Virginia* Laws, statutes, etc. Maternity hospital lav. THE MATERNITY HOSPITAL LAW REQUIREMENTS FOR THE CARE OF MATERNITY PATIENTS AND NEW- BORN INFANTS IN HOSPITALS, MATERNITY HOMES, AND OTHER INSTITUTIONS State Department of Health 1941 PREFACE The State Department of Health has the responsibility for the licensing, regulation, and inspection of maternity hospitals in Vir- ginia. This legislation is reproduced in full in PART I of this pub- lication. For the guidance of those responsible for the operation of maternity hospitals, interpretation of the requirements set forth under Subsection (b) of Section IV of the Maternity Hospital Law has been deemed advisable. Certain of these provisions, rather broad in implication, have been specifically interpreted and are considered to follow strictly the purpose and intent of the legal requirements. These interpretations are set forth in Part II of this publica- tion ; they have the approval and represent the combined opinions of the State Department of Health and special committees from the following organizations: Committee on Maternal Health, Medical Society of Virginia. Virginia Hospital Association. Virginia Obstetrical and Gynecological Society. Virginia Pediatric Society. Application for a Maternity Hospital License should be made on a special form furnished, on request, by the State Department of Health. I. C. Riggin, M. D. State Health Commissioner. Richmond, Virginia, January 1, 1941. PART I The Maternity Hospital Law PART I THE MATERNITY HOSPITAL LAW Chapter 322, Acts of Assembly, 1940, Pages 521-524, Inclusive. Approved March 29, 1940. An ACT to provide for the regulation and inspection of maternity hospitals, to require permits to be obtained for the operation of such hospitals, to vest certain powers in the State Board of Health, to provide for appeals in certain cases, to prescribe penalties for violations, and to repeal an act entitled, “An Act to provide for the licensing, regulation, and inspection of maternity hospitals, and to repeal sections 1925 to 1930, inclusive, of the Code of Virginia.”, approved March 27, 1922. 1. Be it enacted by the General Assembly of Virginia, as follows: Section 1. Definitions.—As used in this act (a) “Board” means the State Board of Health; (b) “Person” means an individual, partnership, association or corporation; (c) “Maternity hospital” means any place or establishment operated or maintained by any person for the care or treatment of women during pregnancy, or for delivery or for care or treatment within ten days after delivery, whether the place or establishment so maintained be a general hospital, a hospital devoted exclusively to ma- ternity cases, a maternity home or lying-in asylum, or a private home. Section 2. Permits required.— (a) No person shall maintain or operate a maternity hospital in this State on or after January first, nineteen hundred and forty-one, unless he shall first obtain from the Board a permit therefor, as hereinafter pro- vided. (b) No permit issued pursuant to this act shall author- ize any person to engage in the business or practice of child- placing, and no person shall engage in such business or prac- tice unless specifically licensed as a child-placing agency by the State Department of Public Welfare, as provided by law. Section 3. Issuance of permits.—The Board is hereby authorized to issue permits to maintain and operate maternity hospitals. Such permits shall be in such form as shall be furnished by the Board and shall have stated thereon the maximum num- ber of maternity patients that may be cared for at any one time in the maternity hospital for the maintenance and opera- tion of which the permit is issued, and shall include a desig- nation of the buildings, floors, or rooms in which maternity patients and infants may be kept and delivery made; and for this purpose the Board is hereby authorized to prescribe such maximum number of patients and to designate such buildings, floors and rooms. The permit shall be posted in a conspicuous place on the maternity hospital premises and all employees of such institution shall be fully informed and instructed with reference thereto by the licensee, to insure strict com- pliance with the provisions of this act. Any permit issued shall remain in effect until revoked or surrendered. No per- mit shall be transferable. A provisional permit may be is- sued to any maternity hospital for a period not to exceed six months if, in the opinion of the Board or its authorized agents, the applicant is worthy and likely to make provision for com- pliance with all of the provisions of this act within such period. Section 4. Qualification for permit; certain facilities and services re- quired.