Level of Designation Applied for:

Level I

Level II

Level II (with extended capabilities)

Level III

Perinatal Center

HOSPITAL:

CITY:

DESCRIPTION OF GEOGRAPHIC AREA SERVED:

PERINATAL CENTER:

DATE OF SITE VISIT:

MEMBERS (titles and affiliated institution) OF SITE VISIT TEAM:

Please use data from previous 3 calendar years:

YEAR

I.

STATISTICS

A.

Maternal Data

1.

Number of obstetrical beds:

a.

Antepartum

b.

Labor / Delivery

LDR / DRP

C/Section Rooms

Delivery Rooms

c.

Intensive Care Beds

d.

Postpartum

2.

Total number of deliveries:

3.

Percent of vaginal deliveries:

Spontaneous

Forceps

Vacuum Extraction

4.

Percent of C/Sections:

% Primary

% Repeat

5.

Number of VBACs:

Attempts

Successes

6.

Percent of inductions:

7.

Percent of augmentations:

8.

Outcomes for Maternal Admissions with the following diagnosis:

Diabetes

# of maternal admission

# transferred out for delivery

# discharged undelivered

# of neonatal deaths

# of fetal deaths

# of neonates transferred

to a higher level facility

Chronic Hypertension

# of maternal admissions

# transferred out for delivery

# discharged undelivered

# of neonatal deaths

# of fetal deaths

# of neonates transferred to a higher level facility

B.

Neonatal Data

1.

Number of nursery beds:

Normal Newborn

Intermediate / Special

care

NICU / Level III

Average daily census in the Special Care Nursery

(Level II or II with extended capabilities or Level III intermediate)

Average daily census

in the NICU (Level III)

C.

Fetal Mortality

1.

Birthweight Specific Data:

<500 grams

501-750

751-1000

1001-1250

1251-1500

1501-2000

2001-2500

2501-3000

3001-3500

3501-4000

4001-4500

4501-5000

5001 PLUS

2.

Live Birth Data:

<500 grams:

Number of infants born

Number of infants ventilated

beyond six hours

Number of ventilated

infants survived

Ventilator days (total)

Oxygen days (total)

Length of stay (days)

501-750 grams

Number of infants born

Number of infants ventilated beyond six hours

Number of ventilated infants survived

Ventilator days (total)

Oxygen days (total)

Length of stay (days)

751-1000 grams:

Number of infants born

Number of infants ventilated beyond six hours

Number of ventilated infants survived

Ventilator days (total)

Oxygen days (total)

Length of stay (days)

1001-1250 grams:

Number of infants born

Number of infants ventilated beyond six hours

Number of ventilated infants survived

Ventilator days (total)

Oxygen days (total)

Length of stay (days)

1251-1500 grams:

Number of infants born

Number of infants ventilated

beyond six hours

Number of ventilated infants survived

Ventilator days (total)

Oxygen days (total)

Length of stay (days)

1501-2000 grams:

Number of infants born

Number of infants ventilated beyond six hours

Number of ventilated infants survived

Ventilator days (total)

Oxygen days (total)

Length of stay (days)

2001-2500 grams:

Number of infants born

Number of infants ventilated beyond six hours

Number of ventilated infants survived

Ventilator days (total)

Oxygen days (total)

Length of stay (days)

2501-3000 grams:

Number of infants born

Number of infants ventilated beyond six hours

Number of ventilated infants survived

Ventilator days (total)

Oxygen days (total)

Length of stay (days)

3001-3500 grams:

Number of infants born

Number of infants ventilated beyond six hours

Number of ventilated infants survived

Ventilator days (total)

Oxygen days (total)

Length of stay (days)

3501-4000 grams:

Number of infants born

Number of infants ventilated beyond six hours

Number of ventilated infants survived

Ventilator days (total)

Oxygen days (total)

Length of stay (days)

4001-4500 grams:

Number of infants born

Number of infants ventilated beyond six hours

Number of ventilated infants survived

Ventilator days (total)

Oxygen days (total)

Length of stay (days)

4501-5000 grams:

Number of infants born

Number of infants ventilated beyond six hours

Number of ventilated infants survived

Ventilator days (total)

Oxygen days (total)

Length of stay (days)

5001 PLUS:

Number of infants born

Number of infants ventilated beyond six hours

Number of ventilated infants survived

Ventilator days (total)

Oxygen days (total)

Length of stay (days)

Incidence of Neonatal Complications:

Pulmonary air leaks

Necrotizing enterocolitis

Retinopathy of Prematurity

Intraventricular hemorrhage

Grade I & II

Grade III & IV

Periventricular leukomalacia

Bronchopulmonary dysplasia

Neonatal Sepsis

Respiratory Distress Syndrome

Persistent Pulmonary Hypertension of the Newborn

Meconium Aspiration Syndrome

Neonatal Surgeries

Seizures

5 minute Apgar <7

D.

OUTCOME STATISTICS

All neonatal deaths are to be counted by the hospital of birth regardless of place of death. Neonates born in emergency rooms are to be counted by the hospital of birth.

1.

Maternal Deaths:

(Attach documentation of joint case review meeting and assigned disposition of mortality for each death.)

