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Neonatal Transport Data System California Perinatal Transport System (CPeTS) Network Database

Managed by California Perinatal Quality Care Collaborative (CPQCC)

Manual of Definitions

For Infants Born in 2007

Version 12.06 December 22K 2006

Neonatal Transport Data System

California Perinatal Transport System (CPeTS) Network Database Managed by California Perinatal Quality Care Collaborative (CPQCC)

Manual of Definitions


Table of Contents

I. REFERRAL…………………………..……………………………………………………

1

Transport Type…………………………………………………………………………….. 1 Dr. Attendance Requested………………………………………………………………. 1 ASAP Neonatal……………………………………………………………………………. 1 Scheduled Neonatal……………………………………………………………............... 1 Other……………………………………………………………………………………….. 1

Indication for Transport…………………………………………………………………... 1 Medical Dx/Rx Services………………………………………………………………….. 1 Growth/Discharge Planning………………………………………………….................. 1 Surgery…………………………………………………………………………………….. 1 Chronic Care………………………………………………………………………………. 1 Insurance…………………………………………………………………………………… 1

Date/Time of Referral…………………………………………………………….............. 2 Date/Time of Acceptance………………………………………………………............... 2

II. PATIENT IDENTIFICATION: HISTORY...…………………………………………….

2

Infant’s Name…………………………………………………………………………….. 2 Sex…………………………………………………………………………………………. 2 Date/Time of Birth……………………………………………………………………….. 2 Insurance…………………………………………………………………………………. 2 Birth weight………………………………………………………………………………. 2 Current Weight……………………………………………………………….................. 2 Gestational Age………………………………………………………………………….. 2 Singleton/Multiple Births……………………………………………………………….. 3 Prenatally Diagnosed Congenital Anomalies………………………………………. 3 Description of Prenatal Diagnosis of Major Birth Defects/Congenital Anomalies…………………………………………………………………………………

3

Code 504 – Other Chromosomal Anomaly…………………………………………….. 3 Code 601 – Skeletal Dysplasia………………………………………………………….. 3 Code 605 – Inborn Error of Metabolism………………………………………………… 3 Code 150 – Other Central Nervous System Defects…………………………………. 3 Code 200 – Other Cardiac Defects……………………………………………………… 3 Code 300 – Other Gastro-Intestinal Defects..…………………………………………. 3 Code 400 – Other Genito-Urinary Defects…………………………………………….. 3 Code 800 – Other Pulmonary Defects………………………………………………….. 3 Code 900 – Other Vascular or Lymphatic Defects…………………………………….. 3 Mother’s Name………………………………………………………………….............. 4

2007 Manual of Definitions – Neonatal Transport Data Collection Tool, ii

Mother’s Birth Date……………………………………………………………………… 4 Mother’s Age………………………………………………………………………………………….

4

Mother’s Medical Record Number (at hospital of delivery)……………............... 4 Mother’s G/P/Ab/L (Gravida/Parity/Abortion/Living)……………………............... 4 Rupture of Membranes…………………………………………………………………. 4 Antenatal Conditions…………………………………………………………............... 5 Hypertension………………………………………………………………………………. 5 Diabetes……………………………………………………………………………………. 5 Infection…………………………………………………………………………………….. 5 Preterm Labor…….……………………………………………………………………….. 5 Bleeding/Abruption/Previa……………………………………………………………….. 5 Other Maternal…………………………………………………………………………….. 5 Unknown…………………………………………………………………………………… 5 Significant Antepartum/Intrapartum Issues………………………………............... 5 Intrapartum Antibiotics……………………………………………………………………. 6 Antenatal Steroids……………………………………………………………….............. 6 Surfactant Treatment……………………………………………………………………… 6 Mode of Delivery…………………………………………………………………………. 6 Check Spontaneous (Spont) Vaginal………………………………………….............. 6 Check Operative (Op) Vaginal…………………………………………………………… 7 Check Cesarean………………………………………………………………………….. 7 Apgar Scores…………………………………………………………………………….. 7

III. INFANT CONDITION……………………………………...........................................

7

Date/Times at which Infant condition was evaluated…………………………….. 7 Referral Date/Time……………………………………………………………………….. 7 Date/Time of Initial Evaluation by Transport Team……………………………….. 7 Date/Time of NICU Evaluation…………………………………………………………. 7 Responsiveness at Time of Referral for Transport……………………………………. 8 Respiratory Rate at Time of Referral for Transport.…………………………………… 8 Oxygen Saturation at Time of Referral for Transport..……………............................ 8 Respiratory Status at Time of Referral for Transport……….……….………………… 8 Oxygen Index at Time of Referral for Transport ……………….…………….............. 8

Vital Signs…………………………………………………………………………………. 8 Heart Rate at Time of Referral for Transport……………………………………………. 9 Blood Pressure at Time of Referral for Transport……………………………………… 9 Use of Pressors at Time of Referral for Transport…………………………………….. 9 Temperature at Time of Referral for Transport…………………………………………. 9 Blood Glucose ……………………………………………………………………………….. 9 Respiratory Support at Time of Referral for Transport……………………………….. 9 Initial Evaluation by Transport Team……………………………………................. 10 Responsiveness at Time of Initial Transport Team Evaluation……………………… 10 Respiratory……………………………………………………………………………………. 10 Vital Signs…………………………………………………………………………………….. 11 Admission to the NICU……………………………………………………................... 12 Responsiveness at Time of Admission to the Receiving NICU………………………….. 12 Respiratory……………………………………………………………………………………. 12 Vital Signs…………………………………………………………………………………….. 13 Blood Glucose at Time of Admission to the Receiving NICU……………………….. 13 Blood Gases at Time of Admission to the Receiving NICU………………………….. 13

2007 Manual of Definitions – Neonatal Transport Data Collection Tool, iii

IV. CLINICAL INFORMATION……………………………………………………………… 15

Hemoglobin/Hematocrit…………………………………………………………………….. 15 Blood Culture…………………………………………………………………………………. 15 Bilirubin………………………………………………………………………………………… 15 Neonatal Screening………………………………………………………………………….. 15 Imaging…………………………………………………………………………………………. 15 Chest X-ray…………………………………………………………………………………….. 15 Other Clinical Information…………………………………………………………………… 15 IV Access Fluids………………………………………………………………………………. 15 Blood Transfusion……………………………………………………………………………. 15 Last Urine………………………………………………………………………………………. 15 Last Stool………………………………………………………………………………………. 15 Enteral Feeding……………………………………………………………………………….. 16 Medication……………………………………………………………………………………… 16 Comments……………………………………………………………………………………… 16 V. OTHER SIGNIFICANT ISSUES………………………………………………………….

16

Surgery…………………………………….……………………………………………………. 16 Allergies…………………………………………….……………………………………………. 16 Death……………………………………………………………………………………………. 16 VI. REFERRAL PROCESS………………………………………………………................

17

Referring Hospital……………………………………………………………………………. 17 Was the Infant Previously Transported…………………………………………………… 17 Previous Transfer Referring Hospital…………………………………………………….. 17 Location of Birth……………………………………………………………………………… 17 Receiving Hospital…………………………………………………………………………… 18 Transport Team On-Site Leader…………………………………………………………… 18 Transport Team From……………………………………………………………………….. 18 Mode of Transport………………………………………………………………….............. 19 VII. TIMELINE………….……………………………………………...………………….

19

Date/Time of Maternal Admission to Labor & Delivery/Hospital……………………. 19 Date/Time of Transport Team Departure for Referring HospitalOOOOOOO.. 19 Date/Time Transport Team Arrived at Referring HospitalOOOOOOOOOO.. 19 Date/Time Transport Team Departed From Referring HospitalOOOOOOOO 19 Date/Time Transport Team Arrived at Receiving FacilityOOOOOOOOOOO 19 VIII. INFORMATION/ MATERIALS TO BE SENT WITH

TRANSPORT TEAM…………………………………………………………………..

20

IX. CARE PROVIDERS………………..………………………………………….………..

20

X. COMMENTS…………………………………………………………………….………..

20

XI. TRANSPORT ISSUES WITH IMPROVEMENT POTENTIAL…………..………….

20

2007 Manual of Definitions – Neonatal Transport Data Collection Tool, iv

APPENDICESOOOOOOOOOOOOOOOOOOOOOOOOOOOO

21

APPENDIX A: ALL CALIFORNIA NEONATAL TRANSPORT FORM COLOR (ACNTF), 3 pages ALL CALIFORNIA NEONATAL TRANSPORT FORM (ACNTF), 3 pages CORE CPETS NEONATAL TRANSPORT FORM (CCNTF), 2 pages

22

APPENDIX B: CPQCC ON-LINE DATA ENTRY (SCREEN SHOTS), 6 pages

23

APPENDIX C: BIRTH DEFECT CODES FOR CCNTF ITEM T.10, 3 pages

24

APPENDIX D: OSHPD FACILITY CODES, 27 pages

25

APPENDIX E: FARENHEIT TO CENTRIGRADE CONVERSION TABLE, 1 page

26

APPENDIX F: NEONATAL TRANSPORT DATA SYSTEM CPETS POLICY AND PROCEDURES, 6 pages

27

APPENDIX G: CPETS PRELIMINARY DRAFT REPORT, 7 pages

28

APPENDIX H: PERINATAL CARES ARTICLE, 3 pages

29

APPENDIX I: TRIPS SCORE, 7 pages

30

APPENDIX J: FREQUENTLY ASKED QUESTIONS (FAQs), 2 pages

31

2007 Manual of Definitions – Neonatal Transport Data Collection Tool, v

I. REFERRAL Note: Items with “*” represent those that MUST be filled out on the online Transport form in order to propagate specific item numbers on the online Admission/Discharge (A/D) Form. The Admission/Discharge (A/D) related Items will be listed as “(A/D Item#)”. T.1 Transport Type Check type of transport requested. DR Attendance Requested. Check if neonatal transport team was initially requested to attend the delivery. ASAP Neonatal. Check if the infant was an acute transport. (An acute transport is for an infant with medical problems that require acute resolution for survival and who is transferred in order to obtain medical, diagnostic, or surgical therapy that is not provided, or that cannot be effectively provided due to temporary staffing/census issues, or that can not be provided due to insurance restrictions at the referring hospital.) Scheduled Neonatal. Check if the infant transport was planned or scheduled.[A scheduled transport is selected for an infant whose initial medical/surgical needs have been met, whose condition has been stabilized and who is transferred to a facility in order to obtain growth care, discharge planning care, chronic care, and/or hospice care. The medical needs of non-acute transfers may range from extensive and extremely complex care (e.g., an infant with lethal anomalies) to minimal care for feeding and growth (e.g., maintenance ).] Other. Check other if the transport does not conform to other definitions. Describe indication. T.2 Indication for Transfer Medical Dx/Rx Services. Check if the infant was transported for medical services. (Medical problems that require acute resolution for survival and who is transferred in order to obtain medical, diagnostic, or surgical therapy that is not provided, or that cannot be effectively provided due to temporary staffing/census issues at the referring hospital.) Growth/Discharge Planning. Check if the infant was transported for convalescent care. [Selected for an infant whose initial medical/surgical needs have been met, whose condition has been stabilized and who is transferred to a facility in order to obtain growth care or discharge planning care. Surgery. Check if the infant was transported primarily for major invasive surgery (requiring general anesthesia, or its equivalent). Chronic Care. Check if the infant was transported following initial medical/surgical intervention, whose condition has been stabilized and who is transferred to a facility for chronic care, and/or hospice care.

2007 Manual of Definitions – Neonatal Transport Data Collection Tool, 1

Insurance. Check if the infant was transported for insurance purposes. T.3 Referral Date and Time Enter the date and time of the initial referral communication between referring and receiving providers/facilities using MM/DD/YYYY and 24-hour clock (eg, 11:30 PM = 2330). T.4 Acceptance Date and Time Enter the date and time of the transport acceptance using MM/DD/YYYY and 24-hour clock (eg, 11:30 PM = 2330). II. PATIENT IDENTIFICATION: HISTORY Infant’s Name *T.9 Infant Sex (A/D Item 5) Check Male or Female. Check Unk if sex cannot be determined. *T.6 Infant Birth Date and Time (A/D Item 4) Enter the date of birth using MM/DD/YYYY. Enter the time of birth using a 24-hour clock (eg, 11:30 PM = 2330). Insurance Enter the type of insurance coverage for this admission. Note: For transports within the first month of life, Mother’s insurance type is assumed to be the infant’s insurance type as well. *T.7 Birth weight (A/D Item 1) Record the birth weight in grams. Since many weights may be obtained on an infant shortly after birth, enter the weight from the Labor and Delivery record if available and judged to be accurate. If unavailable or judged to be inaccurate, use the weight on admission to the neonatal unit or lastly, the weight obtained on autopsy (if the infant expired within 24 hours of birth). (See Appendix J for Pounds to Grams Conversion Table) Current Weight Record current daily weight (or last known weight) in grams. *T.8 Best Estimate of Gestational Age (A/D Item 3) Record the best available estimate of gestational age in weeks and days. Where sources disagree, use the following hierarchy: 1. Obstetric measures, based on last menstrual period, obstetrical parameters, or prenatal ultrasound as recorded in the maternal chart. 2. Neonatologist's estimate, based on physical or neurologic examination, combined physical and gestational age exam (Ballard/Dubowitz), or examination of


the lens. Record gestational age in weeks and days. In cases when the best estimate of gestational age is an exact number of weeks, enter the number of weeks in the space provided for weeks and enter 0 in the space provided for days. Do not leave the number of days blank. Singleton/Multiple Births (a) Check Singleton for any birth (b) Check Multiple for any birth involving more than a singleton infant and

for any multifetal gestation. (c) If Multiple Birth, indicate the infant’s birth order (first, second, etc) as

well as the total number of infants actually delivered (count both live born and still born infants). For example, the second infant born of triplets would be entered as 2 of 3.

Note: Count both live births and stillbirths at the time of delivery but do not count fetuses which have been reabsorbed in utero and are not delivered. *T.10a Congenital Anomalies that were diagnosed Prenatally (A/D Item 49a) Check Yes if the infant had one or more clinically significant birth defects that were diagnosed during the prenatal period. Do not check yes if infant was identified to have congenital anomalies following delivery that were not diagnosed prenatally. Check No if an infant was not prenatally diagnosed as having one or more of birth defects. Check Unk if this information cannot be obtained. *T.10b Enter up to 5 Birth Defect Codes that were all Diagnosed Prenatally (A/D Item 49b) In the spaces provided, you may enter as many as five 3-digit code numbers of birth defects from the list in Appendix D. Do not use general descriptions such as multiple congenital anomalies or complex congenital heart disease . The following Birth Defect Codes require a detailed description in the space provided: Code 504 - Other Chromosomal Anomaly Code 601 - Skeletal Dysplasia Code 605 - Inborn Error of Metabolism Code 150 - Other Central Nervous System Defects Code 200 - Other Cardiac Defects Code 300 - Other Gastro-Intestinal Defects Code 400 - Other Genito-Urinary Defects Code 800 - Other Pulmonary Defects Code 900 - Other Vascular or Lymphatic Defects The following conditions should NOT be coded as Major Birth Defects:


Extreme Prematurity Intrauterine Growth Retardation Small Size for Gestational Age Fetal Alcohol Syndrome Hypothyroidism Intrauterine Infection Cleft Lip without Cleft Palate Club Feet Congenital Dislocation of the Hips Mother’s Name Mother’s Birth Date Enter the date of mother’s birth using MM/DD/YYYY. Mother’s Age Enter mother's age at time of delivery. Give her age in completed years; meaning that a woman who is 30 years and 364 days old should be recorded as 30 years old, not 31. Mother’s Medical Record Number (at hospital of delivery) T.5 Date and Time of Maternal Admission to Labor & Delivery Enter the date using MM/DD/YYYY and time using a 24-hour clock (eg, 11:30 PM = 2330) of mother’s admission to hospital of delivery. If mother was admitted directly to Labor and Delivery Unit state this date and time. If mother was initially admitted to the Emergency Department, received care and either delivered there or was subsequently transferred to the Labor and Delivery Unit state this date and time. T.11 Number of Mother’s Pregnancies Including the Current Pregnancy (Gravida) G. Enter total number of pregnancies (including current pregnancy)

regardless of outcome. Note: Only the total number (Gravida) needs to be filled out on-line. The

numbers for (P/Ab/L) are to be filled out on the All California Neonatal Transport Form.

P. Enter number of birth experiences (>20 weeks) Ab. Enter total number of spontaneous or therapeutic abortions L. Enter number of living children Rupture of Membranes (a) Enter the date using MM/DD/YYYY and time using a 24-hour clock (eg,

11:30 PM = 2330) of rupture of membranes.


(b) Record duration of ruptured membranes in hours (last completed whole hour)

(c) Record fluid appearance, check Clear if fluid is clear of meconium or Meconium if meconium is present in the amniotic fluid on rupture.

Antenatal Conditions This question focuses on antenatal events that may affect the pregnancy and/or delivery of the infant. Check all conditions in the category, which were present in the antenatal period. Check None if none of the listed conditions were present. Check None only if you have access to a reliable and complete prenatal/medical record or history. Check Unk if the information is not obtainable. If a mother presents with no prenatal care and no available medical history, this section should be marked, Unk. If a mother presents with no prenatal care, but there is a medical history present on her chart, applicable items may be selected as appropriate. Hypertension. The medical record should state the diagnosis of hypertension, pregnancy-induced hypertension, eclampsia, preeclampsia, seizures, toxemia, or HELLP syndrome. Diabetes. Maternal diabetes of any type and severity Infection. Includes intrauterine infections of the amniotic sac and fluid (amnionitis, chorioamnionitis) and those of the uterine wall (endometritis) as well as other infections such as which complicate the pregnancy or delivery. Includes Herpes, HIV, or other sexually-transmitted diseases (STD). Preterm Labor. Uterine contractions resulting in dilation of the cervix at a gestational age of less than 37 completed weeks of gestation. Bleeding/Abruption/Previa. Bleeding related to complications with the placenta. Placental abruption refers to premature detachment of the placenta from the uterine wall. Placenta previa refers to low implantation of the placenta in the uterus, usually over the cervix. Other Maternal. Other antenatal maternal complications affecting the infant’s health or the course of delivery. Specify the complication in the space provided. Unknown. Information not obtainable. Significant Intrapartum Issues Describe intrapartum complications affecting the infant’s health or the course of delivery. Specify the complication in the space provided.


