
(21) Consultation for maternal-fetal
			 medicine on a twenty-four hour basis; and
(22) Developmental follow-up of at-risk
			 newborns in the service or referral of such newborns to appropriate
			 programs.
(I) Each provider shall, in accordance
		  with accepted professional standards, develop and follow written policies and
		  procedures to implement the written service plan required by paragraph (H) of
		  this rule.
(J) Each provider shall have the ability
		  to perform all of the following:
(1) An emergency cesarean
			 delivery in accordance with facility policy, but no later than thirty minutes
			 from the time that the decision is made to perform the procedure;
(2) Fetal monitoring;
			 and
(3) Resuscitation and
			 stabilization of newborns and emergency care for the mother and newborn in each
			 delivery room.
(K) Support services (on-site). Each
		  provider shall have the staff and support services to meet the needs of
		  patients and have the following staff and services on-site on a twenty-four
		  hour basis:
(1) Clinical laboratory,
			 capable of providing any necessary testing;
(2) Blood, blood
			 products, and substitutes;
(3) Diagnostic imaging
			 limited to x-ray;
(4) Portable ultrasound visualization
			 equipment for diagnosis and evaluation; and
(5) Respiratory therapy and
			 pulmonary.
(L) Support services (on-call). On a
		  twenty four hour basis, each provider shall have the following services
		  on-site, with staff necessary to provide the services on-call:
(1) Diagnostic imaging,
			 including:
(a) Computed tomography;
(b) Magnetic resonance imaging; and
(c) Fluoroscopy;
(2) Pharmacy;
(3) Anesthesia, except
			 that when a patient or patients are receiving a labor epidural, an
			 anesthesiologist or certified registered nurse anesthetist acting within their
			 scope of practice and under the supervision of a physician, shall remain in
			 attendance with a patient until it is determined the patient is stable, but for
			 at least thirty minutes. After it is determined the patient is stable, an
			 anesthesiologist or certified registered nurse anesthetist may be on-call, but
			 shall remain available to return in accordance with facility policy, but no
			 longer than thirty minutes; and
(4) Biomedical engineering.
(M) Unit management. Each provider shall
		  have qualified individuals on-staff appropriate for the services provided
		  including:
(1) A board-certified
			 obstetrician and a board-certified pediatrician as co-directors of the
			 obstetric and neonatal care service. The co-directors shall establish
			 procedures for patients and shall integrate and coordinate a system for
			 consultation, in-service education and communication with referring obstetric
			 and neonatal care services;
(2) A neonatologist or a
			 pediatrician in consultation with an on-staff neonatologist, to manage the care
			 of newborns and to provide for:
(a) A system for consultation and referral;
(b) Continuing education programs;
(c) Communication and coordination with the obstetrical
				service; and
(d) Defining and establishing appropriate policies,
				protocols, and procedures for the unit nursery or nurseries and neonatal
				follow-up as may be indicated;
(3) A director of
			 anesthesia services who is a board eligible or board certified
			 anesthesiologist;
(4) A single, designated,
			 full-time registered nurse with a bachelor's degree in nursing with
			 demonstrated expertise in obstetric care, or neonatal care, or both responsible
			 for leading the organization and supervising of nursing services in the
			 neonatal care service and the obstetrical service.
(5) A registered nurse to
			 provide clinical perinatal nursing expertise commensurate with the patient
			 acuity and services provided. Expertise may be demonstrated through education,
			 certification or a minimum of five years perinatal experience;
(N) Specialists. Each provider shall have
		  medical, surgical, radiological and pathology specialists on-call based upon
		  the medical needs of the patients.
(O) Sub-specialists. Each provider shall
		  have a maternal-fetal medicine sub-specialist available for
		  consultation.
(P) For every anticipated low risk
		  delivery or uncomplicated delivery with higher-risk conditions, each provider
		  shall have an obstetrician, physician, or certified nurse midwife acting within
		  their scope of practice and under a standard care arrangement with a
		  collaborating physician, in attendance.
For an unanticipated high-risk delivery, every
		  attempt shall be made to secure a second physician or certified nurse
		  practitioner acting within their scope of practice and under a standard care
		  arrangement with a collaborating physician to care for the neonate.
(Q) For every anticipated high-risk
		  delivery, each provider shall have in attendance:
(1) An obstetrician or
			 physician;
(2) A second physician or
			 certified nurse practitioner acting within their scope of practice and under a
			 standard care arrangement with a collaborating physician to care for the
			 neonate; and
(3) Members of the
			 multi-disciplinary team required by paragraph (S) of this rule, one of whom can
			 initiate resuscitation, and one of whom can complete full resuscitation. This
			 can be the same individual.
(R) Each provider shall ensure every
		  newborn requiring mechanical ventilation or continuous positive airway pressure
		  has an initial evaluation by a physician or certified nurse practitioner
		  (neonatal). If stable, qualified staff with experience in newborn airway
		  management and diagnosis and management of air leaks must be on-site to care
		  for such newborns.
(S) Each provider shall have qualified
		  staff on-duty appropriate for the services provided, including at
		  minimum:
(1) Registered nurse staffing,
			 including:
(a) At least two registered nurses competent in obstetric
				and neonatal care for labor and delivery;
(b) A registered nurse with obstetric and neonatal
				experience for each patient in the second stage of labor;
(c) A registered nurse to circulate for the cesarean
				section deliveries;
(d) Additional registered nurses with the appropriate
				education and demonstrated competence, commensurate with the acuity and volume
				of patients served, to provide direct supervision of newborns; and
(e) Additional registered nurses with the appropriate
				education and demonstrated competence, commensurate with the acuity and volume
				of patients served, to provide direct supervision of obstetric
				patients;
(2) At least one member
			 of the nursing staff to attend to newborns when they are not with the mother or
			 her designee; and
(3) A multi-disciplinary
			 team, each of whom have successfully completed the neonatal resuscitation
			 program and can initiate resuscitation. One member of the multi-disciplinary
			 team shall be capable of completing full resuscitation.
(T) Other disciplines. Each provider
		  shall have the following practitioners on-staff:
(1) A licensed social
			 worker to provide psychosocial assessments and family support services.
			 Additional social workers shall be provided based upon the size and needs of
			 the patient population;
(2) A licensed dietitian
			 with knowledge of maternal and newborn nutrition and knowledge of
			 parenteral/enteral nutrition management of at-risk newborns; and
(3) A certified lactation
			 consultant.