TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.10 SCOPE (REPEALED)
Section 640.10 Scope (Repealed)
(Source: Repealed at 35 Ill.
Reg. 2583, effective January 31, 2011)
 | TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.20 DEFINITIONS
Section 640.20 Definitions
"Act" means the Developmental Disability Prevention Act [410
ILCS 250].
"Active Candidate"
means having completed a residency in the appropriate medical discipline in a
program approved by the Residency Review Committee or a program approved by
the Council on Postdoctoral Training (COPT) for the American Osteopathic
Association (AOA). Active candidates shall become board certified within five
years after completion of an approved program.
"Administrative Perinatal Center" or "APC" means
a referral facility intended to care for the high-risk patient before,
during, or after labor and delivery and characterized by sophistication and
availability of personnel, equipment, laboratory, transportation techniques,
consultation and other support services. (Section 2(e) of the Act) An APC is
a university or university-affiliated hospital designated by the Department as
a Level III hospital, that receives financial support from the Department to
provide leadership and oversight of the Regionalized Perinatal Healthcare
Program.
"Advanced Practice Nurse" or "APN" means a
person who has met the qualifications for a certified nurse midwife (CNM);
certified nurse practitioner (CNP); certified registered nurse anesthetist
(CRNA); or a clinical nurse specialist (CNS) and has been licensed by the
Department of Financial and Professional Regulation.
"Affiliated Hospital"
means an institution that has a letter of agreement with a specific APC.
"Apgar" means the
score devised in 1952 by Virginia Apgar to assess the health of newborn
children immediately after birth. The five criteria are Activity (Muscle Tone),
Pulse, Grimace (Reflex Irritability), Appearance (Skin Color), and Respiration.
"Assisted Ventilation" means the movement of gas into and out
of the lung by an external source connected directly to the patient. The
external source may be a resuscitation bag, a continuous distending pressure
device, or a mechanical ventilator. Attachment to the patient can be by way of
a face mask, a head box, an endotracheal tube, nasal prongs, a tracheostomy, or
a negative-pressure apparatus surrounding the thorax.
"Certified Local Health Department" means a local health
department that receives program approval from the Department for all ten
required basic health programs during required program and performance review.
"Congenital" means those intrauterine factors which
influence the growth, development and function of the fetus. (Section 2(b)
of the Act)
"Consultation" means a health care provider obtaining
information from an obstetrician, a maternal-fetal medicine physician or neonatology
specialist via the telephone, in writing, or in person for the purpose of
making patient care decisions and developing a care plan.
"Continuous
Quality Improvement" or "CQI" means a structured organizational
process for involving personnel in planning and executing a continuous flow of
improvements to provide quality health care that meets or exceeds expectations.
"Department" means the Department of Public Health.
(Section 2(h) of the Act)
"Designation" means official recognition of a hospital by the
Department as having met the standards contained in Section 640.40 and Section
640.50 for the level of care that the hospital will provide as a part of a
regional perinatal network for all levels of perinatal care.
"Developmental Disability" means mental retardation,
cerebral palsy, epilepsy, or other neurological handicapping conditions of an
individual found to be closely related to mental retardation or to require
treatment similar to that required by mentally retarded individuals, and the
disability originates before such individual attains age 18, and has continued,
or can be expected to continue indefinitely, and constitutes a substantial
handicap of such individuals. (Section 2(f) of the Act)
"Dietitian" means a
person who is licensed as a dietitian in accordance with the Dietetic and
Nutrition Services Practice Act [225 ILCS 30].
"Disability" means a condition characterized by
temporary or permanent, partial or complete impairment of physical, mental or
psychological function. (Section 2(g) of the Act)
"Environmental" means those extrauterine factors
which influence the adaptation, well being or life of the newborn and may lead
to disability. (Section 2(c) of the Act)
"Essential Resource" means a component, such as medical or nursing
medical staff; a service, such as heat, water, or electrical power, or
equipment that is necessary to maintain the designated level of care.
"Full-time"
means on duty a minimum of 36 hours, four days per week.
"Handicapping Condition" means a medically recognized birth
defect that threatens life or has a potential for a developmental disability in
accordance with Subpart C of the Illinois Health and Hazardous Substances
Registry (77 Ill. Adm. Code 840.210).
"Health
Care Provider" means an individual who provides medical services or
treatments to patients within his or her scope of practice. This may include,
but is not limited to, physician, nurse, dietitian, social worker and
respiratory care provider.
"High-Risk" means an increased level of risk of harm or
mortality to the woman of childbearing age, fetus or newborn from congenital
and/or environmental factors. (Section 2(d) of the Act)
"High-Risk Infant" means a live-born infant fitting the Adverse
Pregnancy Outcomes Reporting System (APORS) case definition. (See 77 Ill. Adm.
Code 840.200.)
"Hospital" means a
facility defined as a hospital in Section 3 of the Hospital Licensing Act [210
ILCS 85].
"Intermediate Care Nursery"
or "ICN" means a nursery that provides nursing care to those infants
convalescing or those sick infants not requiring intensive care.
"Joint Morbidity and
Mortality Review" means the required review of maternal and neonatal cases
attended by the APC's maternal-fetal medicine physician, neonatologist and the
Perinatal Center administrator and/or obstetric and neonatal educators. The review
is a quality improvement initiative under the Medical Studies Act [735 ILCS 5/8-2101]
and consists of cases presented by the attending physician at the Regional
Network Hospital. The review includes all maternal, fetal and neonatal deaths,
as well as selected morbidities as determined by the APC's Regional Quality
Council or defined in the Regional Network Hospital's letter of agreement. The review
provides evaluation and disposition of outcomes to guide educational program
needs and quality improvement initiatives.
"Letter of Agreement"
means a document executed between the APC and the hospital, which includes
responsibilities of each party in regard to the hospital's level of designation
and the services to be provided.
"Maternity or Neonatal Complications" means those medically
determined high-risk conditions, including, but not limited to, those explained
in the Guidelines for Perinatal Care, American Academy of Pediatrics and
American College of Obstetricians and Gynecologists.
"Maternity and Neonatal Service Plan" means the description
required under Subpart O of the Hospital Licensing Requirements (77 Ill. Adm.
Code 250) of the hospital's services for care of maternity and neonatal
patients, and the way in which the services are part of an integrated system of
perinatal care provided by designated perinatal facilities.
"Morbidity" means an
undesired result or complication associated with a pregnancy, whether naturally
occurring or as the result of treatment rendered or omitted.
"Neonatal Intensive Care
Unit" or "NICU" means an intensive care unit for high risk
neonates, directed by a board-certified pediatrician with subspecialty
certification in neonatal/perinatal medicine.
"Neonate" means an infant less than 28 days of age.
"Nurse" means a
registered nurse or a licensed practical nurse as defined in the Nurse Practice
Act [225 ILCS 65].
"Nurse Midwife, Certified"
or "Certified Nurse Midwife" or "CNM" means an individual
educated in the two disciplines of nursing and midwifery who possesses evidence
of certification according to the requirements of the American College of
Nurse-Midwives (ACNM).
"Perinatal" means the period of time between the
conception of an infant and the end of the first month of life. (Section
2(a) of the Act)
"Perinatal Advisory Committee" or "PAC" means the
advisory and planning committee established by the Department, which is
referred to in Section 3 of the Act.
"Pharmacist, Registered"
or "Registered Pharmacist" means a person who holds a certificate of
registration as a registered pharmacist, a local registered pharmacist or a
registered assistant pharmacist under the Pharmacy Practice Act of 1987 [225
ILCS 85].
"Physician" means any
person licensed to practice medicine in all its branches as defined in the
Medical Practice Act of 1987 [225 ILCS 60].
"Preventive Services"
means a medical intervention provided to a high risk mother and/or neonate in
an effort to reduce morbidity and mortality.
"Refer" means to send or direct for treatment.
"Regional Perinatal Network" means any number and combination
of hospitals providing maternity and newborn services at a designated level of
perinatal care.
"Regional Quality Council" or "RQC" means an
organization of representatives of perinatal services, providers and
service-related agencies and organizations within a regional perinatal network
that is responsible for the planning, development, evaluation and operation of
the network and the establishment of regional priorities and policies for
system support activities and staff.
"Registered Nurse"
means a person licensed as a registered professional nurse under the Nurse
Practice Act.
"Respiratory Care Practitioner"
means a person licensed as a respiratory care practitioner under the
Respiratory Care Practice Act [225 ILCS 106].
"Social Worker" means
a person who is a licensed social worker or a licensed clinical social worker
under the Clinical Social Work and Social Work Practice Act [225 ILCS 20].
"Special Care Nursery"
or "SCN" means a nursery that provides intermediate intensive care,
directed by a board-certified pediatrician with subspecialty certification in
neonatal/perinatal medicine, to infants who weigh more than 1250 grams.
"State Perinatal Reporting
System" means any system that requires data collection and submission of
data to the Department. These systems include, but are not limited to, birth
certificate submission, metabolic newborn screening, newborn hearing screening,
perinatal HIV testing, and the Adverse Pregnancy Outcomes Reporting System
(APORS) (see 77 Ill. Adm. Code 840).
"Statewide Quality Council" means the standing subcommittee
established by the Perinatal Advisory Committee that is responsible for
monitoring the quality of care and implementing recommendations for improving
the quality of care being provided in the perinatal care system.
"Substantial Compliance"
means meeting requirements, except for variance from the strict and literal
performance that results in unimportant omissions or defects, given the
particular circumstances involved.
"Substantial Failure"
means the failure to meet requirements, other than unimportant omissions or defects,
given the particular circumstances involved.
"Support Services" means the provision of current information
regarding the identified handicapping conditions, referrals and counseling
services, and the availability of additional consultative services.
(Source: Amended at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.25 INCORPORATED AND REFERENCED MATERIALS
Section 640.25 Incorporated and
Referenced Materials
The following regulations,
standards, statutes and rules are incorporated or referenced in this Part.
a) State of Illinois Statutes:
1) Developmental Disability Prevention Act [410 ILCS 250]
2) Freedom of Information Act [5 ILCS 140]
3) Illinois Health Statistics Act [410 ILCS 520]
4) Hospital Licensing Act [210 ILCS 85]
5) Section 8-2101 of the Code of Civil Procedure (Medical Studies
Act) [735 ILCS 5/8-2101]
6) State Records Act [5 ILCS 160]
7) Illinois Health and
Hazardous Substances Registry Act [410 ILCS 525]
8) Vital Records Act [410
ILCS 535]
9) Respiratory Care
Practice Act [225 ILCS 106]
10) Dietetic
and Nutrition Services Practice Act [225 ILCS 30]
11) Illinois
Administrative Procedure Act [5 ILCS 100]
12) Nurse
Practice Act [225 ILCS 65]
13) Pharmacy
Practice Act of 1987 [225 ILCS 85]
14) Medical
Practice Act of 1987 [225 ILCS 60]
15) Clinical
Social Work and Social Work Practice Act [225 ILCS 20]
b) State of Illinois Rules
1) Department of Public Health – Illinois Health and Hazardous
Substances Registry (77 Ill. Adm. Code 840)
2) Department of Public Health − Hospital Licensing
Requirements (77 Ill. Adm. Code 250)
3) Department of Public Health − Practice and Procedure in
Administrative Hearings (77 Ill. Adm. Code 100)
4) Department of Human Services − Maternal and Child Health
Services Code (77 Ill. Adm. Code 630)
5) Department of Public Health − Access to Public Records
of the Department of Public Health (2 Ill. Adm. Code 1127)
c) Standards or Guidelines
1) Guidelines for Perinatal Care, American Academy of Pediatrics
and American College of Obstetricians and Gynecologists (2007) (which may be
obtained from the American Academy of Pediatrics, 141 Northwest Point Road,
P.O. 927, Elk Grove Village, Illinois 60009-0927)
2) Vermont Oxford Network: VLBW (Very Low Birth Weight) Summary
for Birth Years 2006-2008 (which may be obtained from the Vermont Oxford
Network, 33 Kilburn Street, Burlington, Vermont 05401; www.vtoxford.org)
d) All incorporations by reference of the standards of nationally
recognized organizations refer to the standards on the date specified and do
not include any amendments or editions subsequent to the date specified.
(Source: Amended at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.30 PERINATAL ADVISORY COMMITTEE
Section 640.30 Perinatal
Advisory Committee
a) The Perinatal Advisory Committee (PAC) is an advisory body to
the Department in matters pertaining to the regionalization of perinatal health
care. The purpose is to advise the Department on the establishment and
implementation of policy.
b) The duties of the PAC shall be to advise the Department on and
make recommendations concerning:
1) Health policies and quality of care issues affecting perinatal
health care services and implementation of the State's perinatal health care
plan;
2) The needs of perinatal health care consumers and providers;
3) Methods to seek a better understanding and wider support of
regionalized perinatal health care within the local community;
4) Coordinating and organizing regional networks or systems of
perinatal health care;
5) Policies relating to planning, operating and maintaining
regional networks or systems of perinatal health care;
6) All proposals for rulemaking affecting the provision of
perinatal health care services under the Act; and
7) Hospitals seeking designation or redesignation as described in
Sections 640.40 through 640.70.
c) The PAC shall consist of 22 members appointed by the Director
of the Department and six ex-officio members as follows:
1) Members
A) 10 physicians;
B) Three hospital administrators;
C) Two registered nurses;
D) One social worker;
E) One dietitian;
F) One respiratory care practitioner;
G) One health planner;
H) Two consumers or representatives of the general public
interested in perinatal health care; and
I) One representative of a certified local health department;
2) Ex-Officio Members
A) One representative of the Illinois Department of Healthcare and
Family Services;
B) One representative of the Illinois Department of Human Services;
C) One representative of the Consortium of Perinatal Network
Administrators;
D) One representative of the Chicago Department of Public Health;
E) One representative of the Chicago Maternal and Child Health
Advisory Committee of the Chicago Department of Public Health; and
F) One representative of the Genetic and Metabolic Diseases
Advisory Committee of the Department.
d) Physician membership on the PAC shall consist of four
obstetrician-gynecologists, to include a subspecialist in maternal/fetal
medicine, four pediatricians, to include a subspecialist in neonatal/perinatal
medicine and two family practice physicians.
e) Recommendations for physicians shall be solicited from the
Illinois State Medical Society, the Illinois Section of the American College of
Obstetricians and Gynecologists, the Illinois Chapter of the American Academy
of Pediatrics, and the Illinois Chapter of the American Academy of Family
Practice. Recommendations for hospital administrators and a health planner
shall be solicited from the Illinois Hospital Association. Recommendations for
nurses shall be solicited from the Illinois Nurses Association; the Illinois Section,
Association of Women's Health, Obstetric and Neonatal Nursing (AWHONN); the
National Association of Neonatal Nurses; and the American College of
Nurse-Midwives. Recommendations for a social worker, a dietitian and a respiratory
care practitioner shall be solicited from the Illinois Perinatal Social Work
Association, the Illinois Dietetics Association and the Illinois Society of
Respiratory Care. Recommendations for a representative of a certified local
health department shall be solicited from the Illinois Association of Public
Health Administrators.
f) Membership of the PAC shall be selected to be representative
of the levels of perinatal care described in Section 640.40, as well as of the
different settings in which perinatal care is provided, both geographic and
institutional.
g) Members of the PAC shall serve four-year terms. Ex-officio members
shall have no set term of service. Both members and ex-officio members shall
have full voting privileges.
(Source: Amended at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.40 STANDARDS FOR PERINATAL CARE
Section 640.40 Standards for
Perinatal Care
a) Levels of Perinatal Care
Hospital
licensing requirements for all levels of care are described in Subpart O of
the Hospital Licensing Requirements. All hospitals shall be designated in
accordance with this Part and have a letter of agreement with a designated APC.
(Section 640.70 describes the minimum components for the letter of agreement.)
1) Non-Birthing
Center hospitals do not provide perinatal services, but have a functioning
emergency department. All licensed general hospitals that operate an emergency
department shall have a letter of agreement with an APC for referral of perinatal
patients, regardless of whether the hospital provides maternity or newborn
services. The letter of agreement shall delineate, but is not limited to,
guidelines for transfer/transport of perinatal patients to an appropriate
perinatal care hospital; telephone numbers for consultation and
transfer/transport of perinatal patients; educational needs assessment for
emergency department staff, and provision of education programs to maintain
necessary perinatal skills.
2) Level
I hospitals provide care to low-risk pregnant women and newborns, operate
general care nurseries and do not operate an NICU or an SCN;
3) Level
II hospitals provide care to women and newborns at moderate risk, operate
intermediate care nurseries and do not operate an NICU or an SCN.
4) Level
II with Extended Neonatal Capabilities hospitals provide care to women and
newborns at moderate risk and do operate an SCN but do not operate an NICU.
5) Level
III hospitals care for patients requiring increasingly complex care and do
operate an NICU.
b) Perinatal Network
Non-Birthing
Center, Level I, Level II, Level II with Extended Neonatal Capabilities and
Level III hospitals shall function within the framework of a regionally
integrated system of services, under the leadership of an APC, designed to
maximize outcomes and to promote appropriate use of expertise and resources. Prenatal
consultations, referrals, or transfers and recognition of high risk conditions are
important to improve outcomes. Regional consultant relationships in maternal-fetal
medicine and neonatology referred to in this Part shall be detailed in the
letter of agreement. The hospital shall ensure that staff physicians and
consultants are familiar with the letter of agreement.
c) All
hospitals shall inform the Department of any change in or loss of essential
resources required by this Part within 30 days after the change and/or loss.
