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OB Guideline 34: Institutional Responsibilities

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OB Guideline 34: Institutional Responsibilities

Related to: Clinical Guidelines, Communication, Diagnosis, Documentation, Informed Consent, Nursing, Obstetrics

When obstetrical services are provided in a CRICO-insured institution, the following support services, staff training and arrangements are the responsibility of the institution:

For Emergency Support

  1. Blood products should be available at all times.
  2. Personnel capable of performing an emergent surgical airway must always be immediately available.
  3. Obstetrical (maternal) resuscitation guidelines should be readily available by each institution and include:
    • a designated response team for maternal emergencies in Labor and Delivery that includes members familiar with the physiologic changes of pregnancy and the procedures for notification of the response team; and
    • a designated response team for obstetrical patients who experience emergencies anywhere in the hospital other than Labor and Delivery.
  4. Consultants from other services should be readily available as needed.

For Infant Identification and Protection

  1. Each institution should affirm the identity of the newborn prior to any procedure, testing, and prior to being released to the mother and/or her designee(s) while in the hospital.
  2. Each institution should establish clear protocols to prevent infant abduction.

For General Support

These responsibilities are imbedded in specific guidelines, and repeated here for clarity. CRICO-insured institutions are responsible for:

  1. Adequate resources for record processing and adhering to record keeping standards including compliance with federal regulations (e.g., HIPAA) and its mandate for a designated institutional compliance officer (Guideline 1).
  2. Accommodations for preserving all electronic fetal monitoring tracings (Guideline 1).
  3. Support for quality improvement activities (Guideline 1).
  4. A formal process to resolve disagreements between professional staff about medical management, conduct of labor, or interpretation of tests of fetal status (Guideline 5).
  5. A standard policy and procedure for establishing gestational age (Guideline 7).
  6. A system by which alternative clinician coverage (as needed) is clearly communicated and readily available to all members of the labor and delivery staff (Guideline 14).
  7. Provide and maintain appropriate fetal monitoring apparatus to meet the needs of its patients (Guideline 16).
  8. At least daily multidisciplinary meetings held on the Labor and Delivery unit to discuss all patients’ relevant clinical issues and have appropriate clinical and administrative plans agreed upon by the team caring for the patients (Guideline 16).
  9. A standard policy and procedure for scheduling elective induction of labor (Guideline 16).
  10. A standard policy and procedure for establishing the indication and method for induction of labor, including the preparation and use of oxytocin and use of cervical ripening agents (Guideline 17).
  11. Guidelines for the use of oxytocin (Guideline 18).
  12. Ensuring that enough controlled infusion devices for administration of oxytocin are maintained and available to meet the needs of the patient population (Guideline 18).
  13. Ensuring that a physician with appropriate privileges to administer obstetrical anesthesia (or a designee) will be available in the medical facility from the initiation of an anesthetic until the patient’s post-anesthesia condition is satisfactory and stable Guideline 29).
  14. A policy for the management of patients in the PACU that describes who is responsible for the care of patients in the PACU, how they will be monitored, and the process for discharge (Guideline 29).
  15. A process or program to instruct each patient regarding normal postpartum events. These instructions should include care of the breasts, perineum, bladder, the incision (if appropriate), and signs of complications (Guideline 31).
  16. A process or program to instruct each patient regarding infant care, infant feeding (including the benefits of breastfeeding), and subsequent maternal and newborn medical examinations (Guideline 31).
  17. Identifying and reporting Serious Reportable Events (SREs) to the Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health (Guideline 33).
  18. Developing policies and procedures for disclosure to patients of adverse events and outcomes involving their care Guideline 33).

For Staff Communication, Education, and Training 

  1. A program to evaluate and document staff competence.
  2. Continuing education for all obstetrical personnel including: FHR monitoring, emergency measures for the treatment of shoulder dystocia and eclampsia, and forceps or vacuum application.
  3. Developing a plan for obstetrical safety drills to prepare staff in the event of high acuity, low frequency emergent events such as shoulder dystocia.
 << Guideline 33             Web Guideline Home Page             Appendix A >>

May 1, 2014
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