Intrapartum Antibiotics Indicate Yes if maternal antibiotics were given during the current intrapartum admission, and specify type. Indicate No if no antibiotics were given during the current intrapartum admission and Unk if the information is not obtainable. *T.12a Antenatal Steroids (A/D Item 13) Note: Corticosteroids include betamethasone, dexamethasone, and hydrocortisone. Check Yes if corticosteroids were administered IM or IV to the mother during pregnancy at any time prior to delivery. Check No if no corticosteroids were administered IM or IV to the mother during pregnancy at any time prior to delivery. Check Unk if this information cannot be obtained. *T.12b Date and Time of Last Antenatal Steroid Administration (A/D Item 13) Enter the last date corticosteroids were administered using MM/DDYY. Enter the last time corticosteroids were administered using a 24-hour clock (eg, 11:30 PM = 2330). *T.13 Surfactant Use (A/D Item 21) Check Yes if the infant received an exogenous surfactant at any time. Include this information even if it occurred at the birth hospital prior to transport to your center. If Yes , enter date/time at First Dose. Enter the date using MM/DDYY. Enter the time using a 24-hour clock (eg, 11:30 PM = 2330). Note: the first dose may have occurred prior to or after NICU admission, and may have occurred before transfer, during transport or at your hospital. Check DR if the first dose was administered in the Delivery Room. Check Nsy if the first dose was administered in the Nursery. Check NICU if first dose administered in the NICU. Check No if the infant never received an exogenous surfactant. Check Unk if this information cannot be obtained. Mode of Delivery Choose only one of the following responses: Check Spontaneous (Spont) Vaginal for a normal vaginal delivery. This is any vaginal delivery for which instruments were not used. This includes


cases where manual rotations or other head or shoulder maneuvers were used, provided instruments were not also used. Check Operative (Op) Vaginal for any vaginal delivery for which any instrumentation was used. Episiotomies are not considered operative deliveries. Indicate type of instrumentation: Forceps, Vacuum Check Cesarean for any cesarean delivery (elective or emergent). Indicate Primary or Repeat. Apgar Scores Enter the Apgar score at 1 minute and at 5 minutes as noted in the Labor and Delivery record. Enter the additional Apgar scores every 5 minutes (if 5 minute Apgar was <7), if available. Check Unk for any score that is unknown. If Apgar score was not done, select Not Done (N/D). Note: In general, Apgar scores are repeated every 5 minutes until the infant’s score is greater than or equal to 7, or the infant has been moved to the NICU for ongoing resuscitation and critical care. If you do not see a 10-minute Apgar score on the infant’s chart, but the 5-minute Apgar score is 7 or higher, you can assume that a 10-minute Apgar score was not done, and mark Not Done on the form. If the 5-minute Apgar score is less than 7, there should have been a 10-minute Apgar score done. If you are unable to find it in the record, mark Unk. III. INFANT CONDITION This section of the record provides consistent information at three specific times for evaluation of overall stability. *T. 14 Date/Times at which infant condition was evaluated For each of these items, items T.15 through T.25 need to be filled out. *T.14a Referral Date and Time (this is the same as the referal time in Item T.3 above) Enter the date and time of the initial referral communication between referring and receiving providers/facilities. Time should be reported on the 24-hour clock *T.14b Date and Time of the Initial Evaluation by Transport Team within 15 minutes of Arrival at Referring Hospital. Enter the date and time of the initial evaluation of the infant by the Transport Team within 15 minutes of arrival at the Referring Hospital. Time should be reported on the 24-hour clock. *T.14c Date and Time of NICU Evaluation within 15 minutes of Arrival at Receiving Hospital.


Enter the date and time of the infant’s NICU evaluation within 15 minutes of the arrival at the Receiving Hospital. Time should be reported on the 24-hour clock. *T.15 Responsiveness. Write the number 0 (zero) in the

designated space if the infant died prior to evaluation, 1 (one) demonstrated no responsiveness, seizures or received muscle relaxants at the time of referral for transport. Note: Seizures include compelling clinical evidence of seizures, or of focal or multifocal, clonic or tonic seizures, as well as EEG evidence of seizures, regardless of clinical status. Write the number 2 (two) in the designated space if the infant appeared lethargic or had no cry at the time of referral for transport. Write the number 3 (three) in the designated space vigorously withdraws or cries at the time of referral for transport.

Respiratory *T.16 Respiratory Rate (0 to 130). Indicate infant’s respiratory rate at the time of referral. Note: this rate may be spontaneous or assisted by ventilator. *T.17 Oxygen Saturation (SaO2) (0 to 100). Indicate average oxygen saturation in percentage at the time of referral. Ifunknown, indicate Unk . *T.18 Respiratory Status. Write the number 1 (one) in the designated space if the infant was on the respirator at the time of referral for transport. Write the number 2 (two) in the designated space if the infant had severe respiratory complications, including: apnea, gasping, or was intubated but not on mechanical respirator. Write the number 3 (three) in the designated space for all other respiratory status at the time of referral for transport (including no or mild respiratory complications). *T.19 Oxygen Index (for infants on Respirator only).

a) Mean Airway Pressure (MAP) (0-40). Indicate mean airway pressure at the time of referral for transport if known.

b) Inspired Oxygen Concentration (FiO2) (21-100). Indicate inspired oxygen concentration (21-100%) at the time of referral for transport. If the infant was given supplemental oxygen at the time of referral for transport, write the FIO2 (percentage of oxygen) in the designated space. If the infant was not given supplemental oxygen at the time of referral for transport, leave the designated space blank.


c) Arterial Oxygenation (PAO2) (0-500). Indicate PAO2 from blood gas specimen at the time of referral for transport. (Note: if blood gases were not clinically indicated or available at the time of referral for transport, leave the designated space blank.)

Vital Signs *T.20 Heart Rate (0 to 250). Indicate infant’s heart rate at the time of referral for transport. *T.21 Blood Pressure. Indicate infant’s systolic, diastolic and mean blood pressures at the time of referral for transport. *T.22 Use of Pressors. Indicate Y Yes or N No whether vasopressors were administered at the time of referral for transport. *T.23 Temperature (28.0 to 42.0 C or 82.4 to 107.6 F). If the infant’s core body temperature was measured and recorded at the time of referral for transport, enter the infant’s temperature in degrees centigrade to the nearest tenth of a degree. For centers that measure temperature in degrees Fahrenheit, a Fahrenheit-to-Centigrade conversion table is provided in Appendix K. Use rectal temperature or, if not available, esophageal temperature, tympanic temperature or axillary temperature, in that order. If the infant’s body temperature was not measured at the time of referral for transport, leave this item blank. *T.24 Blood Glucose (0 to 500). Indicate infant’s blood glucose screening results at the time of referral for transport. 1. Responsiveness at Time of Referral for Transport 2. Responsiveness at Time of Initial Transport Team Evaluation 3. Responsiveness at Time of Admission to the Receiving NICU

*T.25 Respiratory Support. Write None (N) if required no respiratory support. Write Hood/NC (H) in the designated space if the infant had spontaneous breathing and was supported using an oxygen hood or nasal cannula at time of referral for transport. Write NCPAP (C) in the designated space if the infant was provided with continuous positive airway pressure (CPAP) using nasal CPAP at time of referral for transport. Write ETT (E) in the designated space if the infant was ventilated using an endotracheal tube at time of referral for transport. Do not enter ETT if an endotracheal tube was placed only for suctioning and assisted ventilation was not given through the tube. Write Unk in the designated space if this information cannot be obtained.


1) Blood Gas Results at Time of Referral for Transport. If arterial blood gas results were clinically indicated and obtained at the time of referral for transport, indicate results. If blood gases not obtained leave this space blank.

d) pH e) PCO2 f) BE (Base Excess/Deficit)

Initial Evaluation by Transport Team. Initial evaluation by the transport team within 15 minutes of arrival at referring facility. (a) Responsiveness at Time of Initial Transport Team Evaluation. Write

the number 0 (zero) in the designated space if the infant died prior to evaluation, 1 (one) demonstrated no responsiveness, seizures or received muscle relaxants at the time of initial transport team evaluation. Note: Seizures include compelling clinical evidence of seizures, or of focal or multifocal, clonic or tonic seizures, as well as EEG evidence of seizures, regardless of clinical status. Write the number 2 (two) in the designated space if the infant appeared lethargic or had no cry at the time of initial transport team evaluation. Write the number 3 (three) in the designated space vigorously withdraws or cries at the time of initial transport team evaluation.

(b) Respiratory

(i) Respiratory Rate at Time of Initial Transport Team Evaluation. Indicate infant’s respiratory rate at the time of referral.

Note: this rate may be spontaneous or assisted by ventilator. (ii) Oxygen Saturation at Time of Initial Transport Team Evaluation.

Indicate average oxygen saturation in percentage at the time of referral. If unknown, indicate Unk.

(iii) Respiratory Status at the time of referral. Write the number 1 (one) in the designated space if the infant

was on the respirator at the time of initial transport team evaluation. Write the number 2 (two) in the designated space if the infant had severe respiratory complications, including: apnea, gasping, or was intubated but not on mechanical respirator. Write the number 3 (three) in the designated space for all other respiratory status at the time of initial transport team evaluation (including no or mild respiratory complications).


(iv) Oxygen Index. Completed only if the infant is on the ventilator at the time of Initial Transport Team Evaluation. If information not obtainable, indicate Unk . a. Mean Airway Pressure (MAP). Indicate mean airway

pressure at the time of initial transport team evaluation if known.

b. Inspired Oxygen Concentration (FiO2). Indicate inspired oxygen concentration (21-100%) at the time of initial transport team evaluation. If the infant was given supplemental oxygen at the time of initial transport team evaluation, write the FIO2 (percentage of oxygen) in the designated space. If the infant was not given supplemental oxygen at the time of initial transport team evaluation, leave the designated space blank.

c. Arterial Oxygenation (PAO2). Indicate PAO2 from blood gas specimen at the time of initial transport team evaluation. (Note: if blood gases were not clinically indicated or available at the time of initial transport team evaluation, leave the designated space blank.)

(c) Vital Signs

(i) Heart Rate (HR) at Time of Initial Transport Team Evaluation. Indicate infant’s heart rate at the time of initial transport team evaluation.

(ii) Blood Pressure (BP) at Time of Initial Transport Team Evaluation. Indicate infant’s systolic, diastolic and mean blood pressures at the time of initial transport team evaluation.

(iii) Pressors at Time of Initial Transport Team Evaluation. Indicate Y Yes or N No whether vasopressors were administered at the time of initial transport team evaluation.

(iv) Temperature (T) at Time of Initial Transport Team Evaluation. If the infant’s core body temperature was measured and recorded at the time of initial transport team evaluation, enter the infant’s temperature in degrees centigrade to the nearest tenth of a degree. For centers that measure temperature in degrees Fahrenheit, a Fahrenheit-to-Centigrade conversion table is provided in Appendix K. Use rectal temperature or, if not available, esophageal temperature, tympanic temperature or axillary temperature, in that order. If the infant’s body temperature was not measured at the time of initial transport team evaluation, leave this item blank.

(d) Blood Glucose at Time of Initial Transport Team Evaluation. Indicate

infant’s blood glucose screening results at the time of initial transport team evaluation.


(e) Blood Gases at the time of Initial Transport Team Evaluation. If blood gases were not clinically indicated or available at the time of initial transport team evaluation, leave the designated space blank.

(i) Respiratory Support at Time of Referral for Transport. Write None (N) if required no respiratory support. Write Hood/NC (H) in the designated space if the infant had spontaneous breathing and was supported using an oxygen hood or nasal cannula at time of referral for transport. Write NCPAP (C) in the designated space if the infant was provided with continuous positive airway pressure (CPAP) using nasal CPAP at time of referral for transport. Write ETT (E) in the designated space if the infant was ventilated using an endotracheal tube at time of referral for transport. Do not enter ETT if an endotracheal tube was placed only for suctioning and assisted ventilation was not given through the tube. Write Unk in the designated space if this information cannot be obtained.

(ii) Blood Gas Results at Time of Initial Transport Team Evaluation. If arterial blood gas results were clinically indicated and obtained at the time of initial transport team evaluation, indicate results. If blood gases not obtained leave this space blank.

a. pH b. PCO2 c. BE (Base Excess/Deficit)

Admission to the NICU (a) Responsiveness at Time of Admission to the Receiving NICU. Write

the number 0 (zero) in the designated space if the infant died prior to evaluation, 1 (one) demonstrated no responsiveness, seizures or received muscle relaxants at the time of admission to the receiving NICU. Note: Seizures include compelling clinical evidence of seizures, or of focal or multifocal, clonic or tonic seizures, as well as EEG evidence of seizures, regardless of clinical status. Write the number 2 (two) in the designated space if the infant appeared lethargic or had no cry at the time of Admission to the Receiving NICU. Write the number 3 (three) in the designated space vigorously withdraws or cries at the time of admission to the receiving NICU.

(b) Respiratory

(i) Respiratory Rate at Time of Admission to the Receiving NICU. Indicate infant’s respiratory rate at the admission to the receiving NICU. Note: this rate may be spontaneous or assisted by ventilator.

(ii) Oxygen Saturation at Time of Admission to the Receiving NICU.


Indicate average oxygen saturation in percentage at the time of referral. If unknown, indicate Unk . (iii) Respiratory Status at the time of referral. Write the number 1 (one) in the designated space if the infant was on the respirator at the time of admission to the receiving NICU. Write the

number 2 (two) in the designated space if the infant had severe respiratory complications, including: apnea, gasping, or was intubated but not on mechanical respirator. Write the number

3 (three) in the designated space for all other respiratory status at the time of admission to the receiving NICU (including no or mild respiratory complications).

(iv) Oxygen Index. Completed only if the infant is on the ventilator at the time of Admission to the Receiving NICU. If information not obtainable, indicate Unk .

a. Mean Airway Pressure (MAP). Indicate mean airway pressure at the time of admission to the receiving NICU if known.

b. Inspired Oxygen Concentration (FiO2). Indicate inspired oxygen concentration (21-100%) at the time of admission to the receiving NICU. If the infant was given supplemental oxygen at the time of Admission to the Receiving NICU, write the FIO2 (percentage of oxygen) in the designated space. If the infant was not given supplemental oxygen at the time of admission to the receiving NICU, leave the designated space blank.

c. Arterial Oxygenation (PAO2). Indicate PAO2 from blood gas specimen at the time of admission to the receiving NICU. (Note: if blood gases were not clinically indicated or available at the time of admission to the receiving NICU, leave the designated space blank.)

(c) Vital Signs

(i) Heart Rate (HR) at Time of Admission to the Receiving NICU. Indicate infant’s heart rate at the time of admission to the

receiving NICU. (ii) Blood Pressure (BP) at Time of Admission to the Receiving

NICU. Indicate infant’s systolic, diastolic and mean blood pressures at the time of admission to the receiving NICU.

(iii) Pressors at Time of Admission to the Receiving NICU. Indicate Y Yes or N No whether vasopressors were administered at the time of admission to the receiving NICU.

(iv) Temperature (T) at Time of Admission to the Receiving NICU. If the infant’s core body temperature was measured and


recorded at the time of admission to the receiving NICU, enter the infant’s temperature in degrees centigrade to the nearest tenth of a degree. For centers that measure temperature in degrees Fahrenheit, a Fahrenheit-to-Centigrade conversion table is provided in Appendix K. Use rectal temperature or, if not available, esophageal temperature, tympanic temperature or axillary temperature, in that order. If the infant’s body temperature was not measured at the time of Admission to the Receiving NICU, leave this item blank.

(d) Blood Glucose at Time of Admission to the Receiving NICU. Indicate

infant’s blood glucose screening results at the time of admission to the receiving NICU.

(e) Blood Gases at the Time of Admission to the Receiving NICU. If blood gases were not clinically indicated or available at the time of admission to the receiving NICU, leave the designated space blank.

(i) Respiratory Support at Time of Referral for Transport. Write None (N) if required no respiratory support. Write Hood/NC (H) in the designated space if the infant had spontaneous breathing and was supported using an oxygen hood or nasal cannula at time of referral for transport. Write NCPAP (C) in the designated space if the infant was provided with continuous positive airway pressure (CPAP) using nasal CPAP at time of referral for transport. Write ETT (E) in the designated space if the infant was ventilated using an endotracheal tube at time of referral for transport. Do not enter ETT if an endotracheal tube was placed only for suctioning and assisted ventilation was not given through the tube. Write Unk in the designated space if this information cannot be obtained.

(ii) Blood Gas Results at Time of Admission to the Receiving NICU.

If arterial blood gas results were clinically indicated and obtained at the time of admission to the receiving NICU, indicate results. If blood gases not obtained leave this space blank.

i. pH ii. PCO2

iii. BE (Base Excess/Deficit)


IV. CLINICAL INFORMATION This information is required to provide continuity of care. Hemoglobin/Hematocrit Enter the date using MM/DD/YYYY and time using a 24-hour clock (eg, 11:30 PM = 2330) and results. Blood Culture Enter the date using MM/DD/YYYY and time using a 24-hour clock (eg, 11:30 PM = 2330) and results. Bilirubin Enter the date using MM/DD/YYYY and time using a 24-hour clock (eg, 11:30 PM = 2330) and results. Neonatal Screening (a) Hearing. Indicate Yes if screening completed, No if screening not

completed and Unk if the information is not obtainable. (b) Metabolic (PKU, T4, Galactosemia, Hemoglobinopathies). Indicate

Yes if screening completed, No if screening not completed and Unk if the information is not obtainable.

(c) Substance Exposure. Indicate Yes if screening completed and provide results, No if screening not completed and Unk if the information is not obtainable.

Imaging Enter type of imagining done and results as well as the date using MM/DD/YYYY and time using a 24-hour clock (eg, 11:30 PM = 2330) Chest X-Ray Enter results as well as the date using MM/DD/YYYY and time using a 24-hour clock (eg, 11:30 PM = 2330) Other Clinical Information IV Access/Fluids Blood Transfusion Enter the date using MM/DD/YYYY and time using a 24-hour clock (eg, 11:30 PM = 2330) Last Urine Enter the date using MM/DD/YYYY and time using a 24-hour clock (eg, 11:30 PM = 2330) Last Stool


Enter the date using MM/DD/YYYY and time using a 24-hour clock (eg, 11:30 PM = 2330) Enteral Feeding First Enteral Feeding. Enter the type (Human Milk Only, Huamn Milk plus Fortifier, or Formula), route administered (PO- oral, OG- oral gavage, NG – nasal gavage, GT – gastrostomy tube, Other – all other enteral feeding routes), and the amount in cc’s. Indicate date using MM/DD/YY and time of the first enteral feeding using a 24-hour clock (eg, 11:30 PM = 2330). If the infant has not yet received his first enteral feeding, this item is not applicable and may be left blank. Last Enteral Feeding Prior to Transport. Enter the type (Human Milk Only, Huamn Milk plus Fortifier, or Formula), route administered (PO- oral, OG- oral gavage, NG – nasal gavage, GT – gastrostomy tube, Other – all other enteral feeding routes), and the amount in cc’s. Indicate date using MM/DD/YY and time of the last enteral feeding prior to transport using a 24-hour clock (eg, 11:30 PM = 2330). If the infant has not yet received his first enteral feeding, this item is not applicable and may be left blank. Medication. Enter the date using MM/DD/YYYY and time using a 24-hour clock (eg, 11:30 PM = 2330) Comments V. OTHER SIGNIFICANT ISSUES Surgery. Enter Yes if infant underwent surgery at any time. Enter No if infant has not undergone surgery. If Yes, note indication. Allergies Death Indicate No if the infant did not die. Check Yes if the infant died between the time of referral for transport and prior to arriving at the receiving NICU. Indicate whether the infant died prior to transport team arrival, prior to departure or prior to admission to receiving NICU.