The hospital shall then replace the required resource within 90 days. Failure
to comply shall result in a review by the Department, with a potential loss of
designation.
(Source: Amended at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.41 LEVEL I STANDARDS FOR PERINATAL CARE
Section 640.41 Level I – Standards
for Perinatal Care
To be designated as Level I, a
hospital shall apply to the Department as described in Section 640.60; shall
comply with all the conditions described in Subpart O of the Hospital Licensing
Requirements that are applicable to the level of care necessary for the
patients served; and shall comply with the following provisions:
a) Level I − General Provisions
1) The Maternity and Neonatal Service Plan shall include:
A) A letter of agreement between the hospital and its APC establishing
criteria for maternal and neonatal consultation; criteria for maternal and neonatal
transports; standards of care of mothers and neonates; and support services to
be provided. (Section 640.70 establishes the minimum components for the letter
of agreement.);
B) Continuing education of staff in perinatal care; and
C) Participation in the CQI program implemented by the APC.
2) The critical considerations in the care of patients
anticipating delivery in these hospitals are as follows:
A) The earliest possible detection of the high-risk pregnancy
(risk assessment); consultation with a maternal-fetal medicine subspecialist or
neonatologist as specified in the letter of agreement; and transfer to the
appropriate level of care; and
B) The availability of trained personnel and facilities to provide
competent emergency obstetric and newborn care. Included in the functions of
this hospital are the stabilization of patients with unexpected problems,
initiation of neonatal and maternal transports, patient and community
education, and data collection and evaluation.
3) The
Level I hospital shall provide continuing education for medical, nursing,
respiratory therapy, and other staff providing general perinatal services, with
evidence of a yearly competence assessment appropriate to the patient
population served.
4) The Level I hospital shall maintain a system of recording
patient admissions, discharges, birth weight, outcome, complications, and
transports to meet the requirement to support network CQI activities described
in the hospital's letter of agreement with the APC. The hospital shall comply
with the reporting requirements of the State Perinatal Reporting System.
b) Level I – Standards for Maternal Care
1) The maternal patient with an uncomplicated current pregnancy
and no previous history that suggests potential difficulties is considered
appropriate for Level I hospitals; however, the hospital's letter of agreement
shall establish the specific conditions for the Level I hospital.
2) Other than those maternal patients identified in subsection
(b)(1), pregnancies of fewer than 36 weeks gestation constitute potentially
high-risk conditions for which the attending health care provider shall consult
with a board-certified obstetrician or maternal-fetal medicine subspecialist to
determine whether a transport or transfer to a higher level of care is needed.
The letter of agreement shall specify policies for consultation and the
hospital's obstetric policies and procedures for each of, but not limited to,
the pregnancy conditions listed in Section 640.Appendix H. Exhibit A.
3) Hospitals
shall have the capability for continuous electronic maternal-fetal monitoring
for patients identified at risk, with staff available 24 hours a day, including
physician and nursing, who are knowledgeable of electronic fetal monitoring use
and interpretation. Physicians and nurses shall complete a competence
assessment in electronic maternal-fetal monitoring every two years.
4) Hospitals
shall provide caesarean section decision-to-incision capabilities within 30
minutes.
c) Level I – Standards for Neonatal Care
1) Neonatal patients greater than 36 weeks gestation or greater
than 2500 grams without risk factors and infants with physiologic jaundice are
generally considered appropriate for Level I hospitals; however, the hospital's
letter of agreement shall establish the specific conditions for Level I hospitals.
2) For all neonatal patients other than those identified in
subsection (c)(1), consultation with a neonatologist is required to determine
whether a transport to a higher level of care is needed. Consultation shall be
specified in the letter of agreement and outlined in the hospital's pediatric
policies and procedures for conditions including, but not limited to:
A) Small-for-gestational age (less than 10th
percentile)
B) Documented sepsis
C) Seizures
D) Congenital heart disease
E) Multiple congenital anomalies
F) Apnea
G) Respiratory distress
H Neonatal asphyxia
I) Handicapping conditions or developmental disabilities that
threaten life or subsequent development
J) Severe anemia
K) Hyperbilirubinemia, not due to physiologic cause
L) Polycythemia
d)
Level I – Resource Requirements
The following
support services shall be available:
1) Blood bank technicians shall be on call and available within
30 minutes for performance of routine blood banking procedures.
2) General anesthesia services shall be on call and available
within 30 minutes to initiate caesarean sections.
3) Radiology services shall be available within 30 minutes.
4) Clinical laboratory services shall include microtechnique for
hematocrit, blood gases, and routine urinalysis within 15 minutes; glucose, blood
urea nitrogen (BUN), creatinine, complete blood count (CBC), routine blood
chemistries, type, cross, Coombs' test and bacterial smear within one hour; and
capability for bacterial culture and sensitivity and viral culture.
5) A physician for the program shall be designated to assume
primary responsibility for initiating, supervising and reviewing the plan for management
of distressed infants. Policies and procedures shall assign responsibility for
identification and resuscitation of distressed neonates to individuals who have
completed a nationally recognized neonatal resuscitation program and are both
specifically trained and immediately available in the hospital at all times,
such as another physician, a nurse with training and experience in neonatal
resuscitation, or a respiratory care practitioner.
e) Application for
Designation, Redesignation or Change in Network
1) To be
designated or to retain designation, a hospital shall submit the required
application documents to the Department. For information needed to complete any
of the processes, see Section 640.50 (Designation and Redesignation of
Non-Birthing Center, Level I, Level II, Level II with Extended Neonatal
Capabilities, Level III Perinatal Hospitals, and Administrative Perinatal
Centers) and Section 640.60 (Application for Hospital Designation and
Redesignation as Non-Birthing Center, Level I, Level II, Level II with Extended
Neonatal Capabilities, Level III Perinatal Hospital, and Administrative
Perinatal Center, and Assurances Required of Applicants).
2) The
following information shall be submitted to the Department to facilitate the
review of the hospital's application for designation or redesignation:
A) Appendix A (fully
completed);
B) Resource Checklist
(fully completed);
C) A
proposed letter of agreement between the hospital and the APC (unsigned);
D) The
curriculum vitae for all directors of patient care, i.e., obstetrics,
neonatal, ancillary medical and nursing.
3) When
the information described in subsection (e)(2) is submitted, the Department
will review the material for compliance with this Part. This documentation will
be the basis for a recommendation for approval or disapproval of the applicant
hospital's application for designation.
4) The
medical co-directors of the APC (or their designees), the medical directors of
obstetrics and maternal and newborn care, and a representative of hospital
administration from the applicant hospital shall be present during the PAC's
review of the application for designation.
5) The
Department will make the final decision and inform the hospital of the official
determination regarding designation. The Department's decision will be based
upon the recommendation of the PAC and the hospital's compliance with this
Part, and may be appealed in accordance with Section 640.45. The Department
will consider the following criteria to determine if a hospital is in
compliance with this Part:
A) Maternity
and Neonatal Service Plan (Subpart O of the Hospital Licensing Requirements);
B) Proposed
letter of agreement between the applicant hospital and its APC in accordance
with Section 640.70;
C) Appropriate
outcome information contained in Appendix A and the Resource Checklist
(Appendices L, M, N and O);
D) Other
documentation that substantiates a hospital's compliance with particular
provisions or standards of perinatal care; and
E) Recommendation of
Department program staff.
(Source: Amended at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.42 LEVEL II AND LEVEL II WITH EXTENDED NEONATAL CAPABILITIES - STANDARDS FOR PERINATAL CARE
Section 640.42 Level II and
Level II with Extended Neonatal Capabilities − Standards for Perinatal
Care
To be designated as Level II or
Level II with Extended Neonatal Capabilities, a hospital shall apply to the
Department as described in Section 640.60 of this Part; shall comply with all
of the conditions described in Subpart O of the Hospital Licensing Requirements
that are applicable to the level of care necessary for the patients served; and
shall comply with the following provisions (specifics regarding standards of
care for both mothers and neonates as well as resource requirements to be
provided shall be defined in the hospital's letter of agreement with its APC):
a) Level II and Level II with Extended Neonatal Capabilities −
General Provisions
A Level II or
Level II with Extended Neonatal Capabilities hospital shall:
1) Provide all services outlined for Level I (Section 640.41(a));
2) Provide diagnosis and treatment of selected high-risk
pregnancies and neonatal problems;
3) Accept selected neonatal transports from Level I or other
Level II hospitals as identified in the letter of agreement with the APC; and
4) Maintain a system for recording patient admissions,
discharges, birth weight, outcome, complications and transports to support
network CQI activities described in the hospital's letter of agreement with the
APC. The hospital shall comply with the reporting requirements of the State
Perinatal Reporting System.
b) Level II – Standards for Maternal Care
1) The following maternal patients are considered to be
appropriate for management and delivery by the primary physician at Level II hospitals
without requirement for a maternal-fetal medicine consultation; however, the
hospital's letter of agreement shall establish the specific conditions for the
Level II hospital:
A) Those listed for Level I (see Section 640.41(b));
B) Normal current pregnancy although obstetric history may suggest
potential difficulties;
C) Selected medical conditions controlled with medical treatment
such as, mild chronic hypertension, thyroid disease, illicit drug use, urinary
tract infection, and non-systemic steroid-dependent reactive airway disease;
D) Selected obstetric complications that present after 32 weeks gestation,
such as, mild pre-eclampsia/pregnancy induced hypertension, placenta previa,
abrupto placenta, premature rupture of membranes or premature labor;
E) Other selected obstetric conditions that do not adversely
affect maternal health or fetal well-being, such as, normal twin gestation,
hyperemesis gravidium, suspected fetal macrosomia, or incompetent cervical os;
F) Gestational diabetes, Class A1 (White's criteria).
2) The attending health care provider shall consult a maternal-fetal
medicine subspecialist, as detailed in the letter of agreement with the APC and
outlined in the hospital's obstetric department policies and procedures, for
each of, but not limited to, the current pregnancy conditions listed in Section
640.Appendix H.Exhibit B. Subsequent patient management and site of delivery
shall be determined by mutual collaboration between the patient's physician and
the maternal-fetal medicine subspecialist.
3) Hospitals
shall have the capability for continuous electronic maternal-fetal monitoring
for patients identified at risk, with staff available 24 hours a day, including
physician and nursing, who are knowledgeable of electronic maternal-fetal
monitoring use and interpretation. Physicians and nurses shall complete a
competence assessment in electronic maternal-fetal monitoring every two years.
c) Level II – Standards for Neonatal Care
1) The following neonatal patients are considered appropriate for
Level II hospitals without a requirement for neonatology consultation:
A) Those listed for Level I (see Section 640.41(c));
B) Premature infants at 32 or more weeks gestation who are
otherwise well;
C) Infants with mild to moderate respiratory distress (not
requiring assisted ventilation in excess of six hours);
D) Infants with suspected neonatal sepsis, hypoglycemia responsive
to glucose infusion, and asymptomatic neonates of diabetic mothers; and
E) Infants with a birth weight greater than 1500 grams who are
otherwise well.
2) The attending physician shall consult a neonatologist for the
following neonatal conditions. Consultation shall be specified in the letter
of agreement with the APC and outlined in the hospital's pediatric department
policies and procedures for conditions including, but not limited to:
A) Birth weight less than 1500 grams;
B) 10 minute Apgar scores of 5 or less;
C) Handicapping conditions or developmental disabilities that
threaten subsequent development in an otherwise stable infant.
3) Minimum conditions for transport shall be specified in the letter
of agreement and outlined in the hospital's pediatric department policies and
procedures for conditions including, but not limited to:
A) Premature birth that is less than 32 weeks gestation;
B) Birth weight less than 1500 grams;
C) Assisted ventilation beyond the initial stabilization period of
six hours;
D) Congenital heart disease associated with cyanosis, congestive
heart failure or impaired peripheral blood flow;
E) Major congenital malformations requiring immediate
comprehensive evaluation or neonatal surgery;
F) Neonatal surgery requiring general anesthesia;
G) Sepsis, unresponsive to therapy, associated with persistent
shock or other organ system failure;
H) Uncontrolled seizures;
I) Stupor, coma, hypoxic ischemic encephalopathy Stage II or
greater;
J) Double-volume exchange transfusion;
K) Metabolic derangement persisting after initial correction
therapy;
L) Handicapping conditions that threaten life for which transfer
can improve outcome.
d) Level II – Resource Requirements
Resources
shall include all those listed for Level I (Section 640.41(d)) as well as the
following:
1) Experienced blood bank technicians shall be immediately
available in the hospital for blood banking procedures and identification of
irregular antibodies. Blood component therapy shall be readily available.
2) Experienced radiology technicians shall be immediately
available in the hospital with professional interpretation available 24 hours a
day. Ultrasound capability shall be available 24 hours a day. In addition,
Level I ultrasound and staff knowledgeable in its use and interpretation shall
be available 24 hours a day.
3) Clinical laboratory services shall include microtechnique
blood gases in 15 minutes and electrolytes and coagulation studies within one hour.
4) Personnel skilled in phlebotomy and intravenous (IV) placement
in the newborn shall be available 24 hours a day.
5) Social work services provided by one social worker, with
relevant experience and responsibility for perinatal patients, shall be
available through the hospital social work department.
6) Protocols for discharge planning, routine follow-up care, and
developmental follow-up shall be established.
7) A respiratory care practitioner with experience in neonatal
care shall be available.
8) One dietitian with experience in perinatal nutrition shall be
available to plan diets to meet the needs of mothers and infants.
9) Capability to provide neonatal resuscitation in the delivery
room shall be satisfied by current completion of a nationally recognized neonatal
resuscitation program by medical, nursing and respiratory care staff or a
hospital rapid response team.
e) Application for
Designation, Redesignation or Change in Network
1) To be
designated or to retain designation, a hospital shall submit the required
application documents to the Department. For information needed to complete any
of the processes, see Section 640.50 and Section 640.60.
2) The
following information shall be submitted to the Department to facilitate the
review of the hospital's application for designation or redesignation:
A) Appendix A (fully
completed);
B) Resource
Checklist (fully completed) (Appendices L, M, N and O);
C) A
proposed letter of agreement between the hospital and the APC (unsigned); and
D) The curriculum
vitae for all directors of patient care, i.e., obstetrics, neonatal, ancillary
medical care and nursing (both obstetrics and neonatal).
3) When
the information described in subsection (e)(2) is submitted, the Department
will review the material for compliance with this Part. This documentation will
be the basis for a recommendation for approval or disapproval of the applicant
hospital's application for designation.
4) The
medical co-directors of the APC (or their designees), the medical directors of
obstetrics and maternal and newborn care, and a representative of hospital
administration from the applicant hospital shall be present during the PAC's
review of the application for designation.
5) The
Department will make the final decision and inform the hospital of the official
determination regarding designation. The Department's decision will be based
upon the recommendation of the PAC and the hospital's compliance with this Part
and may be appealed in accordance with Section 640.45. The Department will
consider the following criteria or standards to determine if a hospital is in
compliance with this Part:
A) Maternity
and Neonatal Service Plan (Subpart O of the Hospital Licensing Requirements);
B) Proposed
letter of agreement between the applicant hospital and its APC, in accordance
with Section 640.70;
C) Appropriate
outcome information contained in Appendix A and the Resource Checklist;
D) Other
documentation that substantiates a hospital's compliance with particular
provisions or standards of perinatal care set forth in this Part; and
E) Recommendation
of Department program staff.
f) Level II with Extended Neonatal Capabilities – Standards for Special
Care Nursery Services
1) The following patients are considered appropriate for Level II
with Extended Neonatal Capabilities hospitals with SCN services:
A) Those listed in subsection (c) of this Section;
B) Infants with low birth weight greater than 1250 grams;
C) Premature infants of 30 or more weeks gestation;
D) Infants on assisted ventilation.
2) For each of the following neonatal conditions, consultation
between the Level II with Extended Neonatal Capabilities attending physician
and the APC or Level III neonatologist is required. The attending neonatologist
at the Level II with Extended Neonatal Capabilities hospital and the attending
neonatologist at the APC or Level III hospital shall determine, by mutual collaboration,
the most appropriate hospital to continue patient care. The Level II hospital
with Extended Neonatal Capabilities shall develop a prospective plan for
patient care for those infants who remain at the hospital. Both the letter of
agreement with the APC and the hospital's department of pediatrics' policies
and procedures shall identify conditions that might require transfer to a Level
III hospital, including, but not limited to::
A) Premature birth that is less than 30 weeks gestation;
B) Birth weight less than or equal to 1250 grams;
C) Conditions listed in subsections (c)(3)(C) through (L) of this
Section.
g) Level II with Extended Neonatal Capabilities – Resource
Requirements
1) Resources shall include all those listed in Section 640.41(d)
for Level I care and in Section 640.42(d) for Level II care, as well as the
following:
A) Obstetric activities shall be directed and supervised by a full-time
obstetrician certified by the American Board of Obstetrics and Gynecology or a
licensed osteopathic physician with equivalent training and experience and certification
by the American Osteopathic Board of Obstetrics and Gynecology.
B) Neonatal activities shall be directed and supervised by a full-time
pediatrician certified by the American Board of Pediatrics Sub-Board of
Neonatal/Perinatal Medicine or a licensed osteopathic physician with equivalent
training and experience and certification by the American Osteopathic Board of
Pediatricians.
