201 Ky. Admin. Regs. 20:670

Current through Register Vol. 51, No. 6, December 1, 2024

Section 201 KAR 20:670 - Licensed certified professional midwives consultation, collaboration, and referral provisions

RELATES TO: KRS 314.400 - 314.414

NECESSITY, FUNCTION, AND CONFORMITY: KRS 314.131(1) authorizes the Board of Nursing to promulgate administrative regulations as may be necessary to enable it to carry into effect the provisions of KRS Chapter 314. KRS 314.404(12) requires the board to promulgate an administrative regulation to define a list of conditions requiring collaboration, consultation, or referral of a client to a physician or other appropriate licensed health care provider, and the process for such collaboration, consultation, or referral. This administrative regulation establishes the process for and the list of conditions requiring collaboration, consultation, and referral.

Section 1.

(1) Consultation does not require an in-person visit. It may include a discussion by the LCPM and an appropriate healthcare provider by telephone or other appropriate electronic communication.

(2) The consultant may recommend further evaluation which may be either in-person, by telehealth, or a records review.

(3) It is the responsibility of the LCPM to initiate a consultation and to communicate clearly to the consultant that the LCPM is seeking a consultation.

(4) A consultation may involve the consultant providing advice and information, providing care to the client or newborn, or prescribing treatment or medication for the client or newborn.

(5) It is the responsibility of the LCPM to provide all relevant client records to the consultant, including a written summary of the client's history and presenting problem, as appropriate.

(6) Consultation shall be fully documented by the LCPM in the client's record, including the consultant's name, date of service, and the consultant's findings, opinions, and recommendations. The LCPM shall discuss the consultant's recommendations with the client.

(7) After consultation and with the informed consent of the client as required by 201 KAR 20:640, care of the client and responsibility for decision making either:

(a) Continues with the LCPM;

(b) Is shared in collaboration by the LCPM and an appropriate licensed healthcare provider;

(c) Is referred completely to an appropriate licensed healthcare provider; or

(d) Is transferred to a licensed healthcare facility providing a higher level of care pursuant to 201 KAR 20:690.

(8) Referral or collaboration shall occur only after dialogue and agreement among the client, the LCPM, and the consultant.

(9) The LCPM shall ensure that the client can understand each provider's role and is able to identify which healthcare provider is responsible for various aspects of the client's care.

(10) Collaboration shall be documented by the LCPM in the client's record, including the name of the collaborating provider and the conditions or symptoms the collaborating provider is managing.

(11) The LCPM shall maintain communication with the collaborating provider to the extent necessary to coordinate client care.

(12) If the condition or symptom requiring collaboration is resolved as mutually agreed upon by the LCPM and the collaborating provider, the LCPM may resume sole management of the client's care if appropriate, and document the decision in the client's record.

(13) Discussion with the client regarding the indications for complete referral of care shall take place in a timely manner following the decision for referral. If possible, this discussion shall occur in person and be documented in the client's record.

(14) It is the responsibility of the LCPM to provide all relevant client records to appropriate providers or facilities, including a written summary of the client's history and presenting problem, as appropriate.

(15) If the condition or symptom requiring referral of care is resolved as mutually agreed upon by the LCPM and other participating providers, the LCPM may resume primary management or enter into a collaboration of care if appropriate, and document the decision in the client's record.

Section 2.

(1) If, on initial or subsequent assessment, one (1) of the conditions listed in this subsection exists, the LCPM shall consult with a physician or other appropriate licensed healthcare provider and shall mutually select either collaboration or referral as appropriate and shall document that recommendation in the client record:

(a) Complete placenta previa;

(b) Partial placenta previa persisting after thirty-two (32) weeks;

(c) HIV infection;

(d) Cardiovascular disease, including hypertension;

(e) Severe psychiatric illness that may result in bodily harm to self or others;

(f) History of cervical incompetence;

(g) Pre-eclampsia or eclampsia;

(h) Intrauterine growth restriction, oligohydramnios or polyhadramnios in the current pregnancy;

(i) Known potentially serious anatomic fetal abnormalities;

(j) Any type of diabetes not controlled by diet;

(k) Substance use disorder with current or recent use; or

(l) Any other condition or symptom which may threaten the life of the client or fetus, as assessed by an LCPM exercising reasonable skill and knowledge.