Enter the date of death using MM/DD/YY. Enter the time of death using a 24-hour clock (eg, 11:30 PM = 2330). VI. REFERRAL PROCESS T. 26 Referring Hospital Write the name of the referring hospital in the designated space. Write the telephone number of the Nursery/NICU of the referring hospital in the designated space. Write the referring hospital’s CPQCC membership number in the designated space. Please refer to the current Membership Directory on the CPQCC website (www.cpqcc.org) when answering this question. If the referring hospital is not a CPQCC member hospital, this item is not applicable and may be left blank. Write the name of the referring Obstetrician in the designated space. Write the telephone number of the referring Obstetrician in the designated space. Write the name of the referring Pediatrician in the designated space. Write the telephone number of the referring Pediatrician in the designated space. Write the name of the informant from the referring hospital in the designated space. Write the telephone number of the informant from the referring hospital in the designated space. T. 27a Was the infant Previously Transported? Check Yes if the infant was transported previously from another hospital to the referring hospital. Check No if the infant was not transported previously from another hospital to the referring hospital. T. 27b Previous Transfer Referring Hospital If transported previously is answered Yes , write the name of the original hospital and it’s CPQCC membership number in the designated spaces. If the original hospital is not a CPQCC member hospital, this item is not applicable and may be left blank. *T. 28 Location of Birth (A/D Form Item 7c) Write the name of the birth hospital in the designated space. Write the telephone number of the Nursery/NICU of the birth hospital in the designated space. Write the birth hospital’s CPQCC membership number in the designated space. Please refer to the current Membership Directory on the CPQCC website (www.cpqcc.org) when answering this


question. If the birth hospital is not a CPQCC member hospital, this item is not applicable and may be left blank. Receiving Hospital Write the name of the receiving hospital in the designated space. Write the telephone number of the NICU of the receiving hospital in the designated space. Write the receiving hospital’s CPQCC membership number in the designated space. Please refer to the current Membership Directory on the CPQCC website (www.cpqcc.org) when answering this question. If the receiving hospital is not a CPQCC member hospital, this item is not applicable and may be left blank. Write the name of the accepting Physician in the designated space. Write the telephone number of the accepting Physician in the designated space. T. 29 Transport Team On-Site Leader. Choose only one of the following responses: Check Sub-specialist MD for Neonatologist Check Peds for pediatrician. Check NNP for Neonatal Nurse Practitioner. Check Transport Specialist for Registered Nurse or Respiratory Therapist specializing in Neonatal/Pediatric Transport Services, Practicing under standardized procedures. Check Nurse for Neonatal Registered Nurse. Check Other for…and specify what type of staff member this is in the space provided. Check Yes if the Transport Team Leader was present prior to arrival of the transport team. Check No if the Transport Team Leader was not present prior to arrival of the transport team. If the answer to where or not the Transport Team Leader was present prior to the arrival of the transport team is answered Yes , enter the date the Transport Team Leader arrived at the referring hospital prior to the transport team using MM/DD/YY. Enter the time the Transport Team Leader arrived at the referring hospital prior to the transport team using a 24-hour clock (eg, 11:30 PM = 2330). T. 30 Transport Team From. Choose one of the following responses: Check Receiving Hospital if the transport team is part of the receiving hospital’s staff (including those used for both Neonatal and Pediatric Transports and based in NICU, Pediatrics, PICU, Emergency Department, etc.)


Check Contract Service if the transport team is not on staff at the receiving hospital. This may include contracted transport teams from another facility inside or outside of the hospital system of the receiving facility. Check Referring Hospital if the transport team is part of the referring hospital’s staff. T. 31 Mode of Transport (a) Select type of transport used. Select only one. Primary type of transport used. (e.g. patient was transported by ambulance to airfield or heliport for helicopter transport, would be coded as helicopter.) Ground for ambulance transport or ambulatory transport (e.g. crossing from one hospital to another immediately adjacent facility.) Helicopter for rotor wing transport. Fixed Wing for airplane transport. VII. TIMELINE Date/Time of Maternal Admission to Labor & Delivery/Hospital Enter the date using MM/DD/YYYY and time using a 24-hour clock (eg, 11:30 PM = 2330) T. 32 Date/Time of Transport Team Departure for Referring Hospital Enter the date using MM/DD/YYYY and time using a 24-hour clock (eg, 11:30 PM = 2330) T. 33 Date/Time Transport Team Arrived at Referring Hospital Enter the date using MM/DD/YYYY and time using a 24-hour clock (eg, 11:30 PM = 2330) Date/Time Transport Team Departed From Referring Hospital Enter the date using MM/DD/YYYY and time using a 24-hour clock (eg, 11:30 PM = 2330) Date/Time Transport Team Arrived at Receiving Facility Enter the date using MM/DD/YYYY and time using a 24-hour clock (eg, 11:30 PM = 2330) Enter the date using MM/DD/YYYY and time using a 24-hour clock (eg, 11:30 PM = 2330)


VIII. INFORMATION/MATERIALS TO BE SENT WITH TRANSPORT TEAM Information/Materials to be Sent with Transport Team Indicate all materials and information provided by referring hospital to transport team. Chart(Patient Record) Check Maternal and/or Neonatal Blood Specimen Check Maternal and/or Neonatal Placenta Imaging Copies Other Specify all additional items transported with infant. IX. CARE PROVIDERS Referring Hospital Enter the date using MM/DD/YYYY and time using a 24-hour clock (eg, 11:30 PM = 2330) Transport Team Enter the date using MM/DD/YYYY and time using a 24-hour clock (eg, 11:30 PM = 2330) X. COMMENTS Please provide you comments in this section. XI. TRANSPORT ISSUES WITH IMPROVEMENT POTENTIAL Transport Issues with Improvement Potential


APPENDICES APPENDIX A: ALL CALIFORNIA NEONATAL TRANSPORT FORM_COLOR (ACNTF) ALL CALIFORNIA NEONATAL TRANSPORT FORM (ACNTF) CORE CPETS NEONATAL TRANSPORT FORM (CCNTF) APPENDIX B: CPQCC ON-LINE DATA ENTRY (SCREEN SHOTS) APPENDIX C: BIRTH DEFECT CODES FOR CCNTF ITEM T.10 APPENDIX D: OSHPD FACILITY CODES APPENDIX E: FARENHEIT TO CENTRIGRADE CONVERSION TABLE APPENDIX F: NEONATAL TRANSPORT DATA SYSTEM

CPETS POLICY AND PROCEDURES APPENDIX G: CPETS PRELIMINARY DRAFT REPORT APPENDIX H: PERINATAL CARES ARTICLE APPENDIX I: TRIPS SCORE APPENDIX J: FREQUENTLY ASKED QUESTIONS (FAQs)


APPENDIX A: ALL CALIFORNIA NEONATAL TRANSPORT FORM_COLOR (ACNTF) ALL CALIFORNIA NEONATAL TRANSPORT FORM (ACNTF) CORE CPETS NEONATAL TRANSPORT FORM (CCNTF)


Referring Hospital, Transport Team/Receiving Hospital, Bold: essential data base components, Plain: hospital preference.

ALL CALIFORNIA NEONATAL TRANSPORT FORM REFERRAL: Information required at initial contact between referring and receiving center/providers to facilitate transport. T.1 Transport type ! DR Attendance Requested ! ASAP Neonatal ! Scheduled Neonatal ! Other ________________ T.2 Indication ! Medical Dx/Rx Services ! Growth/Discharge Planning ! Surgery !Chronic Care ! Insurance T.3 Date/Time(D/T) Referral: @ T.4 Acceptance @ T.5 Maternal Admission to Labor & Delivery/Hospital Date/Time @ PATIENT IDENTIFICATION/HISTORY: Information to be obtained prior to transport. Infant’s Name___________________! Singleton ! Multiple __of __ T.6 Birth D/T _________ @______Ins. ___________

T.7 Birth wt. __ __ __ __ gms Current wt. __ __ __ __ gms T.8 Gestational Age __ __wks__ days T.9 ! M !F !Unk T.10 Prenatally Diagnosed Congenital Anomalies ! Y ! N ! Unk Describe: Mother’s Name Birth Date Age __ __ yrs MedRec# T.11 G __ P ! AB ! L ! ROM Date/Time @ Duration __ __ hrs Fluid ! Clear ! Meconium

Significant Antepartum/Intrapartum Issues: Antibiotics !Y Specify__________ !N !Unk T.12 Steroids !Y !N (last dose) @

Antenatal Conditions ! None ! Unk ! Hypertension ! Diabetes ! Infection ! Preterm Labor ! Bleeding/Abrupt/Previa ! Other: _____________

T.13 Surfactant Given !Y !N !Unk ! DR ! NSY !NICU(first dose) @

Delivery ! Spont. Vag ! Op. Vag !Vacuum ! Forceps ! Cesarean ! Primary ! Repeat

Apgar Scores Score N/D Unk 1 __ __ ! ! 5 __ __ ! ! 10__ __ ! ! 15__ __ ! ! ___________ ___________

INFANT CONDITION CLINICAL INFORMATION Modified TRIPS Score: to be recorded on referral, within 15 minutes of arrival at referring hospital and admit to NICU.

Date Time Results

Referral a

Initial TT Eval b

NICU Admit c

Hgb/HCT @

T.14 Time (24 hour) Bld. Cult. @ T.15 Responsiveness! Bilirubin @

T.16 Rate Screening: Hearing!Y!N! Unk Metabolic!Y!N!Unk T.17 O2 Saturation Subs Exp !Y !N!Ukn T.18 Status" Imaging: CXR @

MAP Other (specify) FiO2 IV Access/Fluids (type, rate, site) R

espi

rato

ry

Oxygen Index* T.19 PAO2 Bld. Trans. @ (type,vol)

T.20 HR Last Urine @ Stool @ T.21 BP Sys/ Dia, Mean

Feeding (type/rt/vol) First Last

T.22 Pressors !Y !N !Y!N !Y !N Meds given within last 24° ! Eye care ! Vit. K

Vita

l Sig

ns

T.23 Temp. C° Date/Time Med Dose Rt. T.24 Blood Glucose

T.25 Resp. Support# pH PCO2 Allergies !Y type ! N !Unk

Bld

. Gas

BE Surgery !Y ! N Indication !NEC ! CHD ! Other !Responsiveness: 0=Death 1=None, Seizure, Muscle Relaxant 2=Lethargic, no cry 3=Vigorously withdraws, cry. #Resp Support: None, Hood/NC. NCPAP, ETT "Respiratory Status: 1=Respirator 2= Severe (apnea, gasping, intubated but not on respirator) 3=Other *Oxygen Index completed if pt. is on vent. Death!No !Yes @ ! Prior to team arrival ! Prior to departure ! Prior to arrival at NICU**


REFERRAL PROCESS T.26 Referring Hospital Name Code Telephone Number Referring OB Referring Peds Informant T.27 Previously Transported? $Y $N From: Hospital Name Code T.28 Birth Hospital (if not listed above) Hospital Name Code Receiving Hospital Accepting Physician T.29 Trans. Team On-Site Leader !Sub-specialist MD !Peds !Other MD/Resident !NNP !Transport Spec. !Nurse Present prior to transport team arrival $Y $N @ T.30 Team From ! Receiving Hospital !Contract Service (CPQCC TT ID ) ! Referring Hospital T.31 Mode !Ground !Helicopter !Fixed Wing Indication Transport Carrier TIMELINE

Date Time Comments T.32 Transport Team Departure for Referring Hospital @ T.33 Transport Team Arrival at Referring Hospital @ Transport Team Departure from Referring Hospital @ Transport Team Arrival at Receiving Facility @ INFORMATION/MATERIALS TO BE SENT WITH TRANSPORT TEAM (CHECK ALL PROVIDED) Chart (pt. record) $Maternal $Neonatal Blood Specimen $Maternal $Neonatal $Placenta $Imagining copies $Other, specify CARE PROVIDERS name /title signature D/T of arrival Referring Hospital @

@

Transport Team @

@ @

@ COMMENTS

**SPECIAL INSTRUCTIONS: For all deaths prior to being admitted at the receiving NICU, complete paper transport form, and fax to the CPQCC Data Center at (510) 620-3144.


CONFIDENTIAL NEONATAL TRANSPORT ISSUES WITH IMPROVEMENT POTENTIAL FORM $Delay in transport, describe: __________________________________________________________________________

Related to$Amb./vehicle issues $Traffic $Missed opportunity for maternal transport $Delay in transferring infant

$Transport Team Difficulties, describe: ___________________________________________________________________ $ Required elements of neonatal transport form incomplete, describe: _________________________________________ $Equipment Difficulties, describe: _______________________________________________________________________ $Unplanned Intervention During Transport, describe: ________________________________________________________ Related to $Airway $Vascular Access $Return to Referring Hospital $Other _______________________________ $CPR during transport $Death prior to admission to receiving NICU** $None $Other, describe Comments Referred for Joint Mortality/Morbidity Review $Y $N $ Unk Date of Review Outcome of Review: $Policy/Procedure Change $Joint QI Project $Education Offering $Consultation $ Other: describe Follow up:



ALL CALIFORNIA NEONATAL TRANSPORT FORM REFERRAL: Information required at initial contact between referring and receiving center/providers to facilitate transport. T.1 Transport type ! DR Attendance Requested ! ASAP Neonatal ! Scheduled Neonatal ! Other ________________ T.2 Indication ! Medical Dx/Rx Services ! Growth/Discharge Planning ! Surgery !Chronic Care ! Insurance T.3 Date/Time(D/T) Referral: @ T.4 Acceptance @ T.5 Maternal Admission to Labor & Delivery/Hospital Date/Time @ PATIENT IDENTIFICATION/HISTORY: Information to be obtained prior to transport. Infant’s Name___________________! Singleton ! Multiple __of __ T.6 Birth D/T _________ @______Ins. ___________

T.7 Birth wt. __ __ __ __ gms Current wt. __ __ __ __ gms T.8 Gestational Age __ __wks__ days T.9 ! M !F !Unk T.10 Prenatally Diagnosed Congenital Anomalies ! Y ! N ! Unk Describe: Mother’s Name Birth Date Age __ __ yrs MedRec# T.11 G __ P ! AB ! L ! ROM Date/Time @ Duration __ __ hrs Fluid ! Clear ! Meconium

Significant Antepartum/Intrapartum Issues: Antibiotics !Y Specify__________ !N !Unk T.12 Steroids !Y !N (last dose) @

Antenatal Conditions ! None ! Unk ! Hypertension ! Diabetes ! Infection ! Preterm Labor ! Bleeding/Abrupt/Previa ! Other: _____________

T.13 Surfactant Given !Y !N !Unk ! DR ! NSY !NICU(first dose) @

Delivery ! Spont. Vag ! Op. Vag !Vacuum ! Forceps ! Cesarean ! Primary ! Repeat

Apgar Scores Score N/D Unk 1 __ __ ! ! 5 __ __ ! ! 10__ __ ! ! 15__ __ ! ! ___________ ___________

INFANT CONDITION CLINICAL INFORMATION Modified TRIPS Score: to be recorded on referral, within 15 minutes of arrival at referring hospital and admit to NICU.

Date Time Results

Referral a

Initial TT Eval b

NICU Admit c

Hgb/HCT @

T.14 Time (24 hour) Bld. Cult. @ T.15 Responsiveness! Bilirubin @

T.16 Rate Screening: Hearing!Y!N! Unk Metabolic!Y!N!Unk T.17 O2 Saturation Subs Exp !Y !N!Ukn T.18 Status" Imaging: CXR @

MAP Other (specify) FiO2 IV Access/Fluids (type, rate, site) R

espi

rato

ry

Oxygen Index* T.19 PAO2 Bld. Trans. @ (type,vol)

T.20 HR Last Urine @ Stool @ T.21 BP Sys/ Dia, Mean

Feeding (type/rt/vol) First Last

T.22 Pressors !Y !N !Y!N !Y !N Meds given within last 24° ! Eye care ! Vit. K

Vita

l Sig

ns

T.23 Temp. C° Date/Time Med Dose Rt. T.24 Blood Glucose

T.25 Resp. Support# pH PCO2 Allergies !Y type ! N !Unk

Bld

. Gas

BE Surgery !Y ! N Indication !NEC ! CHD ! Other !Responsiveness: 0=Death 1=None, Seizure, Muscle Relaxant 2=Lethargic, no cry 3=Vigorously withdraws, cry. #Resp Support: None, Hood/NC. NCPAP, ETT "Respiratory Status: 1=Respirator 2= Severe (apnea, gasping, intubated but not on respirator) 3=Other *Oxygen Index completed if pt. is on vent. Death!No !Yes @ ! Prior to team arrival ! Prior to departure ! Prior to arrival at NICU**


REFERRAL PROCESS T.26 Referring Hospital Name Code Telephone Number Referring OB Referring Peds Informant T.27 Previously Transported? $Y $N From: Hospital Name Code T.28 Birth Hospital (if not listed above) Hospital Name Code Receiving Hospital Accepting Physician T.29 Trans. Team On-Site Leader !Sub-specialist MD !Peds !Other MD/Resident !NNP !Transport Spec. !Nurse Present prior to transport team arrival $Y $N @ T.30 Team From ! Receiving Hospital !Contract Service (CPQCC TT ID ) ! Referring Hospital T.31 Mode !Ground !Helicopter !Fixed Wing Indication Transport Carrier TIMELINE

Date Time Comments T.32 Transport Team Departure for Referring Hospital @ T.33 Transport Team Arrival at Referring Hospital @ Transport Team Departure from Referring Hospital @ Transport Team Arrival at Receiving Facility @ INFORMATION/MATERIALS TO BE SENT WITH TRANSPORT TEAM (CHECK ALL PROVIDED) Chart (pt. record) $Maternal $Neonatal Blood Specimen $Maternal $Neonatal $Placenta $Imagining copies $Other, specify CARE PROVIDERS name /title signature D/T of arrival Referring Hospital @

@

Transport Team @

@ @

@ COMMENTS


Referring Hospital, Transport Team/Receiving Hospital, Plain: hospital preference.

CORE CPETS NEONATAL TRANSPORT FORM REFERRAL T.1 Transport type ! DR Attendance Requested ! ASAP Neonatal ! Scheduled Neonatal ! Other T.2 Indication ! Medical Dx/Rx Services ! Growth/Discharge Planning ! Surgery !Chronic Care ! Ins. T.3 Date/Time(D/T) Referral: @ T.4 Acceptance @ T.5 Maternal Admission to Labor & Delivery/Hospital Date/Time @ PATIENT IDENTIFICATION/HISTORY: T.6 Birth D/T ____________@________ T.7 Birth wt. ___ ___ ___ ___ gms

T.8 Gestational Age ___ ___wks____ days T.9 ! M !F !Unk T.10 Prenatally Diagnosed Congenital Anomalies ! Y ! N ! Unk Describe: T.11 Maternal Gravida ____ T.12 Steroids !Y !N (last dose) @ T.13 Surfactant Given !Y !N !Unk ! DR ! NSY !NICU(first dose) @ INFANT CONDITION REFERRAL PROCESS Modified TRIPS Score: to be recorded on referral, within 15 minutes of arrival at referring hospital and admit to NICU.

T.26 Referring Hospital Name

Referral

a

Initial TT Eval

b

NICU Admit

c

T.27 Previously Transported? $Y $N From: Hospital Name Code

T.14 Time (24 hour) T.28 Birth Hospital (if not listed above) T.15 Responsiveness! Hospital Name Code

T.16 Rate T.29 Trans. Team On-Site Leader T.17 O2 Saturation !Sub-specialist MD !Peds !Other MD/Resident !NNP T.18 Status" !Transport Spec. !Nurse

MAP Present prior to transport team arrival $Y $N @ FiO2 T.30 Team From !Receiving Hospital !Referring Hospital R

espi

rato

ry

Oxygen Index* T.19 PAO2 !Contract Service (CPQCC TT ID )

T.20 HR T.31 Mode !Ground !Helicopter !Fixed Wing T.21 BP Sys/ Dia, Mean

Indication Transport Carrier

T.22 Pressors !Y !N !Y!N !Y !N TIMELINE Date Time

Vita

l Sig

ns

T.23 Temp. C° T.32 Transport Team Departure for Referring Hospital T.24 Blood Glucose @

T.25 Resp. Support# T.33 Transport Team Arrival at Referring Hospital pH @ PCO2 Recorder

Bld

. Gas

BE Comments

!Responsiveness: 0=Death 1=None, Seizure, Muscle Relaxant 2=Lethargic, no cry 3=Vigorously withdraws, cry. #Resp Support: None, Hood/NC. NCPAP, ETT "Respiratory Status: 1=Respirator 2= Severe (apnea, gasping, intubated but not on respirator) 3=Other *Oxygen Index completed if pt. is on vent.