C) The directors of obstetric and neonatal services shall ensure
the back-up supervision of their services when they are unavailable.
D) The obstetric-newborn nursing services shall be directed by a
full-time nurse experienced in perinatal nursing, preferably with a master's
degree.
E) The pediatric-neonatal respiratory therapy services shall be
directed by a full-time respiratory care practitioner with at least three years
experience in all aspects of pediatric and neonatal respiratory therapy, with a
bachelor's degree and completion of the neonatal/pediatric specialty
examination of the National Board for Respiratory Care.
F) Preventive services shall be designated to prevent, detect,
diagnose and refer or treat conditions known to occur in the high risk newborn,
such as: cerebral hemorrhage, visual defects (retinopathy of prematurity), and
hearing loss, and to provide appropriate immunization of high-risk newborns.
G) A person shall be designated to coordinate the local health
department community nursing follow-up referral process, to direct discharge
planning, to make home care arrangements, to track discharged patients, and to
collect outcome information. The community nursing referral process shall
consist of notifying the high-risk infant follow-up nurse in whose jurisdiction
the patient resides. The Illinois Department of Human Services will identify
and update referral resources for the area served by the unit.
H) Each Level II hospital with Extended Neonatal Capabilities
shall develop, with the help of the APC, a referral agreement with a neonatal
follow-up clinic to provide neuro-developmental assessment and outcome data on
the neonatal population. Hospital policies and procedures shall describe the
at-risk population and referral procedure to be followed.
I) If the Level II hospital with Extended Neonatal Capabilities
transports neonatal patients, the hospital shall comply with Guidelines for
Perinatal Care, American Academy of Pediatrics and American College of
Obstetricians and Gynecologists.
2) To provide for assisted ventilation of newborn infants beyond
immediate stabilization, the Level II hospital with Extended Neonatal Capabilities
shall also provide the following:
A) Effective July 1, 2011, a pediatrician or advanced practice
nurse whose professional staff privileges granted by the hospital specifically
include the management of critically ill infants and newborns receiving
assisted ventilation; or an active candidate or board-certified neonatologist
shall be in the hospital the entire time the infant is receiving assisted
ventilation. If infants are receiving on-site assisted ventilation care from an
advanced practice nurse or a physician who is not a neonatologist, an active
candidate or board-certified neonatologist shall be available on call to assist
in the care of those infants as needed.
B) Suitable backup systems and plans shall be in place to prevent
and respond appropriately to sudden power outage, oxygen system failure, and interruption
of medical grade compressed air delivery.
C) Nurses caring for infants who are receiving assisted
ventilation shall have documented competence and experience in the care of those
infants.
D) A respiratory care practitioner with documented competence and
experience in the care of infants who are receiving assisted ventilation shall
also be available to the nursery during the entire time that the infant
receives assisted ventilation.
h) Application for
Designation, Redesignation or Change in Network
1) To be
designated or to retain designation, a hospital shall submit the required
application documents to the Department. For information needed to complete any
of the processes, see Section 640.50 and Section 640.60.
2) The
following information shall be submitted to the Department to facilitate the
review of the hospital's application for designation or redesignation:
A) Appendix
A (fully completed);
B) Resource
Checklist (fully completed) (Appendices L, M, N and O);
C) A
proposed letter of agreement between the hospital and the APC (unsigned); and
D) The
curriculum vitae for all directors of patient care, i.e., obstetrics, neonatal,
ancillary medical, and nursing (both obstetrics and neonatal).
3) When
the information described in subsection (h)(2) is submitted, the Department
will review the material for compliance with this Part. This documentation will
be the basis for a recommendation for approval or disapproval of the applicant
hospital's application for designation.
4) The
medical co-directors of the APC (or their designees), the medical directors of
obstetrics and maternal and newborn care, and a representative of hospital
administration from the applicant hospital shall be present during the PAC's
review of the application for designation.
5) The
Department will make the final decision and inform the hospital of the official
determination regarding designation. The Department's decision will be based
upon the recommendation of the PAC and the hospital's compliance with this
Part, and may be appealed in accordance with Section 640.45. The Department
shall consider the following criteria or standards to determine if a hospital
is in compliance with this Part:
A) Maternity
and Neonatal Service Plan (Subpart O of the Hospital Licensing Requirements);
B) Proposed
letter of agreement between the applicant hospital and its APC in accordance
with Section 640.70;
C) Appropriate
outcome information contained in Appendix A and the Resource Checklist;
D) Other
documentation that substantiates a hospital's compliance with particular provisions
or standards of perinatal care set forth in this Part; and
E) Recommendation of
Department program staff.
(Source: Amended at 41 Ill.
Reg. 3477, effective March 9, 2017)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.43 LEVEL III STANDARDS FOR PERINATAL CARE
Section 640.43 Level III –
Standards for Perinatal Care
To be designated as Level III, a
hospital shall apply to the Department for designation; shall comply with all
of the conditions prescribed in this Part for intensive (Level III) perinatal
care; shall comply with all of the conditions prescribed in Subpart O of the
Hospital Licensing Requirements applicable to the level of care necessary for
the patients served; and shall comply with the following provisions (specifics
regarding standards of care for both mothers and neonates as well as resource
requirements to be provided shall be defined in the hospital's letter of
agreement with its APC):
a) Level III − General Provisions
1) A Level III hospital shall provide all services outlined for
Level I and II (Sections 640.41(a) and 640.42(a)), general, intermediate and special
care, as well as diagnosis and treatment of high-risk pregnancy and neonatal
problems. Both the obstetrical and neonatal services shall achieve Level III
capability for Level III designation. The hospital shall provide for the
education of allied health professionals and shall accept selected maternal and
neonatal transports from Level I, Level II and Level II with Extended Neonatal
Capabilities hospitals.
2) The Level III hospital shall make available a range of
technical and subspecialty consultative support such as pediatric
anesthesiology, ophthalmology, pediatric surgery, genetic services, intensive
cardiac services and intensive neurosurgical services.
3) To qualify as a Level III hospital, these standards and
resource requirements are necessary to ensure adequate competence in the
management of certain high-risk patients. These criteria will be assessed by
reviewing the resources and outcomes of each hospital's admissions, and which
admissions include patients who are subsequently transferred, for the three
most recent calendar years, combined, for which data are available.
4) A Level III hospital that elects not to provide all of the
advanced level services shall have established policies and procedures for
transfer of these mothers and infants to a hospital that can provide the
service needed.
5) The Level III hospital shall maintain a system for recording
patient admissions, discharges, birth weight, outcome, complications, and
transports to meet requirements to support network CQI activities described in
the hospital's letter of agreement with the APC. The hospital shall comply
with the reporting requirements of the State Perinatal Reporting System.
b) Level III – Standards of Care
1) The Level III hospital shall have a policy requiring general
obstetricians and newborn care physicians to obtain consultations from or
transfer care to the appropriate subspecialists as outlined in the standards
for Level II.
2) The
Level III hospital shall accept all medically eligible Illinois residents.
Medical eligibility is to be determined by the obstetric or neonatal director
or his/her designee based on the Criteria for High-Risk Identification
(Guidelines for Perinatal Care, American Academy of Pediatrics and American
College of Obstetricians and Gynecologists).
3) The
Level III hospital shall provide or facilitate emergency transportation of
patients referred to the hospital in accordance with guidelines for inter-hospital
care of the perinatal patient (Guidelines for Perinatal Care)). If the Level
III hospital is unable to accept the patient referred, the APC Level III
hospital shall arrange for placement at another Level III hospital or
appropriate Level II or Level II hospital with Extended Neonatal Capabilities.
4) The
Level III hospital shall have a clearly identifiable telephone number,
facsimile number or other electronic communication, either a special number or
a specific extension answered by unit personnel, for receiving consultation
requests and requests for admissions. This number shall be kept current with
the Department and with the Regional Perinatal Network.
5) The
Level III hospital shall provide and document continuing education for medical,
nursing, respiratory therapy, and other staff providing general, intermediate
and intensive care perinatal services.
6) The
Level III hospital shall provide caesarean section decision-to-incision
capabilities within 30 minutes.
7) The
Level III hospital shall provide data relating to its activities and shall
comply with the requirements of the State Perinatal Reporting System.
8) The
medical co-directors of the Level III hospital shall be responsible for
developing a system ensuring adequate physician-to-physician communication.
Communication with referring physicians of patients admitted shall be
sufficient to report patient progress before and at the time of discharge.
9) Hospitals
shall have the capability for continuous electronic maternal-fetal monitoring
for patients identified at risk, with staff available 24 hours a day, including
physician and nursing, who are knowledgeable of electronic maternal-fetal
monitoring use and interpretation. Physicians and nurses shall complete a
competence assessment in electronic maternal-fetal monitoring every two years.
10) The
Level III hospital, in collaboration with the APC, shall establish policies and
procedures for the return transfer of high-risk mothers and infants to the
referring hospital when they no longer require the specialized care and
services of the Level III hospital.
11) The
Level III hospital shall provide backup systems and plans shall be in place to
prevent and respond to sudden power outage, oxygen system failure and
interruption of medical grade compressed air delivery.
12) The
Level III hospital shall provide or develop a referral agreement with a
developmental follow-up clinic to provide neuro-developmental services for the
neonatal population. Hospital policies and procedures shall describe the
at-risk population and the referral procedure to be followed for enrolling the
infant in developmental follow-up. Infants shall be scheduled for assessments
at regular intervals. Neuro-developmental assessments shall be communicated to
the primary care physicians. Referrals shall be made for interventional care in
order to minimize neurologic sequelae. A system shall be established to track,
record and report neuro-developmental outcome data for the population, as
required to support network CQI activities.
13) Neonatal
surgical services shall be available 24 hours a day.
c) Level III – Resource Requirements
1) Obstetric
activities shall be directed and supervised by a full-time subspecialty
obstetrician certified by the American Board of Obstetrics and Gynecology in
the subspecialty of Maternal and Fetal Medicine, or an osteopathic physician
with equivalent training and experience and certification by the American Osteopathic
Board of Obstetricians and Gynecologists. The director of the obstetric
services shall ensure the backup supervision of his or her services by a
physician with equivalent credentials.
2) Neonatal
activities shall be directed and supervised by a full-time pediatrician
certified by the American Board of Pediatrics sub-board of neonatal/perinatal medicine,
or a licensed osteopathic physician with equivalent training and experience and
certification by the American Osteopathic Board of Pediatricians/Neonatal-Perinatal
Medicine. The director of the neonatal services shall ensure the backup
supervision of his or her services by a physician with equivalent credentials.
3) An
administrator/manager with a master's degree shall direct, in collaboration
with the medical directors, the planning, development and operation of the
non-medical aspects of the Level III hospital and its programs and services.
A) The
obstetric and newborn nursing services shall be directed by a full-time nurse
experienced in perinatal nursing, with a master's degree.
B) Half
of all neonatal intensive care direct nursing care hours shall be provided by
registered nurses who have two years or more of nursing experience in a Level
III NICU. All NICU direct nursing care hours shall be provided or supervised
by registered nurses who have advanced neonatal intensive care training and
documented competence in neonatal pathophysiology and care technologies used in
the NICU. All nursing staff working in the NICU shall have yearly competence
assessment in neonatal intensive care nursing.
4) Obstetric
anesthesia services under the direct supervision of a board- certified
anesthesiologist with training in maternal, fetal and neonatal anesthesia shall
be available 24 hours a day. The directors of obstetric anesthesia services
shall ensure the backup supervision of their services when they are
unavailable.
5) Pediatric-neonatal
respiratory care services shall be directed by a full-time respiratory care
practitioner with a bachelor's degree.
A) The
respiratory care practitioner responsible for the NICU shall have at least
three years of experience in all aspects of pediatric and neonatal respiratory
care at a Level III NICU and completion of the neonatal/pediatrics specialty
examination of the National Board for Respiratory Care.
B) Respiratory
care practitioners with experience in neonatal ventilatory care shall staff the
NICU according to the respiratory care requirements of the patient population,
with a minimum of one dedicated neonatal respiratory care practitioner for
newborns on assisted ventilation, and with additional staff provided as
necessary to perform other neonatal respiratory care procedures.
6) A
physician for the program shall assume primary responsibility for initiating,
supervising and reviewing the plan for management of distressed infants in the
delivery room. Hospital policies and procedures shall assign responsibility for
identification and resuscitation of distressed neonates to individuals who are
both specifically trained and immediately available in the hospital at all
times. Capability to provide neonatal resuscitation in the delivery room may be
satisfied by current completion of a neonatal resuscitation program by medical,
nursing and respiratory care staff or a rapid response team.
7) A
board-certified or active candidate obstetrician shall be present and available
in the hospital 24 hours a day. Maternal-fetal medicine consultation shall be
available 24 hours a day.
8) Medical
director-neonatal: to direct the neonatal portion of the program. Neonatal
activities shall be directed and supervised by a full-time pediatrician
certified by the American Board of Pediatrics Sub-Board of Neonatal/Perinatal
Medicine or a licensed osteopathic physician with equivalent training and
experience and certified by the American Osteopathic Board of
Pediatricians/Neonatal-Perinatal Medicine. The directors of the neonatal
services shall ensure the back-up supervision of their services when they are
unavailable.
9) Neonatal
surgical services shall be supervised by a board-certified surgeon or active
candidate in pediatric surgery appropriate for the procedures performed at the
Level III hospital.
10) Neonatal
surgical anesthesia services under the direct supervision of a board-certified
anesthesiologist with extensive training or experience in pediatric
anesthesiology shall be available 24 hours a day.
11) Neonatal
neurology services under the direct supervision of a board-certified or active
candidate pediatric neurologist shall be available for consultation in the NICU
24 hours a day.
12) Neonatal
radiology services under the direct supervision of a radiologist with extensive
training or experience in neonatal radiographic and ultrasound interpretation
shall be available 24 hours a day.
13) Neonatal
cardiology services under the direct supervision of a pediatric board-certified
or active candidate by the American Board of Pediatrics sub-board of pediatric
cardiology shall be available for consultation 24 hours a day. In addition,
cardiac ultrasound services and pediatric cardiac catheterization services by
staff with specific training and experience shall be available 24 hours a day.
14) A
board-certified or active candidate ophthalmologist with experience in the
diagnosis and treatment of the visual problems of high-risk newborns (e.g.,
retinopathy of prematurity) shall be available for appropriate examinations,
treatment and follow-up care of high-risk newborns.
15) Pediatric
sub-specialists with specific training and extensive experience or subspecialty
board certification or active candidacy (where applicable) shall be available
24 hours a day, including, but not limited to, pediatric urology, pediatric
otolaryngology, neurosurgery, pediatric cardiothoracic surgery and pediatric
orthopedics appropriate for the procedures performed at the Level III hospital.
16) Genetic
counseling services shall be available for inpatients and outpatients, and the
hospital shall provide for genetic laboratory testing, including, but not
limited to, chromosomal analysis and banding, fluorescence in situ
hybridization (FISH), and selected allele detection.
17) The
Level III hospital shall designate at least one person to coordinate the
community nursing follow-up referral process, to direct discharge planning, to
make home care arrangements, to track discharged patients, and to ensure
appropriate enrollment in a developmental follow-up program. The community
nursing referral process shall consist of notifying the follow-up nurse in
whose jurisdiction the patient resides of discharge information on all
patients. The Illinois Department of Human Services will identify and update
referral resources for the area served by the unit. The hospital shall
establish a protocol that defines the educational criteria necessary for
commonly required home care modalities, including, but not limited to,
continuous oxygen therapy, electronic cardio-respiratory monitoring,
technologically assisted feeding and intravenous therapy.
18) One
or more full-time social workers with perinatal/neonatal experience shall be available
to the Level III hospital.
19) One
registered pharmacist with experience in perinatal pharmacology shall be
available for consultation on therapeutic pharmacology issues 24 hours a day.
20) One
dietitian with experience in perinatal nutrition shall be available to plan
diets and education to meet the special needs of high-risk mothers and neonates
in both inpatient and outpatient settings.
d) Application for Hospital
Designation, Redesignation or Change in Network
1) To be
designated or to retain designation, a hospital shall submit the required
application documents to the Department. For information needed to complete any
of the processes, see Section 640.50 and Section 640.60.
2) The
following information shall be submitted to the Department to facilitate the
review of the hospital's application for designation or redesignation:
A) Appendix A (fully
completed);
B) Resource
Checklist (fully completed) (Appendices L, M, N and O);
C) A
proposed letter of agreement between the hospital and the APC (unsigned); and
D) The
curriculum vitae for all directors of patient care, i.e., obstetrics, neonatal,
ancillary medical, and nursing (both obstetrics and neonatal).
3) When
the information described in subsection (d)(2) is submitted, the Department
will review the material for compliance with this Part. This documentation will
be the basis for a recommendation for approval or disapproval of the applicant
hospital's application for designation.
4) The
medical co-directors of the APC (or their designees), the medical directors of
obstetrics and maternal and newborn care, and a representative of hospital
administration from the applicant hospital shall be present during the PAC's
review of the application for designation.
5) The
Department will make the final decision and inform the hospital of the official
determination regarding designation. The Department's decision will be based
upon the recommendation of the PAC and the hospital's compliance with this
Part, and may be appealed in accordance with Section 640.45. The Department
will consider the following criteria to determine if a hospital is in
compliance with this Part:
A) Maternity
and Neonatal Service Plan (Subpart O of the Hospital Licensing Requirements);
B) Proposed
letter of agreement between the applicant hospital and its APC in accordance
with Section 640.70;
C) Appropriate
outcome information contained in Appendix A and the Resource Checklist;
D) Other
documentation that substantiates a hospital's compliance with particular
provisions or standards of perinatal care set forth in this Part; and
E) Recommendation of
Department program staff.
