All California Neonatal Transport



Neonatal Transport Data SystemCalifornia Perinatal Transport System (CPeTS) Network DatabaseManaged by California Perinatal Quality Care Collaborative (CPQCC)Manual of DefinitionsFor Infants Born in 20151905000824230Version 13October 2014Table of ContentsREFERRAL…………………………..………………………………………………………...5Note to Imbedded NICUs……………………………………………………………………5Special Situation Overrides………………………………………………………………..5Transport Type……………………………………………………………………………….6Requested Delivery Attendance…………………………………………………………..EmergentUrgent………………………………………………………………………………………..Scheduled Neonatal………………………………………………………………………..Other…………………………………………………………………………………………Indication for Transport…………………………………………………………………….6Medical Dx/Rx Services……………………………………………………………………Surgery………………………………………………………………………………………Insurance…………………………………………………………………………………….Bed Availability………………………………………………………………………………PATIENT IDENTIFICATION: HISTORY...………………………………………………….7Birth weight……………………………………………………………………………………7Gestational Age………………………………………………………………………………7Sex………………………………………………………………………………………………7Prenatally Diagnosed Congenital Anomalies…………………………………………...7Description of Prenatal Diagnosis of Major Birth Defects/Congenital Anomalies8Code 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………………………………………Mother’s Gravida……………………...........................................................................8Antenatal Steroids……………………………………………………………………………8Surfactant Given……………………………………………………………………………..8TIME SEQUENCE………………………………………………...…………………………..9Date/Time of Maternal Admission to Perinatal Unit or Labor & Delivery…………..9Date/Time Infant Birth……………………………………………………………………….9Date/Time First Surfactant Dose…………………………………………………………..9Date/Time Referral Time (and Referral Hospital Evaluation)………………………..9Date/Time Acceptance Time……………………………………………………………….9Date/Time Transport Team Departure from Transport Team Office/NICU for referring Hospital.......................................................................................................10Date/Time Arrival of Team at Referral Hospital/Patient Bedside and Initial Transport Evaluation………………………………………………………………………..10Date/Time Initial Transport Team Evaluation………………………………………..10Date/Time Arrival at Receiving NICU and Initial NICU Evaluation…………………..10INFANT CONDITION……………………………………..................................................10Date/Times at which Infant Condition was evaluated…………………………………10Date/Time of Initial Evaluation by Transport Team…………………………………….10Date/Time of NICU Evaluation……………………………………………………………..10Responsiveness at time of referral, initial transport and NICU admit………………….11Temperature at time of referral, initial transport and NICU admit……………………….11Heart Rate at time of referral, initial and NICU admit……………………………………..11Respiratory Rate at time of referral, initial and NICU admit……………………………..11Oxygen Saturation at time of referral, initial and NICU admit…………………………..11Respiratory Status at time of referral, initial and NICU admit…………………………..11FiO2 at time of referral, initial and NICU admit…………………………………………….12Respiratory Support at referral, initial and NICU admit………………………………….12Blood Pressure systolic/diastolic and mean at referral, initial and NICU admit……….12Pressors at time of referral, initial and NICU admit…………………………………….....12REFERRAL PROCESS…………………………………………………...........................12Referring Hospital……………………………………………………………………………12Was the Infant Previously Transported………………………………………………….13Previous Transfer Referring Hospital…………………………………………………….13Location of Birth…………………………………………………………………………..,,,13Transport Team On-Site Leader...............................................................................13Transport Team From……………………………………………………………………….14Mode of Transport……………………………………………………………………………14CLINICAL INFORMATION (ALL CALIFORNIA TRANSPORT FORM ONLY)………………………………………………………………………………..NON-CORE FORM - ADDITIONAL CLINICAL INFORMATION……………..1617REFERRING PHYSICIAN AND FACILITY INFORMATION…………………..CARE PROVIDERS……………………………………………………............….COMMENTS…………………………………………………………………………INFORMATION MATERIALS TO BE SENT WITH TRANSPORT TEAM…………………………………………………………………………………TRANSPORT ISSUES WITH IMPROVEMENT POTENTIAL…………………1919191919APPENDICES Please go to for all appendices under Neonatal Transport Data System 2014 materialsAPPENDIX A: CPETS CORE FORM APPENDIX B: BIRTH DEFECT CODES FOR CCNTF ITEM C.6APPENDIX C: OSHPD FACILITY CODESAPPENDIX D: FAHRENHEIT TO CENTRIGRADE CONVERSION TABAPPENDIX E: CPeTS/CPQCC Neonatal Transport Data Report Request 2015APPENDIX F: CALIFORNIA PERINATAL TRANSPORT SYSTEM NEONATAL TRIPS SCORE CALCULATIONS FORM – 2015CPeTS STAFF: Ron Cohen, MD. Director, Northern DivisionD. Lisa Bollman, RN, MSN, CPHQ Director, Southern DivisionMichelle Padreddii, RN, BSN, Data Manager for Northern CaliforniaKevin Van Otterloo, MPA Program Manager for Southern CaliforniaI.REFERRALNote: 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#)”.Note: Infants admitted to embedded NICUs (e.g. an NICU owned and managed by one organization located within a delivery facility owned and managed by another hospital) is not considered an acute inter-facility transport for the