(e) Procedures and policies. The
directors of the obstetrical and newborn services, in cooperation with nursing
service, shall develop procedures and policies which shall be available to the
medical and nursing staff. Minimal procedures shall include the following:
(1) Oxygen shall be administered only with
proper apparatus for its safe administration and control of concentration.
Concentrations of oxygen shall not exceed a safe level commensurate with
current concepts of oxygen therapy.
(2) Identification shall be attached to the
mother and newborn infant before they are removed from the delivery room.
(3) Hospital infection control
protocol shall be followed with each patient admitted to the labor and
delivery, nursery, or postpartum areas with suspected or confirmed
transmissible infection.
(4) Each
newborn shall be transported to the mother's room or other units outside the
nursery in an individual bassinet.
(5) Each infant shall be tested for
phenylketonuria, congenital hypothyroidism, and galactosemia prior to being
discharged.
(6) Additional
policies shall be adopted concerning, at minimum, the following:
(A) The use of oxytoxic drugs and the
administration of anesthetics, sedatives, analgesics, and other drugs;
(B) the development of a current
roster of physicians with a delineation of their obstetrical privileges. The
roster shall be maintained and made available to personnel;
(C) the housing of gynecology patients on the
maternity unit;
(D) the presence
of fathers or other support persons in the labor, delivery, and birthing rooms;
(E) the protocol for visitors to
labor and recovery patients and to the nursery and postpartum units;
(F) attire and handwashing protocols for
obstetrical and newborn unit staff and other hospital staff entering these
units;
(G) the flow of hospital
staff between the obstetric and newborn units and other patient care areas;
(H) the procedure for obtaining
blood samples for newborn screening lists, in compliance with
K.S.A.
65-180 et seq. and any amendments to it,
prior to newborn discharge;
(I)
the procedure for reporting to the licensing agency within 48 hours when two or
more infants in a nursery demonstrate simultaneous evidence of an infectious
disease of a similar nature;
(J)
an infection control program for labor, delivery, postpartum, and nursery area
which shall include specific procedures for patient isolation and the cleaning,
disinfection, and sterilization of patient areas, equipment, and supplies.
(K) arrangements for implementing
patient education programs and family-centered care and for promoting
parental/sibling/newborn attachment and initiation of breastfeeding;
(L) a system to facilitate coordination of
prenatal and postpartum referral and follow up for mothers and newborns at risk
and those being discharged less than 24 hours post delivery;
(M) a defined routine for care of obstetrical
and newborn patients;