SECTION F: NEONATAL CARE
All questions in this section are directed at the Level IV NICU you designate in question F1. DO NOT include patients
in sites other than the Level IV NICU including those in affiliated programs or hospitals.
F1.
Do you have a Level IV1 neonatal intensive care unit (NICU) in your children’s hospital or pediatric
program? (Note that you should answer yes to this question if you have been granted Level IV status or currently
meet the American Academy of Pediatrics guidelines for a Level IV NICU.) Please answer remaining questions
about the Level IV unit specified in this question.
 Yes
 No – Skip to Section G
REQUIRED: IF F1=BLANK, DISPLAY: “F1: A response is required for this question prior to submitting the
survey. Click “OK” to continue with the survey and answer this question later. Click “Cancel” to
provide a response to this question now.”
When responding to questions in this section, we recommend that you consult with the medical director of your
Level IV NICU program to ensure accurate answers that are consistent with the intent of the survey.
As data are reviewed, U.S. News may have questions about responses to individual questions or about an entire
submission. To ensure communication with the appropriate clinical leader, please provide the following
information about the chief of service (or equivalent) for your Level IV NICU program.
Full name:
Title:
Email:
Preferred phone:
REQUIRED: IF NAME, TITLE, EMAIL, OR PHONE=BLANK, DISPLAY: “A response is required for
[Name/Title/Email/Phone] prior to submitting the survey. Click “OK” to continue with the survey
and answer this question later. Click “Cancel” to provide a response to this question now.”
1
(AAP guidelines, Pediatrics, 2012, 130:587-597)
Pediatric Hospital Survey (12/31/2015)
Neonatal Care
F -1
F2.
Please indicate the current total number of attending/on-staff physicians2 who are currently members of the
medical staff who provide care at your Level IV NICU. For each category, please indicate the total number
of full-time equivalents (FTEs)3 devoted to clinical care. [If none, please enter 0.]
Total
Clinical
Physicians
FTEs
a. Pediatric neonatologists (include only board certified/board eligible4 by the
American Board of Pediatrics with subspecialty certification in neonatalperinatal medicine)
________ ________
b. Other attending/on-staff physicians (include all other attending/on-staff
physicians who are not subspecialty board certified/board eligible in neonatalperinatal medicine) who independently care for level IV patients
________ ________
VALIDATE: IF F2x1 IS NOT A WHOLE NUMBER, DISPLAY: “F2x (Total Physicians): Please enter a whole
number (no decimals).”
Note: The preceding questions are used to determine eligibility for Neonatal Care. If you leave any part of these
questions blank, your hospital will be considered ineligible for the rankings in Neonatal Care.
F3.
Does your Level IV NICU program have physician extenders (i.e., nurse practitioners, physician assistants,
and neonatal hospitalists5) who work in or directly support patient care? If yes, please indicate the average
number of patients per physician extender during a typical day shift.




F4.
No, we do not have physician extenders
Yes, < 9 patients per physician extender
Yes, 9-15 patients per physician extender
Yes, >15 patients per physician extender
Please answer the following questions about the nursing staff that work in or directly support your Level
IV NICU program.
a.
b.
c.
d.
Response
Number of FTEs6 of direct clinical care RNs
________
Percent of eligible7 direct clinical care RNs who are nationally certified in neonatal
intensive care (RNC-NIC or CCRN) (Number of eligible certified RN / Total #
eligible RN’s)
________%
Percent of NICU budgeted nursing clinical FTEs that are nurse educators (Number of
budgeted NICU nursing educators FTEs / total NICU budgeted nursing clinical FTEs
x 100. Do not include APN’s in this number.)
________%
Vacancy8 percentage for the NICU (number of unfilled positions/total number of FTEs
budgeted x 100)
________%
VALIDATE: 0 ≤ F4b/c/d ≤ 100; ELSE, DISPLAY: “F4: Please enter a numeric value between 0 and 100.”
2
Attending/on-staff physicians include those who have completed their training in their particular medical specialty, are actively providing clinical
care to patients, and are currently considered a member of the “medical staff” at the hospital. This may include physicians employed by the hospital,
an affiliated university, or some other entity as long as the physician is considered part of the medical staff at the hospital.
3 To calculate physician clinical FTEs, please take the percentage of typical clinical effort that a physician provides to the program and divide by 100.
This resulting decimal will be the clinical FTE for this physician. For example, Dr. A spends 75% of his time in clinical care and 25% in research;
the clinical FTE for Dr. A would be 0.75 FTE (i.e., 75/100=0.75).
4 Note that Board Eligible is now defined by the American Board of Pediatrics as a care provider out of training <6 years; beyond this window, all
neonatologists being counted in this question must be board certified to be included. If a provider does not meet the board eligible or board certified
criteria, then they may only be counted in F2b.
5 Physicians trained in pediatrics, but not board-certified in neonatal-perinatal medicine, who care for patients in the Level IV NICU under the
supervision of a neonatologist. Do not include physicians counted in F2.
6 Calculate clinical nurse (RN) FTEs based on total paid hours for the period of review divided by 2080.
7
For this question, eligible nurses include those who have at least 4 years NICU nursing experience and the specified national certifications in
neonatal intensive care.
