The code block below illustrates how one might use # and // as comments in your logic and calculations.

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

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LOCATe Survey

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Please PREVIEW the instructions attached before beginning. You will need to gather the information described in them to complete the survey. If you have already gathered the data, proceed directly to the survey.

Attachment:RDCP_LOCATe_V92_Instructions.pdf

Please review the freqently asked questions linked below.

Attachment:Levels of Maternal and Neonatal Care Frequently Asked Questions.docx

NOTE: You may save your data at any time by clicking SAVE AND RETURN LATER at the bottom of the page. Be sure to copy and save the return code to a safe place, so that you do not have to start over when you return.

Please review your answers when you are finished, then click SUBMIT on last page to submit your survey.

Facility: Name

* must provide value

Facility: City

* must provide value

Facility: State

* must provide value

Facility: ZIP code

* must provide value

Does your facility receive reimbursements from CMS for designated low-volume or rural hospitals as part of one or more of these federally funded programs?

* must provide value

Yes, as Critical Access Hospital (CAH)

Yes, as Sole Community Hospital (SCH)

Yes, as Medicare-dependent Hospital (MDH)

Yes, as Rural Referral Center (RRC)

Yes, as a Low-Volume Hospital (LVH)

Yes, as a Disproportionate Share Hospital (DSH)

Yes, other (please specify)

No

Specify OTHER CMS or federal program designation:

* must provide value

Date survey was Completed:

* must provide value

M-D-Y

Who was the primary person (survey contact) responsible for organizing and completing this survey?:

Survey contact: Name

* must provide value

Survey contact: Email

* must provide value

Survey contact: Telephone

* must provide value

Please list the job titles of all persons who contributed the information that was needed to complete this survey.
(Example: NICU Director, DON, Quality Director, etc.)

You may enter up to 10 contributors.

Contributor Title 1

* must provide value

Contributor Title 2

Contributor Title 3

Contributor Title 4

Contributor Title 5

Contributor Title 6

Contributor Title 7

Contributor Title 8

Contributor Title 9

Contributor Title 10

S1.1. Hospital data collection START date:

* must provide value

M-D-Y

S1.2. Hospital data collection END date:

* must provide value

M-D-Y

Data collection END date can't be before data collection START date!

-Data collection START date-	-[S1.1]-
-Data collection END date-	-[S1.2]-

Correct the data collection START or END date.

You now have the option of SKIPPING this section.

Do you wish to skip the Neonatal assessment?

* must provide value

Yes

No

N1. Does your facility provide congenital cardiac surgery for neonates onsite?

* must provide value

Yes

No

N1.1. In the last 12 months, did your facility provide 10 or more congenital cardiac surgeries for neonates?

* must provide value

Yes

No

N2. Does your facility provide complex pediatric subspecialty surgery for neonates other than cardiac surgery onsite?

(Capable of surgical repair of complex congenital or acquired conditions)

* must provide value

Yes

No

N2.1. In the last 12 months, did your facility provide 10 or more complex pediatric subspecialty surgeries for neonates other than cardiac surgery?

Yes

No

N3.(1-5). What types of neonatal providers does your facility have available for newborn care?

* must provide value

Neonatologist(s)

Pediatric hospitalist(s)

Neonatal nurse practitioner(s)

Other

None of the above

N3.4.1. Specify OTHERneonatal providers:

* must provide value

N3.1.1. Is a neonatologist always available...

* must provide value

Onsite 24/7

Within 30 minutes

Between 30-60 minutes

More than 60 minutes away

By telemedicine only

By phone consultation only

N3.2.1. Is a pediatric hospitalist always available...

* must provide value

Onsite 24/7

Within 30 minutes

Between 30-60 minutes

More than 60 minutes away

By telemedicine only

By phone consultation only

N3.3.1. Is a neonatal nurse practitioner always available...

* must provide value

Onsite 24/7

Within 30 minutes

Between 30-60 minutes

More than 60 minutes away

By telemedicine only

By phone consultation only

N4. Does your facility have a range of pediatric medical subspecialists and pediatric surgical specialists available?

* must provide value

Pediatric surgeon(s)

Pediatric anesthesiologist(s)

Pediatric ophthalmologist(s)

Pediatric radiologist(s)

Other pediatric subspecialists(s)

None of the above

N4.5.1. Specify OTHER pediatric medical subspecialists and pediatric surgical specialists:

* must provide value

N4.1.1. Is a pediatric surgeon always available...

* must provide value

Onsite 24/7

Within 30 minutes

Between 30-60 minutes

More than 60 minutes away

By telemedicine only

By phone consultation only

N4.2.1. Is a pediatric anesthesiologist always available...

