Texas Administrative Code
Title 25 - HEALTH SERVICES
Part 1 - DEPARTMENT OF STATE HEALTH SERVICES
Chapter 133 - HOSPITAL LICENSING
Subchapter K - HOSPITAL LEVEL OF CARE DESIGNATIONS FOR MATERNAL CARE
Section 133.206 - Maternal Designation Level I
Universal Citation: 25 TX Admin Code ยง 133.206
Current through Reg. 49, No. 38; September 20, 2024
(a) Level I (Basic Care). The Level I maternal designated facility must:
(1) provide care for pregnant and postpartum
patients who are generally healthy, and do not have medical, surgical, or
obstetrical conditions that present a significant risk of maternal morbidity or
mortality; and
(2) have skilled
personnel with documented training, competencies, and annual continuing
education specific for the patient population served.
(b) Maternal Medical Director (MMD). The MMD must be a physician who:
(1) is a family
medicine physician or an obstetrics and gynecology physician, with obstetrics
training and experience, and with privileges in maternal care;
(2) demonstrates administrative skills and
oversight of the Quality Assessment and Performance Improvement (QAPI) Plan;
and
(3) has completed annual
continuing education specific to maternal care.
(c) 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 than the scope of their neonatal
facility must be transferred to a higher level neonatal designated facility
before delivery unless the transfer is unsafe.
(B) Pregnant or postpartum patients
identified with conditions or complications that require a higher level of
maternal care must be transferred to a higher level maternal designated
facility unless the transfer is unsafe.
(2) Provide care for patients with
uncomplicated pregnancies with the capability to detect, stabilize, and
initiate management of unanticipated maternal-fetal or maternal problems that
occur during the antepartum, intrapartum, or postpartum period until the
patient can be transferred to a higher level of neonatal or maternal
care.
(3) An obstetrics and
gynecology physician with obstetrics training and experience must be available
for consultation, at all times.
(4)
Medical, surgical and behavioral health specialists must be available at all
times for consultation appropriate to the patient population served.
(5) Ensure that a qualified physician or
certified nurse midwife with appropriate physician back-up is available to
attend all deliveries or other obstetrical emergencies.
(6) The family medicine physician, primary
physician, or certified nurse midwife with competence in the care of pregnant
patients, whose credentials have been reviewed by the MMD and is on call:
(A) must arrive at the patient bedside within
30 minutes of an urgent request; and
(B) must complete annual continuing
education, specific to the care of pregnant and postpartum patients, including
complicated conditions.
(7) Certified nurse midwives, physician
assistants and nurse practitioners who provide care for maternal patients:
(A) must operate under guidelines reviewed
and approved by the MMD; and
(B)
must have a formal arrangement with a physician with obstetrics training or
experience, and with maternal privileges who must:
(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.
(8) An on-call schedule of providers, back-up
providers, and provision for patients without a physician must be readily
available to facility and maternal staff and posted on the labor and delivery
unit.
(9) Ensure that physicians
providing back-up coverage must arrive at the patient bedside within 30 minutes
of an urgent request.
(10)
Appropriate anesthesia, laboratory, pharmacy, radiology, respiratory therapy,
ultrasonography and blood bank services must be available on a 24-hour basis as
described in §
133.41 of this title (relating to
Hospital Functions and Services) respectively.
(A) Anesthesia personnel with training and
experience in obstetric anesthesia must be available at all times and arrive to
the patient bedside within 30 minutes of an urgent request.
(B) Laboratory and blood bank services must
have guidelines or protocols for:
(i) massive
blood component transfusion;
(ii)
emergency release of blood components; and
(iii) management of multiple blood component
therapy.
(C) Medical
Imaging Services.
(i) If preliminary reading
of imaging studies pending formal interpretation is performed, the preliminary
findings must be documented in the medical record.
(ii) There must be regular monitoring of the
preliminary versus final reading in the QAPI Plan.
(iii) Basic ultrasonographic imaging for
maternal or fetal assessment, including interpretation available at all
times.
(iv) A portable ultrasound
machine immediately available at all times to the labor and delivery and
antepartum unit.
(D) A
pharmacist must be available for consultation at all times.
(11) Obstetrical Services.
(A) The ability to begin an emergency
cesarean delivery and ensure the availability of a physician with the training,
skills, and privileges to perform the surgery 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 must have the capability of
anesthesia, cesarean delivery, and maternal resuscitation on-site during the
trial of labor.
(12)
Resuscitation. The facility must 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,
or a department-approved equivalent course, 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 immediately available at all
times to the labor and delivery, antepartum and postpartum areas.
(13) The facility must have a
written hospital preparedness and management plan for patients with placenta
accreta spectrum disorder who are undiagnosed until delivery, including
educating hospital and medical staff who may be involved in the treatment and
management of placenta accreta spectrum disorder about risk factors, diagnosis,
and management.
(14) The facility
must have written guidelines or protocols for various conditions that place the
pregnant or postpartum patient at risk for morbidity 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 or coagulopathy;
(B) obstetrical hemorrhage, including
promoting the identification of patients at risk, early diagnosis, and therapy
to reduce morbidity and mortality;
(C) placenta accreta spectrum disorder,
including team education, risk factor screening, evaluation, diagnosis,
fostering telemedicine medical services and referral as appropriate, treatment
and multidisciplinary management of both anticipated and unanticipated placenta
accreta spectrum disorder cases, including postpartum care;
(D) hypertensive disorders in pregnancy,
including eclampsia and the postpartum patient to promote early diagnosis and
treatment to reduce morbidity and mortality;
(E) sepsis or systemic infection in the
pregnant or postpartum patient;
(F)
venous thromboembolism in the pregnant and postpartum patient, including
assessment of risk factors, prevention, early diagnosis and
treatment;
(G) shoulder dystocia,
including assessment of risk factors, counseling of patient, and
multidisciplinary management; and
(H) behavioral health disorders, including
depression, substance abuse and addiction that includes screening, education,
consultation with appropriate personnel and referral.
(15) Perinatal Education. A registered nurse
with experience in maternal care must provide the supervision and coordination
of staff education. Perinatal education for high risk events must be provided
at frequent intervals to prepare medical, nursing, and ancillary staff for
these emergencies.
(16) Support
personnel with knowledge and skills in breastfeeding and lactation to meet the
needs of maternal patients must be available at all times.
(17) Social services, pastoral care and
bereavement services must be provided as appropriate to meet the needs of the
patient population served.
(18)
Dietician or nutritionist available with appropriate training and experience
for population served in compliance with the requirements in §
133.41 of this title.
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