8 Note that positions filled by travelers should be considered unfilled positions.
Pediatric Hospital Survey (12/31/2015)
Neonatal Care
F -2
F5.
What is the average patient load per neonatologist (include only attending/on-staff physicians9 board
certified/board eligible10 by the American Board of Pediatrics with subspecialty certification/eligibility in
neonatal-perinatal medicine) in your NICU for week-day shifts?
 < 18 patients per neonatologist
 18-25 patients per neonatologist
 >25 patients per neonatologist
F5.1
What is the average patient load per licensed independent practitioner (defined as in-house attending,
fellow, resident, or physician extender) cared for on the night shift? [Calculate as the average number of
patients in unit at night divided by the average total number of licensed independent practitioners.]
 <15 patients per licensed independent practitioner
 15-20 patients per licensed independent practitioner
 >20 patients per licensed independent practitioner
F6.
What was the average daily census11 for your NICU in the last calendar year?
________ NICU average daily census
F7.
Does your NICU program provide the following NICU-dedicated12 staff for patient care within the unit?
a.
b.
c.
F7.1
NICU-dedicated pharmacist on-site who attends work rounds daily on
weekdays with the clinical team
NICU-dedicated respiratory therapy team who attends work rounds daily on
weekdays with the clinical team
NICU-dedicated registered dieticians who attend work rounds daily on
weekdays with the clinical team
Yes
No
○
○
○
○
○
○
If Yes to F7c, what is the average number of patients per registered dietician?
 <20 patients
 20-30 patients
 >30 patients
9
Attending/on-staff physicians include those who have completed their training in their particular medical specialty, are actively providing clinical
care to patients, and are currently employed by the hospital as a member of the medical staff.
10 Note that Board Eligible is now defined by the American Board of Pediatrics as a care provider out of training <6 years; beyond this window, all
neonatologists being counted in this question must be board certified to be included.
11 Inpatient days in the NICU divided by 365 or by the number of days that the hospital was open if less than 365.
12
Dedicated means that the individual or team that is focused on the care of NICU patients and that they do not provide services elsewhere in the
pediatric program.
Pediatric Hospital Survey (12/31/2015)
Neonatal Care
F -3
F8.
F9.
Are the following family services offered to neonatal patients and their families in your NICU?
Yes
a. NICU-specific Family Psychosocial Support Program13
○
b. Parental visitation (available 24 hours a day, 7 days a week)
○
c. Sibling visitation allowed
○
d
Influenza vaccination program for parents/primary caregivers of your NICU patients
○
e. NICU-specific parent-to-parent support group(s)
○
f.
Designated psychologist or psychiatrist available for referrals and consults with parents
○
g. Child Life support team available to the NICU families and staff
○
h. NICU-dedicated multidisciplinary developmental care team14
○
No
○
○
○
○
○
○
○
○
Does your NICU have a NICU-specific parent advisory committee that meets at least quarterly (or a
subcommittee from the larger parent advisory committee) with members on key NICU leadership
committees?
 Yes
 No
F10.
Does your NICU track the proportion of infants discharged on partial or full breast milk to use as a quality
metric?
 Yes – Go to F10.1
 No – Skip to F10.2
F10.1 In the past calendar year, what percentage of infants15 who were admitted at <7 days of age and
who were discharged home from the NICU before 120 days of age, were on partial or full human
milk feeds at that time of discharge?
 <50%
 50-75%
 >75%
F10.2 Does your hospital/NICU offer a dedicated area within the facility but away from the bedside for milk and
formula preparation? 16 [To answer Yes this area must meet both of the following criteria: a) Infant feeding
preparation room using the aseptic technique (Clean “No-Touch”) technique; b) The room requires restricted
access and healthy personnel; with no other activity occurring in the room.]
 Yes
 No
To answer “yes” to a NICU-specific Family Psychosocial Support Program the unit must have a NICU-specific Family Psychosocial Support
Program that is run by a NICU-dedicated specialist with financial support from the NICU/hospital and which is designed to address family needs
distinct from those needs managed by the NICU social workers.
14 To answer “yes” to this question the NICU must have dedicated occupational therapy, physical therapy and feeding/speech specialists providing
care in the unit, not just consultative service
15
Infants for whom there are definitive contraindications to breastfeeding (i.e., HIV positive or substance abusing mother) should be excluded from
the numerator and the denominator.
13
16
This would be an area in NICU, pharmacy or a dedicated formula or milk lab that meets the ADA guidelines found in the
publication Robbins ST, Meyers R. (2011). Infant Feedings: Guidelines for Preparation of Human Milk and formula in Health Care
facilities. 2nd ed. Chicago: American Dietetic Association.
Pediatric Hospital Survey (12/31/2015)
Neonatal Care
F -4
F10.3 Does your NICU program offer the following for nutrition and breastfeeding?
a.
b.
c.
d.
e.
f.
