1. I. HOSPITAL DATA

   Please use data from most recent three calendar years

2. A. MATERNAL DATA

   	200	200	201
   1. Number of Obstetrical Beds:				Current RN/Patient ratio
   a. Ante-partum
   b. Labor / Delivery LDR
   C/Section Rooms
   Delivery Rooms (LDR, see above)
   c. LDRP
   d. Pospartum				(mother/baby couplets)
   2. Total Number of Women Delivering
   3. Number of Vaginal Deliveries:
   Spontaneous
   *Forceps
   *Vacuum Extraction
   4. Number of C/Sections − add percents-#/%
   Total	/%	/%	/%
   Primary	/%	/%	/%
   Repeat	/%	/%	/%
   5. Number of Vaginal Births After Cesarean (VBAC) – add percent − #/%
   6. Number of inductions
   +7. Number of augmentations

   * Use final delivery modality

   + Augmentation – stimulation of contractions when spontaneous contractions have failed to progress dilation or descent

3. 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.

4. C. LIVE BIRTH DATA

   1. 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. 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

5. 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

6. 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

7. 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

8. 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).

9. II. OB HEMORRHAGE DOCUMENTATION

   1. III. RESOURCE REQUIREMENTS

      Complete attached Resource Checklist for the appropriate level of care − current level and level being applied for if different.

   List OB Hemorrhage cases from the previous calendar year (patients sent to ICU or received 3 or greater units of blood products).

10. IV. ADMINISTRATIVE PERINATAL CENTERS
11. A. Provide documentation of educational activities sponsored by the Administrative Perinatal Center for network hospitals and local health departments.
12. B. Provide evidence of morbidity and mortality reviews with network hospitals.
13. C. Provide written documentation of Regional Perinatal Network CQI Activities.

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

(Source: Amended at 35 Ill. Reg. 2583, effective January 31, 2011)