<<Prev Rule

Texas Administrative Code

Next Rule>>
TITLE 25HEALTH SERVICES
PART 1DEPARTMENT OF STATE HEALTH SERVICES
CHAPTER 133HOSPITAL LICENSING
SUBCHAPTER KHOSPITAL LEVEL OF CARE DESIGNATIONS FOR MATERNAL CARE
RULE §133.209Maternal Designation Level IV

(a) A Level IV (Comprehensive Care). The Level IV maternal designated facility will:

  (1) provide comprehensive care for pregnant and postpartum patients with low risk conditions to the most complex medical, surgical and/or obstetrical conditions and their fetuses, that present a high risk of maternal morbidity or mortality;

  (2) ensure access to on-site consultation to a comprehensive range of medical and maternal subspecialists, surgical specialists and behavioral health specialists;

  (3) ensure capability to perform major surgery on-site;

  (4) have physicians with critical care training available at all times to actively collaborate with Maternal Fetal Medicine physicians and/or Obstetrics and Gynecology physicians with obstetrics training, experience and privileges in maternal care;

  (5) have a maternal fetal medicine critical care team with expertise and privileges to manage or co-manage highly complex, critically ill or unstable maternal patients;

  (6) have skilled personnel with documented training, competencies and annual continuing education, specific for the patient population served;

  (7) facilitate transports; and

  (8) provide outreach education to lower level designated facilities, including the Quality Assessment and Performance Improvement (QAPI) process.

(b) Maternal Medical Director (MMD). The MMD shall be a physician who:

  (1) is a board certified obstetrics and gynecology physician with expertise in the area of critical care obstetrics; or a board certified maternal fetal medicine physician, both with privileges in maternal care;

  (2) demonstrates administrative skills and oversight of the QAPI Program; and

  (3) has completed annual continuing education specific to maternal care, including complicated conditions.

(c) If the facility has its own transport program, there shall be an identified Transport Medical Director (TMD). The TMD shall be a physician who is a board certified maternal fetal medicine physician or board certified obstetrics and gynecology physician with obstetrics privileges, with expertise and experience in critically ill maternal transport.

(d) Program Functions and Services.

  (1) Triage and assessment of all patients admitted to the perinatal service.

    (A) Pregnant patients who are identified at high risk of delivering a neonate that requires a higher level of neonatal care shall be transferred to a higher level neonatal designated facility prior to delivery unless the transfer is unsafe.

    (B) Pregnant or postpartum patients identified with conditions and/or complications that require a service not available at the facility, shall be transferred to an appropriate maternal designated facility unless the transfer is unsafe.

  (2) Supportive and emergency care shall be delivered by appropriately trained personnel, for unanticipated maternal-fetal problems that occur during labor and delivery, through the disposition of the patient.

  (3) A board certified obstetrics and gynecology physician with maternal privileges shall be on-site at all times and available for urgent situations.

  (4) Ensure that a qualified physician, or a certified nurse midwife with appropriate physician back-up, is available to attend all deliveries or other obstetrical emergencies.

  (5) Intensive Care Services. The facility shall have an adult Intensive Care Unit (ICU) and critical care capabilities for maternal patients, including:

    (A) a comprehensive range of medical and surgical critical care specialists and advanced subspecialists on the medical staff;

    (B) a maternal fetal medicine critical care team with experience and expertise in the care of complex or critically ill maternal patients available to co-manage maternal patients; and

    (C) availability of obstetric nursing and support personnel with experience in care for critically ill maternal patients.

  (6) Maternal Fetal Medicine Critical Care Team. The facility shall have a Maternal Fetal Medicine (MFM) critical care team whose members have expertise to assume responsibility for pregnant or postpartum patients who are in critical condition or have complex medical conditions, including;

    (A) co-management of ICU-admitted obstetric patients;

    (B) an MFM team member with full obstetrical privileges available at all times for on-site consultation and management, and to arrive at the patient bedside within 30 minutes of an urgent request; and

    (C) a board certified MFM physician with expertise in critical care obstetrics to lead the team.

  (7) Management of critically ill pregnant or postpartum patients, including fetal monitoring in the ICU, respiratory failure and ventilator support, procedure for emergency cesarean, coordination of nursing care, and consultative or co-management roles to facilitate collaboration.

  (8) Behavioral Health Services.

    (A) Consultation by a behavioral health professional, with experience in maternal and/or neonatal counseling shall be available on-site at all times for in-person visits when requested for prenatal, peri-operative, and postnatal needs of the patient within a time period consistent with current standards of professional practice and maternal care.

    (B) Consultation by a psychiatrist, with experience in maternal and/or neonatal counseling shall be available for in-person visits when requested within a time period consistent with current standards of professional practice and maternal care.

  (9) The primary provider caring for a pregnant or postpartum patient who is a family medicine physician with obstetrics training and experience, obstetrics and gynecology physician, maternal fetal medicine physician, or a certified nurse midwife, physician assistant or nurse practitioner with appropriate physician back-up, whose credentials have been reviewed by the MMD and is on call:

    (A) shall arrive at the patient bedside within 30 minutes for an urgent request; and

    (B) shall complete annual continuing education, specific to the care of pregnant and postpartum patients, including complicated and critical conditions.