NICU-dedicated certified lactation specialists
Cohort of NICU RNs specially trained in lactation counseling
NICU specific Breast Milk committee
Process to rent breast pumps to families
NICU specific risk reduction program that includes processes designed to reduce
breast milk errors
Donor breast milk program with written institution-specific criteria for the
initiation and discontinuation of donor breast milk
Yes
○
○
○
○
No
○
○
○
○
○
○
○
○
SKIP LOGIC: IF F10.3e=Yes, GO TO F10.4; ELSE SKIP TO F10.5
F10.4 Which of the following elements does your NICU specific risk reduction program include?
Yes
No
a. Individual breast milk warmers17 at each bedside
○
○
b. Bar coding system for correct breast milk identification
○
○
Dedicated breast milk technician who prepares milk for proper
c.
○
○
identification and distribution
F10.5. Does your NICU program track the breast milk administration error rate (e.g., wrong breast milk given to
patient)?
 Yes
 No – Skip to F11
F10.6 If yes to F10.5, please report the number of breast milk administration errors, the breast milk
feeding patient days in infants admitted at <7 days of age and discharged home at < 120 days, and
the breast milk administration error rate for the last calendar year? [Calculate as follows: (1)
Determine the number of breast milk administration errors in 2015. (2) Determine the total number of
breast feeding patient days18 in 2015. (3) Divide the number of administration errors by the number of
breast feeding patient days, and multiply by 1,000. Round your result to 2 decimals.]
________(1) Breast milk administration errors
________(2) Breast milk feeding patient days
________(3) Breast milk administration error rate
WARNING:
IF F10.5=1 AND F10.6 (2) = (0 OR BLANK), DISPLAY: “F10.6 (BM feeding patient days):
Please provide a value greater than 0 or answer No to F10.5.”
VALIDATE: IF F10.6 (1) > F10.6 (2), DISPLAY: Please check your responses. The number of
administration errors is higher than the number of feeding patient days.”
IF F10.6 (1) or F10.6 (2) IS NOT A WHOLE NUMBER, DISPLAY: “F10.6x: Please enter a
whole number (no decimals).”
AUTOCALC: F10.6 (3) = [F10.6 (1) / F10.6 (2)]*1000
17
To receive credit for this question the site must have a commercial product designed to warm breast milk at each bedside; hot water baths do not
qualify as breast milk warmers.
18 The total number of breast milk feeding days equals the sum of the lengths of stay (LOS) in days for all infants admitted <7 days and discharged
home <120 days from the NICU on breast milk feeds. divided by the total number of infants admitted <7 days and discharged home <120 days from
the NICU.
Pediatric Hospital Survey (12/31/2015)
Neonatal Care
F -5
F11.
Does your program have NICU-dedicated social workers?19
 Yes
 No – Skip to F12
F11.1 What is the average number of patients per social worker?



F12.
Are the following available on-site to patients in your NICU?
a.
b.
c.
d.
e.
F13.
<15 patients per social worker
15-25 patients per social worker
>25 patients per social worker
Continuous video electroencephalograph (EEG) monitoring20 and reading21
with pediatric neurology support with telemetry capability 24/7
Non-sedated MRI (with or without an MRI-compatible neonatal transporter22)
Virology laboratory with weekday 24 hour availability23
Specialized chemistry laboratory24
Onsite genetic specialists with expertise in interpreting and counseling parents
and family members about exome sequencing results for diagnosis of rare,
Mendelian phenotypes
Yes
No
○
○
○
○
○
○
○
○
○
○
Does your hospital provide a neonatal-specific transport team with each of the following?
a.
b.
c.
d.
e.
A Medical Director who is board-certified in Neonatal-Perinatal Medicine
At least 2 clinicians (e.g., RN, RT, MD, DO, NNP, PA) on each transport who
are non-drivers
All RN’s and RT’s on the neonatal transport team have at least 1 year of NICU
level III or IV experience
Neonatal transport team is immediately25 available 24 x 7 to respond to
emergent neonatal transports
Active servo-controlled cooling on transport for term and near term infants
with hypoxic ischemic encephalopathy26
Yes
○
No
○
○
○
○
○
○
○
○
○
F13.1 Does your NICU have the capability of providing inhaled nitric oxide therapy during transport with highrisk pre-ECMO patients whenever indicated?
 Yes
19
Do not include case managers in your response to this and the follow-up question about social workers.
EEG is a technology for measuring electrical activity produced by the brain, as recorded from electrodes placed on the scalp. EEG monitoring
provides the ability to collect the brain’s electrical activity continuously to help detect and diagnose neurological problems.
21 EEG reading is done by a board-certified physician or psychologist trained in diagnosing disorders related to brain activity.
22 This is an MRI-compatible incubator system with integrated coils to support imaging that includes a trolley to facilitate safe intrahospital transport
of neonates.
23 This is a diagnostic laboratory that supports the NICU by conducting culture and tissue studies to determine the virological conditions. Laboratory
should be able to complete one or more of the following tests: HSV PCR from CSF, HSV PCR from blood, or direct HSV antigen testing for skin
lesions.
24 This specialized diagnostic laboratory has the ability to use tandem mass spectroscopy and other advanced techniques to aid in the diagnosis of
medical conditions in NICU patients. Laboratory should be able to complete one or more of the following tests: Tandem mass spectroscopy, Gas
chromatography- mass spectroscopy, or Amino acid analysis.