purpose of the Transport Data System. ?No TRS form is required.Situational Overrides (applicable to Acute Inter-facility Neonatal Transports)Unique situations can complicate the data collection required for Acute Inter-Facility Neonatal Transports. ?Several situations have been identified that will alter the data required (see below). Refer to Appendix J for the summary table.Requested Delivery Attendance:???? When the referring hospitals requests that the receiving NICU transport team attend the delivery of a suspected high-risk infant (formerly called Delivery Room Attendance Requested) then the referring hospital evaluation (TRIPS Score) C.20a-30a (previously T.15a-25a) are not applicable.? When this special situation is selected this area will gray and not be required. Transport by Referring Center (Self-Transport):? When the referring hospital transport team will be used to transport the infant several sections are gray as they are not applicable. ?These include: C.16 (previously 2), C.17 (previously 3) Date/Time of Transport Team Arrival at Referring Hospital, C.18 (previously T.14b) Transport Team Departure for Referring Facility, and C20b-30b (previously T.15b-25b) Initial Transport Team Evaluation (TRIPS Score). Transport from Emergency Department (ER) or other non-perinatal setting: When infants are transported from non-perinatal settings some data may be not applicable or not available. In this case the following items will gray out: C.10 (previously T.5) Date/Time of Mother’s admission to L&D, C.12 (previously T.6) Date/Time of Birth, C.6a (previously T.10) Prenatally diagnosed congenital anomalies, C.7 (previously T.11) Maternal Gravida, C.8 Antenatal Steroids. Use the current birth weight in C.3 (previously T.7). Safe Surrender Infants:? Infants left at designated Safe Surrender sites frequently have little to no known information about their mother or delivery. ?In this case the following areas are grayed: C.10 (previously T.5) Date/Time of Mother’s admission to L&D, C.6a (previously T.10) Prenatally diagnosed congenital anomalies, C.7 (previously T.11) Maternal Gravida, C.8 (previously T.12a) Antenatal Steroids, C.9 (previously T.13a/b) Surfactant Administration, C.10 (previously T.5) Maternal Admission to Perinatal Unit or Labor and Delivery, C.33 (previously T.28) Birth Hospital.? Other information may need to be estimated such as: C.3 (previously T.7) Birth weight (use current weight if unknown), C.4 (previously T.8) Gestational Age, C.12 (previously T.6) Infant birth date and time. ?C.1Transport Type A CPeTS Acute Inter-facility Transport is defined as any infant that requires medical, diagnostic, or surgical therapy that is not provided, or that cannot be provided due to temporary staffing/census issues, or due to insurance restrictions at the referring hospital. A CPeTS Acute Inter-facility Transports do not include infants transported solely for feeding and growing or hospice care. Check type of transport requested. Requested Delivery Attendance. Check if neonatal transport team was initially requested to attend the delivery.Emergent. Check if the infant was an emergent transport. Immediate response is requested. Urgent. Check if response within 6 hours was needed. 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 planned diagnostic or surgical intervention. The medical needs may be extensive and extremely complex care (e.g., an infant with lethal anomalies).Other. Check other if the transport does not conform to other definitions. Describe indication.C.2Indication for Transport.Medical Services. Check if the infant was transported for medical problems that require acute resolution.Surgery. Check if the infant was transported primarily for major invasive surgery (requiring general anesthesia, or its equivalent). Insurance. Check if the infant was transported for insurance purposes. Bed Availability. Check if the infant was transported due to bed availability issues at the referring facility. II.PATIENT IDENTIFICATION: HISTORYC.3 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)C.4Best 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. C.5Infant Sex (A/D Item 5). Check Male or Female. Check Unk if sex cannot be determined. C.6 Congenital Anomalies that were Diagnosed Prenatally (A/DItem 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. Describe: Enter up to 5 Birth Defect Codes that were allDiagnosed 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 HipsC.7a Maternal Date of Birth C.7b Maternal Gravida Enter total number of pregnancies (including current pregnancy) regardless of outcome. Note: Only the total number (Gravida) needs to be filled out on-line. Thenumbers for (P/Ab/L) are to be filled out on the All California NeonatalTransport Form. P. Enter number of birth experiences (>20 weeks)Ab. Enter total number of spontaneous or therapeutic abortionsL. Enter number of living children C.8aAntenatal 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.C.8b Magnesium Sulfate Check Yes if magnesium sulfate was administered to the mother during the pregnancy at any time prior to delivery.Check No if no magnesium sulfate was administered to the mother during the pregnancy at any time prior to delivery.Check unk if this information cannot be obtained. C.9c Birth Head Circumference (OFC)C.9Surfactant Given (A/D Item 21).Check Yes, No or UNK. 