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TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER l: MATERNAL AND CHILDCARE 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
I. HOSPITAL DATA Please use data from most recent three calendar years
A. MATERNAL DATA
* Use final delivery modality + Augmentation – stimulation of contractions when spontaneous contractions have failed to progress dilation or descent
B. NEONATAL DATA
* 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)
2. Incidence of Neonatal complications (Occurrences at hospital of birth)
* If in expanded VON, use VON data for "all babies" categories
D. FETAL DEATHS
Birth weight Specific Data − # per weight category
E. MORTALITY DATA
* Question #3, only for Level III institutions
F. TRANSPORT DATA
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) |