—(a) The Board shall grant a permit to maintain and operate a maternity hospital to any person who makes appli- cation therefor on forms furnished, on request, by the Board, provided that upon inspection of the maternity hospital by the Board or its duly authorized agents it is found that rea- sonably satisfactory provision has been made by the appli- cant for compliance with all of the requirements of subsec- tion (b) of this section. (b) Every person who shall maintain or operate a ma- ternity hospital in this State shall make provision for the following facilities, services and requirements: (1) Each patient in a maternity hospital shall be under the care of or attended by a licensed physician. (2) A registered graduate nurse shall be available for attendance upon maternity patients and newborn infants at all times, and shall be in charge of or responsible for all nurs- ing care. Sufficient registered and graduate nurses shall be employed to provide adequate nursing supervision and care for all maternity patients and infants. (3) All orders from physicians regarding mothers and infants shall be written in ink on charts or in order books. (4) All employees of a maternity hospital who are in contact with patients at any time and all food handlers shall be subject to examination at any reasonable hour by State or local boards of health, or their agents, to determine free- dom from communicable disease. (5) The construction, space and arrangement of the building or section of the building used as a maternity hos- pital shall be such as to provide reasonable isolation of ma- ternity patients from any other type of patient, insure fa- cilities for efficient care of maternity patients, provide pro- tection against accidents, and conform to State and local fire laws. (6) Such provision shall be made for instruments, equip- ment, linens and other facilities, including facilities for trans- fusion of blood, as may be necessary for the proper care of maternity patients and infants. (7) A room shall be provided as a nursery or each in- fant must have adequate individual care. (8) Standard incubators, or improvised incubators of such design and construction as shall be approved by the Board, shall be provided and maintained in every maternity hospital having deliveries of as many as one hundred patients per year. (9) Isolation facilities shall be available and used for the isolation of infected patients. All necessary precautions shall be taken to prevent the spread of infection to other persons. (10) Adequate provision shall be made for sanitation, general hygiene, and for the protection and handling of food. (11) A maternity hospital shall keep a current register of births with all data required for the issuance of a birth certificate. Such data shall be recorded within twenty-four hours after the admittance, death or discharge of every mother; or after the birth, death, or discharge of every new- born. Such records shall be available to the Board, or its agents, for inspection at all times. Section 5. Inspection.—(a) The Board or its duly authorized agents shall inspect and shall be permitted to inspect every ma- ternity hospital operated or maintained in this State or any room or department thereof, whenever it shall be deemed necessary, and the person or persons in charge thereof shall give the Board and its agents the information required, and afford them every reasonable facility for observing the opera- tion of such hospital. (b) Every maternity hospital in which any unmarried women are received as maternity patients shall be subject to visitation and inspection by the officers and agents of the State Department of Public Welfare, which department shall have the right to inquire into the social service policies and practices of every such hospital pertaining to unmarried wo- men and their children, and for this purpose its officers and agents shall be afforded convenient and reasonable access to the premises, books and records of such hospital by the per- son or persons in charge thereof. Section 6. Revocation of and refusal to grant permits; appeals.— (a) The Board may refuse to grant a permit to any appli- cant, or may revoke any permit granted, whenever such applicant or person to whom such permit was granted shall fail or re- fuse to comply with any provision of this act, or, in the case of a permit already granted, if a greater number of patients be kept at one time than the maximum prescribed by the permit, or if any building, floor, or room be used for any purpose other than that designated on such permit. Whenever a permit is refused to be granted or is revoked, the Board shall immediately notify, in writing, the applicant or person whose permit is so revoked, as the case may be. (b) Whenever the Board revokes or refuses to grant any such permit, the person whose permit is so revoked, or to whom a permit is refused to be granted, shall have a right to appeal to the Circuit Court of the county or to the Cor- poration Court of the city wherein such hospital is located; or, if it be in a city having no Corporation Court, to the Circuit Court of such city; provided, that notice to commence the proceedings be served upon the Board within thirty days after such person receives notice, in writing, of such revoca- tion or refusal. Any such case may be heard by the court or judge thereof in vacation upon ten days’ written notice to the Board, which notice shall be served and returned as provided in section six hundred and forty-one of the Code of Virginia. The court may hear the case after the said ten days’ notice whether the proceedings be matured for hearing at the beginning of the then current or last preceding term of such court or not. If the decision of the court be for the plaintiff the court shall order the Board to reinstate or to grant the permit, as the case may be, upon such terms as the court may prescribe, but if otherwise the proceedings shall be dismissed. Costs shall be awarded as in criminal cases. In any such proceedings the Board shall be named as de- fendant and a writ of error from the decision of such circuit or corporation court shall lie in the Supreme Court of Ap- peals at the suit of either party. Section 7, Penalty, injunction; effect of appeal.