25
Note that transport staff taking call from home would not qualify as immediately available.
26
To answer yes to this question, the infant must be actively cooled using equipment that includes continuous monitoring of infant temperature, with
feedback of infant temperature to the cooling device; the device must auto-regulate to achieve the desired target infant temperature.
20
Pediatric Hospital Survey (12/31/2015)
Neonatal Care
F -6
 No
F13.2 Does your NICU have the capability of reporting response time for emergent neonatal transports from the
time of the transport call to the time of the team dispatch?
 Yes
 No
F14.
Are the following specialized, multidisciplinary treatment teams/programs available to patients in your
NICU?
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
Craniofacial team27 (and follow-up clinic/program)
Spina bifida team28 (and follow-up clinic/program)
Comprehensive retinopathy of prematurity (ROP) program29
Extracorporeal membrane oxygenation (ECMO) team with neonatologists
managing or co-managing the patient 30
Neonatal-neuro intensive care program31
Palliative care program32 that includes some NICU-specific members
Micrognathia team33
Multidisciplinary team34 for the in-hospital care of the chronic lung disease (CLD)
patient
Multidisciplinary team35 for the review of fetal cases with the diagnosis of
congenital diaphragmatic hernia (CDH) who develop delivery and post-delivery
care plans
Multidisciplinary team36 for the in-hospital and post-discharge care of infants with
chronic pulmonary hypertension
Neonatal dialysis team37 with the ability to conduct peritoneal and hemodialysis,
continuous renal replacement therapy, and plasmapheresis
Multidisciplinary team38 for follow-up with congenital diaphragmatic hernia (CDH)
patients after discharge
Yes
○
○
○
No
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
To answer “Yes,” the team must include a pediatric plastic surgeon, pediatric neurosurgeon, pediatric otolaryngologist, social worker, and case
manager.
28 To answer “Yes,” the team must include a pediatric neurosurgeon, pediatric urologist, pediatric orthopedist, pediatric physical therapist (or
physiatrist), and nurse coordinator.
29 To answer “Yes,” the team must include a coordinator as well as a pediatric ophthalmologist and retinal specialist with experience treating ROP.
30 To answer “Yes,” the team must include a medical director, clinical manager, neonatal respiratory team, pediatric respiratory team, and a
neonatal/pediatric cardiac team.
31 To answer “yes,” the team should include a pediatric neurologist, pediatric neuro-radiologist and a neonatologist with experience in neonatal-neuro
intensive care who conduct multi-disciplinary reviews and perform consultations.
32 To answer “Yes,” the program should have individuals trained in palliative care who organize clinical protocols, educate staff, work with hospital
palliative care team, etc.; at least one or more members of the team must have NICU-specific training in the support of NICU patients and families.
The program may be part of a larger institutional palliative care team as long as it meets the above requirements.
33 To answer “Yes,” the team must include a pediatric ENT specialist or pediatric plastic surgeon and a nurse coordinator who has expertise in
conducting surgical care and follow-up for mandibular distraction, tongue-lip adhesion, and tracheostomy procedures.
34 Team must consist of a dedicated pulmonary medicine physician, neonatologist, and nutritionist.
35 Team must consist of a dedicated pediatric surgeon, dedicated neonatologist, maternal-fetal medicine specialists, and a radiologist with the
capability to interpret fetal MRI, and a fetal echo cardiologist.
36 Team must consist of a pediatric cardiologist specializing in care of the chronic PH patient, neonatologist, and nutritionist.
37 Team must consist of a pediatric nephrologist, pediatric surgeon, and neonatologist.
38 To answer “Yes” to this question the follow-up program for infants with CDH must routinely include surgery, nutrition, neurodevelopmental
specialists and pulmonology and routinely follow infants for at least the first 3 years after discharge.
27
Pediatric Hospital Survey (12/31/2015)
Neonatal Care
F -7
F15.
Are the following organized care teams offered by your hospital to transition patients from your NICU to
home?
Yes
No
a. Metabolic team39
○
○
b. Bowel rehabilitation team40 consisting of home TPN management and home
○
○
enteral feeding management
c. Home ventilator management team41
○
○
d. Neuro-developmental follow-up clinic42 for premature/high risk NICU patients
○
○
e. Neuro-developmental clinic43 for high risk congenital heart neonatal patients
○
○
F16.
How many unique patients—referred or inborn (patients that were not referred to another NICU or unit
within your hospital for care other than step-down care)—received care in your level IV NICU for the
following conditions or therapies during the past year? [If none, please enter 0.]
Unique patients
a. Congenital diaphragmatic hernia (ICD-9-CM diagnosis code 756.6)
________
b. Hirschsprung’s disease (ICD-9-CM diagnosis code 751.3)
________
c. Hypothermia treatment (ICD-9-CM procedure code 99.81) for hypoxic
ischemic encephalopathy (ICD-9-CM diagnosis code 768.7x) or severe birth
asphyxia (ICD-9-CM diagnosis code 768.5)
________
d. Spina bifida (ICD-9-CM diagnosis code 741.xx OR 756.17)
________
e. Gastroschisis (ICD-9-CM diagnosis code 756.73)
________
f.