(Source: Amended at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.44 ADMINISTRATIVE PERINATAL CENTER
Section 640.44 Administrative
Perinatal Center
To be designated as an APC, a hospital shall submit an
application to the Department for a grant to provide financial support to
assist the Department in the implementation and oversight of the Regionalized
Perinatal Health Care Program;and shall comply with all of the conditions
described for intensive (Level III) perinatal care in Section 640.43; and shall
comply with all of the conditions described in Subpart O of the Hospital
Licensing Requirements. The APC shall comply with the following:
a) Administrative Perinatal Center − General Provisions
1) An APC shall be a university or university-affiliated hospital,
having Level III hospital designation. An APC may be composed of one or more
institutions. The APC shall be responsible for the administration and
implementation of the Department's regionalized perinatal health care program,
including but not limited to:
A) Continuing education for health care professionals;
B) Leadership
and implementation of CQI projects, including morbidity and mortality reviews
at regional network hospitals;
C) Maternal and neonatal
transport services;
D) Consultation services
for high-risk perinatal patients;
E) Follow-up developmental
assessment programs; and
F) Laboratory
facilities and services available to regional network hospitals.
2) An APC shall be capable of providing the highest level of care
within a regional network appropriate to maternal and neonatal high-risk
patients. The following services shall be available:
A) Consultants in the various medical-pediatric-surgical
subspecialties including, but not limited to, cardiac, neurosurgery, genetics,
and other support services;
B) Follow-up developmental assessment program;
C) Maternal and neonatal transport services; and
D) Laboratory facilities available to the hospitals within the
regional perinatal network.
b) The Department will designate an APC within each regional perinatal network to be responsible
for the administration and implementation of the Department's Regionalized
Perinatal Health Care Program.
c) The APC will be responsible for providing leadership in the
design and implementation of the Department's CQI Program, including the
establishment and regularly scheduled meetings of a regional quality
improvement structure (Regional Quality Council).
d) The APC
shall establish a Joint Mortality and Morbidity Review Committee with the
affiliated regional network hospitals. The Committee shall review all perinatal
deaths and selected morbidity, including, but not limited to, transports of
neonates born with handicapping conditions, or developmental disabilities, or
unique medical conditions. This review shall also include a periodic comparison
of total perinatal mortality and the numbers attributable to categories of
complications. Membership on the Committee shall include, but not be limited
to, pediatricians, obstetricians, family practice physicians, nurses, quality
assurance, pathology, and hospital administration staff and representatives
from the hospital's APC. The network administrator shall prepare a yearly
synopsis of the Regional Perinatal Network's perinatal deaths. This synopsis
shall include statistical information, as well as an identification of the
factors contributing to deaths that are identified as potentially avoidable.
The synopsis shall be shared with the Regional Quality Council. The Council
shall develop, for the Network, an action plan to address issues of
preventability. The Council's action plan shall be forwarded to the Department.
The membership of the Council shall include representatives from all levels and
disciplines of perinatal health care providers.
e) Perinatal Program Oversight
1) The Department shall work in conjunction with the APCs to
conduct site visits at network hospitals to assure compliance with this Part on
a periodic basis not to exceed three years.
2) The requirements of this Part do not apply to infants who,
after having completed initial therapy, are transferred back to the referring
hospital for continuing care. The capability of the hospital to provide
necessary services for these infants shall be determined by mutual consent with
the APC and addressed in the letter of agreement.
3) APCs shall provide information to the Department no less
frequently than quarterly. These reports shall include, but not be limited to,
network education activities; network meetings; overview of CQI activities;
schedule of mortality and morbidity review meetings; and schedule of proposed
and completed network hospital site visits.
(Source: Amended at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.45 DEPARTMENT OF PUBLIC HEALTH ACTION
Section 640.45 Department of
Public Health Action
a) Department Review
1) The
Department will develop a plan for determining the degree of compliance with
this Part on a periodic basis not to exceed three years.
2) During
the site visit, the hospital will receive a determination of substantial
compliance or substantial failure.
b) Department Oversight
The Department
may deny designation or redesignation or revoke designation of any hospital
that fails to achieve substantial compliance with the requirements for
designation or redesignation set forth in this Part. The Department will
consider the following factors in deciding whether to deny designation or
redesignation or to revoke designation:
1) Failure to complete the letter of agreement within 90 days
after receipt of the official site visit report;
2) Failure to have and to comply with an approved Maternity and
Neonatal Service Plan;
3) Failure to complete the site visit and accompanying site visit
report documentation;
4) Failure to comply with all of the requirements of this Part
for the level of designation.
5) Failure to participate in and comply with CQI programs,
including the Regional Quality Council or other programs designed or implemented
by the APC or the Department;
6) Failure to notify the Department of the loss of, or change in,
an essential resource required for its level of designation;
c) The
Department will notify the hospital within 30 days after the site visit as to
whether the hospital has achieved substantial compliance with this Part. The
notification will include specific requirements with which substantial
compliance has not been achieved. If the hospital has not achieved substantial
compliance within 90 days after having received the notice, the Department will
deny or revoke the designation. If progress toward substantial compliance is
being made, per written documentation of the APC, the Department will continue
to work with the hospital and its APC to achieve designation.
d) The Illinois Administrative Procedure Act and the
Department's Practice and Procedure in Administrative Hearings shall apply to
all hearings challenging Department decisions, including those related to
designation, redesignation, and denial or revocation of designation.
(Source: Amended at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.50 DESIGNATION AND REDESIGNATION OF NON-BIRTHING CENTER, LEVEL I, LEVEL II, LEVEL II WITH EXTENDED NEONATAL CAPABILITIES, LEVEL III PERINATAL HOSPITALS AND ADMINISTRATIVE PERINATAL CENTERS
Section 640.50 Designation
and Redesignation of Non-Birthing Center, Level I, Level II, Level II with
Extended Neonatal Capabilities, Level III Perinatal Hospitals and
Administrative Perinatal Centers
a) The hospital shall declare by means of a letter of intent to
the Department and the affiliated APC that it seeks designation as a hospital
with no OB services, or as a Level I, Level II, Level II with Extended Neonatal
Capabilities, or Level III in a Regional Perinatal Network.
b) The Department will acknowledge the letter of intent.
c) The APC shall arrange a site visit to the applicant hospital. The
hospital shall prepare the designation/redesignation documents in accordance
with Section 640.60. The site visit team for Level I, II, II with Extended Neonatal
Capabilities, and III perinatal hospitals shall consist of six members: three
from the APC of the hospital's Regional Perinatal Network, including the
Directors of Neonatology and Maternal-Fetal Medicine or their designees and the
Perinatal Network Administrator; a representative of nursing; one
representative from the PAC; and one representative of the Department. When
travel is not feasible, regardless of the reason, the PAC representative shall
be permitted to participate in the site visit from a remote location via
telephone, Voice over Internet Protocol (VoIP), or video conferencing. The
site visit team shall review the capabilities of the applicant hospital based
on the requirements outlined in the letter of agreement between the applicant hospital
and the APC. The site visit team shall complete the Standardized Perinatal Site
Visit Protocol (see Appendix A) and submit these materials to the medical
directors of the hospital visited for their review and comment within 30 days after
the date of the site visit. The APC shall collaborate with the Department to
develop a summary site visit report within 60 days after the site visit. This
report shall be sent to the hospital within 90 days after the site visit.
d) The Department will coordinate the site visit for APCs. The
team shall consist of five members: one Director of Neonatology, one Director
of Maternal-Fetal Medicine and one Perinatal Network Administrator from a
non-contiguous Center; one representative from the PAC; and one representative
of the Department. When travel is not feasible, regardless of the reason, the
PAC representative shall be permitted to participate in the site visit from a
remote location via telephone, Voice over Internet Protocol (VoIP), or video
conferencing. The Department shall collaborate with the site visit team to
develop a summary site visit report within 60 days after the site visit. This
report shall be forwarded to the hospital within 90 days after the site visit.
e) The Department will review the submitted materials, any other
documentation that clearly substantiates a hospital's compliance with
particular provisions or standards for perinatal care, and the recommendation of
the PAC.
f) The Department will make the final decision and inform the hospital
of the official determination regarding designation. The Department's decision will
be based upon the recommendation of the PAC and the hospital's compliance with this
Part, and may be appealed in accordance with Section 640.45. A 12-month to
18-month follow-up review will be scheduled for any increase in hospital
designation to assess compliance with the requirements of this Part that are
applicable to the new level of designation. The Department shall consider the
following criteria to determine if a hospital is in compliance with this Part:
1) Maternity
and Neonatal Service Plan (Subpart O of the Hospital Licensing Requirements);
2) Proposed
letter of agreement between the applicant hospital and its APC in accordance
with Section 640.70;
3) Appropriate
outcome information contained in Appendix A and the Resource Checklist
(Appendices L, M, N and O);
4) Other
documentation that substantiates a hospital's compliance with particular
provisions or standards of perinatal care set forth in this Part; and
5) Recommendation of
Department program staff.
g) The Department will review all designations at least every
three years to assure that the designated hospitals continue to comply with the
requirements of the perinatal plan. Circumstances that may influence the
Department to review a hospital's designation more frequently than every three
years could include:
1) A hospital's desire to expand or reduce services;
2) Poor perinatal outcomes;
3) Change in APC or Network affiliation;
4) Change in resources that would have an impact on the
hospital's ability to comply with the required resources for the level of
designation; or
5) An APC finds and the Department concurs or determines that a
hospital is not appropriately participating in and complying with CQI programs.
h) Existing designations shall be effective until redesignation
is accomplished.
(Source: Amended at 41 Ill.
Reg. 3477, effective March 9, 2017)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.60 APPLICATION FOR HOSPITAL DESIGNATION OR REDESIGNATION AS A NON-BIRTHING CENTER, LEVEL I, LEVEL II, LEVEL II WITH EXTENDED NEONATAL CAPABILITIES, LEVEL III PERINATAL HOSPITAL AND ADMINISTRATIVE PERINATAL CENTER, AND ASSURANCES REQUIRED OF APPLICANTS
Section 640.60 Application
for Hospital Designation or Redesignation as a Non-Birthing Center, Level I,
Level II, Level II with Extended Neonatal Capabilities, Level III Perinatal Hospital
and Administrative Perinatal Center, and Assurances Required of Applicants
a) Applicant hospitals shall provide the Department with
information based on standards and resources for the applicable level of
designation. The information shall include, but not be limited to the following
(see Appendix A):
1) A definition of the geographic area the hospital currently
serves or plans to serve.
2) A physical description of the hospital, compliance with
Subpart O of the Hospital Licensing Requirements, and a description of the
maternity and nursery units currently in place or in preparation for operation
should the hospital be designated.
3) A physical description of the hospital's staffing in
accordance with this Part as follows:
A) Social work and nutrition services shall be available through a
hospital department for Level II and Level III designation.
B) Names, titles and contact numbers shall be provided for the
Director or Chairman of Maternal-Fetal Medicine, Neonatology, Obstetrics,
Pediatrics and Neonatal Services, Chief Nursing Supervisor, Nursing Supervisor
of Maternity Unit; names and contact numbers of medical staff members in
maternal-fetal medicine, obstetrics and gynecology, neonatology, obstetric anesthesiology,
family practice, anesthesiology; listing of anesthetists, staff for respiratory
therapy, nurse-midwives, and involved house staff.
C) A description of the current nurse/patient ratios in the
nursery, delivery room, postpartum floor and intermediate or intensive care
newborn nurseries for all shifts.
D) A description of the qualifications of nursing personnel
involved in the newborn nursery, delivery room and postpartum area.
E) A description of the staff plans to assure that maternity/nursery
staff are trained and prepared to stabilize infants prior to transfer, and are
available 24 hours a day.
4) A description giving evidence that the hospital's laboratory,
X-ray and respiratory therapy equipment and capabilities meet all of the
conditions described in Subpart O of the Hospital Licensing Requirements and
are available 24 hours a day in-house.
A) Continuous electronic maternal-fetal monitoring shall be
available, and staff with knowledge in its use and interpretation shall be
available 24 hours a day for Level I, Level II, Level II with Extended Neonatal
Capabilities, and Level III designation applicants.
B) Level III and APCs shall provide Level II ultrasound available
on the obstetric floor.
C) Level I ultrasound and staff knowledgeable in its use and
interpretation shall be available at Level II hospitals on a 24-hour-a-day
basis.
5) A description of the capabilities for or capabilities planned
for (giving the start-up time) emergency neonatology surgery, listing
specialists such as surgeons, trained or support staff for neonates, and a
description of the capabilities for caesarean section and start-up time.
6) A description of the present plan for identification of
high-risk maternity and neonatal patients and agreements for consultation with
the APC in cases of maternity and neonatal complications and neonates with
handicapping conditions. This description shall include plans and agreements
for providing:
A) Management of acute surgical or cardiac difficulties;
B) Genetic counseling if a genetically related condition is
diagnosed in the neonate, or if a parent or a known carrier requests the
services;
C) Information, counseling and referral to another health care
provider for parents of neonates with handicapping conditions or developmental
disabilities to ensure informed consent for treatment;
D) Counseling and referral services to another health care
provider to assist these patients in obtaining habilitation and rehabilitation
services;
E) A description of the types of patients the hospital will care
for and the types of patients it will refer to the APC.
7) A description of the history and current level of involvement
with CQI activities as designed and implemented by the APC.
8) All of the information required for hospital designation or
redesignation to the APC with which it is seeking affiliation.
b) The following procedures shall govern the review of perinatal hospitals
applying for designation or redesignation:
1) Hospitals applying for perinatal designation or redesignation
shall provide all of the information contained in the Standardized Perinatal
Site Visit Protocol (Appendix A) and the Resource Checklist (see Appendices L,
M, N and O).
2) The completed written documentation shall be submitted to the
Department three weeks in advance of the scheduled site visit.
3) The Department will send the completed site visit
documentation to the PAC no less than two weeks in advance of the PAC meeting,
to facilitate PAC review of the applicant hospital.
4) A representative of the APC and
representatives of the hospital for which the application is being considered
shall be present at the PAC meeting to respond to questions or concerns of PAC
members regarding the hospital's application for designation or redesignation.
The representative may also be asked to present an oral summary of the
applicant hospital's and the APC's reasons for recommending/not recommending
designation or redesignation to the PAC. A 12- to 18-
month follow-up will be scheduled for any increase in designation to assess compliance
with the new level of designation.
5) The Department will request that the APC conduct a follow-up
site visit to the hospital for review for designation or redesignation if
the initial site visit is more than six months prior to submission to the PAC. Approval
shall be contingent upon receiving the findings of the follow-up site visit.
c) The
following procedure shall be followed to change network affiliation for an
individual hospital:
1) The hospital requesting a change in affiliation
shall submit a written request to the Department. The existing APC shall
provide information for the site visit and review, as requested. The receiving
APC shall conduct the site visit in preparation for a change in network.
2) Representatives
from the hospital and receiving APC shall appear before the PAC and shall
present appropriate documentation as described in Appendix A.
(Source: Amended at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.70 MINIMUM COMPONENTS FOR LETTERS OF AGREEMENT BETWEEN NON-BIRTHING CENTER, LEVEL I, LEVEL II, LEVEL II WITH EXTENDED NEONATAL CAPABILITIES, OR LEVEL III PERINATAL HOSPITALS AND THEIR ADMINISTRATIVE PERINATAL CENTER
Section 640.70 Minimum
Components for Letters of Agreement Between Non-Birthing Center, Level I, Level
II, Level II with Extended Neonatal Capabilities, or Level III Perinatal Hospitals
and Their Administrative Perinatal Center
The following components, at a
minimum, shall be addressed in a letter of agreement between the applicant hospital
and its APC:
a) A description of how maternal and neonatal patients with potential
complications, including handicapping conditions or developmental disabilities,
will be identified.
b) A description of the types of maternal and neonatal cases in
which consultation from the APC or Level III hospital shall be sought and from
which patients shall be selected for transfer. This description shall address
those high-risk mothers or neonates with handicapping conditions, developmental
disabilities, or medical conditions that may require additional medical and
surgical treatment and support services, but would not, however, require
transport to an APC or Level III hospital.
c) A description of how the APC or Level III hospital will report
a patient's progress to the referring physicians, and the criteria for return
of the patient from the APC or Level III hospital to an affiliated hospital
closer to the patient's home.
d) A description of the methods for transporting high-risk
mothers and neonates with physiological support in transit.
e) A description of the information, counseling and referral
services available within the local community and the regional network for
parents or potential parents of neonates with handicapping conditions or
developmental disabilities.
f) A description of the professional educational outreach program
for the regional network, including how efforts will be coordinated.
g) A description of the regional perinatal network's program for
medical and home nursing follow-up, describing systems of liaisons, with a
letter of agreement from the agency providing the home nursing follow-up
services.
h) A description of the methodologies used to monitor, evaluate
and improve the quality of health care services provided by the applicant hospital,
including expectations of both the APC and applicant hospital on joint
participation in CQI activities.
i) A requirement that the hospital shall provide information,
counseling and referral services to another health care provider to parents or
potential parents of neonates with handicapping conditions or developmental
disabilities upon the identification of the handicapping conditions and
developmental disabilities, to assist in obtaining habilitation, rehabilitation
and special education services.
j) A requirement for evaluation and consultation with the APC or
Level III hospital and referral to the APC or Level III hospital, when
determined appropriate by the perinatal conditions or developmental
disabilities, within 24 hours after the identification of the conditions
(specific conditions shall be defined in the letter of agreement).
k) A requirement that procedures for referral to appropriate
state and local education service agencies of children having an identified
handicapping condition or developmental disability requiring evaluation and
assessment under such agencies shall be established. The procedures shall
include obtaining parental consent prior to release of information to the
appropriate state and local educational service agencies.