(Standardized Neonatal Mortality Rate and Standardized Perinatal Mortality Rate. This information should be obtained from the most current Perinatal Health Status Reports.)

2.

Standardized Neonatal Mortality Rate:

3.

Standardized Perinatal Mortality Rate:

(Attach documentation of joint case review meetings and assigned disposition of the mortalities. Give synopsis of action taken on deaths disposed as potentially avoidable.)

II.

STAFF

A.

List the names and titles of directors/chairperson:

Attach CV of Medical Directors; where appropriate identify subspecialty board).

Full

Time

Board

Certified

Sub-board

Certified

Maternal – Fetal

Y/N

Y/N

Y/N

Neonatology

Y/N

Y/N

Y/N

Obstetric

Y/N

Y/N

FP/GP

Y/N

Y/N

Anesthesia

Y/N

Y/N

Obstetric Anesthesia

Y/N

Y/N

Pediatric

Y/N

Y/N

OB/Gyn Residency Program

Y/N

(if applicable)

Pediatric Residency Program

Y/N

(if applicable)

Perinatal Fellowship Program

Y/N

Neonatal Fellowship program

Y/N

Pediatric Surgery

Y/N

Y/N

Y/N

Pediatric Neurosurgery

Y/N

Y/N

Pediatric Radiology

Y/N

Y/N

Pediatric Cardiology

Y/N

Y/N

Y/N

Pediatric Cardiac Surgery

Y/N

Y/N

Pediatric Anesthesiology

Y/N

Y/N

Pediatric Ophthalmology

Y/N

Y/N

Pediatric Nephrology

Y/N

Y/N

Y/N

Pediatric Medical Genetics

Y/N

Y/N

Pediatric Orthopedics

Y/N

Y/N

Pediatric Otolaryngology

Y/N

Y/N

Pediatric Pulmonology

Y/N

Y/N

Y/N

Pediatric Hematology

Y/N

Y/N

Y/N

Pediatric Endocrinology

Y/N

Y/N

Y/N

Pediatric Gastroenterology

Y/N

Y/N

Y/N

B.

Staff Available

On-Call

In-House 24 hours/day

Obstetrics

Neonatology

OB Anesthesia

Maternal / Fetal

C.

Nursing

(List the names, titles, and credentials of nursing staff, as required for this section, with privileges in the Departments of Obstetrics and Pediatrics.  Attach CB of Director of Nursing.)

Director of Nursing (Maternal / Child Nursing)

Director of Nursing (NICU / NBN)

Certified Nurse Midwife / Midwives

Clinical Specialist/Nurse Practitioners – Neonatal and Obstetrics

Transport Coordinators

Neonatal

Y

N

Maternal / Fetal

Y

N

Allied Health Staff

Radiology Director

Y

N

Genetics Director

Y

N

Respiratory Therapy Director

Y

N

Licensed Social Worker

Y

N

Registered Dietitian

Y

N

Director of Laboratory

Y

N

Family Care Coordinator

Y

N

Dedicated Pharmacist

Y

N

D.

Transport Statistics

YEARS

1.

Number of maternal transfers/transports do not include return transfers/transports):

into institution

out of institution

in Network

out of Network

2.

Number of neonatal transfers (do not include return transfers):

into institution

out of institution

in Network

out of Network

3.

Number of in-born infants less than

1250 grams transferred out (state disposition of above infants not transferred):

E.

Transfer Information (Please attach the information requested in this section):

1.

Maternal:

a.

List conditions for which maternal patients were transferred (latest year only):

b.

List hospitals to which maternal patients were transferred (latest year only):

c.

Number of maternal transfer patients refused and reasons for refusal:

2.

Neonatal:

a.

List conditions for which neonates were transferred (latest year only):

b.

List hospitals to which neonates were transferred (latest year only):

c.

Number of neonatal transfer patients refused and reasons for refusal (latest year only):

F.

Anesthesia

1.

Is 24-hour anesthesia available in-house?

Y

N

If yes, who (anesthesiologist, nurse anesthetist)

If anesthesia is on-call, response time?

2.

Location C/Section

performed

in OR suite on obstetrical level

in OR suite on surgery level

3.

Length of time required for start-up of C/Section

G.

Education

1.

Documentation of in-service education programming provided:

Brief description, dates, and attendance:

Y

N

2.

Documentation of fetal monitoring and neonatal resuscitation programs provided. Brief description, dates, and attendance:

3.

Documentation of C/Section Reviews:

H.

Developmental Follow-up Program

Briefly describe your developmental follow-up program, and include the name of the Director of this program and the length of follow-up.

Explain arrangements for integrating Early Intervention Programs with the discharge planning process and developmental follow-up program.

I.

Continuous Quality Improvement (CQI)

Briefly describe CQI Activities specific to Maternal/Fetal/Neonatal Medicine.

J.

Perinatal Centers

1.

Provide documentation of educational activities sponsored by the Center for Network hospital and community health agencies.

2.

Provide documentation of morbidity and mortality reviews with Network hospitals.

3.

Provide documentation of Network Continuous Quality Improvement (CQI) activities.