Death!No !Yes @ ! Prior to team arrival ! Prior to departure ! Prior to arrival at NICU** SPECIAL INSTRUCTIONS: For all deaths prior to being admitted at the receiving NICU, complete paper transport form, and fax to the CPQCC Data Center at (510) 620-3144.

Referring Hospital, Transport Team/Receiving Hospital, Plain: hospital preference.





APPENDIX B: CPQCC ON-LINE DATA ENTRY (SCREEN SHOTS)


APPENDIX C: BIRTH DEFECT CODES FOR CCNTF ITEM T.10


APPENDIX C - BIRTH DEFECTS CODES FOR CCNTF ITEM T.10

Code Other Lethal or Life Threatening Birth Defect

100 Lethal or Life-Threatening Birth Defect which is not listed below

Code Central Nervous System Defects 100 Other lethal or life threatening CNS Defects (DESCRIBE) 101 Anencephaly 102 Meningomyelocele 103 Hydranencephaly 104 Congenital Hydrocephalus 105 Holoprosencephaly 106 Microcephaly 107 Hypopituitary 108 Septic Optic Dysplasia 109 Encephalocele Code Congenital Heart Defects 200 Other lethal or life threatening congenital heart defects

(DESCRIBE)

201 Truncus Arteriosus 202 Transposition of the Great Vessels 203 Tetralogy of Fallot 204 Single Ventricle 205 Double Outlet Right Ventricle 206 Complete Atrio-Ventricular Canal 207 Pulmonary Atresia 208 Tricuspid Atresia 209 Hypoplastic Left Heart Syndrome 210 Interrupted Aortic Arch 211 Total Anomalous Pulmonary Venous Return 212 Coarctation of the Aorta 213 Atrial septal defect (ASD) 214 Ventricular septal defect (VSD) 215 Arrythmias 216 Ebsteins Anomaly 217 Pericardial Effusion 218 Pulmonary Stenosis 219 Hypertrophic Cardiomyopathy Code Gastro-Intestinal Defects 300 Other lethal or life threatening GI Defects (DESCRIBE) 301 Cleft Palate 302 Tracheo-Esophageal Fistula 303 Esophageal Atresia 304 Duodenal Atresia 305 Jejunal Atresia 306 Ileal Atresia 307 Atresia of Large Bowel or Rectum 308 Imperforate Anus 309 Omphalocele

310 Gastroschisis 311 Pyloric Stenosis 312 Annular Pancreas 313 Biliary Atresia 314 Meconium Ilius 315 Malrotation Volvulus 316 Hirschsprung’s Disease Code Genito-Urinary Defects 401 Bilateral Renal Agenesis 402 Bilateral Polycystic, Multicystic, or Dysplastic Kidneys 403 Obstructive Uropathy with Congenital Hydronephrosis 404 Exstrophy of the Urinary Bladder Code Chromosomal Abnormalities 501 Trisomy 13 502 Trisomy 18 503 Trisomy 21 504 Other Chromosomal Abnormality (DESCRIBE) Code Other Birth Defects 601 Skeletal Dysplasia (DESCRIBE) 602 Congenital Diaphragmatic Hernia 603 Hydrops Fetalis with anasarca and one or more of the following: ascites,

pleural effusion pericardial effusion 604 Oligohydramnios sequence including all 3 of the following:

1. Oligohydramnios documented by antenatal ultrasound 5 or more days prior to delivery.

2. Evidence of fetal constraint on postnatal physical exam (such as Potter's facies, contractures, or positional deformities of limbs), and

3. Postnatal respiratory failure requiring endotracheal intubation and assisted ventilation.

605 Inborn Error of Metabolism (DESCRIBE) 606 Myotonic Dystrophy requiring endotracheal intubation and assisted

ventilation. Code Pulmonary Defects 800 Other Pulmonary Defects (DESCRIBE) 801 Congenital Lobar Emphysema 802 Cystic Adenomatoid Malformation 803 Sequestered Lung 804 Aveolar Capillary Dysplasia Code Vascular and Lymphatic Defects 900 Other Vascular or Lymphatic (DESCRIBE) 901 Cystic Hygroma 902 Hemangioma 903 Sacrococcygeaal Teratoma 904 Cerebral AV Malformation Code Other Diagnoses 120 Persistent Pulmonary Hypertension (Dx criteria – Echo or TA/UA gradients)

121 Hematologic 122 Hemolytic Disease of the Newborn (Not ABO) The following conditions should NOT be coded as Major Birth Defects Extreme Prematurity, Limb Abnormalities, Syndactyly, Polydactyly, Hypospadias, Patent Ductus Arteriosus, Pulmonary Hypoplasia (use code 401 for bilateral renal agenesis, or 604 for Oligohydramnios Sequence, if applicable), Intrauterine Growth Retardation, Small for Gestational Age, Fetal Alcohol Syndrome, Hypothyroidism, Intrauterine Infection, Persistent Pulmonary Hypertension (PPHN)

APPENDIX D: OSHPD FACILITY CODES


APPENDIX D - OSHPD FACILITY CODES

SPECIAL LOCATION CODES CODE FACILITY NAME

890000 Home B irth – C a lifornia 880000 Home B irth – O ut of S ta te 890097 E mergency Room – C a lifornia 880097 E mergency Room – O ut of S ta te 890096 C linic -- C a lifornia 880096 C linic – O ut of S ta te 890095 MD O ffice – C a liforn ia 880095 MD O ffice – Out of S ta te 890099 O ther in-pa tient se tting – C a liforn ia 880099 O ther in-pa tient se tting – Out of S ta te 890094 O ther out-pa tient se tting -- C a liforn ia 880094 O ther out-pa tient se tting – O ut of S ta te

OSHPD FACILITY CODES Sorted Alphabetically By City(CPQCC centers indicated in bold italics)

C O D E Hosp i tal Na m e City10735 A lameda Hospita l Alameda

190017 A lhambra Hospita l Alhambra250956 Modoc Medica l C enter Alturas301097 Anahe im G enera l Hospita l Anaheim

301098 Anahei m Memorial Medical Center Anaheim301761 Anahe im Memoria l Medica l C enter West Anaheim

301132 Kaiser Fnd Hosp – Anaheim Anaheim301379 West Anahe im Medica l C enter Anaheim301188 Western Medica l C enter Hospita l - Anahe im Anaheim

70934 Sutter De lta Medica l C enter Antioch361343 St. Mary Regiona l Medica l C enter Apple Valley

190529 Methodist Hospital Of Southern California Arcadia121002 Mad R iver Community Hospita l Arcata400466 Arroyo Grande Community Hospita l Arroyo Grande310791 Sutter Auburn F a ith Hospita l Auburn190045 Ava lon Municipa l Hospita l Ava lon154101 Bakersfie ld Heart Hospita l Bakersfie ld

150722 Bakersfield Memorial Hospital – 34 t h street Bakersfield150722 Bakersfie ld Memoria l Hospita l- 34Th Street Bakersfie ld150775 Good Samaritan Hospita l-Bakersfie ld Bakersfie ld154022 Hea lthsouth Bakersfie ld Rehabilitation Hospita l Bakersfie ld

150736 Kern Medical Center Bakersfield150761 Mercy Hospita l – Bakersfie ld Bakersfie ld154108 Mercy Southwest Hospita l Bakersfie ld150788 San Joaquin Community Hospita l Bakersfie ld

196035 Kaiser Fnd Hosp - Baldwin Park Baldwin Park190049 Legacy Hospita l San Gabrie l Va lley Ba ldwin Park331326 San Gorgonio Memoria l Hospita l Banning361105 Barstow Community Hospita l Barstow190066 Be llflower Medica l C enter Be llflower190069 Be llwood G enera l Hospita l Be llflower194044 B e llwood H e a lth C enter Be llflower

190430 Kaiser Fnd Hosp - Bellflower Bellflower10844 A lta Bates Medica l C enter - Herrick C ampus Berke ley

10739 Alta Bates Sum m it Medical Center - Ashby Berkeley361110 Bear Va lley Community Hospita l B ig Bear Lake141273 Northern Inyo Hospita l B ishop331288 Pa lo Verde Hospita l Blythe

130760 P ioneers Memoria l Hospita l Brawley301126 Brea Community Hospita l Brea301127 K indred Hospita l Brea Brea301109 Anahe im G enera l Hospita l - Buena Park C ampus Buena Park301242 Orange Co Community Hosp - Buena Park Buena Park

190758 Providence/Saint Joseph Medical Center Burbank410852 Mills-Peninsula Medica l C enter Burlingame560508 St. John's P leasant Va lley Hospita l C amarillo434051 Childrens Recovery C enter O f N . C a lifornia C ampbe ll190605 P ine Grove Hospita l C anoga Park190859 West H ills Hospita l & Medica l C enter C anoga Park190860 West Va lley Hospita l And Hea lth C enter C anoga Park340869 Mercy American R iver Hospita l C armichae l

340950 Mercy San Juan Hospital Carm ichael190135 Ka iser Fnd Hosp – C arson C arson

10805 Eden Medica l C enter C astro Va lley10869 Laure l Grove Hospita l C astro Va lley

334017 Charter Behav. H lth SysO f So C a/Pa lm Springs Cathedra l C ity250955 Surprise Va lley Community Hospita l Cedarville190184 College Hospita l C erritos321016 Seneca Hospita l Chester

44006 Butte County Phf Chico40828 Enloe Medica l C enter - Cohasset C ampus Chico40962 Enloe Medica l C enter- Esplanade C ampus Chico44011 Enloe Rehabilitation C enter Chico

364050 C anyon R idge Hospita l Chino361144 Chino Va lley Medica l Center Chino200692 Chowchilla D istrict Memoria l Hospita l Chowchilla370658 Scripps Memoria l Hospita l - Chula V ista Chula Vista

370875 Sharp Chula Vista Medical Center Chula Vista171049 Redbud Community Hospita l C learlake100005 Community Medica l C enter - C lovis C lovis100697 Coa linga Regiona l Medica l C enter Coa linga

364231 Arrowhead Regional Medical Center C o l t o n60870 Colusa Regiona l Medica l C enter Co lusa71018 Mt. D iablo Medica l C enter Concord74039 Mt. D iablo Medica l Pavilion Concord

160702 Corcoran D istrict Hospita l Corcoran331145 Corona Regiona l Medica l C enter-Magnolia Corona331152 Corona Regiona l Medica l C enter-Ma in Corona370689 Sharp Coronado Hospita l And Hea lthcare C enter Coronado301155 College Hospita l Costa Mesa C osta Mesa190163 Aurora Charter O ak Covina

190413 C itrus Va lley Medica l C enter - IC C ampus Covina84001 Sutter Coast Hospita l Crescent C ity

190110 Brotman Medica l C enter Culver C ity410817 Seton Medica l C enter Daly C ity574010 Sutter Davis Hospita l Davis281078 St. He lena Hospita l Deer Park150706 De lano Regiona l Medica l C enter Delano540680 A lta Hospita l D istrict Dinuba240853 Dos Pa los Memoria l Hospita l Dos P a los190243 Downey Regiona l Medica l C enter Downey191306 Lac/Rancho Los Amigos Nationa l Rehab C enter Downey190176 C ity O f Hope Nationa l Medica l C enter Duarte190691 Santa Teresita Hospita l Duarte370697 Scripps Hospita l - E ast County E l C a jon

130699 El Centro Regional Medical Center El Centro371394 Scripps Memoria l Hospita l - Encinitas Encinitas190280 Encino-Tarzana Regiona l Med C tr-Encino Encino

370755 Palomar Medical Center Escondido120981 G enera l Hospita l The Eureka124004 Sempervirens P .H .F . Eureka121080 S t. Joseph Hospita l – Eureka Eureka540755 Memoria l Hospita l At Exeter Exeter848597 David Grant Med C tr / 60th Med Group Fairfield

481357 North Bay Medical Center Fairfield484028 Te lecare Solano Psychiatric Hea lth F acility Fairfield450936 Mayers Memoria l Hospita l Fall River Mills370705 F a llbrook Hospita l D istrict F a llbrook344035 K indred Hospita l – Sacramento F o lsom344029 Mercy Hospita l – Folsom F o lsom

361223 Kaiser Fnd Hosp – Fontana Fontana364110 Ka iser Fnd Hosp – Permanente Chem Dep Prgrm Fontana231013 Mendocino Coast D istrict Hospita l Fort Bragg121051 Redwood Memoria l Hospita l Fortuna

301175 Fountain Valley Rgnl Hosp & Med Ctr – Euclid Fountain Valley304039 Founta in Va lley Rgnl Hosp & Med C tr – Warner Fountain Valley300225 Orange Coast Memoria l Medica l C enter Fountain Valley

14034 Fremont Hospita l Fremont14132 Ka iser Fnd Hosp – Fremont Fremont

10987 Washington Hospital – Fremont Fre m ont391010 San Joaquin G enera l Hospita l French C amp104008 C edar V ista Hospita l Fresno

100717 Com munity Regional Medical Center – Fresno Fresno104089 Fresno County Psychiatric Hea lth F acility Fresno

104047 Fresno Surgery C enter Fresno104062 Ka iser Fnd Hosp – Fresno Fresno104023 San Joaquin Va lley Rehabilitation Hospita l Fresno

100899 St. Agnes Medical Center Fresno100822 University Medica l C enter Fresno

301342 St. Jude Medical Center Fullerton121031 Jerold Phe lps Community Hospita l Garberville301283 G arden Grove Hospita l & Medica l C enter G arden Grove190196 Community Hospita l O f G ardena G ardena190521 Memoria l Hospita l O f G ardena G ardena494047 Woodlands Psychiatric Hea lth F acility Geyserville434138 St. Louise Regiona l Hospita l G ilroy

190323 Glendale Adventist Med Center - Wilson Glendale190522 G lendale Memorial Hospital & Health Center Glendale

190818 Verdugo H ills Hospita l G lendale190328 E ast Va lley Hospita l Medica l C enter G lendora190298 Foothill Presbyterian Hospita l-Johnston Memoria l G lendora190348 Granada H ills Community Hospita l Granada Hills291023 S ierra Nevada Memoria l Hospita l Grass Va lley211006 Marin G enera l Hospita l Greenbrae320874 Indian Valley Hospital Greenville

40802 B iggs Gridley Memoria l Hospita l Gridley160787 Centra l Va lley Genera l Hospita l Hanford160725 Hanford Community Medica l C enter Hanford

190431 Kaiser Fnd Hosp - Harbor City Harbor City190057 Little Co O f Mary San Pedro Hospita l-Harbor C ity Harbor C ity190159 Tri-C ity Regiona l Medica l C enter Hawa iian Grdns190366 Robert F . Kennedy Medica l C enter Hawthorne10858 Kaiser Fnd Hosp – Hayward Hayward

10967 S t. Rose Hospita l Hayward490964 Hea ldsburg D istrict Hospita l Hea ldsburg331194 Hemet Va lley Medica l Center Hemet350784 Haze l Hawkins Memoria l Hospita l Hollister190380 Hollywood Community Hospita l O f Hollywood Hollywood190538 Community & Mission Hsp O f Hntg Park-F lornce Huntington Park190197 Community & Mission Hsp O f Hntg Pk - S lauson Huntington Park301209 Huntington Beach Hospita l Huntngtn Beach331216 John F Kennedy Memoria l Hospita l Indio334457 O asis Psychiatric Hea lth F acility Indio

190148 Centinela Hospital Medical Center Inglewood190230 Danie l Freeman Memoria l Hospita l Inglewood304045 Irvine Regiona l Hospita l And Medica l Center Irvine

34002 Sutter Amador Hospita l Jackson

362041 H i-Desert Medica l C enter Joshua Tree210993 Kentfie ld Rehabilitation Hospita l Kentfield270777 G eorge L Mee Memoria l Hospita l King C ity100745 K ingsburg Medica l C enter K ingsburg371256 Scripps Green Hospita l La Jolla

370771 Scripps Memorial Hospital - L a Jolla La Jolla374141 Ucsd/La Jolla - Thornton Hospita l La Jolla370749 A lvarado Parkway Institute B .H .S . La Mesa

370714 G ross m ont Hosp i t a l L a Mesa190449 K indred Hospita l - La Mirada La Mirada301234 La Pa lma Intercommunity Hospita l La Pa lma301337 South Coast Medica l C enter Laguna Beach

301317 Saddleback Memorial Medical Center Laguna Hills361266 Mounta ins Community Hospita l Lake Arrowhead150737 Kern Va lley Hea lthcare D istrict Lake Isabella171395 Sutter Lakeside Hospita l Lakeport190240 Lakewood Regiona l Med C enter - South Street Lakewood

190034 Antelope Valley Hospital Medical Center Lancaster190455 Lancaster Community Hospita l Lancaster191261 Los Ange les Co H igh Desert Hospita l Lancaster540746 Lindsay D istrict Hospita l Lindsay

10983 Va lley Memoria l Hospita l - Livermore Livermore390923 Lodi Memoria l Hospita l Lodi390922 Lodi Memoria l Hospita l – West Lodi361245 Loma Linda University Community Med C enter Loma Linda

361246 Loma L inda University Medical Center Loma L inda420491 Lompoc Hea lthcare D istrict Lompoc141338 Southern Inyo Hospita l Lone P ine190475 Community Hospita l O f Long Beach Long Beach196168 E arl & Lorra ine Miller Childrens Hospita l Long Beach194981 La C asa Psychiatric Hea lth F acility Long Beach190477 Long Beach Doctors Hospita l Long Beach

190525 Long Beach Memorial Medical Center L ong Beach190587 Pacific Hospita l O f Long Beach Long Beach

190053 St. Mary Medical Center L ong Beach191225 Tom Redgate Memoria l Recovery C enter Long Beach301248 Los A lamitos Medica l C enter Los A lamitos190052 Barlow Respiratory Hospita l Los Angeles

190125 California Hospital Medical Center - LA Los Angeles190555 Cedars Sinai Medical Center Los Angeles

190155 C entury C ity Hospita l Los Angeles190170 Children 's Hospital Of Los Angeles Los Angeles

190661 C ity O f Ange ls Med C enter-Downtown C ampus Los Angeles

190256 E ast Los Ange les Doctors Hospita l Los Angeles190260 Edgemont Hospita l Los Angeles190317 G ateways Hospita l & Menta l Hea lth C enter Los Angeles

190392 Good Samaritan Hospital-Los Angeles Los Angeles190646 Ka iser Fnd Hosp - Menta l Hea lth C enter Los Angeles

190429 Kaiser Fnd Hosp – Sunset Los Angeles190434 Kaiser Fnd Hosp - West L a Los Angeles

190150 Kedren Community Menta l Hea lth C enter Los Angeles190305 K indred Hospita l - Los Ange les Los Angeles190468 Lincoln Hospita l Medica l C enter Los Angeles

191230 M L K JR/Drew Med Ctr Los Angeles191228 Los Ange les Co Usc Medica l C enter Los Angeles190198 Los Ange les Community Hospita l Los Angeles190854 Los Ange les Metropolitan Medica l C enter Los Angeles190534 Midway Hospita l Medica l C enter Los Angeles190581 Orthopaedic Hospita l Los Angeles190307 Pacific A lliance Medica l C enter Inc. Los Angeles190382 Queen O f Ange ls/Hollywood Presbyterian Md C tr Los Angeles190681 San V icente Hospita l Los Angeles190685 Santa Marta Hospita l Los Angeles190712 Shriners Hospita l For Crippled Children - L.A . Los Angeles190762 St. V incent Medica l C enter Los Angeles190784 Temple Community Hospita l Los Angeles