* must provide value

Onsite 24/7

Within 30 minutes

Between 30-60 minutes

More than 60 minutes away

By telemedicine only

By phone consultation only

N4.3.1. Is a pediatric ophthalmologist always available...

* must provide value

Onsite 24/7

Within 30 minutes

Between 30-60 minutes

More than 60 minutes away

By telemedicine only

By phone consultation only

N4.4.1. Is a pediatric radiologist always available...

* must provide value

Onsite 24/7

Within 30 minutes

Between 30-60 minutes

More than 60 minutes away

By telemedicine only

By phone consultation only

N5. Does your facility provide advanced (complex) imaging for neonates onsite 24/7 with interpretation available onsite or remotely 24/7?

(Example: CT, MRI, echocardiography)

* must provide value

Yes

No

N5.1. In the last 12 months, did your facility provide 10 or more advanced imaging procedures for neonates?

* must provide value

Yes

No

N6. Does your facility provide complex ventilation for neonates onsite?

(Example: High frequency ventilation, iNO)

* must provide value

Yes

No

N6.1. In the last 12 months, did your facility provide 10 or more complex ventilation procedures for neonates?

* must provide value

Yes

No

N7. Does your facility provide conventional mechanical and/or continuous positive airway pressure (CPAP) ventilation support for neonates until the infant can be transferred to a higher level facility?

(Ventilation for less than 24 hours)

* must provide value

Yes

No

N7.1. In the last 12 months, did your facility provide 10 or more conventional mechanical and/or continuous positive airway pressure (CPAP) ventilation support for neonates?

* must provide value

Yes

No

N8. Does your facility receive neonatal transports?

* must provide value

Yes

No

N8.(1-2).What type of neonatal transports do you receive?

* must provide value

Complicated, high-risk

Convalescent neonates

N9. Does your facility coordinate emergency transport for neonates?

* must provide value

Yes

No

N10. Does your facility currently have a neonatal level of care designation?

* must provide value

Yes

No

N10.1. What is your neonatal level of care designation?

* must provide value

I

II

III

IV

Other

N10.1.1. Specify OTHERdesignation:

* must provide value

N10.2. How is this neonatal level of care designated?

* must provide value

State regulatory based

State voluntary based

AAP based

Self-designated

Other

Unknown (not sure)

N10.2.1. Specify OTHER designation method:

* must provide value

N11. Based on the 2017 AAP guidelines* for neonatal levels of care, what do you consider your neonatal level of care to be?

* Guidelines for Perinatal Care, 8th edition; AAP Committee on Fetus and Newborn and ACOG Committee on Obstetric Practice; September 15, 2017

https://shop.aap.org/guidelines-for-perinatal-care-8th-edition-paperback/

ISBN-13: 978-1-61002-087-9

* must provide value

I

II

III

IV

Not sure

S2.1.1. Number of live born infants (newborns) at your facility

* must provide value

S2.1.2. Number of newborn deaths at your facility

* must provide value

S2.1.3. Number of high risk newborns transferred out to a facility with a higher level of neonatal care

* must provide value

S1.1.4. Number of convalescent newborns received from a facility with a higher level of neonatal care

* must provide value

S2.2.1. Number of very low birth weight (VLBW) newborns born at your facility. (VLBW = less than 1,500 grams)

* must provide value

S2.2.2. Number of very low birth weight (VLBW) newborn deaths at your facility. (VLBW = less than 1,500 grams)

* must provide value

S2.2.3. Number of very low birth weight (VLBW) newborns that were transferred out to a facility with a higher level of neonatal care. (VLBW = less than 1,500 grams)

* must provide value

S2.2.4. Number of convalescent very low birth weight (VLBW) newborns received from a facility with a higher level of neonatal care. (VLBW = less than 1,500 grams)

* must provide value

S2.3.1. Number of live births born at less than 32 weeks gestation at your facility.

* must provide value

S2.3.2. Number of deaths of newborns born at less than 32 weeks gestation at your facility.

* must provide value

S2.3.3. Number of newborns born at less than 32 weeks gestation that were transferred out to a facility with a higher level of neonatal care.

* must provide value

S2.3.4. Number of convalescent newborns born at less than 32 weeks gestation received from a facility with a higher level of neonatal care

* must provide value

You now have the option of SKIPPING this section.

Do you wish to skip the Maternal assessment?

* must provide value

Yes

No

W1. Does your facility staff an obstetric unit?
(Labor and Delivery, LDR, LDRP)

NOTE: If "No" is selected, the survey assumes that you do NOT provide obstetric services other than emergency care; and you will be routed to the MATERNAL STATISTICS section of the survey.