(2) If a client with a condition listed in subsection (1) of this section declines to accept a medically indicated consultation, collaboration, or referral, the licensed certified professional midwife shall document the refusal in writing and shall transition the client to an appropriate higher level of care.

(3) If the condition mandating referral occurs during labor or delivery or the client is otherwise acutely in jeopardy but refuses the referral, the LCPM shall call 911 and provide care until another appropriate licensed healthcare provider assumes care.

Section 3.

(1) If, on initial or subsequent assessment, one (1) of the following conditions exists, the LCPM shall consult with a physician or other appropriate licensed healthcare provider to mutually select either collaboration or referral as necessary and shall document the recommendation in the client record:

(a) Prior Cesarean section or other surgery resulting in a uterine scar;

(b) Multifetal gestation;

(c) Non-cephalic presentation after thirty-six (36) weeks gestation;

(d) History of severe shoulder dystocia as documented by objective findings; or

(e) Gestational age greater than forty-two (42) weeks.

(2) An individual with a condition listed in subsection (1) of this section may give informed refusal to a consultation or to the consultant's recommendation. Prior to giving informed refusal, the LCPM shall recommend that the individual discuss the condition and the risks involved with a physician or other appropriate licensed healthcare provider. If the client continues to refuse the consultation, collaboration, or referral, the LCPM shall document in the client's record that the client was informed of the condition requiring consultation, collaboration, or referral and the possible consequences. The client shall complete the Informed Refusal Form. The LCPM may continue to assume primary management of the client unless and until the client subsequently consents to the collaborative care or referral.

Section 4.

(1) If, on initial or subsequent assessment, one (1) of the following conditions exists, the LCPM shall recommend consultation, collaboration, or referral with a physician or other appropriate licensed healthcare provider:

(a) Acute or chronic bacterial or fungal infection;

(b) Liver or kidney disease;

(c) Endocrinologic abnormalities;

(d) Hematologic abnormalities other than physiologic anemia of pregnancy;

(e) History of impaired glucose tolerance, history of diabetes satisfactorily controlled by diet and lifestyle changes alone, abnormal blood sugar or glucose tolerance test, or history of gestational diabetes;

(f) Substance use disorder, in remission;

(g) Current asthma or other significant pulmonary disease;

(h) Abnormality in a screening test indicative of possible genital tract malignancy or pre-malignant condition during the pregnancy;

(i) Seizure disorder or other significant neurologic disease;

(j) Abnormal vaginal bleeding during pregnancy other than first trimester bleeding;

(k) History of invasive malignancy;

(l) History of severe and persistent mental illness;

(m) History of prior intrauterine fetal demise or neonatal death;

(n) History of preterm birth; or

(o) Any other condition or symptom which could adversely affect the client or the fetus as assessed by an LCPM exercising reasonable skill and knowledge.

(2) If the client refuses the recommended consultation, collaboration, or referral pursuant to subsection (1) of this section, the LCPM shall document the refusal in the client's record and may continue to assume primary management of the client.

Section 5. Incorporation by Reference.

(1) "Informed Refusal Form", 1/2020, is incorporated by reference.

(2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Kentucky Board of Nursing, 312 Whittington Parkway, Suite 300, Louisville, Kentucky 40222, Monday through Friday, 8:00 a.m. to 4:30 p.m. This material is also available on the board's Web site at https://kbn.ky.gov/document-library/Pages/default.aspx

201 KAR 20:670

46 Ky.R. 2174, 2902; 47 Ky.R. 530; eff. 7-29-2020; TAm eff. 7/12/2022; TAm eff. 11/21/2023.

STATUTORY AUTHORITY: KRS 314.131(1), 314.404