(Source: Amended at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.80 REGIONAL PERINATAL NETWORKS COMPOSITION AND FUNDING
Section 640.80 Regional
Perinatal Networks – Composition and Funding
a) Regional Perinatal Networks, as defined in Section 640.20, may
include any number and combination of hospitals providing maternity and newborn
services at one of the levels of perinatal care, according to policies and
practices described in their letters of agreement. Where more than one Level
III hospital provides services within a Regional Perinatal Network, a letter of
agreement with the APC shall describe how each will participate in the
provision of services included in Section 640.40 of this Part. Regional
Perinatal Networks may also include other agencies, institutions and
individuals providing a complete range of perinatal health services, including
preconceptional, prenatal, perinatal and family follow-up care services, as
part of the regional network.
b) The Department will allocate funds for perinatal health
services provided through Regional Perinatal Networks.
1) Funds will be awarded to Regional Perinatal Networks under the
following mechanisms:
A) The Department will provide grants to designated APCs
responsible for the administration and implementation of the Department's
regionalized perinatal health care program. Under this option, the APC is the
applicant for Maternal and Child Health (MCH) Project funds and will apply as
specified in the Department of Human Services’ Maternal and Child Health
Services Code (77 Ill. Adm. Code 630.30 through 630.70).
B) Grant applications by regional perinatal networks may include
services and responsibilities assigned to APCs and Level III hospitals in
Section 640.40(c) of this Part in addition to the perinatal care services
included in 77 Ill. Adm. Code 630.30 through 630.70.
2) Preventive Services
A portion of
funds available to the Department for funding regional perinatal networks shall
be targeted for preventive services.
(Source: Amended at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.85 EXCEPTIONS TO PART 640
Section 640.85 Exceptions to
Part 640
a) A hospital may request an exception to the standards of care
set forth in this Part in accordance with this Section. Exceptions are not
intended to circumvent Level designations. The hospital or the APC
may seek the advice and consultation of the Department, as well as the PAC, in
regard to the requirements for an exception.
b) Exceptions to the standards of care set forth in this Part may
be granted when the hospital requesting an exception demonstrates that the
resources and quality of care (outcomes) are substantially equivalent to the
resources and quality of care for a facility at the next highest level of
designation, as indicated by the resource requirements set forth in this Part.
If the hospital and its APC agree on the proposed exception, a proposed letter
of agreement shall be submitted to the Department for review and approval. The
Department's review will be based on compliance with this Part, patient care
needs, current practice, outcomes, and geography in the regional perinatal
network.
c) If the hospital and its APC do not agree on any aspect of the
proposed exception, the hospital or the APC shall consult the Subcommittee on
Facility Designation (SFD) of the PAC.
d) The following information shall be submitted to the SFD:
1) A proposed letter of agreement (unsigned);
2) The curriculum vitae for all directors of patient care, i.e.,
obstetrics, neonatal, nursing (obstetrics and neonatal);
3) Appendix A of this Part (fully completed); and
4) A letter from the APC that includes the following information:
A) The
exceptions being requested;
B) Information demonstrating that the quality of care (outcomes)
of the hospital is substantially equivalent to the standards of this Part for
the next highest level of designation for the proposed exceptions;
C) A description of the monitoring system used when consultation
between the attending physician at the hospital and the physician consultant at
a higher level hospital determines that a mother or newborn infant should
remain in the hospital rather than being transferred to the higher level
hospital;
D) A description of any arrangements made between the hospital and
the APC to seek or ensure quality improvement;
E) A copy of the hospital's Maternity and Neonatal Service Plan
(Subpart O of the Illinois Hospital Licensing Requirements); and
F) The PAC's recommendation concerning the exception.
e) The medical co-directors of the APC (or their designees) and
the medical directors of obstetrics and maternal and newborn care and a
representative of hospital administration from the applicant hospital shall
participate (either in person or electronically) in the SFD's review of the
application.
f) Exceptions agreed to between hospital and the SFD shall be
defined in a proposed letter of agreement and submitted to the Department for
review and approval. The Department's review will be based on compliance with
this Part, patient care needs, current practice, outcomes, and geography in the
regional perinatal network.
g) If the SFD is not able to make a decision on the exception,
the SFD shall submit the request for an exception to the Department, including
all of the information submitted to the SFD in accordance with subsection (d)
and the SFD's recommendation concerning the exception.
h) The Director of Public Health shall make the final decision
regarding approval of the exception and the letter of agreement. The
Director's decision shall be based upon the recommendations of the APC and the
SFD and the documentation required in subsection (d) to determine the
facility's compliance with this Part. The Director's decision may be appealed
in accordance with Section 640.45. The Department shall inform the hospital,
the APC and the SFD of the decision.
(Source: Added at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.90 STATE PERINATAL REPORTING SYSTEM
Section 640.90 State Perinatal
Reporting System
a) Purpose
The Department
will maintain a State Perinatal Reporting System to follow selected high-risk
perinatal patients to ensure that those patients are assessed at appropriate
intervals, receive intervention as needed, and are referred for needed support
services.
b) Identification and Referral of High-Risk Maternal Patients
1) Each designated APC and Level III hospital that provides
obstetrical care shall establish criteria and procedures for identifying
high-risk pregnant and postpartum patients. A statement describing the criteria
and procedures shall be on file and shall be provided to the Department on
request.
2) The hospital's Perinatal Review Committee, or other committee
established for the purpose of internal quality control or medical study for
the purpose of reducing morbidity or mortality or improving patient care, shall
collect and submit the information required in subsection (b)(1) to the
Department. These data will be considered confidential under Section 8-2101 of
the Code of Civil Procedure.
c) Identification of Perinatal Patients
1) All Illinois hospitals licensed to provide obstetrical and
newborn services shall report information on all perinatal patients. The
Department requests, but does not require, reports on perinatal patients from
hospitals outside Illinois.(The Department does request reports from the St.
Louis APCs or hospitals maintained by the federal government or other
governmental agencies within the United States.)
2) Each hospital shall prepare a Perinatal Report record (see
Appendix I), to be provided by the Department, for patients meeting one of the
following conditions:
A) Live-birth; or
B) Diagnosed prior to discharge from newborn hospitalization as a
perinatal or neonatal death.
3) Women who present with spontaneous abortion, ectopic pregnancy
or hydatidiform mole are perinatal patients and shall be reported. The products
of induced abortions shall not be reported to the State Perinatal Reporting
System.
4) Fetal death (gestation greater than 20 weeks) is considered a
reportable perinatal outcome. These fetal deaths do not have to be reported
through the State Perinatal Reporting System, because they are already reported
and compiled in the Department's Vital Records database.
5) Every hospital shall provide representatives of the Department
with access to information from all medical, pathological, and other records
and logs related to reportable registry information. The mode of access and the
time during which this access will be provided shall be by mutual agreement
between the hospital and the Department.
6) The State Perinatal Reporting System also will be complemented
with information from the Department's Vital Records live birth database under
the Vital Records Act, the Adverse Pregnancy Outcomes Reporting System under
the Illinois Health and Hazardous Substances Registry Act and other Maternal
and Child Health Reports and submissions.
7) The State Perinatal Reporting System consists of two forms of
reporting. This reporting shall be on the forms provided by the Department or
through electronic means that meets the exact specifications of the
Department's data processing system. Complete perinatal reporting information shall
be reported to the Department within 14 days after infant discharge, regardless
of the method of reporting.
d) Availability of Information
1) The patient and hospital-identifying information submitted to
the Department or certified local health department under the Act and this Part
shall be privileged and confidential and shall not be available for disclosure,
inspection or copying under the Freedom of Information Act or the State Records
Act, except as described in this Section. These data shall also be considered
confidential under Section 8-2101 of the Code of Civil Procedure.
2) Aggregate summaries and reports of follow-up activities may be
provided upon request to hospitals, to APCs, and to the certified local health department
designated by the Department to provide follow-up services to the patients. These
reports may contain information provided by the referring hospital and
information provided by the follow-up certified local health department.
Patient or hospital specific data provided to the appropriate designee under
this Section are confidential and shall be handled in accordance with the
Illinois Health Statistics Act and Section 9 of the Hospital Licensing Act.
These data shall also be considered confidential under Section 8-2101 of the
Code of Civil Procedure.
3) All reports issued by the Department in which the data are
aggregated so that no patient or reporting hospital may be identified shall be
available to the public pursuant to Access to Public Records of the Department
of Public Health and the Freedom of Information Act.
e) Quality Assurance and Continuous Quality Improvement
1) Reporting entities (i.e., hospitals, certified local health
departments and managed care entities (MCEs) shall be subject to review by the
Department to assess the timeliness, correctness and completeness of the
reports submitted by the entity.
2) Reporting entities (i.e., hospitals, certified local health
departments and MCEs shall supply additional information to the Department at
the Department's request when additional information is needed to confirm the
accuracy of reports previously submitted, or to clarify information previously
submitted. The Department will not request data that are more than two years
old.
(Source: Amended at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.100 HIGH-RISK FOLLOW-UP PROGRAM
Section 640.100 High-Risk
Follow-up Program
The Illinois Department of Human
Services manages the high-risk follow-up program in accordance with the
Maternal and Child Health Services Code (77 Ill. Adm. Code 630).
(Source: Amended at 35 Ill.
Reg. 2583, effective January 31, 2011)
Section 640.APPENDIX A Standardized Perinatal Site Visit Protocol
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX A STANDARDIZED PERINATAL SITE VISIT PROTOCOL
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
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ADMINISTRATIVE PERINATAL CENTER:
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GEOGRAPHIC AREA SERVED (Provide description):
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MEMBERS (titles and affiliated institutions) OF SITE
VISIT TEAM:
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I. HOSPITAL DATA
Please use data from most recent
three calendar years
A. MATERNAL DATA
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200
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200
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201
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1. Number of
Obstetrical Beds:
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Current RN/Patient ratio
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a. Ante-partum
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b. Labor / Delivery LDR
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|
|
|
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)
Section 640.APPENDIX B Outcome Oriented Data: Perinatal Facility Designation/
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX B OUTCOME ORIENTED DATA: PERINATAL FACILITY DESIGNATION/
Section
640.APPENDIX B Outcome Oriented Data: Perinatal Facility Designation/
Redesignation
(Repealed)
Section 640.EXHIBIT A Outcome
Oriented Data Form (Repealed)
(Source: Repealed at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX B OUTCOME ORIENTED DATA: PERINATAL FACILITY DESIGNATION/
Section 640.APPENDIX B Outcome Oriented Data:
Perinatal Facility Designation/
Redesignation (Repealed)
Section 640.EXHIBIT B Data Collection Exception Form
(Repealed)
(Source: Repealed at 35 Ill.
Reg. 2583, effective January 31, 2011)
Section 640.APPENDIX C Maternal Discharge Record (Repealed)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX C MATERNAL DISCHARGE RECORD (REPEALED)
Section 640.APPENDIX C Maternal Discharge Record
(Repealed)
Section 640.EXHIBIT A Maternal Discharge Record Form
(Repealed)
(Source: Repealed at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX C MATERNAL DISCHARGE RECORD (REPEALED)
Section 640.APPENDIX C Maternal Discharge Record
(Repealed)
Section 640.EXHIBIT B Instructions
for Completing Maternal Discharge Record (Repealed)
(Source: Repealed at 35 Ill.
Reg. 2583, effective January 31, 2011)
Section 640.APPENDIX D Report of Local Health Nurse, Maternal – Prenatal (Repealed)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX D REPORT OF LOCAL HEALTH NURSE, MATERNAL PRENATAL (REPEALED)
Section 640.APPENDIX D Report
of Local Health Nurse, Maternal – Prenatal (Repealed)
Section 640.EXHIBIT A Local
Health Nurse, Maternal – Prenatal Form (Repealed)
(Source: Repealed at 24 Ill. Reg. 12574, effective August 4, 2000)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX D REPORT OF LOCAL HEALTH NURSE, MATERNAL PRENATAL (REPEALED)
Section 640.APPENDIX D Report
of Local Health Nurse, Maternal – Prenatal (Repealed)
Section 640.EXHIBIT B Instructions
for Completing the Report of Local Health Nurse, Maternal-Prenatal (Repealed)
(Source: Repealed at 24 Ill. Reg. 12574, effective August 4, 2000)
Section 640.APPENDIX E Report of Local Health Nurse, Maternal--Postnatal (Repealed)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX E REPORT OF LOCAL HEALTH NURSE, MATERNAL--POSTNATAL (REPEALED)
Section 640.APPENDIX E Report
of Local Health Nurse, Maternal--Postnatal (Repealed)
Section 640.EXHIBIT A Local
Health Nurse, Maternal--Postnatal Form (Repealed)
(Source: Repealed at 24 Ill. Reg. 12574, effective August 4, 2000)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX E REPORT OF LOCAL HEALTH NURSE, MATERNAL--POSTNATAL (REPEALED)
Section 640.APPENDIX E Report
of Local Health Nurse, Maternal--Postnatal (Repealed)
Section 640.EXHIBIT B Instructions
for Completing the Report of Local Health Nurse, Maternal-Postnatal (Repealed)
(Source: Repealed at 24 Ill. Reg. 12574, effective August 4, 2000)
Section 640.APPENDIX F Report of Local Health Nurse, Infant (Repealed)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX F REPORT OF LOCAL HEALTH NURSE, INFANT (REPEALED)
Section 640.APPENDIX F Report
of Local Health Nurse, Infant (Repealed)
Section 640.EXHIBIT A Local Health Nurse, Infant Form
(Repealed)
(Source: Repealed at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX F REPORT OF LOCAL HEALTH NURSE, INFANT (REPEALED)
Section 640.APPENDIX F Report
of Local Health Nurse, Infant (Repealed)
Section 640.EXHIBIT B Instructions
for Completing the Report of Local Health Nurse, Infant (Repealed)
(Source: Repealed at 35 Ill.
Reg. 2583, effective January 31, 2011)
Section 640.APPENDIX G Sample Letter of Agreement
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX G SAMPLE LETTER OF AGREEMENT
Section 640.APPENDIX G Sample
Letter of Agreement
_________________ (name
of Administrative Perinatal Center) is recognized and designated by the
Illinois Department of Public Health as a Level III Administrative Perinatal
Center providing obstetrical and neonatal care. In order to serve as a Non-Birthing
Hospital, Level I, II, II with Extended Neonatal Capabilities or III,
affiliated with an Administrative Perinatal Center designated by the Illinois
Department of Public Health, __________________(name and address of
hospital) agrees to affiliate with the above Administrative Perinatal Center.
This agreement is consistent
with the Illinois Department of Public Health, Regionalized Perinatal Health
Care Code (77 Ill. Adm. Code 640).
Components
for Letter of Agreement
I. Introductory Remarks: The Administrative Perinatal Center
may list items of organization of the Center.
II. Administrative Perinatal Center Obligations
A. A 24-hour obstetrical and neonatal "hot-line" for
immediate consultation, referral or transport of perinatal patients is
available.
|
Obstetrical
|
Neonatal
|
|
Hospital
|
Telephone #
|
Hospital
|
Telephone #
|
|
|
|
|
B. The Administrative Perinatal Center shall accept all medically
eligible obstetrical/neonatal patients.
C. If the above named Administrative Perinatal Center is unable to
accept a referred maternal or neonatal patient because of bed unavailability,
that Center shall assist in arranging for admission of the patient to another hospital
capable of providing the appropriate level of care.
D. Transportation of neonatal patients remains the responsibility
of the Administrative Perinatal Center. Decisions regarding transport and mode
of transport will be made by the Administrative Perinatal Center neonatologist
in collaboration with the referring health care provider.
E. Transportation of the obstetrical patient remains the
responsibility of the (Level I, Level II, Level II with Extended Neonatal
Capabilities or Level III hospital). Decisions regarding transport, transfer
and mode of transport or transfer shall be made by the Administrative Perinatal
Center maternal-fetal medicine physician in collaboration with the referring health
care provider.
F. The maternal-fetal medicine physician of the Administrative Perinatal
Center, in collaboration with the referring health care provider, shall decide
whether to have an obstetrical patient stabilized before transfer, kept in the
affiliated unit or transferred immediately. The best possible alternatives and
the staff needed for transport shall be determined.
G. The Administrative Perinatal Center shall distribute written
protocols for the mechanism of referral/transfer/transport to the affiliated
hospital physician, administration and nursing service. Protocols are to
include a mechanism for data recording of the time, date and circumstances of
transfer so that this information can be part of the morbidity and mortality
reviews. (See Appendix A.)
H. The Administrative Perinatal Center shall send a written
summary of patient management and outcome to the referring health care provider
of record and to the hospital.
I. The Administrative Perinatal Center shall conduct quarterly
mortality and morbidity conferences at __________________________ Hospital.
