Header:
WISCONSIN ADMINISTRATIVE CODE
DEPARTMENT OF HEALTH SERVICES
CHAPTER DHS 124 HOSPITALS
SUBCHAPTER IV -- SERVICES
Date:
08/31/2009
Document:
DHS 124.20 Clinical services.
(1) SERVICE POLICIES AND PROCEDURES. Hospitals which have surgery, anesthesia, dental or maternity services shall have effective policies and procedures, in addition to those set forth under s. DHS 124.12 (9), relating to the staffing and functions of each service in order to protect the health and safety of the patients.
(2) SURGERY. (a) Policies. 1. Surgical privileges shall be delineated for each member of the medical staff performing surgery in accordance with the individual's competencies and shall be on file with the operating room supervisor.
2. The surgical service shall have a written policy to ensure that the patient will be safe if a member of the surgical team becomes incapacitated.
3. The surgical service shall have the ability to retrieve information needed for infection surveillance, identification of personnel who assisted at operative procedures and the compiling of needed statistics.
4. There shall be adequate provisions for immediate postoperative care. A patient may be directly discharged from post-anesthetic recovery status only by an anesthesiologist, another qualified physician or a registered nurse anesthetist.
5. All infections of clean surgical cases shall be recorded and reported to the hospital administrative staff and the infection control committee. There shall be a procedure for investigating the causes of infection.
6. Rules and policies relating to the operating rooms shall be available and posted in appropriate locations inside and outside the operating rooms.
(b) Supervision. The operating rooms shall be supervised by a registered nurse who is qualified by training and experience to supervise the operating rooms.
(c) Environment. 1. The following equipment shall be available to the operating suites: a call-in system, resuscitator, defibrillator, aspirator, thoracotomy set and tracheotomy set.
2. If explosive gases are used, the surgical service shall have appropriate policies, in writing, for safe use of these gases.
(3) ANESTHESIA. (a) Policies. 1. The anesthesia service shall have effective policies and procedures to protect the health and safety of patients.
2. The anesthesia service shall have written policies for anesthetizing obstetrical patients.
3. The chief of the anesthesia service shall enforce the policies and procedures of the service.
4. If explosive gases are used, the anesthesia service shall have appropriate policies, in writing, for safe use of these gases.
5. The anesthesia service shall provide consultation to other services relating to respiratory therapy, emergency cardiopulmonary resuscitation and special problems in pain relief.
(b) Anesthesia use requirements. 1. Every surgical patient shall have a preanesthetic evaluation by a person qualified to administer anesthesia, with findings recorded within 48 hours before surgery, a preanesthetic visit by the person administering the anesthesia, and an anesthetic record and post-anesthetic follow-up examination, with findings recorded within 48 hours after surgery by the individual who administers the anesthesia.
2. In hospitals where there is no organized anesthesia service, the surgical service shall assume the responsibility for establishing general policies and supervising the administration of anesthetics.
3. If anesthetics are not administered by a qualified anesthesiologist, they shall be administered by a physician anesthetist, dental anesthetist, podiatrist or a registered nurse anesthetist, under supervision as defined by medical staff policy. The hospital, on recommendation of the medical staff, shall designate persons qualified to administer anesthetics and shall determine what each person is qualified to do.
4. The services provided by podiatrist, dentist or nurse anesthetists shall be documented, as well as the supervision that each receives.
5. If a general anesthetic is used and a physician is not a member of the operating team, a physician shall be immediately available in the hospital or an adjacent clinic to assist in emergency situations.
(4) DENTAL SERVICE. (a) Organization. Hospital dental services may be organized as a separate service or as part of another appropriate service.
(b) Services. All dental services shall meet the following requirements:
1. Dentists performing surgical procedures at the hospital shall be members of the medical staff. The scope and extent of surgical procedures a medical staff dentist may perform shall be defined for each dentist;
2. Surgical procedures performed by dentists shall be under the overall supervision of the chief of surgery;
3. Policies for the provision of dental services shall be set out in the medical staff by-laws;
4. Patients admitted to the hospital by dentists for dental care shall receive the same basic medical appraisal as patients admitted for other services. This shall include having a physician who is either a member of the medical staff or is approved by the medical staff to perform an appropriate admission history, physical examination and evaluation of overall medical risk and record the findings in the patient's medical record. A physician member of the medical staff shall be responsible for the medical care of patients admitted by dentists; and
5. Patients admitted for dental care shall have a dental history recorded by the dentist.
(5) MATERNITY. (a) Definitions. In this subsection:
1. "High-risk maternity service" means a service that combines specialized facilities and staff for the intensive care and management of high-risk maternal and fetal patients before and during birth, and to high-risk maternal patients following birth.
2. "Neonatal" means pertaining to the first 28 days following birth.
3. "Perinatal" means pertaining to the mother, fetus or infant, in anticipation of and during pregnancy, and in the first year following birth.
4. "Perinatal care center" means an organized hospital-based health care service which includes a high-risk maternity service and a neonatal intensive care unit capable of providing case management for the most serious types of maternal, fetal and neonatal illness and abnormalities.
