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;
For an infant returned or transferred from a perinatal care center, admission may be made if the following requirements are met:
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;
Nursing staff and facilities are adequate to provide the level of care needed;
The infant is free from all obvious signs of infection prior to transfer; and
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
For an infant proposed for readmission to a newborn nursery after discharge to home, admission may be made if the following conditions are met:
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;
The hospital infection control committee or designee monitors the re-admission of the infant to the nursery;
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.
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.
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.
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.
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.
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.
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.
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.
Hospitals shall develop their own protocols for the apparel worn by staff members who work in the maternity unit.
The service shall have written policies that state which emergency procedures may be initiated by the registered nurse in the maternity service.
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.
Surgery on non-maternity patients may not be performed in the delivery room.
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.
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.
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.
The hospital shall have written policies regarding wearing apparel for all in attendance during labor and delivery.
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.
Delivery rooms shall be separate from operating rooms and shall be used only for deliveries and operative procedures related to deliveries.
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.
The alternative birth room shall be within or in close proximity to the labor and delivery unit.
The alternative birth room shall contain a single bed and shall meet the applicable criteria of a labor room.
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.
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.
Only a physician or a licensed nurse-midwife or a registered nurse who has adequate training and experience may administer a labor-inducing agent.
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.
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.
The hospital shall have written policies and procedures for nursing assessments of the postpartum patient during the entire postpartum course.
Ordinarily only personnel assigned to the nursery may enter the nursery.
Persons entering the nursery shall comply with hospital policies on apparel to be worn in the nursery.
Oxygen monitoring equipment, including oxygen analyzers, shall be available and shall be checked for proper function prior to use and daily during use.
There shall be a written policy which states how frequently oxygen humidifiers are to be cleaned.
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.
Infant incubators shall be adaptable to protective isolation procedures and shall be designed to provide a controlled temperature, controlled humidity and a filtered atmosphere.
External heating units shall be provided as needed for adequate infant care.
The frequency of incubator filter changes shall follow manufacturers' criteria. High density filters shall be regularly checked for accuracy and adequacy.
Hospitals that may require special formula preparation shall develop appropriate policies and procedures.
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.
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.
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.
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.
The hospital shall record the identity of the legally authorized individual who receives the infant.
DHS 124.20 History
Cr. Register, January, 1988, No. 385
, eff. 2-1-88; correction in (5) (i) 6. under s. 13.93 (2m) (b) 7., Stats., Register, August, 1995, No. 476
; r. (5) (a) 3., renum. (5) (a) 4. and 5. to be (5) (a) 3. and 4., r. and recr. (5) (i) 8., Register, August, 1996, No. 488
, eff. 9-1-96; correction in (5) (i) 6. made under s. 13.92 (4) (b) 7., Stats., Register January 2009 No. 637
A hospital may have either a single rehabilitation service or separate services for physical therapy, occupational therapy, speech therapy and audiology.
The service or services shall have written policies and procedures relating to organization and functions.
The service chief shall have the necessary knowledge, experience, and capabilities to properly supervise and administer the service. A rehabilitation service chief shall be a physiatrist or other physician qualified to head the service. If separate services are maintained for physical, occupational, speech therapy services and audiology services, the service chief shall be a qualified physical or occupational therapist or speech pathologist or audiologist or a qualified physician.
(a) Physical therapy.
If physical therapy services are offered, the services shall be given by or under the supervision of a qualified physical therapist.
(b) Occupational therapy.
If occupational therapy services are offered, the services shall be given by or under the supervision of a qualified occupational therapist.
(c) Speech therapy.
If speech therapy services are offered, the services shall be given by or under the supervision of a qualified speech pathologist.
(d) Audiology services.
If audiology services are offered, the services shall be given by or under the supervision of a qualified audiologist.
Facilities and equipment for physical, occupational, speech therapy and audiology services shall be adequate to meet the needs of the service or services and shall be in good condition.
Physical therapy, occupational therapy, speech therapy and audiology services shall be given in accordance with orders of a physician, a podiatrist or any allied health staff member who is authorized by the medical staff to order the service. The orders shall be incorporated into the patient's medical record.
(5) Rehabilitation record.
A record shall be maintained for each patient who receives rehabilitation services. This record shall be part of the patient's medical record.
DHS 124.21 History
Cr. Register, January, 1988, No. 385
, eff. 2-1-88.
If respiratory care services are offered by the hospital, the service shall be under the direction of a qualified physician.