1. The Administrative Perinatal Center's Perinatal Network
Administrator, maternal-fetal medicine physician, neonatologist and/or
obstetrical and neonatal nurse educators shall conduct the conference.
2. ______________________ Hospital shall prepare written
summaries of cases and statistics for discussion, to be available to the Administrative
Perinatal Center at least one week prior to the conference.
3. The Regional Quality Council of each Regional Perinatal Network
shall determine the content of the review. The review shall include, but not
be limited to, stillbirths, neonatal deaths, maternal and/or neonatal
transports.
J. The Administrative Perinatal Center shall transfer patients
back to the referring hospital when medically feasible, in accordance with
physician to physician consultation.
K. The Administrative Perinatal Center shall develop and offer
Perinatal Outreach Education programs at a reasonable cost to include the
following:
1. On-site consultation by Administrative Perinatal Center
physicians and nurse educators as needed.
2. Periodic obstetrical and neonatal needs assessment of
______________ Hospital.
3. Provide __________________ Hospital with protocols for patient
management.
4. Develop Continuing Medical Education programs for
obstetricians, pediatricians and family practitioners either at __________________
Hospital or at the Administrative Perinatal Center site.
5. Mini-Fellowships at the Administrative Perinatal Center for __________________
Hospital physicians and nurses.
6. Programs based on needs assessment by outreach nurse educators
at __________________ Hospital for obstetrical and neonatal nursing staff.
L. The Administrative Perinatal Center shall establish, maintain
and coordinate the educational programs offered for all Non-Birthing Centers, Level
I, Level II, Level II with Extended Neonatal Capabilities, and Level III hospitals
that it serves.
M. The Administrative Perinatal Center shall develop a Regional Quality
Council, including, but not limited to, representatives of each hospital in the
Regional Perinatal Network. This group shall meet at least quarterly to plan
management strategies, evaluate morbidity and mortality reviews, evaluate the
effectiveness of current programs and services and set future goals. The
Regional Quality Council shall determine the data collection system to be used
by the Regional Perinatal Network.
III. __________________ Hospital Obligations
A. __________________ Hospital shall utilize the
"hot-line" established by the Administrative Perinatal Center for
consultation, referral and transport.
B. __________________ Hospital shall transfer to __________________
Administrative Perinatal Center obstetrical and neonatal patients who require
the services of the Administrative Perinatal Center, including, but not limited
to, patients outlined in the Regionalized Perinatal Health Care Code.
C. __________________ Hospital (level of care) shall usually care
for the following maternal and neonatal patients.
D. __________________ Hospital shall develop an ongoing in-house
continuing educational program for the obstetrical and neonatal medical staff
and other disciplines as needed.
E. __________________ Hospital shall participate in continuing
educational programs for both nurses and physicians developed by the __________________
Administrative Perinatal Center. Cost to be shared.
F. __________________ Hospital shall designate representatives to
serve on the __________________ Regional Quality Council.
G. __________________ Hospital shall establish a Perinatal
Development Committee composed of medical and nursing representatives from both
neonatal and obstetrical areas, administration and any other individuals deemed
appropriate.
H. __________________ Hospital shall maintain and share such
statistics as the __________________ Regional Quality Council may deem
appropriate.
I. __________________ Hospital shall develop or to utilize
programs at __________________ Administrative Perinatal Center for follow-up of
neonates with handicapping conditions.
IV. Joint
Responsibilities
A. This agreement will be valid for three years, at which time it
may be renewed or re-negotiated.
B. If either __________________ Hospital or the __________________
Administrative Perinatal Center wishes to change an individualized portion of
this agreement, either may initiate the discussion. If a change in the
agreement is reached, the change must be reviewed by the Department. If the __________________
Hospital wishes to make a change and __________________ Administrative Perinatal
Center is not in agreement, __________________ Hospital can request a hearing
by the Department.
C. If any of the institutions wants to terminate the agreement,
written notification shall be given to the Department and other participating
institutions six months in advance.
(Source: Amended at 35 Ill.
Reg. 2583, effective January 31, 2011)
Section 640.APPENDIX H Written Protocol for Consultation/Transfer/Transport
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX H WRITTEN PROTOCOL FOR CONSULTATION/TRANSFER/TRANSPORT
Section 640.APPENDIX H
Written Protocol for Consultation/Transfer/Transport
Section 640.EXHIBIT A Level
I: Patients for consultation with ________________ (Level III hospital
or Administrative Perinatal Center)
1) Maternal Conditions
A) Previous Pregnancy Problems:
i) Premature infant
ii) Perinatal death or mental retardation
iii) Isoimmunization
iv) Difficult deliveries
v) Congenital malformations
vi) Mid-trimester loss
B) Current Pregnancy Problems:
i) Any medical disorder (e.g., diabetes mellitus,
hemoglobinopathy, chronic hypertension, heart disease, renal disease)
ii) Drug addiction
iii) Multiple gestation
iv) Intrauterine growth retardation
v) Preterm labor less than or equal to 36 weeks
vi) Postdate greater than or equal to 42 weeks
vii) Third trimester bleeding
viii) Abnormal genetic evaluation
ix) Pregnancy induced hypertension
2) Neonatal Conditions
A) Gestation less than or equal to 36 weeks, weight less than or
equal to 2500 grams
B) Small-for-gestational age (less than 10th
percentile)
C) Sepsis
D) Seizures
E) Congenital heart disease
F) Multiple congenital anomalies
G) Apnea
H) Respiratory distress
I) Neonatal asphyxia
J) Handicapping conditions or developmental disabilities that
threaten life or subsequent development
K) Severe anemia
L) Hyperbilirubinemia, not due to physiologic cause
M) Polycythemia
3) Consultation and transfer to a Level III or Administrative Perinatal
Center shall occur for the following conditions:
A) Premature labor or premature birth less than 34 weeks gestation.
B) Birth weight less than or equal to 2000 grams.
(Source: Amended at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX H WRITTEN PROTOCOL FOR CONSULTATION/TRANSFER/TRANSPORT
Section 640.APPENDIX H Written
Protocol for Consultation/Transfer/Transport
Section 640.EXHIBIT B Level
II: Patients for consultation with or transfer to ____________________ (Level
III hospital or Administrative 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, for whom transfer is
deemed advisable by mutual collaboration between the maternal-fetal medicine
physician at the Level III hospital and the obstetrician at the referring
office of the 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 occur 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 congenital heart disease.
E) Major congenital malformations requiring surgery.
F) Assisted ventilation required after initial stabilization
(greater than 6 hours).
G) Oxygen requirements in excess of 50% (greater than 6 hours).
H) 10-minute Apgar scores of 5 or less.
I) Major surgery.
J) Exchange transfusion.
K) Persistent metabolic derangement (e.g., hypocalcemia,
hypoglycemia, metabolic acidosis).
L) Handicapping conditions or developmental disabilities that
threaten life or subsequent development.
4) Consultation and transfer to a Level III hospital or Administrative
Perinatal Center shall occur for the following conditions:
A) Premature labor or premature birth less than 34 weeks gestation.
B) Birth weight less than or equal to 2000 grams.
C) Assisted ventilation beyond the initial stabilization period (6
hours).
(Source: Amended at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX H WRITTEN PROTOCOL FOR CONSULTATION/TRANSFER/TRANSPORT
Section 640.APPENDIX H Written
Protocol for Consultation/Transfer/Transport
Section 640.EXHIBIT C Level I: Maternal and
neonatal patients to be cared for at ________________ hospital (Level III
hospital or Administrative Perinatal Center)
1) Maternal
The maternal patient with an uncomplicated current pregnancy.
2) Neonatal
The neonatal patient greater than
34 weeks gestation or greater than 2000 grams without risk factors and infants
with physiologic jaundice.
(Source: Amended at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX H WRITTEN PROTOCOL FOR CONSULTATION/TRANSFER/TRANSPORT
Section 640.APPENDIX H Written
Protocol for Consultation/Transfer/Transport
Section 640.EXHIBIT D Level
II: Maternal and neonatal patients to be cared for at _________________
hospital (Level III hospital or Administrative Perinatal Center)
1) Maternal
A) The maternal patient with uncomplicated current pregnancy.
B) Patient with normal current pregnancy, although previous
history may suggest potential difficulties.
C) Patient with selected medical conditions, such as mild hypertension
or controlled thyroid disease, when there is no increase in perinatal
morbidity.
D) Patient with selected obstetric complications such as
pre-eclampsia or premature labor greater than 34 weeks.
E) Patient with an incompetent cervix.
F) Patient with gestational diabetes.
2) Neonatal
A) Patients greater than 34 weeks gestation or greater than 1800
grams without risk factors.
B) Patients with mild to moderate respiratory distress (not
requiring assisted ventilation in excess of 6 hours).
C) Patients with suspected neonatal sepsis, hypoglycemia, neonates
of diabetic mothers and post-asphyxia without life-threatening sequelae.
D) Premature infants greater than 1800 grams who are otherwise
well.
(Source: Amended at 35 Ill.
Reg. 2583, effective January 31, 2011)
Section 640.APPENDIX I Perinatal Reporting System Data Elements
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX I PERINATAL REPORTING SYSTEM DATA ELEMENTS
Section 640.APPENDIX I Perinatal
Reporting System Data Elements
1. Child's First Name
2. Child's Middle Name
3. Child's Last Name
4. Child's Suffix
5. AKA
6. Child's Date of Birth
7. Child's Time of Birth
8. Sex
A. Male
B. Female
C. Ambiguous
9. Child of Hispanic Origin
A. Yes
Cuban
Mexican
Puerto Rican
B. No
10. Race
A. Asian
B. Black
C. Caucasian
D. Native American
E. Other
11. Place of Birth
12. City of Birth
13. County of Birth
14. Mother's First Name
15. Mother's Middle Name
16. Mother's Last Name
17. Mother's Maiden Name
18. Mother's Social Security Number
19. Mother's Date of Birth
20. Mother's Street Number
21. Mother's Street Name
22. Mother's Street Direction
23. Mother's Street Type
24. Mother's Street Location
25. Mother's City
26. Mother's County
27. Mother's Zip Code
28. Mother's State
29. Mother's Telephone
30. Mother's Age
31. Mother's Birthplace
A. ________State
B. ________County
32. Mother of Hispanic Origin
A. Yes
Cuban
Mexican
Puerto Rican
B. No
33. Mother's Race
A. Asian
B. Black
C. Caucasian
D. Native American
E. Other
34. Mother's Education (specify highest grade completed)
35. Mother's Occupation
_________________
36. Mother's Business/Industry
37. Mother Employed During Pregnancy
A. Yes
B. No
C. Record Not Available (N/A)
D. Not Stated
38. Marital Status
A. Married
B. Not Married
39. Father's Last Name
40. Father's Middle Name
41. Father's First Name
42. Father of Hispanic Origin
A. Yes
Cuban
Mexican
Puerto Rican
B. No
43. Father's Race
A. Asian
B. Black
C. Caucasian
D. Native American
E. Other
44. Father's Education (specify highest grade completed)
45. Father's Age
46. Father's Occupation
________________
47. Father's Business/Industry
__________________
48. Father Employed
A. Yes
B. No
C. Record N/A
D. Not Stated
49. Pregnancy History
50. Plurality (# this Birth)
If greater than
1, Birth Order of this Birth
51. Previous Live Births
52. Number Live Births Now Living
53. Number Live Births Now Dead
54. Date of Last Live Birth
55. Previous Terminations
56. Number of Other Terminations
57. Date of Last Other Termination
58. Date of Last Normal Menses
59. Month Prenatal Care Began
60. Number of Prenatal Care Visits
61. 1 Minute Apgar Score
62. 5 Minute Apgar Score
63. Estimate of Number of Gestation Weeks
64. Mother Transferred In Prior to Delivery
A. Yes
B. Name of Hospital ________________
Location of Hospital
________________
C. No
65. Infant Transferred (Out)
A. Yes
B. Name of Hospital ____________
Location of Hospital
____________
C. Transfer Code
D. No
66. Reporting Hospital
67. Reporting Hospital City
68. Tobacco Use During Pregnancy
A. Smoked during pregnancy
Average cigarettes per day _____________
B. Stopped smoking during pregnancy
C. Does not smoke
D. Record N/A
E. Not Stated
69. Alcohol Use During Pregnancy
A. Yes
Average number
drinks per day ______
B. No
C. Record N/A
D. Not Stated
70. Mother's Weight Gain
A. Yes
Pounds ______
B. No
C. Record N/A
D. Not Stated
71. Mother's Weight Loss
A. Yes
Pounds ______
B. No
C. Record N/A
D. Not Stated
72. Medical Risk Factors for this Pregnancy
A. Anemia
B. Cardiac Disease
C. Acute or Chronic Lung Disease
D. Diabetes
E. Genital Herpes
F. Hydramnios/Oligohydramnios
G. Hemoglobinopathy
H. Hypertension, Chronic
I. Hypertension, Pregnancy-related
J. Eclampsia
K. Incompetent Cervix
L. Previous Infant 4000 + Grams
M. Previous Preterm or Small-for-Gestational-Age (SGA) Infant
N. Renal Disease
O. Rh Sensitization
P. Uterine Bleeding
Q. None
R. Other, Specify
73. Obstetric Procedures
A. Amniocentesis
B. Electronic Fetal Monitoring
Internal
External
Both
Neither
Record N/A
Not Stated
C. Induction of Labor
D. Stimulation of Labor
Yes
Pitocin _____
Oxytocin _____
No
Record N/A
Not Stated
E. Tocolysis
F. Ultrasound
G. None
H. Other, Specify
74. Complications of Labor and/or Delivery
A. Febrile
B. Meconium
C. Premature Rupture
D. Abruptio Placenta
E. Placenta Previa
F. Other Excessive Bleeding
G. Seizures During Labor
H. Precipitous Labor
I. Prolonged Labor
J. Dysfunctional Labor
K. Breech/Malpresentation
L. Cephalopelvic Disportion
M. Cord Prolapse
N. Anesthetic Complications
O. Fetal Distress
P. None
Q. Other, Specify
75. Method of Delivery
A. Spontaneous Vaginal
B. Mid – Low Forceps
C. Vacuum Extraction
D. Vaginal Breech
E. Caesarean Section Primary
F. Caesarean Section Repeat
G. Other Type
H. Record N/A
I. Not Stated
J. Vaginal Birth After Previous Caesarean Section (VBAC)
K. Other Caesarean Section
76. Abnormal Conditions of Newborn
77. Anemia
78. Birth Injury
79. Fetal Alcohol Syndrome
80. Hyaline Membrane Disease
81. Meconium Aspiration Syndrome
82. Assisted Ventilation > 30 min.
83. Assisted Ventilation = 30 min.
84. Seizures
85. Human Immunodeficiency Virus (HIV)
86. Other, Specify
87. Congenital Anomalies of Newborn
88. Anencephalous
89. Congenital
Syphilis
90. Hypothyroidism
91. Adrenogenital
Syndrome
92. Inborn
Errors of Metabolism
93. Cystic
Fibrosis
94. Immune
Deficiency Disorder
95. Retinopathy
of Prematurity
96. Chorioretinitis
97. Strabismus
98. Intrauterine
Growth Restriction
99. Cerebral
Lipidoses
100. Spina Bifida/Meningocele
101. Hydrocephalus
102. Microcephalus
103. Other CNS Anomalies, Specify ____________
104. Heart Malformations, Specify _____________
105. Other Circulatory/Respiratory Anomalies, Specify ____________
106. Rectal Atresia/Stenosis
107. Tracheoesophageal Fistula/Esophageal Atresia
108. Omphalocele/Gastroschisis
109. Other Gastrointestinal Anomaly
110. Malformed Genitalia
111. Renal Agenesis
112. Other Urogenital Anomaly, Specify ____________
113. Cleft Lip/Palate, Specify ____________
114. Polydactyly/Syndactyly/Adactyly
115. Club Foot
116. Diaphragmatic Hernia
117. Other Musculoskeletal/Integumental Anomaly
118. Down's Syndrome
119. Other Chromosomal Anomaly, Specify ____________
120. None
121. Other, Specify ____________
122. Transfusion
123. Anesthesia
A. Local/ Pudendal
B. Regional
C. General
124. Umbilical Cord Blood Gases Tested
A. Yes
B. No
125. Small-for-Gestational-Age (SGA)
126. Infection of Newborn Acquired Before Birth
127. Infection of Newborn Acquired During Birth
128. Infection of Newborn Acquired After Birth
129. Hereditary Hemolytic Anemias
130. Hemolytic Diseases of the Newborn
131. Due to Rh Incompatibility Only
132. Due to ABO Incompatibility
133. Due to Other Causes
134. Drug Toxicity or Withdrawal
A. Yes, Specify ____________
B. No
135. Highest Bilirubin, Total ________
136. Admit to Designated Patient Unit
A. Yes
B. No
137. Genetic Screenings Conducted
138. Rh Determination
A. Mother's Blood Type _______ Rh Factor _______
Immune
Globulin Given
B. Yes
C. No
139. Hepatitis B – Surface Antigen
A. Positive
B. Negative
140. Non-Obstetrical Infections
A. Syphilis
B. Gonorrhea
C. Rubella
D. Other
141. Obstetrical Infections
A. Antepartum
Amnionitis/Chorioamnionitis
Urinary Tract
Infection
B. Postpartum
Endometritis
Infection of
Wound
Urinary Tract
Infection
142. Mother admitted within 72 hours after delivery
A. Precipitous Delivery
B. Planned Home Birth
143. Drug Use During Pregnancy
A. Cocaine
B. Heroin
C. Marijuana
D. Other Street Drugs
E. None
F. Record N/A
G. Not Stated
144. Transfusion
145. Prenatal Screening Conducted for
A. Gestational Diabetes
(Blood Glucose
Tolerance Test)
B. Congenital/Birth Defects
A. Maternal Alpha Feta Protein
B. Chromosomal
C. Other
146. Number of Days Maintained on Ventilation Before
Transfer to Level III Center-Days
147. Prenatal Ultrasound
A. Yes
B. No
C. Record N/A
D. Not Stated
148. Chorionic Villus Sampling
149. Were Newborn Screening Tests Conducted?
A. Yes
B. No
150. Mother
Transferred Out to Another Hospital After Delivery Destination Hospital Code
151. Mother Transferred From Emergency Room
152. Infant Transferred In Transfer Code
153. Consult Administrative Perinatal Center or Another Level III
154. Infant Maternal
|
A.