—(a) Any person who shall maintain or operate a maternity hospital without having- obtained the permit required by this or after his permit is revoked, shall be guilty of a misdemeanor and, upon conviction thereof, shall be punished by a fine of not less than five hundred nor more than one thousand dollars. (b) Any court of record having chancery jurisdiction in the county or city where any such hospital is located shall have jurisdiction to enjoin the operation of any such hospital maintained without such permit, at the suit of the Board. (c) An appeal, taken as hereinbefore provided from the decision of the Board revoking or refusing to issue a permit, shall operate to stay any prosecution hereunder and to sus- pend the operation of any such injunction pending a final disposition of such appeal, and if the court in such proceed- ings order the permit to be reinstated or granted by the Board, a prosecution hereunder shall be barred. Section 8. Exemptions.—None of the following persons shall be deemed to maintain a maternity hospital for the purposes of this act: (1) Any person who receives and cares for not more than one woman during any one period of twelve months; (2) Persons who shall receive and care for women related to such person by blood or marriage only; and (3) Licensed physicians who receive women at their offices for occasional examination and treatment only. 2. Be it further enacted by the General Assembly of Vir- ginia, That an act entitled “An act to provide for the licensing, regulation, and inspection of maternity hospitals, and to repeal sections nineteen hundred and twenty-five to nineteen hundred and thirty, inclusive, of the Code of Virginia.”, approved March twenty-seventh, nineteen hundred and twenty-two, and all other acts or parts of acts in conflict with this act be, and the same are hereby, repealed; provided, however, that the said repeal shall not take effect until January first, nineteen hundred and forty-one and the provisions of the said act shall remain in full force and effect until that date. PART II Interpretations of the Maternity Hospital Law PART II INTERPRETATIONS OF THE MATERNITY HOSPITAL LAW It is appreciated that rig-id standardization negatives the spirit and progressiveness of medical, administrative, and nursing staffs of any hospital. However, the interpretations of the requirements, and the suggestions here presented, are in accord with accepted principles for the care of maternity patients and newborn infants. It is hoped that each hospital, through its own initiative, will de- velop methods which are in keeping with the requirements and suggestions outlined herein, and are appropriate to its individual needs. The various requirements set forth under separate divisions of subsection (b), Section IV of the Maternity Hospital Law, are reproduced in italics on subsequent pages, and each section fol- lowed by an interpretation. (1) “Each patient in a maternity hospital shall be under the care of or attended by a licensed physician” Requirement for compliance with law: Each patient in a maternity hospital must be under the care of or attended by a licensed physician. Recommended: A qualified obstetrician, if available, should be selected to serve as chief of the obstetrical service. If a qualified obstetrician is not available locally, it is sug- gested that, where practical, an obstetrician from a nearby area be appointed as obstetrical consultant to serve in an advisory capacity. A qualified pediatrician, if available, should be selected to serve as chief of the pediatric service. If a qualified pediatrician is not available locally it is sug- gested that, where practical, a pediatrician from a nearby area be appointed as pediatric consultant to serve in an advisory capacity. Conferences of the hospital stafif should be held at monthly • intervals to discuss morbidity, mortality, and procedures to im- prove maternal and neonatal care. (2) “A registered graduate nurse shall be available for attendance upon maternity patients and newborn infants at all times, and shall be in charge of or responsible for all nursing care. Sufficient registered graduate nurses shall be employed to provide adequate nursing supervision and care for all maternity patients and in- fants.” Requirement for compliance with law: At least one registered graduate nurse must be available to assume responsibility for the nursing care of fraternity pa- tients and newborn infants. A