Section 640.APPENDIX H  Written Protocol for Referral/Transfer/Transport

Exhibit A  Level I:  Patients for consultation with ________________ (Level III facility or Perinatal Center)

1)         Maternal Conditions

A)        Previous Pregnancy Problems:

i)          Premature infant

ii)         Perinatal death or mental retardation

iii)         Isoimmunization

iv)        Difficult deliveries

v)         Congenital malformations

vi)        Mid-trimester loss

B)        Current Pregnancy Problems:

i)          Any medical disorder (e.g., diabetes mellitus, hemoglobinopathy, chronic hypertension, heart disease, renal disease)

ii)         Drug addiction

iii)         Multiple gestation

iv)        Intrauterine growth retardation

v)         Preterm labor less than or equal to 36 weeks

vi)        Postdate greater than or equal to 42 weeks

vii)        Third trimester bleeding

viii)       Abnormal genetic evaluation

ix)        Pregnancy induced hypertension

2)         Neonatal Conditions

A)        Gestation less than or equal to 36 weeks, weight less than or equal to 2500 grams

B)        Small-for-gestational age (less than 10th percentile)

C)        Sepsis

D)        Seizures

E)         Congenital heart disease

F)         Multiple congenital anomalies

G)        Apnea

H)        Respiratory distress

I)          Neonatal asphyxia

J)         Infants identified as having handicapping conditions or developmental disabilities which threaten life or subsequent development

K)        Severe anemia

L)         Hyperbilirubinemia, not due to physiologic cause

M)       Polycythemia

3)         Consultation and transfer to a Level III or Perinatal Center shall occur for the following conditions:

A)        Premature labor or premature birth less than 34 weeks gestation.

B)        Birthweight less than or equal to 2000 grams.

4)         Exceptions:

A)        Exceptions to the standards of care set forth in this Part may be necessary based on patient care needs, current practice, outcomes, and geography in the regional perinatal network.

B)        Exceptions to the standards of care of this Part may be granted when the facility requesting an exception demonstrates that the staffing, equipment and quality of care (outcomes), are substantially equivalent to the standards and quality of care for any Level II or Level III facility in their Regional Perinatal Network.

C)        Such exceptions shall be negotiated between the applicant facility and their Perinatal Center.  The applicant facility or the Perinatal Center shall seek the advice and consultation of the Department, as well as the Perinatal Advisory Committee, to facilitate negotiations regarding exceptions to these standards of care.  Any exception to the standards of care of this Part must be defined in the letter of agreement.

D)        The Department shall review all letters of agreement and modification of letters of agreement.  The Department shall use the criteria described in Section 640.41(e)(2) in order to approve or deny approval of any provision of or any letter of agreement.

(Source:  Amended at 24 Ill. Reg. 12574, effective August 4, 2000)