|
A.
|
Yes, with Transfer
|
|
|
|
|
|
B.
|
B.
|
Yes, No Transfer
|
|
|
|
|
|
C.
|
C.
|
No Consultation
|
|
|
|
|
|
D.
|
D.
|
Not Stated
|
155. Mother Died In Hospital
156. Fetal Death
157. Infant Died in Hospital
158. Extrauterine Pregnancy
159. Ectopic Pregnancy
160. Admission Date – Infant
161. Admission Date – Maternal
162. Discharge Date – Infant
163. Discharge Date – Maternal
164. Payment Method
A. Yes
Medicaid
Medicaid HMO
HMO
Medicare
CHAMPUS
Title V
Health Insurance
Self Pay
Not Stated
Other, Specify
__________
B. No
165. Were prenatal records available prior to delivery?
A. Yes
B. No
166. Maternal Diagnosis (Specify up to 8 Diagnoses)
167. Mother's Medical Record Number _________________
168. Infant Diagnoses (Including Congenital Anomalies);
Specify up to 8 Diagnoses
169. Infant Released to:
|
A. Home
|
|
|
|
|
|
|
|
B. Other Hospital
|
Name and Location
|
|
|
|
|
|
|
C. Long Term Care
|
Name and Location
|
|
|
|
|
|
|
D. Other Child Care Agency
|
Name and Location
|
|
|
|
|
|
170. Infant Patient ID
171. Infant Medical Record Number __________________
172. Referrals
A. Community Social Services
B. Division of Specialized Services for Children (DSCC)
C. Department of Healthcare and Family Services (HFS)
D. Department of Children and Family Services (DCFS)
E. Other, Specify _________________
F. None
G. Early Intervention program
H. Other _______________
173. Feedings
174. Breast Fed
175. Bottle
176. Tube
177. Formula
178. Frequency
179. Amount
180. Infant Medications
181. Birth Weight
182. Birth Head Circumference
183. Birth Length
184. Discharge Weight
185. Discharge Head Circumference
186. Discharge Length
187. Infant Discharge Treatment
188. Other Concerns
189. RN Contact at Hospital – Phone Number
190. Relative/Friend
191. Relationship
192. Address/Phone #
193. Family Informed of Local Health Nurse Visit
A. Yes
B. No
194. Primary Care Physician's Name –
195. Mother Gravida Para F_ P_ A_ L_
196. Signature
197. Title
198. Report Date
(Source: Amended at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX J GUIDELINE FOR APPLICATION PROCESS FOR DESIGNATION, REDESIGNATION OR CHANGE IN DESIGNATION
Section 640.APPENDIX J Guideline for Application
Process for Designation, Redesignation or Change in Designation
Initial Process:
The hospital administration shall:
Send a Letter of Intent for change in status to the
Department and affiliated Administrative Perinatal Center 6 to12 months before
expected review by the PAC.
Prepare appropriate documents for site visit. Required
documents and assistance with preparation are available through affiliate Administrative Perinatal Center. The site visit team will include, but not be limited to,
Co-Directors of Administrative Perinatal Center and Network Administrator,
Perinatal Advisory Committee and Department. The Department will assign the
additional representatives required.
Send information three weeks in advance of the scheduled
site visit to:
Illinois Department of Public
Health
Perinatal Program Administrator
535 West Jefferson
Springfield, Illinois 62761
Assemble appropriate representation from the hospital on the
day of the site visit to be available to present an overview of the hospital
and to answer questions from the site visit team. Hospital representatives
should include at a minimum:
• Hospital
administration
• Chair
of OB/GYN
• Chair
of Family Practice, if appropriate
• Chair
of Pediatrics
• Director
of Anesthesiology
• Director
of Maternal-Fetal Medicine, if appropriate
• Director
of Neonatology, if appropriate
• Director
of Nursing
Once the site visit has been completed and the hospital and Administrative
Perinatal Center are satisfied that the application is complete, the Administrative Perinatal Center will contact the Department in writing to schedule
application review before the Perinatal Advisory Committee.
On the day of the review, the following representatives must
be present from the hospital to be reviewed:
• Hospital
administration
• Chair
of OB/GYN
• Chair
of Family Practice, if appropriate
• Chair
of Pediatrics
• Director
of Maternal-Fetal Medicine, if appropriate
• Director
of Neonatology, if appropriate
• Director
of Nursing
• Co-Directors
of Affiliate Perinatal Network
• Network
Administrator from Affiliate Perinatal Network
• Other
personnel as identified by hospital, Perinatal Advisory Committee or
Sub-Committee
After reviewing the application, the PAC will present a
formal outline of the issues and recommendations to the Department.
After review of the recommendations and deliberations, the
Department will send a formal letter as to the status of the hospital.
The hospital and the Administrative Perinatal Center
will work together to address the recommendation in the follow-up letter.
The Administrative Perinatal Center will be responsible for
monitoring any indicators or required changes that are identified by the PAC.
In preparation for re-review, the hospital and Administrative Perinatal Center will prepare information only on issues addressed in the
follow-up letter.
The Administrative Perinatal Center will contact the
Department to schedule the re-review meeting.
The Administrative Perinatal Center will send appropriate
documents, identified in the follow-up letter, to the Department three weeks
before the re-review is scheduled.
Only representatives from the Administrative Perinatal
Center shall attend the re-review meeting to answer any questions the review
committee may have concerning the identified items. Hospital representatives
may attend the meeting if they choose.
The Illinois Department of Public Health will send a formal
follow-up letter to the hospital and the Administrative Perinatal Center concerning the outcome of the meeting and any follow-up instructions.
(Source: Added at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX K ELEMENTS FOR SUBMISSION FOR DESIGNATION, REDESIGNATION OR CHANGE IN DESIGNATION
Section 640.APPENDIX K Elements for Submission for
Designation, Redesignation or Change in Designation
Level III Review
• Appendix
A
• Resource
Checklist for Level III
• Evaluation
letter from Administrative Perinatal Center
• Vita
for co-directors
• Credentials
for Obstetric (OB)/Family Practice (FP) physicians, Advance Practice Nurses
(APN), Neonatology & Anesthesia
• Copy
of OB/Peds Departmental Rules
• Maternal-Fetal
Medicine (MFM), Neonatology Consultation/referral tool/QA reports for 3 months
• Mortality
and Morbidity (M&M) statistics and description of the process/participation
• Transport
statistics, both into and out of hospital
• Listing
of educational classes
• Description
of educational classes
• Description
of CQI
• 3
months of call schedules for OB, Maternal-Fetal Medicine and Neonatology
(current and last 2 actual or 3 proposed schedules)
Level II with Extended Neonatal Capabilities Review
• Appendix
A
• Resource
Checklist for Level II with Extended Neonatal Capabilities
• Evaluation
letter from Administrative Perinatal Center
• Vita
for Director of Neonatology, Maternal-Fetal Medicine (MFM), if appropriate
• Credentials
for Obstetricians/Family Practice physicians, Advanced Practice Nurses (APN),
Neonatology & Anesthesia
• Copy
of OB/Peds Departmental Rules
• Consultation/referral
tool/QA reports for 3 months
• Mortality
and Morbidity (M&M) statistics and description of process/participation
• Transport
statistics, both into and out of hospital
• Listing
of educational classes
• Description
of CQI
• 3
months of call schedules for OB, MFM and Neonatology as appropriate
Level II Review
• Appendix
A
• Resource
Checklist for Level II
• Evaluation
letter from Administrative Perinatal Center
• Credentials
for Obstetrics (OB)/Family Practice (FP) physicians, Advance Practice Nurses
(APN), Neonatology & Anesthesia
• Copy
of OB/Peds Departmental Rules
• Consultation/referral
tool/QA reports for 3 months
• Mortality
and Morbidity (M&M) statistics and description of process/participation
• Transport
statistics − out of hospital
• Listing
of educational classes
• Description
of CQI
Level I Review
• Appendix
A
• Resource
Checklist for Level I
• Evaluation
letter from Administrative Perinatal Center
• Credentials
for Obstetrics (OB)/Family Practice (FP) physicians, Advance Practice Nurses (APNs),
Neonatology & Anesthesia
• Mortality
and Morbidity (M&M) statistics and description of process/participation
• Transport
statistics − out of hospital
• Listing
of educational classes
• Description
of CQI
Administrative Perinatal Center
• Network
description
• Educational
programs
• Network
projects
• Discussion
with representatives from Regional Network Hospitals
• Network
participation
• Network
evaluation
• Network
challenges
• Network
M&M statistics
• University
integration
(Source: Added at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX L LEVEL I RESOURCE CHECKLIST
Section 640.APPENDIX L Level I Resource Checklist
Level I Resource
Checklist
Briefly describe
institutional compliance:
1. The
hospital shall provide continuing education for medical, nursing, respiratory
therapy and other staff who provide general perinatal services, with evidence
of a yearly competence assessment appropriate to the population served.
RECOMMENDATIONS:
2. The
hospital shall provide documentation of participation in Continuous Quality Improvement
(CQI) implemented by the Administrative Perinatal Center.
RECOMMENDATIONS:
3. The
hospital shall provide documentation of the health care provider's risk
assessment and consultation with a maternal-fetal medicine sub-specialist or
neonatologist as specified in the letter of agreement and hospital's policies
and procedures, and transfer to the appropriate level of care.
RECOMMENDATIONS:
4. The
hospital shall provide documentation of the availability of trained personnel
and facilities to provide competent emergency obstetric and newborn care.
RECOMMENDATIONS:
5. The
hospital shall maintain a system of recording admissions, discharges, birth
weight, outcome, complications and transports to meet the requirement to support
CQI activities described in the hospital's letter of agreement with the Administrative Perinatal Center. The hospital shall comply with the reporting requirements
of the State Perinatal Reporting System.
RECOMMENDATIONS:
6. The
hospital shall provide documentation of the capability for continuous
electronic maternal-fetal monitoring for patients identified at risk with staff
available 24 hours a day, including physicians and nursing, who are
knowledgeable of electronic fetal monitoring use and interpretation. Staff
shall complete a competence assessment in electronic maternal-fetal monitoring
every two years.
RECOMMENDATIONS:
7. The
hospital shall have the capability of performing caesarean sections
(C-sections) within 30 minutes of decision-to-incision.
RECOMMENDATIONS:
8. The
hospital shall have blood bank technicians on call and available within 30
minutes for performance of routine blood banking procedures.
RECOMMENDATIONS:
9. The
hospital shall have general anesthesia services on call and available under 30
minutes to initiate C-section.
RECOMMENDATIONS:
10. The
hospital shall have radiology services available within 30 minutes.
RECOMMENDATIONS:
11. The
hospital shall have the following clinical laboratory resources available:
Microtechniques
for hematocrit, within 15 minutes; glucose, blood urea nitrogen (BUN),
creatinine, blood gases, routine urine analysis, complete blood count, routine
blood chemistries, type & cross, Coombs test, bacterial smear within 1
hour; and capabilities for bacterial culture and sensitivity and viral culture.
RECOMMENDATIONS:
12. The
hospital shall designate a physician to assume primary responsibility for
initiating, supervising and reviewing the plan for management of distressed
infants. Policies and procedures shall assign responsibility for the
identification and resuscitation of distressed neonates to individuals who have
successfully completed a neonatal resuscitation program and are both
specifically trained and immediately available in the hospital at all times.
RECOMMENDATIONS:
13. The
hospital shall be responsible for assuring that staff physicians and
consultants are aware of standards and guidelines in the letter of agreement.
RECOMMENDATIONS:
14. The
hospital shall provide documentation of health care provider participation in
Joint Mortality and Morbidity reviews.
RECOMMENDATIONS:
(Source: Added at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX M LEVEL II RESOURCE CHECKLIST
Section 640.APPENDIX M Level II Resource Checklist
Level II Resource
Checklist
Briefly describe
institutional compliance:
The Level II hospital shall provide all of the services
outlined for Level I general care.
1. The
hospital shall provide continuing education for medical, nursing, respiratory
therapy and other staff who provide general perinatal services, with evidence of
a yearly competence assessment appropriate to the population served.
RECOMMENDATIONS:
2. The
hospital shall provide documentation of participation in Continuous Quality
Improvement (CQI) implemented by the Administrative Perinatal Center.
RECOMMENDATIONS:
3. The
hospital shall provide documentation of the health care provider’s risk
assessment and consultation with a maternal-fetal medicine sub-specialist or
neonatologist as specified in the letter of agreement and hospital’s policies
and procedures, and transfer to the appropriate level of care.
RECOMMENDATIONS:
4. The
hospital shall provide documentation of the availability of trained personnel
and facilities to provide competent emergency obstetric and newborn care.
RECOMMENDATIONS:
5. The
hospital shall maintain a system of recording admissions, discharges, birth
weight, outcome, complications and transports to meet the requirement to
support CQI activities described in the hospital’s letter of agreement with the
Administrative Perinatal Center. The hospital shall comply with the
reporting requirements of the State Perinatal Reporting System.
RECOMMENDATIONS:
6. The
hospital shall provide documentation of the capability for continuous
electronic maternal-fetal monitoring for patients identified at risk with staff
available 24 hours a day, including physicians and nursing, who are
knowledgeable of electronic fetal monitoring use and interpretation. Staff
shall complete a competence assessment in electronic maternal-fetal monitoring
every two years.
RECOMMENDATIONS:
7. The
hospital shall have the capability of performing caesarean sections within 30
minutes of decision to incision.
RECOMMENDATIONS:
8. The
hospital shall have experienced blood bank technicians immediately available in
the hospital for blood banking procedures and identification of irregular
antibodies. Blood component therapy shall be readily available.
RECOMMENDATIONS:
9. The
hospital shall have general anesthesia services on call and available under 30
minutes to initiate C-section.
RECOMMENDATIONS:
10. The
hospital shall have experienced radiology technicians immediately available in
the hospital with professional interpretation available 24 hours a day. Ultrasound
capability shall be available 24 hours a day. In addition, Level I ultrasound
and staff knowledgeable in its use and interpretation shall be available 24
hours a day.
RECOMMENDATIONS:
11. The
hospital shall have the following clinical laboratory resources available:
Micro-techniques
for hematocrit and blood gases within 15 minutes; glucose, blood urea nitrogen
(BUN), creatinine, blood gases, routine urine analysis, electrolytes and
coagulation studies, complete blood count, routine blood chemistries, type
& cross, Coombs’ test, bacterial smear within 1 hour; and capabilities for
bacterial culture and sensitivity and viral culture.
RECOMMENDATIONS:
12. The
hospital shall designate a physician to assume primary responsibility for
initiating, supervising and reviewing the plan for management of distressed
infants. Policies and procedures shall assign responsibility for the
identification and resuscitation of distressed neonates to individuals who have
successfully completed a neonatal resuscitation program and are both
specifically trained and immediately available in the hospital at all times.
RECOMMENDATIONS:
13. The
hospital shall ensure that personnel skilled in phlebotomy and IV placement in
newborns are available 24 hours a day.
RECOMMENDATIONS:
14. Social
worker services shall be provided by one social worker, with relevant
experience and responsibility for perinatal patients, and available through the
hospital social work department.
RECOMMENDATIONS:
15. The
hospital shall ensure that protocols for discharge planning, routine follow-up
care, and developmental follow-up are established.
RECOMMENDATIONS:
16. The
hospital shall ensure that a licensed respiratory care practitioner with
experience in neonatal care is available 24 hours a day.
RECOMMENDATIONS:
17. The
hospital shall ensure that a dietitian with experience in perinatal nutrition
is available to plan diets to meet the needs of mothers and infants.
RECOMMENDATIONS:
18. The
hospital shall ensure that staff physicians and consultants are aware of
standards and guidelines in the letter of agreement.
RECOMMENDATIONS:
19. The
hospital shall provide documentation of health care provider participation in
Joint Mortality and Morbidity reviews.
(Source: Added at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX N LEVEL II WITH EXTENDED NEONATAL CAPABILITIES RESOURCE CHECKLIST
Section 640.APPENDIX N Level II with Extended Neonatal
Capabilities Resource Checklist
Level II with
Extended Neonatal Capabilities Resource Checklist
Briefly describe
institutional compliance:
1. The
hospital shall provide documentation that the obstetrical activities are
directed and supervised by a full-time board-certified obstetrician or a
licensed osteopathic physician with equivalent training and experience and
certification by the American Osteopathic Board of Obstetricians and
Gynecologists.