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. Given in Delivery room or Nursery?III.TIME SEQUENCEC.10 Date and Time of Maternal Admission to Perinatal Unit orLabor and Delivery.Enter the date using MM/DD/YYYY and time using a 24-hour clock (egg, 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. Enter Unk for TIME ONLY if this information is unavailable (Online only).C.11 Antenatal Steroid Administration (A/D Item 13).Check Yes, No or UNK if the infant received antenatal steroid at any time. Include this information even if it occurred at the birth hospital prior to transport to your center. Given in Delivery room or Nursery?C.12Infant 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 (egg, 11:30 PM = 2330). Enter UNK if unknown (Online only)C.13 Date and Time of First Dose Surfactant Administration.Enter date/time at First Dose. Enter the date using MM/DDYY. Enter the time using a 24-hour clock (egg, 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/N/A if this information cannot be obtained. C.14Referral (and Referring Hospital Evaluation Time).Enter the date and time of the initial referral communication between referring and receiving providers/facilities. Time should be reported using MM/DD/YYYY and the 24-hour clock (egg, 11:30 PM = 2330). The same time is used for the referral evaluation which should be done within 15 minutes. Enter UNK if unknown (Online only)C.15Acceptance Date and Time. Enter the date and time of the transport acceptance using MM/DD/YYYY and 24-hour clock (ex. 11:30 PM = 23:30). Enter UNK if unknown (Online only)C.16 Date/Time of Transport Team Departure from TransportTeam Office/NICU for Referring Hospital.Enter the date using MM/DD/YYYY and time using a 24-hour clock (ex. 11:30 PM = 23:30) Enter UNK if unknown (Online only)C.17/C.18 Date/Time of Arrival of Team at ReferringHospital/Patient Bedside and Initial Transport Team Evaluation.Enter the date using MM/DD/YYYY and time using a 24-hour clock (ex. 11:30 PM = 23:30) Enter UNK if unknown (Online only)C.19 Date and Time of NICU Evaluation within 15 minutes ofArrival 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. Enter UNK if unknown (Online only)IV.INFANT CONDITIONThis section of the record provides consistent information at three specific times for evaluation of overall stability. They should be recorded at referral, within 15 minutes of arrival of the Transport team and then again within 15 minutes of arrival into the receiving NICU.Date/Times at which infant condition was evaluated (For each of these items, items C.20 through C.29 need to be filled out).C.14 Referral (and Referring Hospital Evaluation Time) 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. The same time is used for the referral evaluation which should be done within 15 minutes. Enter UNK if unknown (Online only)C.18 Date and Time of Arrival of Transport Team at Referring Hospital/Patient Bedside and Initial Transport Evaluation.Enter the date and time that the transport team arrived at the referring hospital. Time should be reported on the 24-hour clock. The same time is used for the initial transport team evaluation which should be done within 15 minutes. Enter UNK if unknown (Online only)C.19 Date and Time of Arrival at Receiving NICU and Initial EvaluationEnter the date and time that the transport team arrived at the receiving hospital NICU. Time should be reported on the 24-hour clock. The same time is used for the initial NICU evaluation which should be done within 15 minutes. Enter UNK if unknown (Online only)C.20 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. This also refers to normal age appropriate behavior. Enter UNK if unknown (Online only)C.21Temperature (20.0 to 45.0 C or 68 to 113 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 leave this item blank.If the infant is being actively cooled please enter the infant’s actual temperature.If the infant was undergoing intentional cooling for therapeutic purposes, indicate Yes on the second line and select type of cooling if applicable: Passive, Selective Head, Selective Body, Other or Unknown.If the infant was not undergoing intentional cooling, indicate No and skip the method of cooling.If the infants core body temperature is too low to register please check the box. Enter UNK if unknown (Online only)C.22Heart Rate (0 to 250).Indicate infant’s heart rate. Enter UNK if unknown (Online only)C.23 Respiratory Rate (0 to 400 HIFI/OSC). Indicate infant’s respiratory rate. Note: this rate may be spontaneous or assisted by ventilator. Enter UNK if unknown (Online only)C.24Oxygen Saturation (SaO2) (0 to 100). Indicate average oxygen saturation in percentage. If unknown, indicate UNK (Online only).C.25Respiratory 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 (including none or mild respiratory complications). Enter UNK if unknown (Online only)C.26 Inspired Oxygen ConcentrationInspired Oxygen Concentration (FiO2) (21-100). Indicate inspired oxygen concentration (21-100%). If the infant was given supplemental oxygen, write the FIO2 (percentage of oxygen) in the designated space. If the infant was not given supplemental oxygen, leave the designated space blank. Enter UNK if unknown (Online only)C.27Respiratory Support. Write None (0) if required no respiratory support. Write Hood/NC (1) in the designated space if the infant had spontaneous breathing and was supported using an oxygen hood or nasal cannula. Write NCPAP (2) in the designated space if the infant was provided with continuous positive airway pressure (CPAP) using nasal CPAP. Write ETT (3) in the designated space if the infant was ventilated using an endotracheal tube. 