Section 640

Section 640.APPENDIX A Standardized Perinatal Site Visit Protocol

Standardized Perinatal Site Visit Protocol

Components of site visit tool − information to be completed by applicant hospital prior to site visit and reviewed and approved at time of site visit by site visit team.

HOSPITAL: CITY: , Illinois

Level of Designation Applied for: Level I ____ Level II _____ Level II with Extended Neonatal Capabilities ____ Level III ____ Administrative Perinatal Center

ADMINISTRATIVE PERINATAL CENTER:

DATE OF SITE VISIT:

GEOGRAPHIC AREA SERVED (Provide description):



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

I. HOSPITAL DATA

Please use data from most recent three calendar years

A. MATERNAL DATA

	200	200	201
1. Number of Obstetrical Beds:				Current RN/Patient ratio
a. Ante-partum
b. Labor / Delivery LDR
C/Section Rooms
Delivery Rooms (LDR, see above)
c. LDRP
d. Pospartum				(mother/baby couplets)
2. Total Number of Women Delivering
3. Number of Vaginal Deliveries:
Spontaneous
*Forceps
*Vacuum Extraction
4. Number of C/Sections − add percents-#/%
Total	/%	/%	/%
Primary	/%	/%	/%
Repeat	/%	/%	/%
5. Number of Vaginal Births After Cesarean (VBAC) – add percent − #/%
6. Number of inductions
+7. Number of augmentations

* Use final delivery modality

+ Augmentation – stimulation of contractions when spontaneous contractions have failed to progress dilation or descent

B. NEONATAL DATA

1. Number of nursery beds:	200	200	201	Current RN/Patient Ratio
Normal newborn
Intermediate/Special care
NICU/Level III only
2. Average daily census in the Special Care Nursery* (Level II or II with extended neonatal capabilities)
3. Average daily census in the NICU (Level III only)

* Provide explanation of how average daily census in Special Care Nursery was calculated.

C. LIVE BIRTH DATA

1. Birth Weight Specific Data – indicate # born & died in each category (example 10/2)

(Use Electronic Birth Certificate data for live births) (add percent for LBW and VLBW in shaded areas)

	200	200	201
< 500 grams	/	/	/
500 − 749	/	/	/
750 – 999	/	/	/
1000 − 1249	/	/	/
1250 − 1499	/	/	/
Percent for VLBW
1500 – 1999	/	/	/
2000 – 2499	/	/	/
Percent for LBW
2500 – 2999	/	/	/
3000 – 3499	/	/	/
3500 – 3999	/	/	/
4000 – 4499	/	/	/
4500 – 4999	/	/	/
5000 Plus	/	/	/
Total Live Births/Neonatal Deaths

2. Incidence of Neonatal complications (Occurrences at hospital of birth)

Use <1500 gram VON data	200	200	201
Necrotizing enterocolitis
Retinopathy of prematurity
Intraventricular hemorrhage − Grade III Grade IV
Peri-ventricular leukomalacia
Broncho-pulmonary dysplasia
*Use all babies for categories below
Respiratory Distress Syndrome (ICD 9 code 769)
Persistent Pulmonary Hypertension of the Newborn (ICD 9 code 747.83)
Meconium Aspiration Syndrome (ICD 9 code 770.1)
Neonatal Surgeries
Seizures (ICD 9 code 779.0)
Infections (7 ICD 9 code 771.81)
5 minute Apgar <7 (exclude infants <500 grams)

* If in expanded VON, use VON data for "all babies" categories

D. FETAL DEATHS

Birth weight Specific Data − # per weight category

	200	200	201
<500 grams
500 − 749
750 − 999
1000 − 1249
1250 − 1499
1500 − 1999
2000 − 2499
2500 − 2999
3000 − 3499
3500 − 3999
4000 − 4499
4500 − 4999
5000 Plus
Total Fetal Deaths

E. MORTALITY DATA

	200	200	201
1. Maternal Deaths (Hospital of Delivery) (attach table with individual dispositions, factors and cause of death) Pregnancy Related Non-pregnancy Related
2. Perinatal Deaths (attach summary table with dispositions and factors per year for 3 years) a. Fetal Deaths (FD) b. Neonatal Deaths (ND)
*3. Mortality Rates (all births) a. Fetal Mortality Rate (FD/total births X 1000) b. Neonatal Mortality Rate (ND/total live births X 1000) c. Perinatal Mortality Rate (FD + ND/total births X 1000) d. Vermont Oxford Standard Mortality Rate

* Question #3, only for Level III institutions

F. TRANSPORT DATA

	200	200	201
1. Number of maternal transfers/transports/transports (Do not include return transfers/transports )
Into institution
Out of institution

	200	200	201
2. Number of neonatal transfers (Do not include return transfers/transports)
Into institution
Out of institution

3. Provide maternal and neonatal transport information for the most current calendar year (for Perinatal Centers, provide transport information by hospital, by gestational age and by year for 3 years).

II. OB HEMORRHAGE DOCUMENTATION

List OB Hemorrhage cases from the previous calendar year (patients sent to ICU or received 3 or greater units of blood products).

III. RESOURCE REQUIREMENTS

Complete attached Resource Checklist for the appropriate level of care − current level and level being applied for if different.

IV. ADMINISTRATIVE PERINATAL CENTERS

A. Provide documentation of educational activities sponsored by the Administrative Perinatal Center for network hospitals and local health departments.

B. Provide evidence of morbidity and mortality reviews with network hospitals.

C. Provide written documentation of Regional Perinatal Network CQI Activities.

(Source: Amended at 35 Ill. Reg. 2583, effective January 31, 2011)