190796 Ucla Medical Center Los Angeles190930 Ucla Neuropsychiatric Hospita l Los Angeles191216 US C Kenne th Norris Jr. C ancer Hospita l Los Angeles194219 Usc University Hospita l Los Angeles191389 Usc University Hospita l - Norfolk Los Angeles190873 Westside Hospita l Los Angeles190878 White Memoria l Medica l C enter Los Angeles240924 Memoria l Hospita l Los Banos Los Banos430743 Community Hospita l O f Los G a tos Los G a tos430915 Mission O aks Hospita l Los G a tos461024 S ierra Va lley D istrict Hospita l Loya lton

190754 St. Francis Medical Center L ynwood204019 Children 's Hospital Central California Madera

201281 Madera Community Hospita l Madera260011 Mammoth Hospita l Mammoth Lks

392287 Doctors Hospita l O f Manteca Manteca394009 S t. Dominic's Hospita l Manteca190500 Danie l Freeman Marina Hospita l Marina De l Rey220733 John C Fremont Hea lthcare D istrict Mariposa

70924 Contra Costa Regiona l Medica l C enter Martinez

580996 R ideout Memoria l Hospita l Marysville414018 Menlo Park Surgica l Hospita l Menlo Park244027 Marie Green Psychiatric C enter - P H F Merced240942 Mercy Medica l C enter Merced-Community Merced240948 Mercy Medica l C enter Merced-Dominican Merced190385 Providence Holy Cross Medica l C enter Mission H ills

304113 Children 's Hospital At Mission Mission Viejo301262 Mission Hospita l Regiona l Medica l C enter Mission V ie jo

500852 Doctors Medical Center Modesto500939 Memorial Hospital Medical Center - Modesto Modesto

500954 Modesto Rehabilitation Hospita l Modesto504001 Stanislaus Behaviora l Hea lth C enter Modesto504038 Stanislaus Surgica l Hospita l Modesto190541 Monrovia Community Hospita l Monrovia361166 Doctors' Hospita l Medica l C enter O f Montcla ir Montcla ir190081 Beverly Hospita l Montebe llo270744 Community Hospita l Monterey Peninsula Monterey

190315 Garfield Medical Center Monterey Park190547 Monterey Park Hospita l Monterey Park334048 Moreno Va lley Community Hospita l Moreno Va lley334487 R iverside County Regiona l Medica l C enter Moreno Va lley430824 Monte V illa Hospita l Morgan H ill410828 Seton Medica l C enter - Coastside Moss B e ach470871 Mercy Medica l C enter Mt. Shasta Mount Shasta

430763 El Cam ino Hospital Mountain View334068 Rancho Springs Medica l C enter Murrieta281047 Queen O f The Va lley Hospita l - Napa Napa

370759 Paradise Valley Hospital National City361458 Colorado R iver Medica l C enter Needles

301205 Hoag Memorial Hospital Presbyterian Newport Beach301304 Newport Bay Hospita l Newport Beach

190568 Northridge Hospital Medical Center Northridge190766 Coast P laza Doctors Hospita l Norwa lk190570 Norwa lk Community Hospita l Norwa lk

214034 Nova to Community Hospita l Novato500967 O ak Va lley D istrict Hospita l (2-Rh) O akda le

10846 A lameda Co Med C tr - H ighland C ampus O akland10776 Children 's Hospital Med Center Of No. Oakland10856 Kaiser Fnd Hosp - Oakland Campus Oakland

13687 Mpi Chemica l Dependency Recovery Hospita l O akland10937 Summit Medica l C enter - North Pavilion O akland13626 Summit Medica l C enter - South Pavilion O akland10782 Thunder Road C hem ica l D ependency R ecovery O akland

370780 Tri-City Medical Center Oceanside560501 O ja i Va lley Community Hospita l O ja i361274 K indred Hospita l Ontario Ontario301140 Chapman Medica l C enter Orange

300032 Children 's Hospital Of Orange County Orange304159 Hea lthbridge Children's Rehabilitation Hospita l Orange301340 St. Joseph Hospita l - Orange Orange

301279 University Of California Irvine Medical Center Orange40937 Oroville Hospita l Oroville

560838 Pacific Shores Hospita l Oxnard560529 St. John 's Regional Medical Center Oxnard331164 Desert Regional Medical Center Palm Springs434040 Lucile Salter Packard Children 's Hosp - Palo Alto

430905 Stanford Hospita l Palo Alto190432 Kaiser Fnd Hosp - Panorama City Panorama City

190524 Mission Community Hospita l - Panorama C ampus Panorama C ity40875 F eather R iver Hospita l Paradise

190599 Suburban Medica l C enter Paramount190400 Huntington Memorial Hospital Pasadena

190462 Las Encinas Hospita l Pasadena190759 St. Luke Medica l C enter Pasadena332172 Va lley P laza Doctors Hospita l Perris491001 Peta luma Va lley Hospita l Peta luma190616 P ico R ivera Medica l C enter P ico R ivera

73449 Doctors Medica l C enter - P inole C ampus P inole73638 Los Medanos Community Hospita l - Loveridge Rd P ittsburg

301297 P lacentia Linda Hospita l P lacentia94002 E l Dorado County P H F Placerville90933 Marsha ll Hospita l D ivide We llness Placerville14050 Va lleycare Medica l Center P leasanton

194010 American Recovery C enter Pomona190137 C asa Colina Hospita l For Rehab Medicine Pomona

190630 Pomona Valley Hospital Medical Center Po m ona560468 Anacapa Hospita l Port Hueneme540798 S ierra V iew D istrict Hospita l Porterville320859 E astern P lumas Hea lth C are Portola370977 Pomerado Hospita l Poway320986 P lumas D istrict Hospita l Quincy330120 Betty Ford C enter At E isenhower The Rancho Mirage331168 E isenhower Memoria l Hospita l Rancho Mirage524004 Hea lth Crest Red B luff521041 St. E lizabeth Community Hospita l Red B luff

450949 Mercy Medical Center Redding

454012 Northern C a lifornia Rehabilitation Hospita l Redding454013 Patients' Hospita l O f Redding Redding450940 Redding Medica l C enter Redding451019 Shasta County P H F Redding364014 Loma Linda University Behavoria l Med C enter Redlands

361308 Redlands Co m munity Hospital Redlands410804 Ka iser Fnd Hosp – Redwood C ity Redwood C ity

410891 Sequoia Hospital Redwood City100797 S ierra K ings D istrict Hospita l Reedley

74093 Ka iser Fndn Hosp - R ichmond C ampus R ichmond150782 R idgecrest Regiona l Hospita l R idgecrest

334025 Kaiser Fnd Hosp - R iverside Riverside331226 Knollwood Psychiatric & Chemica l Depndncy C tr R iverside

331293 Parkview Com munity Hospital Medical Center Riverside331312 R iverside Com munity Hospital Riverside

364188 Heritage Hospita l Rnch Cucmnga190020 Bhc A lhambra Hospita l Rosemead190410 C ity O f Ange ls Medica l Center-Ingleside Campus Rosemead314024 Ka iser Fnd Hosp - Va lley Medica l C enter Roseville311000 Sutter Roseville Medica l C enter Roseville314029 Te lecare P lacer County Psychiatric H lth F acility Roseville344021 Heritage O aks Hospita l Sacramento

340913 Kaiser Fnd Hosp - Sacramento Sacramento342344 Ka iser Fnd Hosp - South Sacramento Sacramento340947 Mercy G enera l Hospita l Sacramento

340951 Methodist Hospital Of Sacramento Sacramento344011 Sacramento County P .H . F . Sacramento344114 Shriners Hospita ls For Children Northern C a lif. Sacramento342392 S ierra V ista Hospita l Sacramento344017 Sutter C enter For Psychiatry Sacramento341051 Sutter G enera l Hospita l Sacramento

341052 Sutter Memorial Hospital Sacramento341006 University Of California Davis Medical Center Sacramento274043 Natividad Medical Center Salinas270875 Salinas Valley Memorial Hospital Salinas

50932 Mark Twa in S t. Joseph's Hospita l San Andreas361323 Community Hospita l O f San Bernardino San Bernardino

361339 St. Bernardine Medical Center San Bernardino364121 Sun Hea lth Robert H . Ba llard Rehabilitation Hosp San Bernardino301325 San C lemente Hospita l & Medica l C enter San C lemente370652 A lvarado Hospita l Medica l C enter San Diego374063 A lvarado Hospita l Medica l C enter/Sdri San Diego374024 Aurora San D iego San Diego

370673 Children 's Hospital - San Diego San Diego374094 Continenta l Rehabilitation Hospita l O f San D iego San Diego

370730 Kaiser Fnd Hosp - San Diego San Diego370721 K indred Hospita l - San D iego San Diego837502 Nava l Medica l C enter (Ba lboa) San Diego374055 San D iego County Psychiatric Hospita l San Diego374084 San D iego Hospice Acute C are C enter San Diego

370744 Scripps Mercy Hospital San Diego370693 Sharp C abrillo Hospita l San Diego

370695 Sharp Mary Birch Hospital For Wo m en San Diego370694 Sharp Memoria l Hospita l San Diego

370782 University Of Calif-San Diego Medical Center San Diego370787 V illa V iew Community Hospita l Inc. San Diego374049 V ista Pacifica San Diego190673 San D imas Community Hospita l San D imas190676 Mission Community Hospita l - San F ernando San Fernando380826 C a lifornia Pacific Med C tr-C a lifornia E ast San Francisco

380777 California Pacific Med Ctr-California West San Francisco380933 C a lifornia Pacific Med C tr-Davies C ampus San Francisco380929 C a lifornia Pacific Med C tr-Pacific C ampus San Francisco382715 Chinese Hospita l San Francisco380842 Hebrew Home For The Aged D isabled/Aph San Francisco

380857 Kaiser Fnd Hosp - Geary S F San Francisco380865 Laguna Honda Hospita l & Rehabilitation C enter San Francisco380868 Langley Porter Psychiatric Institute San Francisco

380939 San Francisco General Hospital San Francisco380960 St. Francis Memoria l Hospita l San Francisco380964 St. Luke's Hospita l San Francisco380965 St. Mary's Medica l C enter--San Francisco San Francisco

381154 U C S F M e d i c a l C e n t e r San Francisco380895 Ucsf Medica l C enter At Mount Z ion San Francisco190200 San Gabriel Valley Medical Center San Gabrie l434032 Charter Behaviora l Hea lth System O f San Jose S an Jose

430779 Good Sa m ar i tan Hosp i tal-San Jose S an Jos e431506 Ka iser Fnd Hosp - Santa Teresa Comm Hosp S an Jose

430837 O ' C o n n o r H o s p i t a l - S a n J o s e S an Jos e430705 Regional Medical O f San Jose S an Jos e

430879 San Jose Medica l C enter S an Jose430883 Santa Clara Valley Medical Center S an Jos e

10811 A lameda Co Med C tr - F a irmont C ampus San Leandro10887 K indred Hospita l - San Francisco Bay Area San Leandro14113 S .T .A .R .S . - P H F San Leandro13619 San Leandro Hospita l San Leandro

400480 French Hospita l S an Lu is O b isp

400511 San Luis Obispo G enera l Hospita l San Luis Obisp400524 Sierra Vista Regional Medical Center San Luis Obisp

410752 Crysta l Springs Rehabilitation C enter San Mateo410742 Mills Peninsula Hea lth C enter San Mateo410782 San Mateo Co. G enera l Hospita l San Mateo

70904 Doctors Medica l C enter - San Pablo C ampus San Pablo190680 Little Company O f Mary - San Pedro Hospita l San Pedro210992 Ka iser Fnd Hosp - San Rafae l San Rafael

74017 San Ramon Regiona l Medica l C enter San Ramon74011 San Ramon Rehabilitation Hospita l San Ramon

100791 Sanger G enera l Hospita l Sanger301258 Coasta l Communities Hospita l Santa Ana301167 K indred Hospita l - Santa Ana Santa Ana301314 Santa Ana Hospita l Medica l Center Inc Santa Ana

301566 Western Medical Center - Santa Ana Santa Ana420483 Goleta Va lley Cottage Hospita l Santa Barbara424047 Rehabilitation Institute At Santa Barbara Santa Barbara

420506 Santa Barbara Cottage Care Center Santa Barbara420514 Santa Barbara Cottage Hospita l Santa Barbara424002 Santa Barbara County P .H .F . Santa Barbara420528 St. Francis Medica l C enter O f Santa Barbara Santa Barbara

430805 Kaiser Fnd Hosp - Santa Clara Santa Clara441807 Dominican Hospita l-Santa Cruz/Frederick Santa Cruz

440755 Do m inican Hospital-Santa Cruz/Soquel Santa Cruz444012 Sutter Maternity & Surgery C enter O f Santa Cruz Santa Cruz420493 Marian Medica l C enter Santa Maria

190687 Santa Monica - UCLA Medical Center Santa Mon ica190756 St. John 's Hospital & Health Center Santa Mon ica

560521 Santa Paula Memoria l Hospita l Santa Paula494019 Ka iser Fnd Hosp - Santa Rosa Santa Rosa494048 Santa Rosa Memoria l Hospita l-Fulton Santa Rosa

491064 Santa Rosa Me m or ial Hosp ital-Montgo m ery S anta Rosa490907 Santa Rosa Memoria l Hospita l-Sotoyome Santa Rosa490919 Sutter Medica l C enter O f Santa Rosa Santa Rosa491103 Sutter Warrack Hospita l Santa Rosa491338 Pa lm Drive Hospita l Sebastopol100793 Se lma Community Hospita l Se lma190708 Sherman O aks Hospita l And Hea lth C enter Sherman O aks560526 S imi Va lley Hospita l & H lth C are Svcs - Heywood Simi Valley560525 S imi Va lley Hospita l & H lth C are Svcs-Sycamore Simi Valley420522 Santa Ynez Va lley Cottage Hospita l Solvang491076 Sonoma Va lley Hospita l Sonoma

552209 Sonora Community Hospita l - F a irview Sonora551034 Sonora Community Hospita l - Forest Sonora551061 Tuolumne G enera l Hospita l Sonora190352 Greater E l Monte Community Hospita l South E l Monte

90793 Barton Memoria l Hospita l South Lk Tahoe410806 Ka iser Fnd Hosp - South San Francisco South San Fran

390846 Da m eron Hospital S t o c k t o n394003 San Joaquin County P.H.F. S t o c k t o n

392232 St. Joseph's Behaviora l Hea lth C enter S tockton391042 S t. Joseph's Medica l C enter O f S tockton S tockton334018 Menifee Valley Medical Center Sun C ity190696 Pacifica Hospita l O f The Va lley Sun Valley180919 Lassen Community Hospita l Inc Susanville

191231 Los Angeles County Olive View-UCLA Med Syl mar150830 Mercy Westside Hospita l Taft

190517 Encino-Tarzana Regional Med Ctr-Tarzana Tarzana190782 Tarzana Treatment C enter Tarzana150808 Tehachapi Hospita l Tehachapi400548 Twin C ities Community Hospita l Temple ton560492 Los Robles Regiona l Medica l C enter Thousand O aks190232 De l Amo Hospita l Torrance

190470 L ittle Company Of Mary Hospital Torrance191227 Harbor-UCLA Medical Center Torrance

194967 Star V iew Adolescent - P H F Torrance190422 Torrance Memorial Medical Center Torrance

391056 Sutter Tracy Community Hospita l Tracy291053 Tahoe Forest Hospita l Truckee540816 Tulare D istrict Hospita l Tulare500867 Emanue l Medica l Center Inc Turlock304079 Hea lthsouth Tustin Rehabilitation Hospita l Tustin301357 Tustin Hospita l Medica l C enter Tustin234004 Mendocino County P H F Ukiah231396 Ukiah Va lley Medica l C enter/Hospita l Drive Ukiah

361318 San Antonio Com munity Hospital Upland484001 North Bay Vacava lley Hospita l Vacaville190949 Henry Mayo Newha ll Memoria l Hospita l Valencia481015 C a lifornia Specia lty Hospita l Vallejo480989 Ka iser Fnd Hosp - Rehabilitation C enter Va lle jo Vallejo481094 Sutter Solano Medica l C enter Vallejo190814 Hollywood Community Hospita l O f Van Nuys Van Nuys194599 Lions G ate Psychiatric Hea lth F acility Van Nuys190810 Northridge Hospita l Med C enter - Sherman Way Van Nuys

190812 Valley Presbyterian Hospital Van Nuys

560203 Aurora V ista De l Mar Hospita l Ventura560473 Co m munity Memorial Hospital-San Ventura560481 Ventura County Medical Center Ventura

364144 Desert Va lley Hospita l Victorville361370 V ictor Va lley Community Hospita l Victorville540827 Community Hea lth C enter Visalia

540734 Kaweah Delta D istrict Hospital Visalia70988 John Muir Medical Center Walnut Creek70990 Kaiser Fnd Hosp - Walnut Creek Walnut Creek

444013 Watsonville Co m munity Hospital Watsonville531059 Trinity Hospita l Weaverville

190636 Citrus Valley Medical Center - Qv Campus West Covina190857 Doctors Hospita l O f West Covina Inc West Covina190458 Specia lty Hospita l O f Southern C a lifornia/Sgv West Covina564018 Los Robles Regiona l Medica l C enter – E . C ampus Westlake V illge190867 SH C Specia lty Hospita l Westlake V illge301380 K indred Hospita l Westminster Westminster

190631 Presbyterian Intercom munity Hospital Whittier190883 Whittier Hospita l Medica l C enter Whittier334001 Inland Valley Regional Medical Center W ildomar230949 Frank R Howard Memoria l Hospita l W illits110889 G lenn Medica l C enter W illows571086 Woodland Memoria l Hospita l Woodland

191450 Kaiser Fnd Hosp - Woodland Hills Woodland Hills190552 Motion P icture & Te levision Hospita l Woodland H ills474007 F a irchild Medica l C enter Yreka510882 Fremont Medica l C enter Yuba C ity514001 Sutter-Yuba Psychiatric Hea lth F acility Yuba C ity

OSHPD FACILITY CODES Sorted Alphabetically By Hospital Name(CPQCC centers indicated in bold italics)

C O D E Hosp i tal Na m e City10811 A lameda Co Med C tr - F a irmont C ampus San Leandro10846 A lameda Co Med C tr - H ighland C ampus O akland10735 A lameda Hospita l Alameda

190017 A lhambra Hospita l Alhambra10844 A lta Bates Medica l C enter - Herrick C ampus Berke ley

10739 Alta Bates Sum m it Medical Center - Ashby Berkeley540680 A lta Hospita l D istrict Dinuba370652 A lvarado Hospita l Medica l C enter San Diego374063 A lvarado Hospita l Medica l C enter/Sdri San Diego370749 A lvarado Parkway Institute B .H .S . La Mesa194010 American Recovery C enter Pomona560468 Anacapa Hospita l Port Hueneme301097 Anahe im G enera l Hospita l Anaheim301109 Anahe im G enera l Hospita l - Buena Park C ampus Buena Park

301098 Anahei m Memorial Medical Center Anaheim301761 Anahe im Memoria l Medica l C enter West Anaheim

190034 Antelope Valley Hospital Medical Center Lancaster364231 Arrowhead Regional Medical Center C o l t o n

400466 Arroyo Grande Community Hospita l Arroyo Grande190163 Aurora Charter O ak Covina374024 Aurora San D iego San Diego560203 Aurora V ista De l Mar Hospita l Ventura190045 Ava lon Municipa l Hospita l Ava lon154101 Bakersfie ld Heart Hospita l Bakersfie ld