Tracheoesophageal fistula (TEF) or esophageal atresia (ICD-9-CM diagnosis
code 530.84, 750.3)
________
g. Omphalocele (ICD-9-CM diagnosis code 756.72)
________
h. Small bowel (duodenal, jejunal, or ileal) atresia (ICD-9-CM diagnosis code
751.1)
________
i.
Imperforate anus (ICD-9-CM diagnosis code 751.2)
________
j.
Extracorporeal life support therapy (CPT codes 33946, 33947, 33948 or 33949)
________
VALIDATE: IF F16x IS NOT A WHOLE NUMBER, DISPLAY: “F16x: Please enter a whole number (no
decimals).”
F16.1. Do all surgical patients in your NICU have either a mandatory neonatal consult or a neonatologist comanaging their care?
 Yes
 No
F16.2 What percentage of anesthesiologists who provide care for your NICU patients, have board-certification in
pediatric anesthesia?
_______ %
VALIDATE: 0 ≤ F16.2 ≤ 100. ELSE DISPLAY: “F16.2: Please enter a numeric value between 0 and 100.”
To answer “Yes,” the team must include a geneticist, metabolic specialist, developmental specialist, and nutritionist.
To answer “Yes,” the team must include a pediatric gastroenterologist (or other metabolic specialist), social worker, and nutritionist
41 To answer “Yes,” the team must include a pediatric pulmonologist, social worker, and case manager.
42 A program focused on premature/high risk NICU patients led by a neuro-developmental specialist (a neonatologists with training in neurological
care, a pediatric neurologist specializing in neonatal care, or a neurodevelopmental psychologist) providing neurodevelopmental evaluation, along
with integrated occupational therapy, physical therapy, speech evaluations, as needed along with social work support for families.
43 A program focused on high risk congenital heart NICU patients led by a neuro-developmental specialist (a neonatologists with training in
neurological care, a pediatric neurologist specializing in neonatal care, or a neurodevelopmental psychologist) providing neurodevelopmental
evaluation, a cardiologist, and integrated occupational therapy, physical therapy, speech evaluations, as needed along with social work support for
families.
39
40
Pediatric Hospital Survey (12/31/2015)
Neonatal Care
F -8
F17.
Does your hospital provide a cardiac intensive care unit (CICU)44 where newborn infants < 28 days of age
needing specialized care for heart conditions are cared for?
 Yes—Go to Question F18
 No—Skip to Question F20
Does your NICU program engage in the following interaction with your hospital’s CICU?
F18.
a.
b.
All preterm45 cardiac patients < 28 days of age receive a neonatology consult
All newborn cardiac patients < 28 days of age (preterm and full term) receive a
neonatology consult
Yes
○
No
○
○
○
F19.
This question was moved to the Congenital Cardiology and Cardiothoracic Surgery section of the survey.
F20.
Does your hospital provide a percutaneous intravenous central catheter (PICC) team with specialized
training in placing and maintaining PICC lines in NICU patients?
 Yes—Go to Question F20.1
 No—Go to Question F21
F20.1 If yes, what coverage model does the PICC team provide?
 24/7 PICC line placement services
 Day shift PICC line placement services only
 Other coverage model
F21.
Does your hospital provide a simulation/training laboratory (or training center) with NICU procedures or
code simulation programs?
 Yes
 No
F22.
Does your hospital mandate that core NICU staff participate in multidisciplinary training at least once
every 2 years in each of the following areas?
a.
b.
c.
d.
e.
f.
g.
Neonatal mock – unplanned code response in the NICU
Arrhythmia treatment including use of a defibrillator
Simulation of emergency evacuation of the NICU
Simulation for maintenance of Neonatal Resuscitation Program (NRP) and/or Pediatric
Advanced Life Support (PALS) active status
ECMO emergency simulation training
Exchange transfusion simulation or just in time training using a multi-disciplinary
model, e.g., RN and MDs together
Other training (specify below)
Yes
○
○
○
No
○
○
○
○
○
○
○
○
○
○
○
F22.1. If “yes” to F22g, please specify what these “other” protocols NICU staff are trained in:
44
Define CICU as a separate critical care unit from the NICU and PICU for the full care of the neonatal/pediatric cardiac patient, (e.g., pre and
postoperative care of the neonatal/pediatric cardiac patient)
45 Note that “preterm” refers to patients that had less than 37 weeks of gestation.
Pediatric Hospital Survey (12/31/2015)
Neonatal Care
F -9
F23.
For your fellows and your physician extenders (NNP/PA’s), does your Neonatology Division track NICU
procedure/protocol proficiency for chest tube placement, intubation, and neonatal resuscitation at least
every 2 years by use of procedure count or simulation training?
 Yes – Go to F23.1
 No – Skip to F23.2
F23.1. For each of the following NICU procedures/protocols, what percentage of neonatal fellows and
physician extenders completed their proficiency requirement (performance of procedure,
simulation, or other training) in the last two calendar years? [If training is not offered, please leave
blank.]
