Ill. Admin. Code tit. 77, pt. 640, app A
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 |
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.
Ill. Admin. Code tit. 77, pt. 640, app A