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# ID [               ]{.underline} 

# [Perinatal Hepatitis B Hospital Policy and Practices Survey]{.underline}

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# The purpose of this questionnaire is to obtain data from delivery hospitals to assess current policies and practices regarding perinatal infections, particularly hepatitis B virus infection. 

1.  Please indicate your name
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ and telephone \#
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2.  Please indicate your professional category

> Nurse
>
> Pediatrician
>
> Clinical Nurse Manager
>
> Administrative personnel
>
> Other -- Please specify
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3.  Please indicate your title
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> **Admission to Labor and Delivery --** Perinatal Hepatitis B Policy

4.  Do you currently have a **written policy** to review prenatal HBsAg
    (hepatitis B surface antigen) test results at the time of admission
    to the Labor and Delivery (L & D) unit for all pregnant women?

> Yes No Don't Know

5.  Do you currently have **routine pre-printed admission orders**\* to
    review HBsAg test results at the time of admission for delivery for
    all pregnant women?

> Yes No Don't Know

6.  For women admitted to L & D who do not have a documented HBsAg test
    result, do you currently have a **written policy** for HBsAg testing
    as soon as possible after admission?

> Yes No Don't Know

7.  For women admitted to L & D who do not have a documented HBsAg test
    result, do you currently have **routine pre-printed admission
    orders\*** for HBsAg testing as soon as possible after admission?

> Yes No Don't Know

8.  Do you currently have a **written policy** for repeat testing of
    pregnant, HBsAg-negative women who are at risk for HBV infection
    during pregnancy? (e.g. \>1 sex partner in the previous six months,
    evaluation or treatment for an STD, recent or current injection drug
    use, HBsAg-positive sex partner or who have had clinical hepatitis).

> Yes No Don't Know

##### Prophylaxis Management of Infants According to Maternal HBsAg Status

9.  Do you currently have a **written policy** for administration of
    HBIG (hepatitis B immune globulin) within 12 hours of birth for all
    infants born to HBsAg-positive mothers?

> Yes No Don't Know

10. Do you currently have **routine pre-printed admission orders**\* for
    administration of HBIG (hepatitis B immune globulin) within 12 hours
    of birth for all infants born to HBsAg-positive mothers?

> Yes No Don't Know
>
> **ID [                ]{.underline}**

11. Do you currently have a **written policy** for administration of
    hepatitis B vaccine within 12 hours of birth for all infants born to
    HBsAg-positive mothers?

> Yes No Don't Know

12. Do you currently have **routine pre-printed admission orders**\* for
    administration of hepatitis B vaccine within 12 hours of birth for
    all infants born to HBsAg-positive mothers?

> Yes No Don't Know

13. Do you currently have a **written policy** for administration of
    hepatitis B vaccine within 12 hours of birth for all infants born to
    mothers with unknown HBsAg status?

> Yes No Don't Know

14. Do you currently have **routine pre-printed admission orders**\* for
    administration of hepatitis B vaccine within 12 hours of birth for
    all infants born to mothers with unknown HBsAg status?

> Yes No Don't Know

### Maternal Status Documentation and Universal Vaccination of Infants

15. Do you currently have a **written policy** for documentation of
    maternal HBsAg test results in the infant medical record?

> Yes No Don't Know

16. Do you currently have a **written policy** to routinely administer
    the hepatitis B vaccine to all newborns before hospital discharge?

> Yes No Don't Know

17. Do you currently have **routine pre-printed admission orders**\* to
    routinely administer the hepatitis B vaccine to all newborns before
    hospital discharge?

> Yes No Don't Know

**Delivery Hospital Characteristics**

18. How many live births did your hospital have in "[INSERT
    YEAR]{.mark}"? \_\_\_\_\_\_\_\_\_\_

19. Who is responsible for making policy within the hospital regarding
    neonatal practice (receipt/non-receipt of hepatitis B vaccine or
    HBIG) in the neonatal nursery? Please check all that apply.

> Neonatal nursery committee
>
> Chief pediatrician
>
> Chief obstetrician
>
> Neonatologist
>
> Nurse Manager
>
> Clinical nurse educator
>
> Pediatric department
>
> Other: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

20. What levels of neonatal care does your hospital provide? Check all
    that apply.

> Level 1: basic Level 2: specialty care Level 3: neonatal intensive
> care

**ID [                ]{.underline}**

> []{.mark}
>
> *[Below are examples of additional questions that could be included on
> HIV (also consider adding questions on syphilis, GBS, etc)]{.mark}*
>
> **Admission to Labor and Delivery --** HIV Policy

21. Do you currently have a **written policy** to review prenatal HIV
    test results at the time of admission to the Labor and Delivery (L
    & D) unit for all pregnant women?

> Yes No Don't Know

22. Do you currently have **routine pre-printed admission orders**\* to
    review HIV test results at the time of admission for delivery for
    all pregnant women?

> Yes No Don't Know

23. For women admitted to L & D who do not have a documented HIV test
    result, do you currently have a **written policy** for HIV testing
    as soon as possible after admission?

> Yes No Don't Know

24. For women admitted to L & D who do not have a documented HIV test
    result, do you currently have **routine pre-printed admission
    orders**\* for HIV testing as soon as possible after admission?

> Yes No Don't Know

##### Prophylaxis Management of Women and Infants According to Maternal HIV Status

25. Do you currently have written policies for administration of
    intrapartum antiretroviral prophylaxis to all **HIV-infected women**
    to prevent mother-to-child transmission of HIV?

> Yes No Don't Know

26. Do you currently have written policies for administration of
    **neonatal** antiretroviral prophylaxis to all **HIV-exposed
    infants** to prevent mother-to-child transmission of HIV?

> Yes No Don't Know

27. Do you currently have written policies to test **newborns for HIV**
    if mothers HIV status remains **unknown** at delivery??

> Yes No Don't Know

##### HIV Consent

28. Is **separate** maternal written consent for HIV testing required by
    this hospital?

> Yes No Don't Know

**Thank you for your participation.**