Neonatal
Physician
Fellows
extenders46
a. Chest tube placement
________%
________%
b. Intubation
________%
________%
c. Neonatal resuscitation program (NRP)
________%
________%
VALIDATE: 0 ≤ F23.1x ≤ 100. ELSE DISPLAY: “F23.1x: Please enter a numeric value between 0 and
100.”
F23.2 For your attending physicians, does your NICU provide simulation or other training to maintain and
document competency in institution-specific infrequently performed procedures (e.g., chest tube
placement, pericardiocentesis, or abdominal paracentesis)?
 Yes
 No – Skip to F24
F23.3 What percentage of your attending physicians participated in a competency simulation or other
training for an infrequently performed procedure in the last 24 months?
________% Percentage of physicians participating in competency simulation
WARNING:
IF F23.2=YES AND F23.2=0, DISPLAY: “F23.3: If none of your physicians participated in
a competency training, please answer No to F23.2.”
VALIDATE: 0 < F23.3x ≤ 100. ELSE DISPLAY: “F23.3x: Please enter a numeric value greater than 0
and less than or equal to 100.”
F24.
Does your NICU program participate in any of the following clinical research or data exchange programs?
a.
b.
c.
Vermont Oxford Network47 Expanded Database for infants > 1,500 grams or the
Children’s Hospitals Neonatal Database (CHND)48
Extracorporeal Life Support Organization (ELSO)49 data exchange
network/registry
Other clinical research or data exchange program
Yes
No
○
○
○
○
○
○
46
This includes Neonatal Nurse Practitioners, Physician Assistants, and Neonatal Hospitalists.
See http://www.vtoxford.org.
48 See https://www.childrenshospitals.org/. Note that participating in the CHA administrative dataset PHIS cannot be used to answer yes to this
question. The PHIS is not a dataset designed for quality improvement and does not have QI collaborative activities associated with the dataset
participation; if PHIS is included in the write in section it should not be valued as is participation in VON and /or CHND.
49 See http://www.elso.org/
47
Pediatric Hospital Survey (12/31/2015)
Neonatal Care
F -10
F24.1. If “yes” to F24c, please specify what other programs you participate in:
F25.
Does your NICU program participate in any clinical research studies registered on clinical trials.gov that
allow your patients access to novel or experimental treatment options?
 Yes
 No
F26.
Does your hospital track central line associated blood stream infections (CLABSI) rates for your Level IV
NICU patients?
 Yes
 No – Skip to F27
F26.1 Please report the number of CLABSI events, central line days, and CLABSI rate per 1,000 central
line days for your NICU in the last calendar year? [Calculate as follows: (1) Determine the number of
CLABSI events according to NHSN guidelines. (2) Determine the total number of central line/umbilical
line days50 in 2015. (3) Divide CLABSI events by central lines days and multiply by 1,000. Round your
result to 2 decimals.]
________ (1) CLABSI events
________ (2) Central line days
________ (3) CLABSI rate
WARNING:
If B21=Yes AND B22(2) = (0 OR BLANK), DISPLAY, “B22 (central line days)): Please
provide a value greater than 0 or answer No to B21.”
VALIDATE: IF F26 (1) or F26b (2) IS NOT A WHOLE NUMBER, DISPLAY: “F26x: Please enter a
whole number (no decimals).”
IF F26 (1) > F26 (2), DISPLAY: F26: Please check your responses. The number of CLABSI events
is higher than the number of central line days.”
AUTOCALC: F26 (3) = [F26 (1) / F26 (2)]*1000
F27.
Is your NICU program currently engaged in any of the following activities?
a.
b.
c.
d.
e.
Implemented a formal plan for clinical quality review and improvement
Determined appropriate data-based performance metrics for clinical quality
Regularly tracked patient data (e.g., diagnoses, treatment plans, test results,
readmission rates, immunization at discharge, percent discharge on breast milk,
etc.) and other supporting information to measure progress against your clinical
quality performance metrics
Presented results of your program’s clinical quality performance metrics to your
clinical staff on a regular basis
Participated in one or more quality improvement initiatives specific to neonatal
care
Yes
○
○
No
○
○
○
○
○
○
○
○
50
According to NHSN guidelines, a patient with one or more central lines on a given day equals 1 central line day. Provide the composite CLABSI
rate for all umbilical and central venous catheters for your pediatric service.
Pediatric Hospital Survey (12/31/2015)
Neonatal Care
F -11
F27.1. If “yes” to any part of F27, please describe one quality improvement initiative and how it improved
the quality of your program in the last calendar year. [To receive credit, you must discuss what
actions your hospital took as a result of this quality initiative and the impact it had on your program.]
F28.
Does your NICU program have a specified Quality Improvement (QI)/safety leader(s) with training in
QI/outcome procedures? If yes, how much of their time is dedicated to QI and safety in the NICU?





Yes, > 0.75 FTE
Yes, 0.50-0.74 FTE
Yes, 0.26-0.49 FTE
Yes, < 0.25 FTE
No
F28.1 In the last calendar year, did you have a parent/family member of a former NICU patient involved in one
or more initiatives as an integral member of the QI/safety team?
 Yes
 No
F29.