qualified, registered graduate nurse must be in charge of or responsible for all nursing procedures for maternity patients and newborn infants as directed by the attending physician. Student nurses, practical nurses, and nursery maids, if used to assist in the nursing care of these patients, must perform such duties under the direction and immediate supervision of a quali- fied graduate nurse. Patients under analgesia or anaesthesia during the time of labor or delivery must have some one in constant and continu- ous attendance, and this constant and continuous attendance must be maintained for a period of not less than one hour after delivery. Recommended: A minimum of one nurse for each 4 or 5 maternity patients by day and from 8 to 10 such patients by night should be pro- vided for. Not more than 8 newborn infants should be under the care of any one individual nurse. (3) “All orders from physicians regarding mothers and infants shall be written in ink on charts or in order hooks.” Requirement for compliance with law; All physician’s orders must be written in full in order book or on chart and signed by the physician issuing the order. Verbal orders, including orders given by physicians over the telephone, must be confirmed, in writing, within a few hours by the physician issuing the order. (4) “All employees of a maternity hospital who are in contact zvith patients at any time and all food handlers shall he subject to exam- ination at any reasonable hour by State or local boards of health, or their agents, to determine freedom from communicable disease.” Requirement for compliance with law; Freedom from communicable disease must be insisted upon for all employees. (5) “The construction, space and arrangement of the building or sec- tion of the building used as a maternity hospital shall be such as to provide reasonable isolation of maternity patients from any other type of patient, insure facilities for efficient care of maternity patients, provide protection against accidents, and conform to State and local fire laws.” Requirement for compliance with law: Maternity patients must be segregated from other types of patients—preferably on a separate floor or an entirely sepa- rate section of one floor. No patient with any evidence of infection shall be admitted to, or at any time be kept in, the obstetrical division, either in ward, semi-private or private rooms unless given isolation care. Provision must be made for the isolation of maternity pa- tients with evidence of infection. Labor and delivery rooms, when designated as such, must be entirely separate from operating and emergency rooms and preferably be in, or readily accessible to, the obstetrical divi- sion. When delivery rooms are provided for, operating rooms must not be used for delivery except for infected cases or when a major operative procedure is indicated. The equipment of delivery rooms must be limited to instru- ments and supplies necessary for immediate use, and all other equipment and supplies must be kept in supply rooms, closets or cabinets outside of, but readily available to, the delivery room. Recommended: Every effort should be made to supply the obstetrical divi- sion with adequate equipment and this equipment should not be used in other divisions, and vice versa. Janitors and maids for obstetrical floors or divisions should, where possible, serve on that floor or division only. (6) “Such provision shall be made for instruments, equipment, linens and other facilities, including facilities for transfusion of blood, as may be necessary for the proper care of maternity patients and infants.” Requirement for compliance with law: Each attendant assisting in the delivery of patients must wear a clean cap, mask, and sterile gown and gloves. All attendants and persons entering- a labor or delivery room, during labor or delivery, must wear a clean cap, gown and mask. Each infant must be marked for identification by one of the reliable methods in use, before being taken to the nursery, and such identification must be maintained while the infant is in the hospital. Equipment for venoclysis (glucose and normal saline) and for transfusion of blood must be provided for, in, or imme- diately adjacent to the delivery room. A sterile uterine pack must be kept readily available for use at all times. A heated bed must be available for the reception of new- born infants. This bed may be heated by hot water bottles or by any other adequate method. A simple method for aspirating mucus from the throat of the newborn must be provided for. A method to administer oxygen to newborn infants must be provided. This may be a simple tube and funnel attached to any oxygen tank, or a more elaborate apparatus, as desired. All instruments commonly accepted as needed for delivery, repair of perineal lacerations, and other procedures necessary for the adequate care of mother and infant, must be provided and maintained. (7) “A room shall he provided as a nursery or each infant must have adequate individual care.” Requirement for compliance with law: A separate room must be provided as a nursery. In the smaller hospitals, where it is not