Frequently Asked Questions
Perinatal Verification Surveys and Designation Rules
The following are questions that the Texas Perinatal Services team has received from Texas hospitals, with responses from the Texas Department of State Health Services. If you have questions, please email us and we are happy to assist in finding the answers.
Does the Texas Department of State Health Services have a list of diagnoses for specific levels of care for the maternal patient population, or an exclusion or inclusion list of maternal patients/diagnosis by level of facility available to use as a guide?
The facility may refer to the Consensus of Care document from ACOG for a general description of patient types.
In the neonatal rules, there were definitive patients, such as surgical and gestation, that helped to define where patients were to be cared for. However, in the maternal rules, there is room for interpretation. For example: Will all hypertensive patients be required to be cared for in level II and above facilities due to this being a “medical, surgical, or obstetrical conditions that present a significant risk of maternal morbidity or mortality”?
The determination of what patients will be treated at a hospital will be made by the practicing physician which is a medical decision. The state office does not regulate medical practice.
What are the expectations for the written protocol addressing when each level should stabilize and transfer (#13; Rule 133.206, #15; Rule 133.207, #21; Rule 133.208)? And, what is the recommendation from the state office on how facilities can define the appropriate place for patients to receive pregnancy related care?
The facility and the physicians providing maternal care will define what patient population they are capable of providing care for.
For all levels the rule requires the following: The facility shall have written guidelines or protocols for various conditions that place the pregnant or postpartum patient at risk for morbidity and/or mortality, including promoting prevention, early identification, early diagnosis, therapy, stabilization, and transfer. The guidelines or protocols must address a minimum of sepsis and/or systemic infection in the pregnant or postpartum patient;
To determine compliance to this rule, can a facility provide its maternal sepsis, chorioamnionitis, and Group Beta Strep policies/procedures that are consistent with current standards of practice and then have its medical records demonstrate compliance to the internal policies?
Will the state accept only an electronic scoring system for sepsis? And, if that is the expectation, what scoring system is acceptable?
There are many different ways to be compliant with requirements. If a facility can demonstrate compliance without an electronic scoring system, and it meets current practice, it would be considered compliant.
The surveyors will review what the facility has provided and determine if it is congruent with current practice and that it is reflected in practice through case reviews.
MEWS (Modified Early Warning System) – currently most widely used in the healthcare setting and different between organizations, requires monitoring of: vital signs, urine output and responsiveness. Determining a MEWS score involves assigning a number between 0 and 3 to each of the components.
SIRS (Systemic Inflammatory Response Syndrome) - at least two of the following four criteria: fever >38.0°C or hypothermia <36.0°C, tachycardia >90 beats/minute, tachypnea >20 breaths/minute, leucocytosis >12*109/l or leucopoenia <4*109/l. Monitors vital signs, WBC, lactic acid, organ dysfunctions. MEWT (Maternal Early Warning Trigger) - addresses the four most common areas of maternal morbidity: sepsis, cardiopulmonary dysfunction, preeclampsia-hypertension, and hemorrhage. Triggers need to be sustained for >20 minutes and were defined as severe (single abnormal value): heart rate respiratory rate, mean arterial pressure, oxygen sats <90% or nurse concern; nonsevere (required 2 abnormal values): temperature >38 or <36°C, blood pressure>160/110 or <85/45 mm Hg, HR >110 or <50 bpm, respiratory rate >24 or <10/min, oxygen saturation <93%, fetal HR >160 bpm, altered level of consciousness or disproportionate pain.
MEOWS (Modified Early Obstetric Warning Score) – monitors vital signs, urine output, responsiveness, pain, lochia and proteinuria.
MEWS (Maternal Early Warning System) - monitors vital signs, urine output, responsiveness and patients with hypertension reporting headache or shortness of breath.