This answer is appropriate for most children's hospitals, many small rural hospitals and other hospitals who do not specifically staff an obstetric unit.

* must provide value

Yes

No

W1.1. What type of obstetric / maternal care patients does your facility accept?

(Low - ex. uncomplicated twins, uncomplicated caesarian, well-controlled gestational diabetes
Moderate - ex. poorly controlled diabetes or hypertension, placenta previa w/no prior surgery, complicated caesarian delivery
High - ex. maternal cardiac disease, placenta percreta, coagulation disorders, respiratory distress requiring ventilator support)

* must provide value

Low risk, uncomplicated / minimal complications

Moderate risk, higher risk complications

High risk, severe / multiple complications

W2. Does your facility have a formal written plan for the transport of complicated obstetric / maternal patients?

* must provide value

Yes

No

W2.(1-3). Does this FORMAL WRITTEN PLAN include...

* must provide value

Mechanism and procedure for maternal transport to a higher-level facility available at all times

Mechanism to facilitate and openly accept maternal transports from lower-level hospitals

Neither

W3. Does your facility have medical and / or surgical intensive care units onsite that are available to accept obstetric / maternal care patients?

* must provide value

Medical

Surgical

Both

Neither

W3.1. Are adult critical care providersphysically present at all times in the ICU(s)?

* must provide value

Yes

No

W3.2. Does a maternal fetal medicine specialist participate in daily rounds with ICU team for obstetric patients in the ICU?

* must provide value

Yes

No

W3.3. Does your facility have an OB intensive care unit onsite that is managed by an MFM; OR an ICU onsite that is co-managed by a MFM?

* must provide value

Yes, MFM managed OB ICU

Yes, MFM co-managed ICU

No

W4.Does your facility provide these basic medical support services?

(Equipment must be readily available and staffed 24/7)

* must provide value

Yes, Laboratory

Yes, Blood bank

Yes, Both

Neither

W4.1.1.Does the blood bank have the ability at all times to initiate massive transfusion protocol, with process to obtain more blood and component therapy as needed?

* must provide value

Yes

No

W4.(2-9). Does your facility provide these diagnostic imaging services?

(Equipment must be onsite and staffed 24/7; interpretation may be onsite or remote)

* must provide value

Limited obstetric ultrasound

Standard obstetric ultrasound

Non-obstetric ultrasound

Maternal echocardiography

Specialized obstetric ultrasound w/ Doppler studies

CT scan

MRI

Basic Interventional radiology

None of the above

W4.2.1 Are interpretation services for limited obstetric ultrasound...

* must provide value

Readily available at all times

Readily available on a daily basis

Other availability

W4.2.1.1. Specify OTHER availability of limited obstetric ultrasound

* must provide value

W4.3.1 Are interpretation services for standard obstetric ultrasound...

* must provide value

Readily available at all times

Readily available on a daily basis

Other availability

W4.3.1.1. SpecifyOTHERavailability of standard obstetric ultrasound

* must provide value

W4.4.1 Are interpretation services for non-obstetric ultrasound...

* must provide value

Readily available at all times

Readily available on a daily basis

Other availability

W4.4.1.1. SpecifyOTHERavailability of non-obstetric ultrasound

* must provide value

W4.5.1 Are interpretation services formaternal echocardiography...

* must provide value

Readily available at all times

Readily available on a daily basis

Other availability

W4.5.1.1. Specify OTHERavailability ofmaternal echocardiography

* must provide value

W4.6.1 Are interpretation services forspecialized obstetric ultrasound with Doppler studies...

* must provide value

Readily available at all times

Readily available on a daily basis

Other availability

W4.6.1.1. Specify OTHERavailability of specialized obstetric ultrasound with Doppler studies

* must provide value

W4.7.1 Are interpretation services forcomputed tomography (CT) scan...

* must provide value

Readily available at all times

Readily available on a daily basis

Other availability

W4.7.1.1. Specify OTHERavailability ofcomputed tomography (CT) scan

* must provide value

W4.8.1 Are interpretation services for magnetic resonance imaging (MRI)...

* must provide value

Readily available at all times

Readily available on a daily basis

Other availability

W4.8.1.1. Specify OTHERavailability ofmagnetic resonance imaging (MRI)

* must provide value

W4.9.1 Are interpretation services for basic interventional radiology...

* must provide value

Readily available at all times

Readily available on a daily basis

Other availability

W4.9.1.1. Specify OTHERavailability ofbasic interventional radiology

* must provide value

W4.(10-12).Does your facility provide these subspecialty surgical services that are readily available at all times for consultation and treatment as needed onsite?