Do your physicians and physician extenders (e.g., nurse practitioners and physician assistants) in your
NICU program use ICU-focused standardized hand-off tools (e.g., SBAR, 5-Ps or other) to inform clinical
staff during team transitions between night/day/weekend shifts about the patient and care received?
 Yes
 No – Skip to F30
F29.1 Which of the following standardized hand-off tools does your NICU program use to inform clinical
staff during team transitions? [Check all that apply.]
Shift hand-off (a standard hand-off tool used at the time of change of shift change for clinical teams)
Team change hand-off (e.g., end of clinic rotation) (a standardized tool used at the time of team
change, e.g., end of the month team change)
Pre-op hand-off from neonatology to surgery & anesthesia (i.e., multidisciplinary hand-off tool used
before surgery to assure pertinent information is passed on to the surgery team regarding the patient)
Post-op hand-off tool from operating room staff to neonatology nurse or neonatology attending (e.g.,
multidisciplinary hand-off tool used post-operatively to assure all pertinent information that occurred
in the surgery arena is passed on to the clinical team caring for the patient)
F30.
Do nurses in your NICU program use ICU-focused standardized hand-off tools (e.g., SBAR, 5-Ps or other)
to inform clinical staff during team transitions between night/day/weekend shifts about the patient and
care received?
 Yes
 No – Skip to F31
Pediatric Hospital Survey (12/31/2015)
Neonatal Care
F -12
F30.1 If Yes, which of the following standardized hand-off tools do nurses in your NICU program use to
inform clinical staff during team transitions? [Check all that apply.]
Shift hand-off (a standard hand-off tool used at the time of change of shift change for clinical teams)
Pre-op hand-off from neonatology to surgery & anesthesia (i.e., multidisciplinary hand-off tool used
before surgery to assure pertinent information is passed on to the surgery team regarding the patient)
Post-op hand-off tool from operating room staff to neonatology nurse or neonatology attending (e.g.,
multidisciplinary hand-off tool used post-operatively to assure all pertinent information that occurred
in the surgery arena is passed on to the clinical team caring for the patient)
F31.
Does your NICU program track patients’ first postoperative temperatures and use it as a quality metric?51
 Yes
 No – Skip to F32
F31.1 If Yes, what percentage52 of patient first postoperative temperatures were < 36°C (<96.8°F) in the
past year?
________%
WARNING:
IF F31=1 AND F31.1 = BLANK, DISPLAY: “F31.1: Please enter a value or answer No to
F31.”
VALIDATE: 0 ≤ F31.1 ≤ 100. ELSE DISPLAY: “F31.1: Please enter a numeric value between 0 and 100.”
F32.
Do you track unintended extubation (invasive airway loss in infants without a tracheostomy) in patients
who are being treated in the NICU?
 Yes
 No – Skip to F33
F32.1 If Yes to F32, please report the number of unintended extubations, patient ventilator days, and the
rate of unintended extubations? [Calculate as follows: (1) Determine the number of unintended
extubations in 2015 – excluding infants with a tracheostomy. (2) Determine the total number of patient
ventilator days in 2015 – again, excluding infants with tracheostomies. (3) Divide the number of
unintended extubations by the patient ventilator days and multiply by 100. Round your result to 2
decimals.]
________ (1) Unintended extubations
________ (2) Ventilator days
________ (3) Unintended extubation rate
WARNING:
IF F32=YES AND F32.1 (2) = (0 OR BLANK), DISPLAY: “F32.1 (Ventilator days): Please
provide a value greater than 0 or answer No to F32.”
VALIDATE: IF F32.1 (1) or F32.1 (2) IS NOT A WHOLE NUMBER, DISPLAY: “F32.1x: Please enter a
whole number (no decimals).”
IF F32.1 (1) > F32.1 (2), DISPLAY: “Please check your responses. The number of
unintended extubations is higher than the number of ventilator days.”
AUTOCALC: F32.1 (3) = [F32.1 (1) / F32.1 (2)]*100
51
The first postoperative temperature is the first temperature on return to the NICU after a patient has received an operating room (OR) procedure or
the first temperature following an in-NICU operative procedure after handoff from anesthesiology.
52
Note that patients who have recently undergone open heart cardiac surgery and are on intentional body cooling therapy should be excluded from
numerator and denominator.
Pediatric Hospital Survey (12/31/2015)
Neonatal Care
F -13
F32.2 What is your quality review process for cases of unintended extubation? Check all that apply.
We do not have a quality review process
Mini-RCA53 review within 12 hours of the event
Multidisciplinary team review weekly
Multidisciplinary team review monthly
Multidisciplinary team review quarterly
Other (please specify): (300 character limit)
____________________________________________________
F33.
Does your hospital track hospital readmissions54 of NICU graduates within 7 days of discharge home from
the NICU?
 Yes
 No – Skip to F34
F33.1 What is your NICU’s 7-day unplanned hospital readmission rate?
________% Readmission rate (report as a percentage)
WARNING:
IF F33=1 AND F33.1 = BLANK, DISPLAY: “F33.1: Please enter a value or answer No to
F33.”
VALIDATE: 0 ≤ F33.1 ≤ 100. ELSE DISPLAY: “F33.1: Please enter a numeric value between 0 and 100.”