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. Enter UNK if unknown (Online only) C.28 Blood Pressure. Indicate infant’s systolic, diastolic and mean blood pressures. If too low to register please check the box in the online form. Enter UNK if unknown (Online only)C.29 Use of Pressors. Indicate Y (Yes) or N (No) whether vasopressors were administered. V.REFERRAL PROCESS C.30Referring Hospital.Write the name 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 () when answering this question. If the referring hospital is not a CPQCC member hospital, this item is not applicable and may be left blank. C.31a 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.C.31b From If transported previously is answered Yes , write the name of the original hospital and its 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.C.32 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 () when answering this question. If the birth hospital is not a CPQCC member hospital, this item is not applicable and may be left blank.C.33Transport Team On-Site Leader. Choose only one of the following responses: Check Sub-specialist MD for NeonatologistCheck 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 and specify what type of staff member this is in the space provided. C.34a 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 Referring Hospital if the transport team is part of the referring hospital’s staff.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. Please describe.C.34b Amended list of Contract Services.The list has been amended with the list of fixed wing ambulance services in California from the Association of Air Medical Services (). The additional codes are as follows: ? 800000 = Other Contract Service800001 = Aeromedevac, Inc.800002 = Air Rescue - AirRescue International800003 = CALSTAR - California Shock Trauma Air Rescue800004 = PHI Air Medical800005 = Life Flight - Stanford Life Flight Transport Program800006 = REACH - REACH Air Medical Services, Mediplane, Inc. 800007 = Sierra LifeFlight800008 = Pro TransportC.35Mode of Transport.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.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. Do not collect the CPeTS.Enter the date of death using MM/DD/YY. Enter the time of death using a 24-hour clock (ex. 11:30 PM = 2330).Write the name and telephone number of the Referring Transport Coordinator in the designated space. Comments. Please add any comments from the transport team of incidents relevant to this transport.Modified TRIPS ScoreThe severity of the infant condition is very important to assess quickly and can dictate the composition of the transport team and the type of transport requested. Being able to assess the infant condition at different times and then predict mortality or even death is part of California Perinatal Transport System. The assessment of the infant condition at referral, initial transport and NICU admission using the Modified TRIPS Score can be used to calculate the risk of death of the infant within 7 days of transport. The TRIPS methodology in California is a physiology-based assessment comprised of temperature, blood pressure, response to noxious stimuli, respiratory status, use of pressors to support blood pressure and use of a ventilator. It is used both for the infant condition and as an assessment of the quality of care at the referral center by assessing changes in the infant condition between Referral and Initial Modified TRIPS Score. It is also used to assess the quality of the neonatal transport by assessing change in the Modified TRIPS Score during the actual transport. Reviewing the Modified TRIPS Score helps identify quality improvement initiatives. An online trips score / risk of mortality calculator suitable for smart phones is available at ( google TRIPS SCORE CALCULATOR ) . VI. CLINICAL INFORMATION (ALL CALIFORNIA TRANSPORT FORM ONLY)This information is helpful to provide continuity of care. Infant nameSingleton/Multiple Births. Check Singleton for any birth Check Multiple for any birth involving more than a singleton infant and for any multifetal gestation. 