* must provide value

Adult cardiac surgery

Neurosurgery

Organ transplantation (e.g. heart, liver, kidney)

None of the above

W5. Does your facility have written policies & procedures in place for severe maternal morbidity events?

(Obstetric hemorrhage, hypertensive emergency, etc.)

* must provide value

Yes

No

W5.(1-3). Do theseWRITTEN POLICIES & PROCEDURES include...

* must provide value

Obstetric hemorrhage events

Hypertensive emergency events

Other severe morbidity events

W5.3.1.Specify OTHER severe maternal morbidity events:

* must provide value

W5.1.1 Has your staff practiced drills in preparation for obstetric hemorrhage events within the last 12 months?

* must provide value

Yes

No

W5.2.1 Has your staff practiced drills in preparation for obstetric hypertensive emergency events within the last 12 months?

* must provide value

Yes

No

W6. Is every birth attended by at least one qualified birthing professional (midwife, family physician, or OB-GYN) and an appropriately trained and qualified RN with level-appropriate competencies as demonstrated by nursing competency documentation?

* must provide value

Yes

No

W6.(1-6).What types of obstetric providers does your facility have available to provide maternal care?

* Midwives who meet International Confederation of Midwives standards and who are legally recognized to practice within the jurisdiction of the state.

* must provide value

Obstetrician

Maternal Fetal Medicine Specialist

Family Medicine Physician

Internal Medicine Physician

Midwife*

Other (please specify other obstetric providers)

W6.6.1. Specify OTHER obstetric provider(s):

* must provide value

W6.1.1. Is an OBSTETRICIAN always...

* must provide value

Physically present at all times with full inpatient privileges

Readily available at all times with full inpatient privileges

Available for consultation and assistance or to be onsite, but not 24/7

Available by telemedicine only

Available by phone only

W6.1.2. Is the physician obstetric leadership a board-certified or board-eligible obstetrician with experience in obstetric care.

* must provide value

Yes

No

W6.2.Is a Maternal Fetal Medicine Specialist always...

* must provide value

Readily available at all times with inpatient privileges

Readily available at all times for consultation on site, by phone or by telemedicine as needed

Available for consultation, but not 24/7

Available by telemedicine only

Available by phone only

W6.2.2. Is the director of MFM services a board-certified Maternal Fetal Medicine Specialist?

* must provide value

Yes

No

W6.3.1.Is a Family Medicine physician always...

* must provide value

Physically present at all times with full inpatient privileges

Readily available at all times with full inpatient privileges

Available for consultation, but not 24/7

Available by telemedicine only

Available by phone only

W7. Does your facility have a physician with privileges to perform an emergency C-section who is readily available at all times?

* must provide value

Yes

No

W7.(1-3). What type of physician?

* must provide value

Obstetrician/Gynecologist

Family Medicine Physician with obstetric fellowship training and/or equivalent training skills in obstetrics; and with surgical skill to perform cesarean delivery

Other

W7.3.1. Specify OTHER obstetric provider:

* must provide value

W8. Does your facility have anesthesia providers available for labor analgesia and surgical anesthesia?

(anesthesiologists, nurse anesthetists, or anesthesiologist assistants working with an anesthesiologists)

* must provide value

Yes

No

W8.1.Does your facility have Certified Registered Nurse Anesthetists (CRNA) and/or an Anesthesiologist Assistants working with an Anesthesiologist available for labor analgesia and surgical anesthesia?

* must provide value

Yes

No

W8.1.1.Is a Certified Registered Nurse Anesthetist (CRNA) and/or an Anesthesiologist Assistant always...

* must provide value

Physically present at all times

Readily available at all times

Available to be onsite, but not 24/7

W8.2. Does your facility have a physician anesthesiologist available for labor analgesia and surgical anesthesia?

* must provide value

Yes

No

W8.2.1.Is a physician Anesthesiologist always...

* must provide value

Physically present at all times

Readily available at all times

Available to be onsite, but not 24/7

Available by telemedicine only

Available by phone only

W8.2.2.Is the director of obstetric anesthesia a board-certified physician anesthesiologist with fellowship training or experience in obstetric anesthesia?

* must provide value

Yes

No

W9. Does your facility have ageneral surgeon available for obstetric patients?

* must provide value

Yes

No

W9.1.Is a General Surgeon always...

* must provide value

Physically present at all times

Readily available at all times

Available to be onsite, but not 24/7

Available by telemedicine only

Available by phone only

W10. Does your facility have OTHER types of board-certified or board-eligible physician specialists/subspecialists that are available for obstetric patients?