  (10) Certified nurse midwives, physician assistants and nurse practitioners who provide care for maternal patients:

    (A) shall operate under guidelines reviewed and approved by the MMD; and

    (B) shall have a formal arrangement with a physician with obstetrics training and/or experience, and with maternal privileges who will:

      (i) provide back-up and consultation;

      (ii) arrive at the patient bedside within 30 minutes of an urgent request; and

      (iii) meet requirements for medical staff as described in §133.205 of this title (relating to Program Requirements) respectively.

  (11) An on-call schedule of providers, back-up providers, and provision for patients without a physician will be readily available to facility and maternal staff and posted on the labor and delivery unit.

  (12) Ensure that the physician providing back-up coverage shall arrive at the patient bedside within 30 minutes for an urgent request.

  (13) Anesthesia Services shall comply with the requirements found at §133.41 of this title (relating to Hospital Functions and Services) and shall have:

    (A) anesthesia personnel with experience and expertise in obstetric anesthesia shall be available on-site at all times;

    (B) a board certified anesthesiologist with training and/or experience in obstetric anesthesia in charge of obstetric anesthesia services;

    (C) a board certified anesthesiologist with training and/or experience in obstetric anesthesia, including critically ill obstetric patients available for consultation at all times, and arrive at the patient bedside within 30 minutes for urgent requests; and

    (D) anesthesia personnel on call, including back-up contact information, posted and readily available to the facility and maternal staff and posted in the labor and delivery area.

  (14) Laboratory Services shall comply with the requirements found at §133.41 of this title and shall have:

    (A) laboratory personnel on-site at all times;

    (B) a blood bank capable of:

      (i) providing ABO-Rh specific or O-Rh negative blood, fresh frozen plasma, cryoprecipitate, and platelet components on-site at all times;

      (ii) implementing a massive transfusion protocol;

      (iii) ensuring guidelines for emergency release of blood components; and

      (iv) managing multiple blood component therapy; and

    (C) perinatal pathology services available.

  (15) Medical Imaging Services shall comply with the requirements found at §133.41 of this title and shall have:

    (A) personnel appropriately trained in the use of x-ray equipment available on-site at all times;

    (B) advanced imaging, including computed tomography (CT), magnetic resonance imaging (MRI), and echocardiography available at all times;

    (C) interpretation of CT, MRI and echocardiography within a time period consistent with current standards of professional practice and maternal care;

    (D) a radiologist with critical interventional radiology skills available at all times;

    (E) advanced ultrasonographic imaging for maternal or fetal assessment, including interpretation available at all times; and

    (F) a portable ultrasound machine available in the labor and delivery and antepartum unit.

  (16) Pharmacy services shall comply with the requirements found in §133.41 of this title and shall have a pharmacist with experience in perinatal pharmacology available at all times.

  (17) Respiratory Therapy Services shall comply with the requirements found at §133.41 of this title and shall have a respiratory therapist immediately available on-site at all times.

  (18) Obstetrical Services.

    (A) The ability to begin an emergency cesarean delivery within a time period consistent with current standards of professional practice and maternal care.

    (B) Ensure the availability and interpretation of non-stress testing, and electronic fetal monitoring.

    (C) A trial of labor for patients with prior cesarean delivery shall have the capability of anesthesia, cesarean delivery, and maternal resuscitation on-site during the trial of labor.

  (19) Resuscitation. The facility shall have written policies and procedures specific to the facility for the stabilization and resuscitation of the pregnant or postpartum patient based on current standards of professional practice. The facility:

    (A) ensures staff members, not responsible for the neonatal resuscitation, are immediately available on-site at all times who demonstrate current status of successful completion of ACLS and the skills to perform a complete resuscitation; and

    (B) ensures that resuscitation equipment, including difficult airway management equipment for pregnant and postpartum patients, is readily available in the labor and delivery, antepartum and postpartum areas.

  (20) The facility shall have written guidelines or protocols for various conditions that place the pregnant or postpartum patient at risk for morbidity and/or mortality, including promoting prevention, early identification, early diagnosis, therapy, stabilization, and transfer. The guidelines or protocols must address a minimum of:

    (A) massive hemorrhage and transfusion of the pregnant or postpartum patient in coordination of the blood bank, including management of unanticipated hemorrhage and/or coagulopathy;

    (B) obstetrical hemorrhage, including promoting the identification of patients at risk, early diagnosis, and therapy to reduce morbidity and mortality;

    (C) hypertensive disorders in pregnancy, including eclampsia and the postpartum patient to promote early diagnosis and treatment to reduce morbidity and mortality;

    (D) sepsis and/or systemic infection in the pregnant or postpartum patient;

    (E) venous thromboembolism in the pregnant and postpartum patient, including assessment of risk factors, prevention, early diagnosis and treatment;

    (F) shoulder dystocia, including assessment of risk factors, counseling of patient, and multi-disciplinary management; and

    (G) behavioral health disorders, including depression, substance abuse and addiction that includes screening, education, consultation with appropriate personnel and referral.

  (21) The facility shall have nursing leadership and staff with training and experience in the provision of maternal critical care who will coordinate with respective neonatal services.

  (22) The facility shall have a program for genetic diagnosis and counseling for genetic disorders, or a policy and process for consultation referral to an appropriate facility.

Cont'd...

Next Page

Link to Texas Secretary of State Home Page | link to Texas Register home page | link to Texas Administrative Code home page | link to Open Meetings home page