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. Current Weight in gramsDiagnosisAllergies.Check Yes if the infant has known allergies, and write in what type of allergies the infant has. Check No if the infant has no known allergies. Check Unk if there is no indication in the record regarding whether or not the infant has known allergies.Any Surgeries Enter Yes if infant underwent surgery at any time. Enter No if infant has not undergone surgery. If Yes, note indication.Mother’s Name Mother’s Birth Date. Enter the date of mother’s birth using MM/DD/YYYY. Insurance Type. Enter the Insurance of the Mother if known.Note: For transports within the first month of life, Mother’s insurance type is assumed to be the infant’s insurance type as well. Medical Record Number at Delivery HospitalGravida, Para, Abortions, LivingRupture of Membranes (a) Enter the date using MM/DD/YYYY and time using a 24-hour clock (ex. 11:30 PM = 23:30) 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- see CPQCC Admission/Discharge FormThis 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 severityInfection. 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.Antepartum or Intrapartum 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. Delivery Type. 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. VII. NON CORE FORM - ADDITIONAL CLINICAL INFORMATIONVentilator SettingsEnter the Type or Mode of ventilation along with Oxygen %, Pressures, Rate and Inspiratory/Expiratory timesBlood Gas Results at time of referral, initial transport or NICU admit. If arterial blood gas results were clinically indicated and obtained for transport, indicate results. If blood gases not obtained leave this space blank.pHPCO2BE (Base Excess/Deficit)Intravenous and Fluid Administration.If applicable document IV Type, Fluids, Rate and Times Hemoglobin/Hematocrit.Enter the date using MM/DD/YYYY and time using a 24-hour clock (ex. 11:30 PM = 23:30) and results.Blood Culture.Enter the date using MM/DD/YYYY and time using a 24-hour clock (ex 11:30 PM = 23:30) and results.Imaging.Enter type of imagining done and results as well as the date using MM/DD/YYYY and time using a 24-hour clock (ex. 11:30 PM = 23:30).Chest X-Ray.Enter results as well as the date using MM/DD/YYYY and time using a 24-hour clock (ex. 11:30 PM = 23:30).Bilirubin.Enter the date using MM/DD/YYYY and time using a 24-hour clock (ex. 11:30 PM = 23:30) and results.Neonatal Screening. Hearing. Indicate Yes if screening completed, No if screening not completed and Unk if the information is not obtainable. Metabolic (PKU, T4, Galactosemia, Hemoglobinopathies). Indicate Yes if screening completed, No if screening not completed and Unk if the information is not obtainable. Substance Exposure. Indicate Yes if screening completed and provide results, No if screening not completed and Unk if the information is not obtainable. Medication AdministrationIf applicable document any medications given in the delivery room, last doses of medication given at the referral center and medications given en route.Enter the date using MM/DD/YYYY and time using a 24-hour clock (ex. 11:30 PM = 23:30). Medication name, Dose and RouteEnteral Feeding. First Enteral Feeding. Enter the type (Human Milk Only, Human 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 (egg, 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, Human 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 (ex. 11:30 PM = 23:30).If the infant has not yet received his first enteral feeding, this item is not applicable and may be left blank.Last Urine.Enter the date using MM/DD/YYYY and time using a 24-hour clock (ex. 11:30 PM = 23:30)Last Stool.Enter the date using MM/DD/YYYY and time using a 24-hour clock (ex. 11:30 PM = 23:30)Other Clinical Information.Blood Transfusion.Enter the date using MM/DD/YYYY and time using a 24-hour clock (ex. 11:30 PM = 23:30VIII. REFERRING PHYSICIAN AND FACILITY INFORMATIONWrite the name of the referring hospital in the designated space. Write the telephone number of the NICU of the referring hospital in the designated space. This should include the OB, Pediatrician and Informant. Write the referring hospital’s CPQCC membership number in the designated space. Please refer to the current Membership Directory on the CPQCC website () 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 accepting Physician in the designated space. Write the telephone number of the accepting Physician in the designated space. IX.CARE PROVIDERS Referring Hospital.Enter the date using MM/DD/YYYY and time using a 24-hour clock (egg, 11:30 PM = 2330)Transport Team.Enter the date using MM/DD/YYYY and time using a 24-hour clock (egg, 11:30 PM = 2330)MENTSPlease provide your comments in this section.RMATION/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 NeonatalBlood Specimen.Check Maternal and/or NeonatalImaging Copies.Other.Specify all additional items transported with infantXII.TRANSPORT ISSUES WITH IMPROVEMENT POTENTIAL Transport Issues with Improvement Potential Form allows providers form both referring and receiving hospitals, as well as the transport team, to identify aspects of the transport that were either problematic or didn’t go as expected, thereby subject to quality improvement. This form is intended for internal use only (i.e., it should not be filed with the infant’s chart or submitted to CPeTS) and should be used to alert providers to issues that may benefit from internal Quality Improvement strategies.Delay in Transport:Check Delay in transport if a transport delay occurred. Describe