* must provide value

Cardiologist(s)

Hematologist(s)

Infectious Disease Specialist(s)

Nephrologist(s)

Critical Care Specialist(s) (Anesth, IM, OBGYN, Peds, and/or Surg)

Neurologist(s)

Behavioral health specialist(s)

Gastroenterologist(s)

Neonatologist(s)

Other specialists

None of the above

W10.10.1. Specify OTHER TYPES of physician specialists / subspecialists:

* must provide value

W10.1.1. Is a cardiologist always..

* must provide value

Physically present at all times

Readily available at all times

Available to be onsite, but not 24/7

Available by telemedicine only

Available by phone only

W10.2.1. Is a Hematologist always...

* must provide value

Physically present at all times

Readily available at all times

Available to be onsite, but not 24/7

Available by telemedicine only

Available by phone only

W10.3.1. Is an infectious disease specialist always...

* must provide value

Physically present at all times

Readily available at all times

Available to be onsite, but not 24/7

Available by telemedicine only

Available by phone only

W10.4.1. Is a nephrologist always...

* must provide value

Physically present at all times

Readily available at all times

Available to be onsite, but not 24/7

Available by telemedicine only

Available by phone only

W10.5.1. Is a critical care specialist always...

* must provide value

Physically present at all times

Readily available at all times

Available to be onsite, but not 24/7

Available by telemedicine only

Available by phone only

W10.6.1. Is a neurologist always...

* must provide value

Physically present at all times

Readily available at all times

Available to be onsite, but not 24/7

Available by telemedicine only

Available by phone only

W10.7.1. Is a behavioral health specialist always...

* must provide value

Physically present at all times

Readily available at all times

Available to be onsite, but not 24/7

Available by telemedicine only

Available by phone only

W10.8.1. Is a gastroenterologist always...

* must provide value

Physically present at all times

Readily available at all times

Available to be onsite, but not 24/7

Available by telemedicine only

Available by phone only

W10.9.1. Is a neonatologist always...

* must provide value

Physically present at all times

Readily available at all times

Available to be onsite, but not 24/7

Available by telemedicine only

Available by phone only

W11. Does your facility currently have a MATERNAL LEVEL of CARE designation?

* must provide value

Yes

No

W11.1. What is your MATERNAL LEVEL of CARE designation?

* must provide value

Birthing center

I

II

III

IV

Other

W11.6.1. Specify OTHER maternal level of care designation:

* must provide value

W11.2. How is your MATERNAL LEVEL of CARE designated?

* must provide value

State regulatory based

State voluntary based

ACOG based

Self-designated

Other (please specify)

Unknown (not sure)

W11.2.1. Specify OTHER maternal level of care method:

* must provide value

W12. Based on the 2019ACOG / SMFM GUIDELINES for maternal levels of care, what do you consider your MATERNAL LEVEL of CARE to be?

* Levels of maternal care. Obstetric Care Consensus No. 9. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;134:e41-55.

https://www.acog.org/Clinical-Guidance-and-Publications/Obstetric-Care-Consensus-Series/Levels-of-Maternal-Care

Birthing center

I

II

III

IV

Not sure

S3.1. Number of pregnant women who were DELIVERED at your facility.

* must provide value

S3.2. Number of postpartum women TRANSPORTED OUT to a higher level of care facility AFTER delivery.

* must provide value

S3.3. Number of women who delivered at your facility that RECEIVED 4 or MORE UNITS of WHOLE BLOOD or PACKED CELLS during their delivery event (not to exceed 24 hours).

* must provide value

S3.4. Number of women who delivered at your facility that were ADMITTED to an INTENSIVE CARE UNIT (ICU) during their delivery event (not to exceed 24 hours).

* must provide value

S3.5. Maternal DEATHS prior to discharge.

* must provide value

S4.1. Fetal deaths at 20 to 24 weeks gestation.

* must provide value

S4.2. Fetal deaths at 25 to 28 weeks gestation.

* must provide value

S4.3. Fetal deaths at MORE THAN 28 weeks gestation.

* must provide value

P1. Does your facility practice DISASTER RESPONSE drills

* must provide value

Yes

No

P1.1.(1-2). Do these drills include...

* must provide value

Neonatal Units (Well newborn nursery, Special care nursery, NICU, etc.)?

Obstetric Units (L&D, LDR, LDRP, etc.)

None of the above

Which verification process will your organization be using? Check all that apply.

* must provide value

DHSS

Joint Commission

American Academy of Pediatrics

END OF SURVEY

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