Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 640 - REGIONALIZED PERINATAL HEALTH CARE CODE › Appendix A - Standardized Perinatal Site Visit Protocol

Current through Register Vol. 48, No. 28, July 12, 2024
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.