the situation that resulted in the transport delay in the space provided. Check Amb./vehicle issues if the delay was related to problems with the transportation rig or vendor. Check Traffic is the delay was related to traffic issues out of the control of the transport team. Check Missed opportunity for maternal transport if the delay was related to either an unwitting or deliberate failure to identify a patient who could benefit from maternal transport in time to safely affect that transport. Check Delay in transferring infant if the delay was related to either an unwitting or deliberate failure to identify a patient who could benefit from neonatal transport in time to safely affect that transport.Transport Team Difficulties:Check Transport Team Difficulties, if they occurred, and describe these difficulties in the space provided.Equipment Difficulties:Check Equipment Difficulties, if they occurred, and describe these difficulties in the space provided.Unplanned Intervention During Transport:Check Unplanned Intervention During Transport if any unplanned intervention was required. Describe the situation that resulted in the unplanned intervention in the space provided. Check Airway if the intervention involved the establishment or maintenance of a patent airway. Check Vascular Access if the intervention involved establishing or maintaining functional vascular access. Check Return to Referring Hospital if a situation arose requiring that the transport team and infant return to the referring hospital. This may involve a problem with the infant, the transport equipment, the transport rig, or the transport team. Check Other if some other situation arose requiring that the transport team and infant return to the referring hospital, and describe the situation in the space provided.CPR During Transport:Check CPR during transport if the infant required resuscitation during transport.Death Prior to Admission to Receiving NICU:Check Death prior to admission to receiving NICU, if the infant being transported expires during the actual transport (i.e., after leaving the referring hospital but before being admitted to the receiving hospital). Please note the Special Instructions at the bottom of this form: 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.None:Check None is there were no identified neonatal transport issues with improvement potential identified during the transport.Other:Check Other if any issues, other than those identified above, arose during the transport, and describe the situation in the space ments:Please provide your comments in this section.Referral to Joint Mortality/Morbidity Review:Check “Y” if the transport was referred for Joint Mortality/Morbidity Review by either the referring or receiving hospital, or both. Check “N” if the transport was not referred for Joint Mortality/Morbidity Review by either the referring or receiving hospital, or both. Check “Unk” if you do not know whether or not the transport was referred for Joint Mortality/Morbidity Review by either the referring or receiving hospital, or both.If the transport was referred for Joint Mortality and Morbidity Review, write the date of the review in the space provided.Outcome of Review: Check Policy/Procedure Change if the M&M Review requested a change in unit policy and/or procedure. Check Joint QI Project if the M&M Review recommended or resulted in a joint QI project between the referring and receiving hospital, and/or the transport team. Check Education Offering if the M&M Review recommended or resulted in continuing education or in-service being offered to appropriate providers and/or staff at the referring and/or receiving hospital, or to the neonatal transport team. Check Consultation if the M&M review recommended or resulted in obtaining appropriate consultation for the referring and/or receiving hospital, or the neonatal transport team. Check Other if the M&M Review resulted in any other outcomes not listed above, and describe these outcomes in the space provided.Follow up: Record the outcome of the quality improvement process stimulated by this worksheet in the space provided. Record any follow up or additional strategies planned to deal with the QI issue identified.APPENDICES APPENDIX A CORE CPETS ACUTE INTER-FACILITY- NEONATAL TRANSPORT FORM – 2015 PLEASE PRINT ELIGIBLY REFERRAL Special Situations: ? None ? Delivery Attendance ? Transport by Referring Facility ? Transport from ER ? Safe Surrender C.1 Transport type ? Requested Delivery Attendance ? Emergent ? Urgent ? Scheduled Maternal Date of Birth ? Unknown C.2. Indication ? Medical Services ? Surgery ? Insurance ? Bed Availability PATIENT IDENTIFICATION/HISTORY: C.3 Birth weight ___ ___ ___ ___ grams C.4 Gestational Age ___ ___weeks____ days C.5 ? Male ?Female ?Unknown C.6 Prenatally Diagnosed Congenital Anomalies ? Yes ? No ? Unknown Describe: C.7 a.Maternal Gravida Steroids ?Yes ?No ? Unknown Antenatal Magnesium Sulfate ?Yes ?No ? Unknown C.9 Surfactant Given ?Yes ?No ?Unknown ? Delivery Room ? Nursery Birth Head Circumference (OFC) cm TIME SEQUENCE Date Time C.10 Maternal Admission to Perinatal Unit or Labor & Delivery C.11 Last Antenatal Steroid