RECOMMENDATIONS:
2. The
hospital shall provide documentation that the neonatal activities are directed
and supervised by a full-time pediatrician certified by the American Board of
Pediatrics Sub-Board of Neonatal/Perinatal Medicine or a licensed osteopathic
physician with equivalent training and experience and certification by the
American Osteopathic Board of Pediatricians.
RECOMMENDATIONS:
3. The
directors of obstetrics and neonatal services shall ensure back-up supervision
of their services when they are unavailable.
RECOMMENDATIONS:
4. The
hospital shall provide documentation that the obstetric-newborn nursing service
is directed by a full-time nurse experienced in perinatal nursing, preferably with
a master's degree.
RECOMMENDATIONS:
5. The
hospital shall provide documentation that the pediatric-neonatal respiratory
therapy services are directed by a full-time licensed respiratory care
practitioner with a bachelor's degree.
RECOMMENDATIONS:
6. The
hospital shall provide documentation that the practitioner responsible for the
Special Care Nursery has at least three years experience in all aspects of
pediatric and neonatal respiratory therapy and completion of the neonatal/pediatric
specialty examination of the National Board for Respiratory Care.
RECOMMENDATIONS:
7. Preventive
services shall be designed to prevent, detect, diagnose and refer or treat
conditions known to occur in the high-risk newborn, such as cerebral
hemorrhage, visual defects (retinopathy of prematurity) and hearing loss, and
to provide appropriate immunization of high-risk newborns.
RECOMMENDATIONS:
8. The
hospital shall ensure that a person is designated to coordinate the local
health department community nursing follow-up process, to direct discharge
planning, to make home care arrangements, to track discharged patients, and to
collect outcome information. The community nursing referral process shall
consist of notifying the high-risk follow-up nurse in whose jurisdiction the
patient resides. The Illinois Department of Human Services will identify and
update referral resources for the area served by the unit.
RECOMMENDATIONS:
9. The
hospital shall provide documentation that the Level II hospital with Extended
Neonatal Capabilities has developed, with the assistance of the Administrative Perinatal Center, a referral agreement with a neonatal follow-up clinic to
provide neuro-developmental assessment and outcome data on the neonatal
population. Institutional policies and procedures shall describe the at-risk
population and referral procedure to be followed.
RECOMMENDATIONS:
10. The
hospital shall ensure that if the Level II hospital with Extended Neonatal Capabilities
transports neonatal patients, the hospital complies with Guidelines for
Perinatal Care, American Academy of Pediatrics and American College
of Obstetricians.
RECOMMENDATIONS:
To provide for assisted ventilation of newborn infants
beyond immediate stabilization:
1. The
hospital shall provide documentation that a pediatrician or advanced practice
nurse, whose professional staff privileges granted by the hospital specifically
include the management of critically ill infants and newborns receiving
assisted ventilation, a pediatrician receiving post-graduate training in a
neonatal-perinatal medicine fellowship program accredited by the Accreditation
Council of Graduate Medical Education or an active candidate or board-certified
neonatologist is present in the hospital the entire time that the infant is
receiving assisted ventilation. If infants are receiving on-site assisted
ventilation care from an advance practice nurse or a physician who is not a
neonatologist, a board-certified neonatologist or active candidate neonatologist
shall be available on call to assist in the care of those infants as needed.
RECOMMENDATIONS:
2. The
hospital shall provide suitable backup systems and planning to prevent and
respond appropriately to sudden power outage, oxygen system failure, and
interruption of medical grade compressed air delivery.
RECOMMENDATIONS:
3. The
hospital shall provide documentation that the nurses caring for infants who are
receiving assisted ventilation have documented competence and experience in the
care of such infants.
RECOMMENDATIONS:
4. The
hospital shall provide documentation that the licensed respiratory care
practitioner has documented competence and experience in the care of the
infants who are receiving assisted ventilation and is also available to the
Special Care Nursery during the entire time that the infant receives assisted
ventilation.
RECOMMENDATIONS:
(Source: Added at 35 Ill.
Reg. 2583, effective January 31, 2011)
| TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 640
REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX O LEVEL III RESOURCE CHECKLIST
Section 640.APPENDIX O Level III Resource Checklist
Level III
Resource Checklist
Briefly describe
institutional compliance:
The Level III hospital shall provide all of the services
outlined for Level I and Level II general, intermediate and special care, as
well as diagnosis and treatment of high-risk pregnancy and neonatal problems.
Both the obstetrical and neonatal services shall achieve Level III capability
for Level III designation.
Level III General Provisions
1. The
hospital shall provide documentation of participation in Continuous Quality
Improvement (CQI) implemented by the Administrative Perinatal Center.
RECOMMENDATIONS:
2. The
hospital shall provide documentation of health care provider participation in
Joint Morbidity & Mortality Reviews.
RECOMMENDATIONS:
3. The
hospital shall have the following clinical laboratory resources available:
Microtechniques for hematocrit and
blood gases within 15 minutes; glucose, blood urea nitrogen (BUN), creatinine,
blood gases, routine urine analysis, electrolytes and coagulation studies,
complete blood count, routine blood chemistries, type & cross, Coombs test,
bacterial smear within one hour; and capabilities for bacterial culture and
sensitivity and viral culture.
RECOMMENDATIONS:
4. The
hospital shall ensure that experienced radiology technicians are immediately
available in the hospital with professional interpretation available 24 hours a
day. Ultrasound capability shall be available 24 hours a day with additional
ultrasound availability on the OB floor and staff knowledgeable in its
interpretation.
RECOMMENDATIONS:
5. The
hospital shall provide blood bank technicians immediately available in the
hospital for blood banking procedures and identification of irregular
antibodies. Blood components shall be readily available.
RECOMMENDATIONS:
6. The
hospital shall ensure that personnel skilled in phlebotomy and IV placement in
newborns are available 24 hours a day.
RECOMMENDATIONS:
Level III Standards
1. The
Level III hospital shall provide documentation of a policy requiring health
care professionals, in both obstetrics and pediatrics, to obtain consultation
from or transfer of care to the maternal-fetal medicine or neonatology
sub-specialists as outlined in the standards for Level II.
RECOMMENDATIONS:
2. The
Level III hospital shall accept all medically eligible Illinois residents.
Medical eligibility is to be determined by the obstetrical or neonatal director
or his/her designee based on the Criteria for High-Risk Identification
(Guidelines for Perinatal Care, American Academy of Pediatrics and American
College of Obstetricians and Gynecologists).
RECOMMENDATIONS:
3. The
Level III hospital shall provide or facilitate emergency transportation of
patients referred to the hospital in accordance with guidelines for inter-hospital
care of the perinatal patient (Guidelines for Perinatal Care, American
Academy of Pediatrics and American College of Obstetricians and
Gynecologists). If the Level III hospital is unable to accept the patient
referred, the Administrative Perinatal Center shall arrange for placement at
another Level III hospital or appropriate Level II or Level II hospital with
Extended Neonatal Capabilities.
RECOMMENDATIONS:
4. The
Level III hospital that elects not to provide all of the advanced level
services shall have established policies and procedures for transfer of these
mothers and infants to a hospital that can provide the service needed as
outlined in the letter of agreement.
RECOMMENDATIONS:
5. The
Level III hospital shall have a clearly identifiable telephone number,
facsimile number and/or other electronic communication, either a special number
or a specific extension answered by unit personnel, for receiving consultation
requests and requests for admissions. This number shall be kept current with
the Department and with the Regional Perinatal Network.
RECOMMENDATIONS:
6. The
Level III hospital shall provide and document continuing education for medical,
nursing, respiratory therapy, and other staff providing general, intermediate
and intensive care perinatal services.
RECOMMENDATIONS:
7. The
Level III hospital shall provide caesarean section decision-to-incision within
30 minutes.
RECOMMENDATIONS:
8. The
hospital shall provide data relating to activities and shall comply with the
requirements of the State Perinatal Reporting System.
RECOMMENDATIONS:
9. The
medical co-directors of the Level III hospital shall be responsible for
developing a system ensuring adequate physician-to-physician communication.
Communication with referring physicians of patients admitted shall be
sufficient to report patient progress before and at the time of discharge.
RECOMMENDATIONS:
10. The
hospital shall provide documentation of the capability for continuous
electronic maternal-fetal monitoring for patients identified at risk with staff
available 24 hours a day, including physicians and nursing, who are
knowledgeable of electronic fetal monitoring use and interpretation. Staff
shall complete a competence assessment in electronic maternal-fetal monitoring
every two years.
RECOMMENDATIONS:
11. The
Level III hospital, in collaboration with the Administrative Perinatal
Center, shall establish policies and procedures for the return transfer of
high-risk mothers and infants to the referring hospital when they no longer
require the specialized care and services of the Level III hospital.
RECOMMENDATIONS:
12. The
Level III hospital shall provide suitable backup systems and planning to
prevent and respond to a sudden power outage, oxygen system failure, and
interruption of medical grade compressed air delivery.
RECOMMENDATIONS:
13. The
Level III hospital shall provide or develop a referral agreement with a
follow-up clinic to provide neuro-developmental services for the neonatal
population. Hospital policies and procedures shall describe the at-risk
population and the referral procedure to be followed for enrolling the infant
in developmental follow-up. Infants shall be scheduled for assessments at
regular intervals. Neuro-developmental assessments shall be communicated to
the primary physicians. Referrals shall be made for interventional care in
order to minimize neurological sequelae. A system shall be established to
track, record and report neuro-developmental outcome data for the population,
as required to support network CQI activities.
RECOMMENDATIONS:
14. Neonatal
surgical services shall be available 24 hours a day.
RECOMMENDATIONS:
Level III Resource Requirements
1. The
Level III hospital shall provide documentation that obstetrical activities
shall be directed and supervised by a full-time subspecialty obstetrician
certified by the American Board of Obstetrics and Gynecology in the
subspecialty of maternal-fetal medicine or a licensed osteopathic physician
with equivalent training and experience and certification by the American
Osteopathic Board of Obstetricians and Gynecologists. The director of
obstetric services shall ensure the back-up supervision of his or her services
by a physician with equivalent credentials.
RECOMMENDATIONS:
2. The
Level III hospital shall provide documentation that neonatal activities shall
be directed and supervised by a full-time pediatrician certified by the
American Board of Pediatrics Sub-Board of Neonatal/Perinatal Medicine or a
licensed osteopathic physician with equivalent training and experience and
certification by the American Osteopathic Board of
Pediatricians/Neonatal-Perinatal Medicine. The director shall ensure the
back-up supervision of his or her services by a physician with equivalent
credentials.
RECOMMENDATIONS:
3. The
Level III hospital shall provide documentation that an administrator/manager
with a master's degree shall direct, in collaboration with the medical
directors, the planning, development and operation of the non-medical aspects
of the Level III hospital and its programs and services.
RECOMMENDATIONS:
4. The
Level III hospital shall provide documentation that the obstetric and newborn
nursing services are directed by a full-time nurse experienced in perinatal
nursing with a master's degree.
RECOMMENDATIONS:
5. The
Level III hospital shall provide documentation that half of all neonatal
intensive care direct nursing care hours are provided by registered nurses who
have had two years or more nursing experience in a Level III NICU. All NICU
direct nursing care hours shall be provided or supervised by licensed
registered nurses who have advanced neonatal intensive care training and
documented competence in neonatal pathophysiology and care technologies used in
the NICU. All nursing staff working in the NICU shall have yearly competence
assessment in neonatal intensive care nursing.
RECOMMENDATIONS:
6. The
Level III hospital shall provide documentation that obstetrical anesthesia
services, under the supervision of a board-certified anesthesiologist with training
in maternal, fetal and neonatal anesthesia, are available 24 hours a day. The
director of obstetric anesthesia shall ensure the back-up supervision of his or
her services when he or she is unavailable.
RECOMMENDATIONS:
7. The
Level III hospital shall provide documentation that pediatric-neonatal
respiratory therapy services are directed by a full time licensed respiratory
care practitioner with a bachelor's degree.
RECOMMENDATIONS:
8. The
Level III hospital shall provide documentation that the respiratory care
practitioner responsible for the NICU has at least three years of experience in
all aspects of pediatric and neonatal respiratory care at a Level III Neonatal
Intensive Care Unit and completion of the neonatal/pediatrics specialty
examination of the National Board for Respiratory Care.
RECOMMENDATIONS:
9. The
Level III hospital shall provide documentation that respiratory care
practitioners with experience in neonatal ventilatory care staff the NICU
according to the respiratory care requirements of the patient population, with
a minimum of one dedicated neonatal licensed respiratory care practitioner for
newborns on assisted ventilation, and with additional staff provided as
necessary to perform other neonatal respiratory care procedures.
RECOMMENDATIONS:
10. The Level III hospital shall provide
documentation that a physician for the program
assumes primary responsibility for initiating, supervising and reviewing the
plan for management of distressed infants in the delivery room. Hospital
policies and procedures shall assign responsibility for identification and
resuscitation of distressed neonates to individuals who are both specifically
trained and immediately available in the hospital at all times. Capability to
provide neonatal resuscitation in the delivery room may be satisfied by current
completion of a neonatal resuscitation program by medical, nursing and
respiratory care staff or a rapid response team.
RECOMMENDATIONS:
11. The
Level III hospital shall provide documentation that a
board-certified or active candidate obstetrician is present and available in
the hospital 24 hours a day. Maternal-fetal medicine consultation shall be
available 24 hours a day.
RECOMMENDATIONS:
12. The
Level III hospital shall provide documentation that a
board-certified neonatologist, active candidate neonatologist or a pediatrician
receiving postgraduate training in a neonatal-perinatal medicine fellowship
program accredited by the Accreditation Council of Graduate Medical Education
is present and available in the hospital 24 hours a day to provide care for
newborns in the NICU.
RECOMMENDATIONS:
13. The Level III hospital shall provide
documentation that neonatal surgical services are
supervised by a board-certified surgeon or active candidate in pediatric
surgery appropriate for the procedures performed at the Level III hospital.
RECOMMENDATIONS:
14. The Level III hospital shall provide
documentation that neonatal surgical anesthesia
services under the direct supervision of a board-certified anesthesiologist
with extensive training or experience in pediatric anesthesiology are available
24 hours a day.
RECOMMENDATIONS:
15. The Level III hospital shall provide
documentation that neonatal neurology services, under
the direct supervision of a board-certified or active candidate pediatric
neurologist, are available for consultation in the NICU 24 hours a day.
RECOMMENDATIONS:
16. The
Level III hospital shall provide documentation that neonatal radiology
services, under the direct supervision of a board-certified radiologist with
extensive training or experience in neonatal radiographic and ultrasound
interpretation, are available 24 hours a day.
RECOMMENDATIONS:
17. The
Level III hospital shall provide documentation that neonatal cardiology
services, under the direct supervision of an active candidate pediatrician or a
pediatrician board- certified by the American Board of Pediatrics Sub-Board of Pediatric
Cardiology, are available for consultation 24 hours a day. In addition,
cardiac ultrasound services and pediatric cardiac catheterization services by
staff with specific training and experience shall be available 24 hours a day.
RECOMMENDATIONS:
18. The
Level III hospital shall provide documentation that a board-certified or
active candidate ophthalmologist with experience in the diagnosis and treatment
of the visual problems of high-risk newborns (retinopathy of prematurity) is
available for appropriate examinations, treatment and follow-up care of
high-risk newborns.
RECOMMENDATIONS:
19. The
Level III hospital shall provide documentation that pediatric
sub-specialists with specific training and extensive experience or subspecialty
board certification or active candidacy (when applicable) are available 24
hours a day, including, but not limited to, pediatric urology, pediatric
otolaryngology, neurosurgery, pediatric cardiothoracic surgery and pediatric
orthopedics appropriate for the procedures performed at the Level III hospital.
RECOMMENDATIONS:
20. The
Level III hospital shall provide documentation that genetic
counseling services are available for inpatients and outpatients, and the
hospital shall provide for genetic laboratory testing, including, but not
limited to, chromosomal analysis and banding, fluorescence in situ
hybridization (FISH), and selected allele detection.
RECOMMENDATIONS:
21. The Level III hospital shall designate at least one person
to coordinate the community nursing follow-up referral process, to direct
discharge planning, to make home care arrangements, to track discharged
patients, and to ensure appropriate enrollment in a developmental follow-up
program. The community nursing referral process shall consist of notifying the
follow-up nurse in whose jurisdiction the patient resides of discharge
information on all patients. The Illinois Department of Human Services will
identify and update referral resources for the area served by the unit.
RECOMMENDATIONS:
22. The
Level III hospital shall establish a protocol that defines educational criteria
necessary for commonly required home care modalities,
including, but not limited to, continuous oxygen therapy, electronic
cardio-respiratory monitoring, technologically assisted feeding and intravenous
therapy.
RECOMMENDATIONS:
23. The
Level III hospital shall provide documentation that one
or more full-time licensed medical social workers with perinatal/neonatal experience
are dedicated to the Level III hospital.
RECOMMENDATIONS:
24. The
Level III hospital shall provide documentation that one
registered pharmacist with experience in perinatal pharmacology is available
for consultation on therapeutic pharmacology issues 24 hours a day.
RECOMMENDATIONS:
25. The
Level III hospital shall provide documentation that one
dietitian with experience in perinatal nutrition is available to plan diets and
education to meet the special needs of high-risk mothers and neonates in both
inpatient and outpatient settings.
RECOMMENDATIONS:
(Source: Added at 35 Ill.
Reg. 2583, effective January 31, 2011)
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