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

Exhibit B  Level II:  Patients for consultation with or transfer to ____________________ (Level III facility or Perinatal Center)

1)        Maternal Conditions (Consultation)

           A)        Essential hypertension on medication.

           B)        Chronic Renal disease.

C)        Chronic medical problems with known increase in perinatal mortality or morbidity.

D)        Prior birth of neonate with serious complication resulting in a handicapping condition.

E)        Abnormalities of the reproductive tract known to be associated with an increase in preterm delivery.

           F)         Previous delivery of preterm infant 34 weeks gestation.

           G)        Insulin dependent diabetes Class B or greater.

2)        Maternal Conditions (Transfer)

A)        Patients from the above consultation list, which deemed advisable by mutual collaboration between Maternal-Fetal Medicine physician at the Level III facility and the obstetrician at the referring office of hospital.

           B)        Isoimmunization with possible need for intrauterine transfusion.

           C)        Suspected congenital anomaly compatible with life.

           D)        Insulin-dependent diabetes mellitus.

           E)         Cardiopulmonary disease with functional impairment.

           F)         Multiple gestation with exception of twins.

           G)        Premature labor prior to 32 weeks.

           H)        Premature rupture of membranes prior to 32 weeks.

I)         Medical and obstetrical complication of pregnancy, possibly requiring induction of labor or cesarean section for maternal or fetal conditions prior to 32 weeks gestation.

            J)         Severe pre-eclampsia or eclampsia.

3)         Neonatal Conditions (Consultation or transfer):  Specify whether consultation or transfer will be done for each of the following:

            A)        Gestation less than 32 weeks or less than 1800 grams.

            B)        Sepsis unresponsive to therapy.

            C)        Uncontrolled seizures.

            D)        Significant congential heart disease.

            E)        Major congenital malformations requiring surgery.

            F)        Infants requiring ventilation after initial stabilization (greater than 6 hours).

            G)        Infants with oxygen requirements in excess of 50% (greater than 6 hours).

            H)        Infants with ten minute Apgar scores of 5 or less.

            I)         All neonates requiring major surgery.

            J)         Infants requiring exchange transfusion.

K)        Persistent metabolic derangement (e.g., hypocalcemia, hypoglycemia, metabolic acidosis).

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

4)         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.

            C)        Mechanical ventilation beyond the initial stabilization period (6 hours).

5)         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 may 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.