Administration (last dose) ? N/A ? Unknown C.12 Infant Birth C.13 Surfactant (first dose) ? N/A ? Unknown C.14 Referral (and Referring Hospital Evaluation) C.15 Acceptance C.16 Transport Team Departure from Transport Team Office/NICU for Referring Hospital C.17 Arrival of Team at Referring Hospital/Patient Bedside and Initial Transport Evaluation C.18 Initial Transport Team Evaluation C.19 Arrival at Receiving NICU and Initial Evaluation INFANT CONDITION REFERRAL PROCESS Modified TRIPS Score: to be recorded on referral, within 15 minutes of arrival at referring hospital and admit to NICU. C.30 Referring Hospital Name Previous CPQCC ID# Referral Initial Transport NICU Admit C.31 Previously Transported? ?Yes ?No From: C.32 Birth Hospital Name Time (24 hour) C.14 C.18 C.19 C.33Transport Team On-Site Leader (check only one) ?Sub-specialist Physician ?Pediatrician ?Other MD/Resident ?Neonatal Nurse Practitioner ?Transport Specialist ?Nurse C.20 Responsiveness? C.21 Temperature C° C.34Team From ?Receiving Hospital ?Referring Hospital ?Contract Service Describe: Too low to register ?Yes ?Yes ?Yes Was the infant cooled? ?Y ?N ?Y?N ?Y ?N Method of cooling? C.35 Mode ?Ground ?Helicopter ?Fixed Wing C.22 Heart Rate Death?No ?Yes ?Prior to Team Arrival ? Prior to Departure from Referring Hospital ? Prior to Arrival at Receiving NICU C.23 Respiratory Rate C.24 Oxygen Saturation Transport Team RN Signature C.25 Respiratory Status ? Referring Hospital Transport Nursing Contact Information Name: Telephone C.26 Inspired Oxygen Concentration C.27 Respiratory Support ? C.28 Blood Pressure Systolic/ Diastolic, Mean Comments Too low to register ?Yes ?Yes ?Yes C.29 Pressors ?Y ?N ?Y?N ?Y ?N ?Responsiveness: 0=Death 1=None, Seizure, Muscle Relaxant 2=Lethargic, no cry 3=Vigorously withdraws, cry ?Method of cooling: Passive, Selective Head, Selective Body, Other, Unknown ?Respiratory Status: 1=Respirator 2= Severe (apnea, gasping, intubated not on respirator) 3=Other ?Respiratory Support: 0 = None, 1 = Hood/Nasal Cannula. 2 = Nasal Continuous Positive Airway Pressure, 3 = Endotracheal Tube Patient Identification Stamp This data is mandatory for all infants transported in the State of California per California Perinatal Transport System. Rev 10/2014 APPENDIX BBIRTH DEFECTS CODES FOR ITEM 49Code Other Lethal or Life Threatening Birth Defect100 Other Lethal or Life-Threatening Birth Defect which is not listed belowCode Central Nervous System Defects100 Other lethal or life threatening CNS Defects (DESCRIBE)101 Anencephaly102 Meningomyelocele103 Hydranencephaly104 Congenital Hydrocephalus105 HoloprosencephalyCodeCongenital Heart Defects200 Other lethal or life threatening congenital heart defects(DESCRIBE)201 Truncus Arteriosus202 Transposition of the Great Vessels203 Tetralogy of Fallot204 Single Ventricle205 Double Outlet Right Ventricle206 Complete Atrio-Ventricular Canal207 Pulmonary Atresia with intact ventricular septum208 Tricuspid Atresia209 Hypoplastic Left Heart Syndrome210 Interrupted Aortic Arch211 Total Anomalous Pulmonary Venous Return212 Penatalogy of Cantrell (Thoraco-Abdominal Ectopia Cordis)CodeGastro-Intestinal Defects300 Other lethal or life threatening GI Defects (DESCRIBE)301 Cleft Palate302 Tracheo-Esophageal Fistula303 Esophageal Atresia304 Duodenal Atresia305 Jejunal Atresia306 Ileal Atresia307 Atresia of Large Bowel or Rectum308 Imperforate Anus309 Omphalocele310 Gastroschisis311 Biliary AtresiaCodeGenito-Urinary Defects401 Bilateral Renal Agenesis402 Bilateral Polycystic, Multicystic, or Dysplastic Kidneys403 Obstructive Uropathy with Congenital Hydronephrosis404 Exstrophy of the Urinary Bladder400 Other Lethal or Life Threatening Genito-Urinary defects notlisted above (DESCRIBE)CodeChromosomal Abnormalities501 Trisomy 13502 Trisomy 18503 Trisomy 21505 TriploidyCodeOther Birth Defects601 Skeletal Dysplasia (DESCRIBE)602 Congenital Diaphragmatic Hernia603 Hydrops Fetalis with anasarca and one or more of thefollowing: ascites, pleural effusion, pericardial effusion604 Oligohydramnios sequence including all 3 of the following: (1)Oligohydramnios documented by antenatal ultrasound 5 ormore days prior to delivery, (2) evidence of fetal constraint onpostnatal physical exam (such as Potter’s facies,contractures, or positional deformities of limbs), and (3)postnatal respiratory failure requiring endotracheal intubationand assisted ventilation.605 Inborn Error of Metabolism (description required)606 Myotonic Dystrophy requiring endotracheal intubation andassisted ventilation607 Conjoined Twins608 Trachael Agenesis or Atresia609 Thanatophoric Dysplasia Types 1 and 2610 Hemoglobin BartsCodePulmonary Defects800 Other Lethal or Life Threatening Pulmonary Malformation(DESCRIBE)801 Congenital Cystic Adenomatoid Malformation of the LungAPPENDIX COSHPD #HOSPITAL NAMECITYCOUNTY010735ALAMEDA HOSPITALALAMEDAALAMEDA010989ALAMEDA HOSPITAL AT WATERS EDGEALAMEDAALAMEDA010956ALAMEDA HOSPITAL-SOUTH SHORE CONVALESCENT HOSPITALALAMEDAALAMEDA190017ALHAMBRA HOSPITAL MEDICAL CENTERALHAMBRALOS ANGELES250956MODOC MEDICAL CENTERALTURASMODOC301097ANAHEIM GENERAL HOSPITALANAHEIMORANGE301098ANAHEIM REGIONAL MEDICAL CENTERANAHEIMORANGE304409KAISER