(b) Reporting numbers of beds and bassinets. The number of beds and bassinets for maternity patients and newborn infants, term and premature, shall be designated by the hospital and reported to the department. Any change in the number of beds and bassinets shall also be reported to the department.
(c) Maternity admission requirements. The hospital shall have written policies for maternity and non-maternity patients who
may be admitted to the maternity unit. Regardless of patients admitted:
1. A maternity patient shall meet hospital admission criteria for the maternity unit;
2. The reason for admission shall be the treatment of a disease, condition or a normal physiologic process which occurs during the maternity cycle;
3. A maternity patient delivered enroute to the maternity unit shall be admitted without isolation precautions provided that the patient's history and assessment prior to admission does not reveal the presence of a communicable disease or infection;
4. The hospital shall have policies and procedures for handling maternity patients who have infectious diseases; and
5. Hospitals which admit adults other than maternity patients to the maternity unit shall have written policies that include criteria for admission or exclusion and the care of both maternity and non-maternity patients, and shall comply with the following:
a. Only non-infectious patients may occupy maternity beds used for non-maternity patients;
b. Newborn infants and labor and delivery suites shall be segregated from areas used for non-maternity patients; and
c. In small units, one room shall be designated exclusively for maternity patients.
(d) Newborn admission requirements. The hospital shall have written policies for admission of newborn infants to the nursery and criteria for identifying conditions for which infants may be directly admitted or readmitted to the newborn nursery for further treatment and follow-up care. Conditions for admission include:
1. For an infant delivered enroute to a hospital, admission may be made directly to the newborn nursery if an admission history and physical assessment does not reveal the likelihood of communicable disease or infection;
2. For an infant returned or transferred from a perinatal care center, admission may be made if the following requirements are met:
a. The physician responsible for care of the infant at the perinatal care center recommends transfer, and the accepting physician agrees to assume management of the infant's care;
b. Nursing staff and facilities are adequate to provide the level of care needed;
c. Parents of infants are informed of the recommended transfer;
d. The infant is free from all obvious signs of infection prior to transfer; and
e. The hospital infection control committee assumes responsibility for monitoring admission of returned or transferred infants in conjunction with the obstetrical and pediatric staff of the unit; and
3. For an infant proposed for readmission to a newborn nursery after discharge to home, admission may be made if the following conditions are met:
a. The nursery shall be approved by the medical staff, hospital administrative staff and nursing service as the hospital unit most qualified to care for the particular infant and the infant's condition;
b. The hospital infection control committee or designee monitors the re-admission of the infant to the nursery;
c. The hospital has written policies for all aspects of the re-admission; and
d. The level of medical care and nurse staffing is adequate to meet the needs of all the infants in the nursery.
(e) High-risk infants. Each maternity service shall have adequate facilities, personnel, equipment and support services for the care of high-risk infants, including premature infants, or a plan for transfer of these infants to a recognized intensive infant care or perinatal care center.
(f) Institutional transfer of patients. 1. Written policies and procedures for inter-hospital transfer of perinatal and neonatal patients shall be established by hospitals which are involved in the transfer and transport of these patients.
2. A perinatal care center or high-risk maternity service and the sending hospital shall jointly develop policies and procedures for the transport of high-risk maternity patients.
3. Policies, personnel and equipment for the transfer of infants from one hospital to another shall be available to each hospital's maternity service. The proper execution of transfer is a joint responsibility of the sending and receiving hospitals.
(g) Personnel. 1. The labor, delivery, postpartum and nursery areas of maternity units shall have available the continuous services and supervision of a registered nurse for whom there shall be documentation of qualifications to care for women and infants during labor, delivery and in the postpartum period.
2. When a maternity unit requires additional nursing staff on an emergency basis, the needed personnel may be transferred from another service if they meet the infection control criteria of the maternity unit and the transferred persons have not come into direct contact, during the same working day, with patients who have transmissible or potentially transmissible infections.
3. Nursing personnel assigned to care for maternity and newborn patients may not have other duties which could lead to infection being transmitted to those patients.
4. Personnel assigned to maternity units may be temporarily reassigned to the care of non-infectious patients on other units of the hospital and return to the maternity unit on the same shift.
5. Hospitals shall develop their own protocols for the apparel worn by staff members who work in the maternity unit.
6. The service shall have written policies that state which emergency procedures may be initiated by the registered nurse in the maternity service.
(h) Infection control. 1. The maintenance of the infection surveillance and control program in the maternity service shall be integrated with that of the entire hospital and its infection control committee.
2. Surgery on non-maternity patients may not be performed in the delivery room.
3. There shall be written policies and procedures for hand and forearm washing which shall apply throughout the maternity service and which shall be followed by staff and visitors to the service.
4. The hospital shall have written policies and procedures and the physical and staffing capabilities for isolating newborn infants. Hospitals unable to effectively isolate and care for infants shall have an approved plan for transferring the infants to hospitals where the necessary isolation and care can be provided.