F33.2 Do you have a multidisciplinary review of these cases to determine if readmissions were
preventable?
 Yes
 No
F34.
Do have the following available for very-low-birth-weight (VLBW, <1,500 grams) and low gestational age
(GA, <29 weeks) infants admitted to your NICU within 30 days of birth?
a.
b.
c.
Starter protein solution available on day of admission
Very low birth weight feeding protocol
“Kangaroo care” routinely provided for infants receiving mechanical ventilation
Yes
○
○
○
No
○
○
○
F34.1 Does your NICU program have or is it associated with a fetal diagnosis and counselling program55?





Yes, within your children’s hospital
Yes, within another hospital that is attached to or in close proximity to your hospital (e.g., bridge, tunnel)
Yes, within another hospital that is NOT attached to or in close proximity to your hospital
Yes, other scenario
No
53
A mini root cause analysis (RCA) is a standardized focused review documented by the bedside caretakers following an event to determine the
causes of the problem and possible solutions. This typically involves a treating nurse, physician, and others involved in the incident. The results of
the review are reported to a NICU specific quality improvement team for review and development of action plan.
54 Note that admissions to the NICU or any site in your hospital following NICU discharge should be considered a readmission when it is
unscheduled and directly related to the reason for the original admission.
55
To answer yes to this question, the program must include at minimum maternal-fetal medicine physicians, pediatric surgeons, geneticists, genetic
counselors, neonatologists, palliative care specialists, psychosocial support services for parents and a dedicated program coordinator.
Pediatric Hospital Survey (12/31/2015)
Neonatal Care
F -14
F35.
Does your NICU provide prescriber directed feedback for medication prescribing errors?
 Yes
 No
F36.
Does your NICU or hospital have a medication error reporting system/database?
 Yes
 No – Skip to F37
F36.1. If yes, does your NICU have a formalized process for evaluating medication errors?
 Yes
 No
F37.
Does your NICU audit hand hygiene compliance rates for providers (MDs, RNs, and RTs) by electronic
monitoring or direct observation56 (including secret shoppers) using a standard tool/form?
 Yes, via electronic monitoring or direct observation (including secret shoppers)
 No – Skip to Question F38
F37.1. What were the numbers for the total hand hygiene compliance opportunities completed for your
NICU in the last calendar year?
Values
a. Number of compliant hand hygiene opportunities observed in the NICU
________
b. Total number of hand hygiene opportunities observed in the NICU
________
WARNING:
IF F37=1 AND F37.1b = (0 OR BLANK), DISPLAY: “F37.1b: Please enter a value greater
than 0 or answer No to F37.”
VALIDATE: IF F37.1x IS NOT A WHOLE NUMBER, DISPLAY: “F37.1x: Please enter a whole number
(no decimals).”
IF F37.1a > F37.1b, DISPLAY: “F37.1: Please check your responses. The number of
compliant opportunities cannot be greater than the number of opportunities observed.”
F38.
Do you have a NICU-specific formal antimicrobial stewardship program (ASP) to monitor and report
usage of high risk, broad spectrum antimicrobials (e.g. vancomycin, meropenem) in the NICU?
 Yes
 No – Skip to F39
F38.1 If yes to F38, please describe your monitoring process?
56
Direct observers (including secret shoppers) are individuals who are trained hand hygiene monitors. This should not include patient or family
observations.
Pediatric Hospital Survey (12/31/2015)
Neonatal Care
F -15
This year, the following questions are being asked for informational purposes and will not be scored. Responses
will be analyzed and the information obtained will be used to determine institutions’ ability to provide certain data
and to help formulate future questions around important care issues such as coordination with fetal care
providers, infant nutrition during hospitalization and disease specific outcome metrics.
F39.
Does your NICU program track57 the proportion of all infants discharged or transferred to another floor or
facility from your NICU who had weight, height, and head circumference documented in the medical
record at both admission and discharge (or transfer)?
 Yes
 No – Skip to F41
F40.
Does your hospital measure length of infants in your NICU with a length board?
 Yes
 No
F41.
Is your NICU capable of reporting the disease specific median length of hospital stay for the most recent 5
year period (fiscal or calendar year) for infants discharged home from your hospital? [Note that future
surveys may ask for information such as total number of patients treated, survival percentage, and median length
of stay for patient groups such as those requested in F16. It is understood that some questions will require riskadjustment.]
 Yes
 No
F42.
For Neonatology, what was the primary time period used for reporting patient volume on questions with
ICD-9 codes?
 Calendar year (January 1, 2015-December 31, 2015)
 Fiscal year (October 1, 2014-September 30, 2015)
 Some other timeframe [Specify below]
F43.
If you selected “some other timeframe,” please provide the timeframe used for reporting patient volume on
questions with ICD-9 codes.
COMMENTS FOR SECTION F:
If needed, you may provide clarifications to the responses you provided to the questions asked in this section only. All
other comments, suggestions or questions should be sent to PediatricHospSurvey@rti.org.
57
The growth measurement can only be counted if it was performed and documented within 24 hours of admission or 1 week of discharge/transfer.
Pediatric Hospital Survey (12/31/2015)
Neonatal Care
F -16