possible to provide a sepa- rate room for a nursery, each infant must be given individual care and isolation technique. Common dressing, bathing, and diapering tables, when used, must be draped with separate clean linens or satisfactory clean paper sheeting immediately before use for each baby. Recommended: The nursery should be furnished with stationary bathing facilities, a properly protected dressing table, and accurate in- fant scales. No visitors should be admitted to the nursery. (8) “Standard incubators, or improvised incubators of such design and construction as shall be approved by the Board, shall be provided and maintained in every maternity hospital having deliveries of as many as one hundred patients per year.” Requirement for compliance with law: An approved incubator for premature infants must be pro- vided and maintained in each hospital having as many as one hundred deliveries during the preceding year. Recommended: Where possible, premature infants should be cared for in a separate nursery. The nurse-supervisor in charge should have special training in the nursing care of premature infants. (9) “Isolation facilities shall be available and used for the isolation of infected patients. All necessary precautions shall be taken to pre- vent the spread of infection to other persons.” Requirement for compliance with law: Maternity patients with evidence of infection must be promptly isolated from non-infected cases. All newborn infants with a suspicious rash or symptoms of infectious or contagious disease must be promptly isolated. An infant delivered outside of a maternity hospital, and admitted to such a hospital during the neonatal period must be kept out of the newborn nursery, and be given isolation care for such length of time as is commonly accepted as neces- sary. Nurses caring for patients with communicable diseases must not have contact with the obstetrical division or the nursery. Provision must be made for proper sterilization of an ade- quate supply of water, basins, instruments, linens, dressings, and other supplies necessary for the proper care of obstetrical patients and newborn infants. Separate bed pans, marked for the use of each individual obstetrical patient, must be provided, and each bed pan must be sterilized by an approved method upon the discharge of the pa- tient. When bed pans are not provided for individual obstet- rical patients each bed pan must be sterilized after each use. Clean bed pan covers must be provided at all times for each bed pan and these must not be used interchangeably until laundered. Nursery nurses must wear a clean gown, cap and mask, in addition to uniform, when handling babies. Physicians must wear masks and gowns when entering the nursery. Recommended: Nurses employed in the obstetrical division or in the nur- sery should be assigned exclusively to such duties, whenever possible, for a continuous period of days, weeks, or preferably months, as may be determined by the hospital management and the chiefs of the obstetric and pediatric staffs, and during such service these nurses should have as little contact with other patients and other parts of the hospital as may be possible. Except in extreme emergency, nurses from other floors or divisions should not be permitted to relieve nurses in the obstetrical division or in the nursery during periods when nurses regularly assigned to this division are temporarily absent (meals, afternoons off, and similar absences). Where possible, no equipment of any kind used in the care of obstetrical patients and newborn infants should be used for any other purpose, and vice versa. (10) “Adequate provision shall he made for sanitation, general hy- giene, and for the protection and handling of food.” Requirement for compliance with law: Provision must be made for sanitation, general hygiene, and for the protection and handling of food in conformity with State and local health ordinances. (11) “A maternity hospital shall keep a current register of births with all data required for the issuance of a birth certificate. Such data shall he recorded “within twenty-four hours after admittance, death or discharge of every mother; or after the birth, death or discharge of every newborn. Such records shall he available to the Board, or its agent, for inspection at all times.” Requirement for compliance with law: Sufficient data must be maintained to furnish information necessary for the issuance of birth and death certificates for maternity patients and newborn infants. A chart, or similar record, must be kept for each maternity patient and newborn infant. Such chart must show essential information regarding history of the case, examinations, treat- ments, and progress of the patient up to and including day of discharge. Such charts must be kept on file for not less than one year after discharge of patients. The opinions, suggestions, or findings of a physician acting as consultant to a maternity case or newborn infant must be placed in the chart of the patient over the signature of the con- sultant ; this is especially necessary for opinions regarding ad- visability of therapeutic abortion.