150722 Bakersfield Memorial Hospital – 34 t h street Bakersfield150722 Bakersfie ld Memoria l Hospita l- 34Th Street Bakersfie ld190052 Barlow Respiratory Hospita l Los Angeles

361105 Barstow Community Hospita l Barstow90793 Barton Memoria l Hospita l South Lk Tahoe

361110 Bear Va lley Community Hospita l B ig Bear Lake190066 Be llflower Medica l C enter Be llflower190069 Be llwood G enera l Hospita l Be llflower194044 B e llwood H e a lth C enter Be llflower330120 Betty Ford C enter At E isenhower The Rancho Mirage190081 Beverly Hospita l Montebe llo190020 Bhc A lhambra Hospita l Rosemead

40802 B iggs Gridley Memoria l Hospita l Gridley301126 Brea Community Hospita l Brea

190110 Brotman Medica l C enter Culver C ity44006 Butte County Phf Chico

190125 California Hospital Medical Center - LA Los Angeles380826 C a lifornia Pacific Med C tr-C a lifornia E ast San Francisco

380777 California Pacific Med Ctr-California West San Francisco380933 C a lifornia Pacific Med C tr-Davies C ampus San Francisco380929 C a lifornia Pacific Med C tr-Pacific C ampus San Francisco481015 C a lifornia Specia lty Hospita l Vallejo364050 C anyon R idge Hospita l Chino190137 C asa Colina Hospita l For Rehab Medicine Pomona104008 C edar V ista Hospita l Fresno

190555 Cedars Sinai Medical Center Los Angeles190148 Centinela Hospital Medical Center Inglewood

160787 Centra l Va lley Genera l Hospita l Hanford190155 C entury C ity Hospita l Los Angeles301140 Chapman Medica l C enter Orange334017 Charter Behav. H lth SysO f So C a/Pa lm Springs Cathedra l C ity434032 Charter Behaviora l Hea lth System O f San Jose S an Jose

370673 Children 's Hospital - San Diego San Diego304113 Children 's Hospital At Mission Mission Viejo204019 Children 's Hospital Central California Madera

10776 Children 's Hospital Med Center Of No. Oakland190170 Children 's Hospital Of Los Angeles Los Angeles300032 Children 's Hospital Of Orange County Orange

434051 Childrens Recovery C enter O f N . C a lifornia C ampbe ll382715 Chinese Hospita l San Francisco361144 Chino Va lley Medica l Center Chino200692 Chowchilla D istrict Memoria l Hospita l Chowchilla190413 C itrus Va lley Medica l C enter - IC C ampus Covina

190636 Citrus Valley Medical Center - Qv Campus West Covina190661 C ity O f Ange ls Med C enter-Downtown C ampus Los Angeles190410 C ity O f Ange ls Medica l Center-Ingleside Campus Rosemead190176 C ity O f Hope Nationa l Medica l C enter Duarte100697 Coa linga Regiona l Medica l C enter Coa linga190766 Coast P laza Doctors Hospita l Norwa lk301258 Coasta l Communities Hospita l Santa Ana190184 College Hospita l C erritos301155 College Hospita l Costa Mesa C osta Mesa361458 Colorado R iver Medica l C enter Needles

60870 Colusa Regiona l Medica l C enter Co lusa190538 Community & Mission Hsp O f Hntg Park-F lornce Huntington Park190197 Community & Mission Hsp O f Hntg Pk - S lauson Huntington Park540827 Community Hea lth C enter Visalia

270744 Community Hospita l Monterey Peninsula Monterey190196 Community Hospita l O f G ardena G ardena190475 Community Hospita l O f Long Beach Long Beach430743 Community Hospita l O f Los G a tos Los G a tos361323 Community Hospita l O f San Bernardino San Bernardino100005 Community Medica l C enter - C lovis C lovis

560473 Co m munity Memorial Hospital-San Ventura100717 Com munity Regional Medical Center – Fresno Fresno

374094 Continenta l Rehabilitation Hospita l O f San D iego San Diego70924 Contra Costa Regiona l Medica l C enter Martinez

160702 Corcoran D istrict Hospita l Corcoran331145 Corona Regiona l Medica l C enter-Magnolia Corona331152 Corona Regiona l Medica l C enter-Ma in Corona410752 Crysta l Springs Rehabilitation C enter San Mateo

390846 Da m eron Hospital S t o c k t o n190500 Danie l Freeman Marina Hospita l Marina De l Rey190230 Danie l Freeman Memoria l Hospita l Inglewood848597 David Grant Med C tr / 60th Med Group Fairfield190232 De l Amo Hospita l Torrance150706 De lano Regiona l Medica l C enter Delano

331164 Desert Regional Medical Center Palm Springs364144 Desert Va lley Hospita l Victorville361166 Doctors' Hospita l Medica l C enter O f Montcla ir Montcla ir392287 Doctors Hospita l O f Manteca Manteca190857 Doctors Hospita l O f West Covina Inc West Covina

500852 Doctors Medical Center Modesto73449 Doctors Medica l C enter - P inole C ampus P inole70904 Doctors Medica l C enter - San Pablo C ampus San Pablo

441807 Dominican Hospita l-Santa Cruz/Frederick Santa Cruz440755 Do m inican Hospital-Santa Cruz/Soquel Santa Cruz

240853 Dos Pa los Memoria l Hospita l Dos P a los190243 Downey Regiona l Medica l C enter Downey196168 E arl & Lorra ine Miller Childrens Hospita l Long Beach190256 E ast Los Ange les Doctors Hospita l Los Angeles190328 E ast Va lley Hospita l Medica l C enter G lendora320859 E astern P lumas Hea lth C are Portola

10805 Eden Medica l C enter C astro Va lley190260 Edgemont Hospita l Los Angeles331168 E isenhower Memoria l Hospita l Rancho Mirage

430763 El Cam ino Hospital Mountain View130699 El Centro Regional Medical Center El Centro

94002 E l Dorado County P H F Placerville500867 Emanue l Medica l Center Inc Turlock

190280 Encino-Tarzana Regiona l Med C tr-Encino Encino190517 Encino-Tarzana Regional Med Ctr-Tarzana Tarzana

40828 Enloe Medica l C enter - Cohasset C ampus Chico40962 Enloe Medica l C enter- Esplanade C ampus Chico44011 Enloe Rehabilitation C enter Chico

474007 F a irchild Medica l C enter Yreka370705 F a llbrook Hospita l D istrict F a llbrook

40875 F eather R iver Hospita l Paradise190298 Foothill Presbyterian Hospita l-Johnston Memoria l G lendora

301175 Fountain Valley Rgnl Hosp & Med Ctr – Euclid Fountain Valley304039 Founta in Va lley Rgnl Hosp & Med C tr – Warner Fountain Valley230949 Frank R Howard Memoria l Hospita l W illits

14034 Fremont Hospita l Fremont510882 Fremont Medica l C enter Yuba C ity400480 French Hospita l S an Lu is O b isp

104089 Fresno County Psychiatric Hea lth F acility Fresno104047 Fresno Surgery C enter Fresno301283 G arden Grove Hospita l & Medica l C enter G arden Grove

190315 Garfield Medical Center Monterey Park190317 G ateways Hospita l & Menta l Hea lth C enter Los Angeles120981 G enera l Hospita l The Eureka270777 G eorge L Mee Memoria l Hospita l King C ity

190323 Glendale Adventist Med Center - Wilson Glendale190522 G lendale Memorial Hospital & Health Center Glendale

110889 G lenn Medica l C enter W illows420483 Goleta Va lley Cottage Hospita l Santa Barbara150775 Good Samaritan Hospita l-Bakersfie ld Bakersfie ld

190392 Good Samaritan Hospital-Los Angeles Los Angeles430779 Good Sa m ar i tan Hosp i tal-San Jose S an Jos e

190348 Granada H ills Community Hospita l Granada Hills190352 Greater E l Monte Community Hospita l South E l Monte

370714 G ross m ont Hosp i t a l L a Mesa160725 Hanford Community Medica l C enter Hanford

191227 Harbor-UCLA Medical Center Torrance350784 Haze l Hawkins Memoria l Hospita l Hollister490964 Hea ldsburg D istrict Hospita l Hea ldsburg524004 Hea lth Crest Red B luff304159 Hea lthbridge Children's Rehabilitation Hospita l Orange154022 Hea lthsouth Bakersfie ld Rehabilitation Hospita l Bakersfie ld304079 Hea lthsouth Tustin Rehabilitation Hospita l Tustin380842 Hebrew Home For The Aged D isabled/Aph San Francisco331194 Hemet Va lley Medica l Center Hemet190949 Henry Mayo Newha ll Memoria l Hospita l Valencia

364188 Heritage Hospita l Rnch Cucmnga344021 Heritage O aks Hospita l Sacramento362041 H i-Desert Medica l C enter Joshua Tree

301205 Hoag Memorial Hospital Presbyterian Newport Beach190380 Hollywood Community Hospita l O f Hollywood Hollywood190814 Hollywood Community Hospita l O f Van Nuys Van Nuys301209 Huntington Beach Hospita l Huntngtn Beach

190400 Huntington Memorial Hospital Pasadena320874 Indian Valley Hospital Greenville334001 Inland Valley Regional Medical Center W ildomar304045 Irvine Regiona l Hospita l And Medica l Center Irvine121031 Jerold Phe lps Community Hospita l Garberville220733 John C Fremont Hea lthcare D istrict Mariposa331216 John F Kennedy Memoria l Hospita l Indio70988 John Muir Medical Center Walnut Creek

301132 Kaiser Fnd Hosp – Anaheim Anaheim196035 Kaiser Fnd Hosp - Baldwin Park Baldwin Park190430 Kaiser Fnd Hosp - Bellflower Bellflower

190135 Ka iser Fnd Hosp – C arson C arson361223 Kaiser Fnd Hosp – Fontana Fontana

14132 Ka iser Fnd Hosp – Fremont Fremont104062 Ka iser Fnd Hosp – Fresno Fresno

380857 Kaiser Fnd Hosp - Geary S F San Francisco190431 Kaiser Fnd Hosp - Harbor City Harbor City

10858 Kaiser Fnd Hosp – Hayward Hayward190646 Ka iser Fnd Hosp - Menta l Hea lth C enter Los Angeles10856 Kaiser Fnd Hosp - Oakland Campus Oakland

190432 Kaiser Fnd Hosp - Panorama City Panorama City364110 Ka iser Fnd Hosp – Permanente Chem Dep Prgrm Fontana410804 Ka iser Fnd Hosp – Redwood C ity Redwood C ity480989 Ka iser Fnd Hosp - Rehabilitation C enter Va lle jo Vallejo

334025 Kaiser Fnd Hosp - R iverside Riverside340913 Kaiser Fnd Hosp - Sacramento Sacramento370730 Kaiser Fnd Hosp - San Diego San Diego

210992 Ka iser Fnd Hosp - San Rafae l San Rafael430805 Kaiser Fnd Hosp - Santa Clara Santa Clara

494019 Ka iser Fnd Hosp - Santa Rosa Santa Rosa431506 Ka iser Fnd Hosp - Santa Teresa Comm Hosp S an Jose342344 Ka iser Fnd Hosp - South Sacramento Sacramento410806 Ka iser Fnd Hosp - South San Francisco South San Fran

190429 Kaiser Fnd Hosp – Sunset Los Angeles314024 Ka iser Fnd Hosp - Va lley Medica l C enter Roseville70990 Kaiser Fnd Hosp - Walnut Creek Walnut Creek

190434 Kaiser Fnd Hosp - West L a Los Angeles191450 Kaiser Fnd Hosp - Woodland Hills Woodland Hills

74093 Ka iser Fndn Hosp - R ichmond C ampus R ichmond540734 Kaweah Delta D istrict Hospital Visalia

190150 Kedren Community Menta l Hea lth C enter Los Angeles210993 Kentfie ld Rehabilitation Hospita l Kentfield

150736 Kern Medical Center Bakersfield150737 Kern Va lley Hea lthcare D istrict Lake Isabella190449 K indred Hospita l - La Mirada La Mirada190305 K indred Hospita l - Los Ange les Los Angeles344035 K indred Hospita l – Sacramento F o lsom370721 K indred Hospita l - San D iego San Diego

10887 K indred Hospita l - San Francisco Bay Area San Leandro301167 K indred Hospita l - Santa Ana Santa Ana301127 K indred Hospita l Brea Brea361274 K indred Hospita l Ontario Ontario301380 K indred Hospita l Westminster Westminster100745 K ingsburg Medica l C enter K ingsburg331226 Knollwood Psychiatric & Chemica l Depndncy C tr R iverside194981 La C asa Psychiatric Hea lth F acility Long Beach301234 La Pa lma Intercommunity Hospita l La Pa lma191306 Lac/Rancho Los Amigos Nationa l Rehab C enter Downey380865 Laguna Honda Hospita l & Rehabilitation C enter San Francisco190240 Lakewood Regiona l Med C enter - South Street Lakewood190455 Lancaster Community Hospita l Lancaster380868 Langley Porter Psychiatric Institute San Francisco190462 Las Encinas Hospita l Pasadena180919 Lassen Community Hospita l Inc Susanville

10869 Laure l Grove Hospita l C astro Va lley190049 Legacy Hospita l San Gabrie l Va lley Ba ldwin Park190468 Lincoln Hospita l Medica l C enter Los Angeles540746 Lindsay D istrict Hospita l Lindsay194599 Lions G ate Psychiatric Hea lth F acility Van Nuys190057 Little Co O f Mary San Pedro Hospita l-Harbor C ity Harbor C ity190680 Little Company O f Mary - San Pedro Hospita l San Pedro

190470 L ittle Company Of Mary Hospital Torrance390923 Lodi Memoria l Hospita l Lodi390922 Lodi Memoria l Hospita l – West Lodi364014 Loma Linda University Behavoria l Med C enter Redlands361245 Loma Linda University Community Med C enter Loma Linda

361246 Loma L inda University Medical Center Loma L inda420491 Lompoc Hea lthcare D istrict Lompoc190477 Long Beach Doctors Hospita l Long Beach

190525 Long Beach Memorial Medical Center L ong Beach301248 Los A lamitos Medica l C enter Los A lamitos191261 Los Ange les Co H igh Desert Hospita l Lancaster191228 Los Ange les Co Usc Medica l C enter Los Angeles190198 Los Ange les Community Hospita l Los Angeles

191231 Los Angeles County Olive View-UCLA Med Syl mar190854 Los Ange les Metropolitan Medica l C enter Los Angeles

73638 Los Medanos Community Hospita l - Loveridge Rd P ittsburg560492 Los Robles Regiona l Medica l C enter Thousand O aks564018 Los Robles Regiona l Medica l C enter – E . C ampus Westlake V illge

434040 Lucile Salter Packard Children 's Hosp - Palo Alto121002 Mad R iver Community Hospita l Arcata201281 Madera Community Hospita l Madera260011 Mammoth Hospita l Mammoth Lks

420493 Marian Medica l C enter Santa Maria244027 Marie Green Psychiatric C enter - P H F Merced211006 Marin G enera l Hospita l Greenbrae

50932 Mark Twa in S t. Joseph's Hospita l San Andreas90933 Marsha ll Hospita l D ivide We llness Placerville

450936 Mayers Memoria l Hospita l Fall River Mills540755 Memoria l Hospita l At Exeter Exeter240924 Memoria l Hospita l Los Banos Los Banos

500939 Memorial Hospital Medical Center - Modesto Modesto190521 Memoria l Hospita l O f G ardena G ardena231013 Mendocino Coast D istrict Hospita l Fort Bragg234004 Mendocino County P H F Ukiah334018 Menifee Valley Medical Center Sun C ity414018 Menlo Park Surgica l Hospita l Menlo Park340869 Mercy American R iver Hospita l C armichae l340947 Mercy G enera l Hospita l Sacramento150761 Mercy Hospita l – Bakersfie ld Bakersfie ld344029 Mercy Hospita l – Folsom F o lsom

450949 Mercy Medical Center Redding240942 Mercy Medica l C enter Merced-Community Merced240948 Mercy Medica l C enter Merced-Dominican Merced470871 Mercy Medica l C enter Mt. Shasta Mount Shasta

340950 Mercy San Juan Hospital Carm ichael154108 Mercy Southwest Hospita l Bakersfie ld150830 Mercy Westside Hospita l Taft

340951 Methodist Hospital Of Sacramento Sacramento190529 Methodist Hospital Of Southern California Arcadia

190534 Midway Hospita l Medica l C enter Los Angeles410742 Mills Peninsula Hea lth C enter San Mateo

410852 Mills-Peninsula Medica l C enter Burlingame190524 Mission Community Hospita l - Panorama C ampus Panorama C ity190676 Mission Community Hospita l - San F ernando San Fernando301262 Mission Hospita l Regiona l Medica l C enter Mission V ie jo430915 Mission O aks Hospita l Los G a tos

191230 M L K JR/Drew Med Ctr Los Angeles500954 Modesto Rehabilitation Hospita l Modesto250956 Modoc Medica l C enter Alturas190541 Monrovia Community Hospita l Monrovia430824 Monte V illa Hospita l Morgan H ill190547 Monterey Park Hospita l Monterey Park334048 Moreno Va lley Community Hospita l Moreno Va lley190552 Motion P icture & Te levision Hospita l Woodland H ills361266 Mounta ins Community Hospita l Lake Arrowhead

13687 Mpi Chemica l Dependency Recovery Hospita l O akland71018 Mt. D iablo Medica l C enter Concord74039 Mt. D iablo Medica l Pavilion Concord

274043 Natividad Medical Center Salinas837502 Nava l Medica l C enter (Ba lboa) San Diego301304 Newport Bay Hospita l Newport Beach

481357 North Bay Medical Center Fairfield484001 North Bay Vacava lley Hospita l Vacaville454012 Northern C a lifornia Rehabilitation Hospita l Redding141273 Northern Inyo Hospita l B ishop190810 Northridge Hospita l Med C enter - Sherman Way Van Nuys

190568 Northridge Hospital Medical Center Northridge190570 Norwa lk Community Hospita l Norwa lk

214034 Nova to Community Hospita l Novato500967 O ak Va lley D istrict Hospita l (2-Rh) O akda le334457 O asis Psychiatric Hea lth F acility Indio

430837 O ' C o n n o r H o s p i t a l - S a n J o s e S an Jos e560501 O ja i Va lley Community Hospita l O ja i301242 Orange Co Community Hosp - Buena Park Buena Park300225 Orange Coast Memoria l Medica l C enter Fountain Valley

40937 Oroville Hospita l Oroville190581 Orthopaedic Hospita l Los Angeles190307 Pacific A lliance Medica l C enter Inc. Los Angeles190587 Pacific Hospita l O f Long Beach Long Beach560838 Pacific Shores Hospita l Oxnard190696 Pacifica Hospita l O f The Va lley Sun Valley491338 Pa lm Drive Hospita l Sebastopol331288 Pa lo Verde Hospita l Blythe

370755 Palomar Medical Center Escondido

370759 Paradise Valley Hospital National City331293 Parkview Com munity Hospital Medical Center Riverside

454013 Patients' Hospita l O f Redding Redding491001 Peta luma Va lley Hospita l Peta luma190616 P ico R ivera Medica l C enter P ico R ivera190605 P ine Grove Hospita l C anoga Park130760 P ioneers Memoria l Hospita l Brawley301297 P lacentia Linda Hospita l P lacentia320986 P lumas D istrict Hospita l Quincy370977 Pomerado Hospita l Poway