(i) Labor and delivery. 1. The hospital shall have written policies and procedures that specify who is responsible for and the contents of the documentation of the nursing assessment of the patient in labor and delivery, monitoring of vital signs, observation of fetal heart, performance of obstetrical examinations, observation of uterine contractions and support of the patient, performance of newborn assessment and emergency measures that may be initiated by the registered nurse.
2. The hospital shall have written policies regarding wearing apparel for all in attendance during labor and delivery.
3. Equipment that is needed for normal delivery and the management of complications and emergencies occurring with either the mother or infant shall be provided and maintained in the labor and delivery unit. The items needed shall be determined by the medical staff and the nursing staff.
4. Delivery rooms shall be separate from operating rooms and shall be used only for deliveries and operative procedures related to deliveries.
5. a. Hospitals desiring to establish an alternative birth room shall have policies governing the use of the room, a plan for control of infection and a detailed plan for staff coverage, and shall indicate in these policies what the involvement of the medical staff, nursing services, hospital administrative staff and infection control committee is to be in this program.
b. The alternative birth room shall be within or in close proximity to the labor and delivery unit.
c. There shall be a written visitor policy for the alternative birth room.
d. The alternative birth room shall contain a single bed and shall meet the applicable criteria of a labor room.
e. An alternative birth room shall meet the applicable standards of s. DHS 124.35 (4) for a labor and delivery area and the capability shall exist to provide appropriate emergency care to the mother and infant.
6. Any person delivering an infant shall be responsible for care of the baby's eyes in compliance with s. 253.11, Stats., and s. DHS 145.06 (4).
7. An accepted method of infant identification shall be used.
8. a. Only a physician or a nurse-midwife licensed under s. 441.15, Stats., and ch. N 4 may order the administration of a labor-inducing agent.
b. Only a physician or a licensed nurse-midwife or a registered nurse who has adequate training and experience may administer a labor-inducing agent.
c. A registered nurse shall be present when administration of a labor-inducing agent is initiated and shall remain immediately available to monitor maternal and fetal well-being. A physician's or licensed nurse-midwife's standing orders shall exist allowing the registered nurse to discontinue the labor-inducing agent if circumstances warrant discontinuation.
d. Appropriately trained hospital staff shall closely monitor and document the administration of any labor-inducing agent. Monitoring shall include monitoring of the fetus and monitoring of uterine contraction during administration of a labor-inducing agent. The physician or licensed nurse-midwife who prescribed the labor-inducing agent, or another capable physician or licensed nurse-midwife, shall be readily available during its administration so that, if needed, he or she will arrive at the patient's bedside within 30 minutes after being notified.
(j) Postpartum care. 1. Maternity patients shall be adequately observed after delivery.
2. The hospital shall have written policies and procedures for nursing assessments of the postpartum patient during the entire postpartum course.
(k) Newborn nursery and the care of newborns. 1. Ordinarily only personnel assigned to the nursery may enter the nursery.
2. Persons entering the nursery shall comply with hospital policies on apparel to be worn in the nursery.
3. a. Oxygen, medical air and suction shall be readily available to every nursery.
b. Oxygen monitoring equipment, including oxygen analyzers, shall be available and shall be checked for proper function prior to use and daily during use.
c. Oxygen concentrations shall be documented.
d. There shall be a written policy which states how frequently oxygen humidifiers are to be cleaned.
4. a. Infant sleeping units shall be of a type that permit ease of cleaning and shall be readily accessible to staff for the purpose of care and examination of the infant.
b. Infant incubators shall be adaptable to protective isolation procedures and shall be designed to provide a controlled temperature, controlled humidity and a filtered atmosphere.
c. External heating units shall be provided as needed for adequate infant care.
d. The frequency of incubator filter changes shall follow manufacturers' criteria. High density filters shall be regularly checked for accuracy and adequacy.
5. Hospitals that may require special formula preparation shall develop appropriate policies and procedures.
6. a. Hospitals that permit siblings to visit the maternity unit shall have a written policy and procedure detailing this practice. The policy shall be developed jointly by the chief of maternity service, the chief of pediatrics service, the hospital's infection control committee, the nursing service and the chief executive officer.
b. The policy at a minimum shall indicate those patients eligible for the program, the hours the program is offered, the length of visiting time, personnel responsible for monitoring the program, program monitoring requirements for infection control and the physical location of the visit.
c. Siblings are not allowed in the nursery.
7. When circumcisions are performed according to religious rites, a separate room apart from the newborn nursery shall be provided. A physician, physician's assistant or registered nurse shall be present during the performance of the religious rite. Aseptic techniques shall be used when an infant is circumcised.
(L) Discharge of infants. 1. An infant may be discharged only to a parent who has lawful custody of the infant or to an individual who is legally authorized to receive the infant. If the infant is discharged to a legally authorized individual, that individual shall provide identification and, if applicable, the identification of the agency the individual represents.
2. The hospital shall record the identity of the legally authorized individual who receives the infant.
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