190630 Pomona Valley Hospital Medical Center Po m ona190631 Presbyterian Intercom munity Hospital Whittier

190385 Providence Holy Cross Medica l C enter Mission H ills190758 Providence/Saint Joseph Medical Center Burbank

190382 Queen O f Ange ls/Hollywood Presbyterian Md C tr Los Angeles281047 Queen O f The Va lley Hospita l - Napa Napa334068 Rancho Springs Medica l C enter Murrieta171049 Redbud Community Hospita l C learlake450940 Redding Medica l C enter Redding

361308 Redlands Co m munity Hospital Redlands121051 Redwood Memoria l Hospita l Fortuna

430705 Regional Medical O f San Jose S an Jos e424047 Rehabilitation Institute At Santa Barbara Santa Barbara580996 R ideout Memoria l Hospita l Marysville150782 R idgecrest Regiona l Hospita l R idgecrest

331312 R iverside Com munity Hospital Riverside334487 R iverside County Regiona l Medica l C enter Moreno Va lley190366 Robert F . Kennedy Medica l C enter Hawthorne

14113 S .T .A .R .S . - P H F San Leandro344011 Sacramento County P .H . F . Sacramento

301317 Saddleback Memorial Medical Center Laguna Hills270875 Salinas Valley Memorial Hospital Salinas361318 San Antonio Com munity Hospital Upland

301325 San C lemente Hospita l & Medica l C enter San C lemente374055 San D iego County Psychiatric Hospita l San Diego374084 San D iego Hospice Acute C are C enter San Diego190673 San D imas Community Hospita l San D imas

380939 San Francisco General Hospital San Francisco190200 San Gabriel Valley Medical Center San Gabrie l331326 San Gorgonio Memoria l Hospita l Banning150788 San Joaquin Community Hospita l Bakersfie ld

394003 San Joaquin County P.H.F. S t o c k t o n391010 San Joaquin G enera l Hospita l French C amp

104023 San Joaquin Va lley Rehabilitation Hospita l Fresno430879 San Jose Medica l C enter S an Jose

13619 San Leandro Hospita l San Leandro400511 San Luis Obispo G enera l Hospita l San Luis Obisp410782 San Mateo Co. G enera l Hospita l San Mateo

74017 San Ramon Regiona l Medica l C enter San Ramon74011 San Ramon Rehabilitation Hospita l San Ramon

190681 San V icente Hospita l Los Angeles100791 Sanger G enera l Hospita l Sanger301314 Santa Ana Hospita l Medica l Center Inc Santa Ana

420506 Santa Barbara Cottage Care Center Santa Barbara420514 Santa Barbara Cottage Hospita l Santa Barbara424002 Santa Barbara County P .H .F . Santa Barbara

430883 Santa Clara Valley Medical Center S an Jos e190685 Santa Marta Hospita l Los Angeles

190687 Santa Monica - UCLA Medical Center Santa Mon ica560521 Santa Paula Memoria l Hospita l Santa Paula494048 Santa Rosa Memoria l Hospita l-Fulton Santa Rosa

491064 Santa Rosa Me m or ial Hosp ital-Montgo m ery S anta Rosa490907 Santa Rosa Memoria l Hospita l-Sotoyome Santa Rosa190691 Santa Teresita Hospita l Duarte420522 Santa Ynez Va lley Cottage Hospita l Solvang371256 Scripps Green Hospita l La Jolla370697 Scripps Hospita l - E ast County E l C a jon370658 Scripps Memoria l Hospita l - Chula V ista Chula Vista371394 Scripps Memoria l Hospita l - Encinitas Encinitas

370771 Scripps Memorial Hospital - L a Jolla La Jolla370744 Scripps Mercy Hospital San Diego

100793 Se lma Community Hospita l Se lma124004 Sempervirens P .H .F . Eureka321016 Seneca Hospita l Chester

410891 Sequoia Hospital Redwood City410817 Seton Medica l C enter Daly C ity410828 Seton Medica l C enter - Coastside Moss B e ach370693 Sharp C abrillo Hospita l San Diego

370875 Sharp Chula Vista Medical Center Chula Vista370689 Sharp Coronado Hospita l And Hea lthcare C enter Coronado

370695 Sharp Mary Birch Hospital For Wo m en San Diego370694 Sharp Memoria l Hospita l San Diego451019 Shasta County P H F Redding190867 SH C Specia lty Hospita l Westlake V illge190708 Sherman O aks Hospita l And Hea lth C enter Sherman O aks190712 Shriners Hospita l For Crippled Children - L.A . Los Angeles

344114 Shriners Hospita ls For Children Northern C a lif. Sacramento100797 S ierra K ings D istrict Hospita l Reedley291023 S ierra Nevada Memoria l Hospita l Grass Va lley461024 S ierra Va lley D istrict Hospita l Loya lton540798 S ierra V iew D istrict Hospita l Porterville342392 S ierra V ista Hospita l Sacramento

400524 Sierra Vista Regional Medical Center San Luis Obisp560526 S imi Va lley Hospita l & H lth C are Svcs - Heywood Simi Valley560525 S imi Va lley Hospita l & H lth C are Svcs-Sycamore Simi Valley491076 Sonoma Va lley Hospita l Sonoma552209 Sonora Community Hospita l - F a irview Sonora551034 Sonora Community Hospita l - Forest Sonora301337 South Coast Medica l C enter Laguna Beach141338 Southern Inyo Hospita l Lone P ine190458 Specia lty Hospita l O f Southern C a lifornia/Sgv West Covina

100899 St. Agnes Medical Center Fresno361339 St. Bernardine Medical Center San Bernardino

394009 S t. Dominic's Hospita l Manteca521041 St. E lizabeth Community Hospita l Red B luff

190754 St. Francis Medical Center L ynwood420528 St. Francis Medica l C enter O f Santa Barbara Santa Barbara380960 St. Francis Memoria l Hospita l San Francisco281078 St. He lena Hospita l Deer Park

190756 St. John 's Hospital & Health Center Santa Mon ica560508 St. John's P leasant Va lley Hospita l C amarillo

560529 St. John 's Regional Medical Center Oxnard121080 S t. Joseph Hospita l – Eureka Eureka301340 St. Joseph Hospita l - Orange Orange392232 St. Joseph's Behaviora l Hea lth C enter S tockton391042 S t. Joseph's Medica l C enter O f S tockton S tockton

301342 St. Jude Medical Center Fullerton434138 St. Louise Regiona l Hospita l G ilroy190759 St. Luke Medica l C enter Pasadena380964 St. Luke's Hospita l San Francisco

190053 St. Mary Medical Center L ong Beach361343 St. Mary Regiona l Medica l C enter Apple Valley380965 St. Mary's Medica l C enter--San Francisco San Francisco

10967 S t. Rose Hospita l Hayward190762 St. V incent Medica l C enter Los Angeles430905 Stanford Hospita l Palo Alto504001 Stanislaus Behaviora l Hea lth C enter Modesto504038 Stanislaus Surgica l Hospita l Modesto194967 Star V iew Adolescent - P H F Torrance

190599 Suburban Medica l C enter Paramount10937 Summit Medica l C enter - North Pavilion O akland13626 Summit Medica l C enter - South Pavilion O akland

364121 Sun Hea lth Robert H . Ba llard Rehabilitation Hosp San Bernardino250955 Surprise Va lley Community Hospita l Cedarville

34002 Sutter Amador Hospita l Jackson310791 Sutter Auburn F a ith Hospita l Auburn344017 Sutter C enter For Psychiatry Sacramento

84001 Sutter Coast Hospita l Crescent C ity574010 Sutter Davis Hospita l Davis

70934 Sutter De lta Medica l C enter Antioch341051 Sutter G enera l Hospita l Sacramento171395 Sutter Lakeside Hospita l Lakeport444012 Sutter Maternity & Surgery C enter O f Santa Cruz Santa Cruz490919 Sutter Medica l C enter O f Santa Rosa Santa Rosa

341052 Sutter Memorial Hospital Sacramento311000 Sutter Roseville Medica l C enter Roseville481094 Sutter Solano Medica l C enter Vallejo391056 Sutter Tracy Community Hospita l Tracy491103 Sutter Warrack Hospita l Santa Rosa514001 Sutter-Yuba Psychiatric Hea lth F acility Yuba C ity291053 Tahoe Forest Hospita l Truckee190782 Tarzana Treatment C enter Tarzana150808 Tehachapi Hospita l Tehachapi314029 Te lecare P lacer County Psychiatric H lth F acility Roseville484028 Te lecare Solano Psychiatric Hea lth F acility Fairfield190784 Temple Community Hospita l Los Angeles

10782 Thunder Road C hem ica l D ependency R ecovery O akland191225 Tom Redgate Memoria l Recovery C enter Long Beach

190422 Torrance Memorial Medical Center Torrance370780 Tri-City Medical Center Oceanside

190159 Tri-C ity Regiona l Medica l C enter Hawa iian Grdns531059 Trinity Hospita l Weaverville540816 Tulare D istrict Hospita l Tulare551061 Tuolumne G enera l Hospita l Sonora301357 Tustin Hospita l Medica l C enter Tustin400548 Twin C ities Community Hospita l Temple ton

190796 Ucla Medical Center Los Angeles190930 Ucla Neuropsychiatric Hospita l Los Angeles374141 Ucsd/La Jolla - Thornton Hospita l La Jolla

381154 U C S F M e d i c a l C e n t e r San Francisco380895 Ucsf Medica l C enter At Mount Z ion San Francisco231396 Ukiah Va lley Medica l C enter/Hospita l Drive Ukiah

100822 University Medica l C enter Fresno341006 University Of California Davis Medical Center Sacramento301279 University Of California Irvine Medical Center Orange370782 University Of Calif-San Diego Medical Center San Diego

191216 US C Kenne th Norris Jr. C ancer Hospita l Los Angeles194219 Usc University Hospita l Los Angeles191389 Usc University Hospita l - Norfolk Los Angeles

10983 Va lley Memoria l Hospita l - Livermore Livermore332172 Va lley P laza Doctors Hospita l Perris

190812 Valley Presbyterian Hospital Van Nuys14050 Va lleycare Medica l Center P leasanton

560481 Ventura County Medical Center Ventura190818 Verdugo H ills Hospita l G lendale361370 V ictor Va lley Community Hospita l Victorville370787 V illa V iew Community Hospita l Inc. San Diego374049 V ista Pacifica San Diego10987 Washington Hospital – Fremont Fre m ont

444013 Watsonville Co m munity Hospital Watsonville301379 West Anahe im Medica l C enter Anaheim190859 West H ills Hospita l & Medica l C enter C anoga Park190860 West Va lley Hospita l And Hea lth C enter C anoga Park

301566 Western Medical Center - Santa Ana Santa Ana301188 Western Medica l C enter Hospita l - Anahe im Anaheim190873 Westside Hospita l Los Angeles190878 White Memoria l Medica l C enter Los Angeles190883 Whittier Hospita l Medica l C enter Whittier571086 Woodland Memoria l Hospita l Woodland494047 Woodlands Psychiatric Hea lth F acility Geyserville

APPENDIX E: FARENHEIT TO CENTRIGRADE CONVERSION TABLE


APPENDIX F: NEONATAL TRANSPORT DATA SYSTEM

CPETS POLICY AND PROCEDURES


Neonatal Transport Data System California Perinatal Transport Systems (CPeTS)

Managed by California Perinatal Quality Care Collaborative (CPQCC)

Policy

CPeTS Neonatal Transport Data System components must be completed for all neonates

acutely transferred to or from a CCS designated NICU as well as all facilities

participating in CPQCC. An acute transfer is for the purpose of medical diagnostic or

treatment services, surgery, and/or insurance and may be ASAP or Scheduled. Thirty-

three required data elements will be electronically reported via the CPQCC Transport

Activity Report. These required data elements were selected in-order to inform transport

quality improvement issues felt to be most important by panels representing sending and

receiving hospitals. Two transport forms are available. The Core CPeTS Neonatal

Transport Form (CCNTF) consists only of these 33 data elements along with a separate

Confidential Neonatal Transport Issues with Improvement Potential form. However, in

reviewing this form, transport personnel and data abstractors requested that we also

develop a more comprehensive transport inventory, the All California Neonatal Transport

Form (ACNTF) in order to facilitate the communication of key clinically important

information from the referring to the receiving hospital. Embedded in this model

transport form are the 33 required elements. In addition, we have also included optional

CPQCC data items that the data abstractors have found to be very difficult to locate in the

medical records of transferred infant such as APGAR scores and antenatal conditions.

We have also included data items that were felt to be useful in transferring the care of the

infant across institutions, such as previous lab tests, medications and feeding. The extent

to which The All California Neonatal Transport Form is completed beyond the 33

required data elements is at the discretion of the receiving NICU.

Materials

A. All California Neonatal Transport Form (ACNTF)

B. Core CPeTS Neonatal Transport Form (CCNTF)

C. Data Definitions and Procedure Manual

Procedure (Directions for Completing The Core CPeTS Neonatal Transport Form

(CCNTF)…required elements only )

I. Data Collection Responsibility: Completing the CPeTS Neonatal Transport Form

is the joint responsibility of the referring and receiving hospital.

a. Data elements to be completed by the referring hospital are shown on the

sample form in yellow – on the actual form they appear in 10% gray scale.

b. Data to be completed by the receiving facility are shown without any shading

or color.

c. The second page of the core CPeTS transfer form , Confidential Transport

Issues with Improvement Potential pertains to technical quality improvement

issues– this section can be completed by staff from either facility. This

section should be separated prior to placing the required elements form into

the patient record. The separated Confidential Transport Issues with

Improvement Potential section is then handled following internal hospital

policies for QI data.

d. For all deaths prior to being admitted at the receiving NICU, complete paper

transport form, and fax to the CPQCC Data Center at (510) 620-3144.

Procedure (Directions for Completing The All California Neonatal Transport

Form)

II. Data Collection Responsibility: Completing the All California Neonatal Transport

Record (ACNTF) is the joint responsibility of the referring and receiving hospital.

a. Data elements to be completed by the referring hospital are shown on the

sample form in yellow – on the actual form they appear in 10% gray scale.

b. Data to be completed by the receiving facility are shown in blue on the sample

form and 15% gray scale on the actual form.

c. Information collected for continuity of care is not highlighted and should be

completed by members of both the referring and receiving hospitals in order

to ensure safe and effective transfer of care.

d. The third page of the ACNTF, the “ Confidential Transport Issues with

Improvement Potential” pertains to quality improvement issues and may be

completed by staff from either facility. This section should be separated prior

to placing the form into the patient record. The separated Confidential

Transport Issues with Improvement Potential Form is then handled following

internal hospital policies for QI data. (Note: This form appears without

highlight following the main form).

e. For all infant deaths occurring between the departure from the referring

facility and arrival at the receiving NICU, complete paper transport form, and

fax to the CPQCC Data Center at (510) 620-3144.

III. Referring Hospital

a. The neonatal transport form that is select for use [Core CPeTS Neonatal

Transport Form (CCNTF) or the All California Neonatal Transport Form

(ACNTF)] should be initiated when a neonate is identified as a potential

candidate for transport to another facility.

b. Information requested in the following sections should be obtained prior to

calling the receiving hospital. This information is necessary in order to assess

patient stability, potential complications and to co-manage care prior to

transfer of care. (Note: Delay in referral to collect data should be avoided. If

specific information is not available at the initial call it can be transmitted by

telephone prior to transport team departure from the receiving hospital.)

i. Referral Information

ii. Patient Identification/History

iii. Infant Condition Modified TRIPS Score

c. Information contained in these sections should be provided to the receiving

hospital at the time of the referring call. Patient referral is usually

accomplished by physician to physician consultation with follow up

communication by nursing to facilitate and coordinate care prior to transport.

Completing the NTR prior to the call and faxing this information to the

receiving facility will help to ensure safe and effective hand off of patients

between providers.

d. The following sections should be completed prior to transport with the most

current data available.

i. Clinical Information

ii. Other Significant Issues

iii. Information / Materials Sent with Transport Team and Care

Providers.

e. Prior to transport you must also complete the required data elements

contained in the Referral Process section of the form.

f. Additional comments, documentation of procedures, patient response to

procedures and other significant information can be recorded in the

Comments section at any point in the transport process.

g. Information gathered at any point during the resuscitation, stabilization,

referral, and transport process regarding quality improvement issues, may be

recorded in the Confidential Neonatal Transport Issues with Improvement

Potential form found following ACNTF and CCNTF. It should be

separated from the patient information sections (page 1 and 2) prior to

placement of these sections in the patient record. The separated form is then

handled following internal hospital policies for QI data. Issues identified

should reviewed jointly by referring and receiving hospitals staff at Mortality

and Morbidity Reviews, annual review of Regional Cooperation Agreement or

other appropriate QI venue.

IV. Transport Team or Receiving Hospital

a. Transport Team members or receiving hospital staff should review, with the

informant from the referring hospital, all information in the following sections.

Receipt of this information by fax may allow more complete communication

and facilitate the transport.

i. Referral Information

ii. Patient Identification/History

iii. Infant Condition Modified TRIPS Score (referral) sections.

b. On arrival at the referring hospital, the transport team members are

responsible for assigning the second Infant Condition Modified TRIPS

Score section within 15 minutes of arrival (Initial Transport Team).

c. The following sections should be completed prior to transport with the most

current data available in consultation with staff from the referring facility.

d. Prior to leaving the referral hospital, the transport team is responsible to

assure that all of the CPeTS required data elements asked of the referral

hospital have been completed. In addition the transport team should ensure

that those items that have been requested by the receiving hospital’s transfer

protocols are also completed.

i. Clinical Information

ii. Other Significant Issues

iii. Referral Process

iv. Timeline

v. Information / Materials Sent with Transport Team and Care

Providers

e. Additional comments, documentation of procedures, patient response to

procedures and other significant information can be recorded in the

Comments section at any point in the transport process.

f. Upon return to receiving NICU (within 15 minutes of arrival) the third and

final (NICU admit) Infant Condition Modified TRIPS Score section should

be completed.

g. Information gathered at any point during the resuscitation, stabilization,

referral, and transport process regarding quality improvement issues, may be

recorded on the Confidential Neonatal Transport Issues with

Improvement Potential Form . It should be separated from the patient

information sections (page 1 and 2) prior to placement of these sections in the

patient record. The separate form is then handled following internal hospital

policies for QI data. Issues identified should reviewed jointly by referring and

receiving hospitals staff at Mortality and Morbidity Reviews, annual review of

Regional Cooperation Agreement and/or Memorandum of Understanding

(MOU), or other appropriate QI venue. These issues may also be used to

identify joint policy and procedure requirements, educational opportunities

and or gaps in services that should be referred to the teams responsible for

annual review and negotiation of their Regional Cooperation Agreement,

Transport Agreement and/or Memorandum of Understanding (MOU).

V. Electronic Data Entry: After completing the chosen neonatal transport data

collection form, per hospital policy it may be put in the patient’s record as a Transfer

Document. In addition a copy should be made and stored in a location designated by

your CPQCC data abstracter. The 33 required data elements are entered into the

required CPeTS dataset by the CPQCC data abstractor any time prior to the entry of

the patient’s core CPQCC data utilizing the CPQCC confidential online data entry

system. To enter transport data the patient must have an assigned CPQCC ID number.

Note that any CPeTS data element that is also on the CPQCC dataset will be

propagated onto the CPQCC data entry screens thus avoiding the need for having to

enter the same data twice.

a. The 33 required data elements with item numbers (found in BOLD Red

highlight on the sample and BOLD on the forms) are to be electronically

reported via the CPQCC as described above. All acutely transported patients

less then 29 days old are eligible for inclusion in the CPQCC dataset.

VI. Data definitions and directions for completing each item on the CCNTF can be found

in the attached 2007 Manual of Definitions – Neonatal Transport Data Collection

Tools.

APPENDIX G: CPETS PRELIMINARY DRAFT REPORT


SENDING HOSPITAL REPORTAcute Transport Activity

Infants 1,500 grams or less born between 01/01/2006 and 12/31/2006California Perinatal Transport Systems (CPeTS)

Center ID: 0000

Center Same CCS Level within CPQCC

Center-Network Comparison

(N=141) (N Centers=94 )

N % Last Year's% % Median% Lower Quartile

% Upper Quartile

Acute Transport Type

Dr Attendance Requested

43 30.5 30.6 25 19 30

ASAP Neonatal 71 50.4 50.6 41 35 50

Scheduled Neonatal

27 19.1 17.6 32 24 39

Other 0 0 1.2 0 0 2

Birth Weight

For a finer birth weight breakdown, click here.750 grams or less

28 19.9 19.4 24 16 28

751-1,000 grams

35 24.8 24.1 21 15 27

1,001-1,500 grams

78 55.3 56.5 55 47 65

Gestational Age

For a finer gestational age breakdown, click here.

under 25 weeks 19 13.5 13.5 16 11 20

25 to 27 weeks 43 30.5 35.3 27 20 33

28 to 30 weeks 56 39.7 32.4 36 30 40

31 to 33 weeks 21 14.9 17.1 16 13 23

34 to 37 weeks 2 1.4 1.8 2 0 5

https://www.cpqccreport.org/reports/0098/2004/SB/tables/all/table1__2_1.php#group21


38 to 41 weeks 0 0 0 0 0 0

Total Time from Maternal Admission to Transport Referral Time

under 6 hours 19 13.5 13.5 16 11 20

6 to 12 hours 43 30.5 35.3 27 20 33

13 to 18 hours 56 39.7 32.4 36 30 40

19 to 24 hours 21 14.9 17.1 16 13 23

25 to 30 hours 2 1.4 1.8 2 0 5

greater 30 hours

0 0 0 0 0 0

Prenatally Diagnosed Congenital Malformations

Yes 64 45.4 44.7 49 43 55

No 77 54.6 55.3 50 45 56

Unknown 0 0 0 0 0 0

Major Birth Defect


28 19.9 19.4 24 16 28

751-1,000 grams

35 24.8 24.1 21 15 27

1,001-1,500 grams

78 55.3 56.5 55 47 65

Wait Time Until Referral

under 6 hours 19 13.5 13.5 16 11 20

6 to 12 hours 43 30.5 35.3 27 20 33

13 to 18 hours 56 39.7 32.4 36 30 40

19 to 24 hours 21 14.9 17.1 16 13 23

25 to 30 hours 2 1.4 1.8 2 0 5

greater 30 hours

0 0 0 0 0 0

Modified TRIPS Score at Time of Referral Temperature (degrees C)


<36.1 or >37.6 28 19.9 19.4 24 16 28

36.1-36.5 or 37.2-37.6

35 24.8 24.1 21 15 27

36.6-37.1 78 55.3 56.5 55 47 65

Respiratory Status

Severe 28 19.9 19.4 24 16 28

Moderate 35 24.8 24.1 21 15 27

None 78 55.3 56.5 55 47 65

Systolic BP (mm Hg)

<20 28 19.9 19.4 24 16 28

20-40 35 24.8 24.1 21 15 27

>40 78 55.3 56.5 55 47 65

Responsiveness

None, seizure, muscle relaxant

28 19.9 19.4 24 16 28

Lethargic response, no cry

35 24.8 24.1 21 15 27

Withdraws vigorously, cries

78 55.3 56.5 55 47 65

Antenatal Steroids

Yes 64 45.4 44.7 49 43 55

No 77 54.6 55.3 50 45 56

Unknown 0 0 0 0 0 0

RECEIVING HOSPITAL REPORTAcute Transport Activity

Infants 1,500 grams or less born between 01/01/2006 and 12/31/2006California Perinatal Transport Systems (CPeTS)

Center ID: 0000

Center Same CCS Level within CPQCCCenter-Network

Comparison(N=141) (N Centers=94 )

N % Last Year's% % Median% Lower Quartile

% Upper Quartile

Acute Transport Type

Dr Attendance Requested

43 30.5 30.6 25 19 30

ASAP Neonatal 71 50.4 50.6 41 35 50

Scheduled Neonatal

27 19.1 17.6 32 24 39

Other 0 0 1.2 0 0 2

Birth Weight


28 19.9 19.4 24 16 28

751-1,000 grams

35 24.8 24.1 21 15 27

1,001-1,500 grams

78 55.3 56.5 55 47 65

Gestational Age

For a finer gestational age breakdown, click here.

under 25 weeks 19 13.5 13.5 16 11 20

25 to 27 weeks 43 30.5 35.3 27 20 33

28 to 30 weeks 56 39.7 32.4 36 30 40

31 to 33 weeks 21 14.9 17.1 16 13 23

34 to 37 weeks 2 1.4 1.8 2 0 5

38 to 41 weeks 0 0 0 0 0 0

Total Time from Acceptance to NICU Admission at Receiving Hospital



under 6 hours 19 13.5 13.5 16 11 20

6 to 12 hours 43 30.5 35.3 27 20 33

13 to 18 hours 56 39.7 32.4 36 30 40

19 to 24 hours 21 14.9 17.1 16 13 23

25 to 30 hours 2 1.4 1.8 2 0 5

greater 30 hours

0 0 0 0 0 0

Total Time from Acceptance to Arrival of Transport Team at Referring Hospital

under 6 hours 19 13.5 13.5 16 11 20

6 to 12 hours 43 30.5 35.3 27 20 33

13 to 18 hours 56 39.7 32.4 36 30 40

19 to 24 hours 21 14.9 17.1 16 13 23

25 to 30 hours 2 1.4 1.8 2 0 5

greater 30 hours

0 0 0 0 0 0

Total Time from Acceptance to Departure of Transport Team from Referring Hospital

under 6 hours 19 13.5 13.5 16 11 20

6 to 12 hours 43 30.5 35.3 27 20 33

13 to 18 hours 56 39.7 32.4 36 30 40

19 to 24 hours 21 14.9 17.1 16 13 23

25 to 30 hours 2 1.4 1.8 2 0 5

greater 30 hours

0 0 0 0 0 0

Modified TRIPS Score at Initial Transport Team Evaluation Temperature (degrees C)

<36.1 or >37.6 28 19.9 19.4 24 16 28

36.1-36.5 or 37.2-37.6

35 24.8 24.1 21 15 27

36.6-37.1 78 55.3 56.5 55 47 65

Respiratory Status

Severe 28 19.9 19.4 24 16 28

Moderate 35 24.8 24.1 21 15 27

None 78 55.3 56.5 55 47 65

Systolic BP (mm Hg)

<20 28 19.9 19.4 24 16 28

20-40 35 24.8 24.1 21 15 27

>40 78 55.3 56.5 55 47 65

Responsiveness


28 19.9 19.4 24 16 28


35 24.8 24.1 21 15 27


78 55.3 56.5 55 47 65

Modified TRIPS Score at NICU Admission Temperature (degrees C)

<36.1 or >37.6 28 19.9 19.4 24 16 28

36.1-36.5 or 37.2-37.6

35 24.8 24.1 21 15 27

36.6-37.1 78 55.3 56.5 55 47 65

Respiratory Status

Severe 28 19.9 19.4 24 16 28

Moderate 35 24.8 24.1 21 15 27

None 78 55.3 56.5 55 47 65

Systolic BP (mm Hg)

<20 28 19.9 19.4 24 16 28

20-40 35 24.8 24.1 21 15 27

>40 78 55.3 56.5 55 47 65

Responsiveness


28 19.9 19.4 24 16 28


35 24.8 24.1 21 15 27


78 55.3 56.5 55 47 65

Change in TRIPS Score Temperature (degrees C)

<36.1 or >37.6 28 19.9 19.4 24 16 28

36.1-36.5 or 37.2-37.6

35 24.8 24.1 21 15 27

36.6-37.1 78 55.3 56.5 55 47 65

Respiratory Status

Severe 28 19.9 19.4 24 16 28

Moderate 35 24.8 24.1 21 15 27

None 78 55.3 56.5 55 47 65

Systolic BP (mm Hg)

<20 28 19.9 19.4 24 16 28

20-40 35 24.8 24.1 21 15 27

>40 78 55.3 56.5 55 47 65

Responsiveness


28 19.9 19.4 24 16 28


35 24.8 24.1 21 15 27


78 55.3 56.5 55 47 65

APPENDIX H: PERINATAL CARES ARTICLE


January 1, 2007 Dear Newborn Care Provider:

The California Perinatal Transport System (CPeTS), formerly the Northern and Southern California Perinatal Dispatch Centers, is pleased to announce the Neonatal Transport Data System will resume on January 1, 2007. CPeTS has engaged the California Perinatal Quality Care Collaborative (CPQCC) to manage the data system. This collaboration will optimize data quality, timeliness and enhance the understanding of transport patterns, outcomes and opportunities for quality improvement in California. It will also improve the availability of timely data reports to both referring and receiving facilities participating in the program. Mandate to Collect, Analyze and Utilize Data CPeTS was established in 1976 pursuant to California Assembly Bill 4439. This act enabled the development of two dispatch centers to facilitate transports of critically ill infants and mothers with high risk conditions to Neonatal Intensive Care Units and Perinatal High Risk Units. CPeTS is charged with the responsibility to collect and analyze perinatal and neonatal transport data for regional planning, outreach program development, and outcome analysis. The previous data collection system was halted in response to changing data collection needs as well as HIPPA compliance issues. Hospitals are mandated to systematically review and report neonatal transports in California by: California Children’s Services (CCS) Manual of Procedures, Chapter 3 – Provider Standards, Section 3.25 Standards for Neonatal Intensive Care Units (NICU), State of California, Department of Health Services, California Medical Services, January 1, 1999.

! §3.25.1-30 Infant morbidity and mortality data concerning birth weight, survival, transfer, incidence of certain conditions and other information as required shall be submitted to the Chief, Children’s Medical Services Branch/CCS Program annually.

! 4.A.(4) Maintenance of written records of each neonatal transport completed shall be available for review by CCS program staff.

! 4B….All guidelines and reporting requirements of the Regional Perinatal Dispatch Center (aka CPeTS) shall be followed.

California Code of Regulations, Title 22: Social Security, Volume 28, Revised November, 1995. Perinatal Unit General Requirements §70547 (a4) Formal arrangements for consultation and/or transfer of an infant to an intensive care newborn nursery, or a mother to a hospital with the necessary services for problems beyond the capability of the perinatal unit.

(b) There shall be written policies and procedures developed and maintained by the person responsible for the service in consultation with other appropriate health professionals and administration. These policies and procedures shall reflect the standards and recommendations of the American College of Obstetricians and Gynecologists…and the American Academy of Pediatrics… Guidelines for Perinatal Care, fifth edition, 2002, AAP/ACOG requires the following minimal regional evaluation of perinatal transport programs:

! Patient Outcome Data: Unexpected neonatal morbidity (eg, hypothermia or tension pneumothorax) or mortality during transport as well as morbidity or mortality of patients at the receiving hospital.

! Logistic Information: frequency of failure to transfer patients generally considered to require tertiary care (eg, newborns born at < 32 weeks of gestation), availability of all the services that may be needed by the perinatal patient, accessibility of services, capability to connect the patient quickly and appropriately with the services needed, and programs to promote patient and community awareness of available and appropriate regional referral programs.

Development of the Neonatal Transport Data System Under the leadership of Drs. Jeffrey Gould and Alvin Hackel, key informant interviews and a series of focus groups were held around the State to identify key issues in perinatal transport. More than seventy-five individuals involved in perinatal transport provided expert guidance to identify and prioritize five major issues with improvement potential. These issues included:

! Underutilization of maternal transport; ! Delay in decision to transport infant; ! Difficulty in obtaining transport placement/acceptance; ! Delay in effecting transport following decision; and ! Consistent referring facility competency to stabilize the infant prior to the

transport team’s arrival, as well as transport team competency. A Workgroup was formed with volunteers from a variety of facilities to develop a data collection tool which was tested in preliminary as well as final formats. An integrated on-line data entry system which will allow linkage of transport data to outcome data within the CPQCC network was developed by Beate Danielsen. Beta testing occurred in November, 2006 with data collection and on-line reporting of more than one hundred and fifty neonatal transports. Following review and approval of the new system by Susann Steinberg, MD, Chief, Maternal, Child and Adolescent Health Branch/Office of Family Planning, California Department of Health Services, and Marion Dalsey, MD, Chief, Children’s Medical Services as well as the CPeTS and CPQCC Executive Committees, the new system will debut in January, 2007.

CPeTS Release 122106.doc, 2

Features of the Neonatal Transport Record The Neonatal Transport Data System data collection tools [All California Neonatal Transport Form (ACNTF) or Core CPeTS Neonatal Transport Form (CCNTF)] must be completed for all neonates transferred to or from a CCS designated NICU as well as all facilities participating in CPQCC. Selected data elements will be electronically reported via the CPQCC Transport Activity Report. Completing the ACNTF or CCNTF is the joint responsibility of the referring and receiving hospitals. Information necessary to assess patient stability, potential complications and to co-manage care prior to transport will be collected by the referring facility staff and transmitted to the transport team and /or the receiving facility. The modified Transport Risk Index of Physiologic Stability (TRIPS) Score contained in the Infant Condition Section will provide uniform assess of patient status and stability at the time of referral, transport team arrival at referring facility and return to receiving NICU. At any point during the resuscitation, stabilization, referral, and transport process information regarding quality improvement issues, may be recorded on the Confidential Neonatal Transport Issues with Improvement Potential Form. This form will be separate from the basic transport record prior to placement in the patient record. The separated form is then handled following internal hospital policies for QI data. Issues identified should be reviewed jointly by referring and receiving hospitals staff at: Mortality and Morbidity Reviews; annual review of Memorandum of Understanding, Transport Agreement or Regional Cooperation Agreements; or other appropriate QI venue. These issues may also be used to identify joint policy and procedure requirements, educational opportunities and/or gaps in services that should be referred to the teams responsible for annual review and negotiation of these contracts. Release of Neonatal Transport Data Collection Materials Materials will be distributed to all perinatal facilities in California by mail in January by CPeTS. For more information on the Neonatal Transport Data System visit the CPeTS website at www.perinatal.org or attend the CPQCC 2007 Data Training Worshops (schedule to be posted at www.CPQCC.org). Sincerely, California Perinatal Transport System

Alvin Hackel, MD, FAAP: Director, Northern California D. Lisa Bollman, RNC, MSN, CPHQ: Director, Southern California

California Perinatal Quality Care Collaborative

Jeffrey B. Gould, MD, MPH: Principal Investigator Grace Villarin Duenas, MPH: Program Manager, CPQCC Data Center

CPeTS Release 122106.doc, 3

http://www.perinatal.org/

http://www.cpqcc.org/

APPENDIX I: TRIPS SCORE


APPENDIX J: FREQUENTLY ASKED QUESTIONS (FAQs)


2007 CPeTS FAQ 122006.doc, 1

CPQCC Network Database

Frequently Asked Questions


Version 12.06 December 20, 2006

CPeTS Database On-Line Form Q: Are the data entry screens built yet -- we are building the documentation forms now, and making them mirror the data entry area works best? A: The development of the data entry screens for the on-line Core CPeTS Neonatal Transport Form (CCNTF) of the CPeTS Database was beta-tested by volunteer CPQCC Members from November 1 through December 14, 2006. The 2006 CPQCC data management system was upgraded on December 15, 2006 to incorporate these changes. The 2007 system upgrades for www.cpqccdata.org will go live on January 1, 2007.

The on-line form of the Core CPeTS Neonatal Transport Form (CCNTF) has been designed to collect selected variables from the paper All California Neonatal Transport Form (ACNTF). We plan to release the Manual, EDS specifications and forms on the www.cpqcc.org website by Friday, December 22, 2006. 2007 EDS Specifications Q: Will there be an electronic data transfer specifications document? A: Yes, we are finalizing the EDS specifications for a combined CPQCC Network – CPeTS Database. The EDS specifications is divided into three sections: 1) ID Section, 2) CPeTS section, and 3) CPQCC section.

We have added a tracking variable to identify records that are eligible into the CPeTS database. In short the CPQCC Network Database will be expanded with the linkage to the Core CPeTS Neonatal Transport Form (CCNTF). The 2007 EDS Specifications for the CPQCC Network Database (Version 9.06, Sept 11, 2006) has been revised to incorporate these updates. Reverse Transports Q: How will CPQCC handle reverse or back transports - at least half of the babies we transport out are babies who go to a lower level of care AND did not have a diagnosis which got them into the CPQCC data set. At the NCPeTS our transport coordinator was told these would need to be reported to CPQCC but I was unclear of the mechanism - same numbering sequence? Only send the reverse transport data? Or are these babies to be a new admit criteria for the CPQCC dataset? A: The policy is that the paper All California Neonatal Transport Form (ACNTF) MUST be completed for all neonates transferred to or from a CCS designated NICU, as

2007 CPeTS FAQ 122006.doc, 2

well as, all facilities participating in CPQCC. Completing the paper All California Neonatal Transport Form (ACNTF) is the joint responsibility of the referring and receiving hospital.

Then, the Receiving hospital has the responsibility to identify the Acute Transfer cases and then to initiate an on-line Core CPeTS Neonatal Transport Form (CCNTF) for all eligible infants into the CPeTS Database. The on-line CCNTF consists of select data elements from the paper ACNTF that will be electronically reported through the CPeTS Database. The Data Contact simply has to log-on to CPQCC’s www.cpqccdata.org site.

Only acute transfers are included in the combined CPQCC Network - CPeTS database. However, the All California Neonatal Transport Form (paper form) could prove useful in its entirely or in part to document and transfer information between hospitals for an infant who is no an acute transport. This would be at the discretion of the involved hospitals and it is important to note that information collected using this form on a non-acute transport is not to be entered into the CPeTS database. The on-line Core CPeTS Neonatal Transport Form (CCNTF) is designed to only pick up Acute Transfers. Acute transfers are defined as “An infant with medical problems that require acute resolution for survival who is transferred in order to obtain medical, diagnostic, or surgical therapy that is not provided, or that cannot be effectively provided due to temporary staffing/census issues, or that can not be provided due to insurance restrictions at the referring hospital is considered acute.” Acute transfers can be classified as either ASAP or Scheduled. A baby therefore is always eligible for the entire set of CPQCC forms if it is eligible for the CPeTS Database (either because of birth weight, gestational age, or because it is an acute transfer). If after being transferred into a CPQCC center, the baby is transferred back, this is picked up by the transfer-out section of the Admission/Discharge (A/D) form. Three situations are possible:

a) The baby is transferred out for non-acute reasons (growth/discharge planning or chronic care). In this case, CPQCC should not get any more forms for this baby. There should only be one CCNT form and one A/D form for this baby. The transfer-out section of the A/D section submitted by the CPQCC center should be updated.

b) The baby is transferred out to a CPQCC center for acute reasons within 28 days of life. In this case, the receiving hospital has to fill out a CCNT form and an A/D form, and the combined CPQCC Network – CPeTS Database will have two CCNT forms and two A/D forms for this baby. The reason for the transfer out of the first CPQCC center has to clearly indicate acute reasons.

c) The baby is transferred out to a non-CPQCC center for acute reasons within 28 days of life. In this case, the receiving hospital does not participate in CPQCC, and there are no more forms to send to CPQCC. For this baby, only the additional information collected via the transfer-out section of the A/D form will be collected.

With the demographic information we collect on the CCNTF and A/D forms we will be able to link all these records.

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