FND HOSP - ORANGE COUNTY - ANAHEIMANAHEIMORANGE301132KAISER FND HOSP - ORANGE COUNTY - LAKEVIEWANAHEIMORANGE301379WEST ANAHEIM MEDICAL CENTERANAHEIMORANGE301188WESTERN MEDICAL CENTER ANAHEIMANAHEIMORANGE074097KAISER FND HOSP - ANTIOCHANTIOCHCONTRA COSTA070934SUTTER DELTA MEDICAL CENTERANTIOCHCONTRA COSTA361343ST. MARY MEDICAL CENTER IN APPLE VALLEYAPPLE VALLEYSAN BERNARDINO190529METHODIST HOSPITAL OF SOUTHERN CALIFORNIAARCADIALOS ANGELES121002MAD RIVER COMMUNITY HOSPITALARCATAHUMBOLDT400466MARIAN REGIONAL MEDICAL CENTER, ARROYO GRANDEARROYO GRANDESAN LUIS OBISPO400683ATASCADERO STATE HOSPITALATASCADEROSAN LUIS OBISPO310791SUTTER AUBURN FAITH HOSPITALAUBURNPLACER190045CATALINA ISLAND MEDICAL CENTERAVALONLOS ANGELES154101BAKERSFIELD HEART HOSPITALBAKERSFIELDKERN150722BAKERSFIELD MEMORIAL HOSPITALBAKERSFIELDKERN154160CRESTWOOD PSYCHIATRIC HEALTH FACILITY 2BAKERSFIELDKERN150775GOOD SAMARITAN HOSPITAL-BAKERSFIELDBAKERSFIELDKERN154044GOOD SAMARITAN HOSPITAL-SOUTHWEST D/P APHBAKERSFIELDKERN154022HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITALBAKERSFIELDKERN150736KERN MEDICAL CENTERBAKERSFIELDKERN150761MERCY HOSPITAL - BAKERSFIELDBAKERSFIELDKERN154108MERCY SOUTHWEST HOSPITALBAKERSFIELDKERN150788SAN JOAQUIN COMMUNITY HOSPITALBAKERSFIELDKERN196035KAISER FND HOSP - BALDWIN PARKBALDWIN PARKLOS ANGELES190049KINDRED HOSPITAL BALDWIN PARKBALDWIN PARKLOS ANGELES331326SAN GORGONIO MEMORIAL HOSPITALBANNINGRIVERSIDE364430BARSTOW COMMUNITY HOSPITALBARSTOWSAN BERNARDINO190066BELLFLOWER MEDICAL CENTERBELLFLOWERLOS ANGELES194044BELLWOOD HEALTH CENTERBELLFLOWERLOS ANGELES010844ALTA BATES SUMMIT MED CTR-HERRICK CAMPUSBERKELEYALAMEDA010739ALTA BATES SUMMIT MEDICAL CENTERBERKELEYALAMEDA361110BEAR VALLEY COMMUNITY HOSPITALBIG BEAR LAKESAN BERNARDINO141273NORTHERN INYO HOSPITALBISHOPINYO331288PALO VERDE HOSPITALBLYTHERIVERSIDEOSHPD #HOSPITAL NAMECITYCOUNTY130760PIONEERS MEMORIAL HEALTHCARE DISTRICTBRAWLEYIMPERIAL301127KINDRED HOSPITAL BREABREAORANGE301109ANAHEIM GENERAL HOSPITAL - BUENA PARK CAMPUSBUENA PARKORANGE190758PROVIDENCE ST. JOSEPH MEDICAL CENTERBURBANKLOS ANGELES413500BURLINGAME HEALTH CARE CENTER D/P SNFBURLINGAMESAN MATEO410852MILLS-PENINSULA MEDICAL CENTERBURLINGAMESAN MATEO560508ST. JOHN'S PLEASANT VALLEY HOSPITALCAMARILLOVENTURA434051CHILDRENS RECOVERY CENTER OF NORTHERN CALIFORNIACAMPBELLSANTA CLARA190859WEST HILLS HOSPITAL AND MEDICAL CENTERCANOGA PARKLOS ANGELES344170CRESTWOOD PSYCHIATRIC HEALTH FACILITY-CARMICHAELCARMICHAELSACRAMENTO340950MERCY SAN JUAN MEDICAL CENTERCARMICHAELSACRAMENTO014233EDEN MEDICAL CENTERCASTRO VALLEYALAMEDA250955SURPRISE VALLEY COMMUNITY HOSPITALCEDARVILLEMODOC504081TELECARE STANISLAUS COUNTY PHFCERESSTANISLAUS190184COLLEGE HOSPITALCERRITOSLOS ANGELES321016SENECA HEALTHCARE DISTRICTCHESTERPLUMAS044006BUTTE COUNTY MENTAL HEALTH SERVICESCHICOBUTTE040828ENLOE MEDICAL CENTER - COHASSETCHICOBUTTE040962ENLOE MEDICAL CENTER- ESPLANADECHICOBUTTE044011ENLOE REHABILITATION CENTERCHICOBUTTE364050CANYON RIDGE HOSPITALCHINOSAN BERNARDINO361144CHINO VALLEY MEDICAL CENTERCHINOSAN BERNARDINO370775PARADISE VALLEY HSP D/P APH BAYVIEW BEH HLTHCHULA VISTASAN DIEGO370658SCRIPPS MERCY HOSPITAL CHULA VISTACHULA VISTASAN DIEGO370875SHARP CHULA VISTA MEDICAL CENTERCHULA VISTASAN DIEGO171049ST. HELENA HOSPITAL - CLEARLAKECLEARLAKELAKE100005CLOVIS COMMUNITY MEDICAL CENTERCLOVISFRESNO100697COALINGA REGIONAL MEDICAL CENTERCOALINGAFRESNO105051DEPARTMENT OF STATE HOSPITAL - COALINGACOALINGAFRESNO364231ARROWHEAD REGIONAL MEDICAL CENTERCOLTONSAN BERNARDINO060870COLUSA REGIONAL MEDICAL CENTERCOLUSACOLUSA074039JOHN MUIR BEHAVIORAL HEALTH CENTERCONCORDCONTRA COSTA071018JOHN MUIR MEDICAL CENTER-CONCORD CAMPUSCONCORDCONTRA COSTA331145CORONA REGIONAL MEDICAL CENTER-MAGNOLIACORONARIVERSIDE331152CORONA REGIONAL MEDICAL CENTER-MAINCORONARIVERSIDE370689SHARP CORONADO HOSPITAL AND HEALTHCARE CENTERCORONADOSAN DIEGO374321VILLA CORONADO CONVALESCENT (DP/SNF)CORONADOSAN DIEGO301155COLLEGE HOSPITAL COSTA MESACOSTA MESAORANGE301781FAIRVIEW DEVELOPMENTAL CENTERCOSTA MESAORANGE190163AURORA CHARTER OAKCOVINALOS ANGELES190413CITRUS VALLEY MEDICAL CENTER - IC CAMPUSCOVINALOS ANGELES084001SUTTER COAST HOSPITALCRESCENT CITYDEL NORTEOSHPD #HOSPITAL NAMECITYCOUNTY197931EXODUS RECOVERY P.H.F.CULVER CITYLOS ANGELES190110SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITYCULVER CITYLOS ANGELES410817SETON MEDICAL CENTERDALY CITYSAN MATEO574010SUTTER DAVIS HOSPITALDAVISYOLO150706DELANO REGIONAL MEDICAL CENTERDELANOKERN196403KAISER FND HOSP - DOWNEYDOWNEYLOS ANGELES191306LAC/RANCHO LOS AMIGOS NATIONAL REHAB CENTERDOWNEYLOS ANGELES190243PIH HOSPITAL - DOWNEYDOWNEYLOS ANGELES190176CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITALDUARTELOS ANGELES130699EL CENTRO REGIONAL MEDICAL CENTEREL CENTROIMPERIAL491267SONOMA DEVELOPMENTAL CENTERELDRIDGESONOMA371394RADY CHILDREN’S HOSPITAL SAN DIEGO AT SCRIPPS ENCINITAS (RCHSD)ENCINITASSAN DIEGO190280ENCINO HOSPITAL MEDICAL CENTERENCINOLOS ANGELES374382PALOMAR MEDICAL CENTERESCONDIDOSAN DIEGO370755RADY CHILDREN’S NICU AT PALOMAR MEDICAL CENTER (RCHSD)ESCONDIDOSAN DIEGO120981GENERAL HOSPITAL, THEEUREKAHUMBOLDT124004SEMPERVIRENS P.H.F.EUREKAHUMBOLDT121080ST. JOSEPH HOSPITAL - EUREKAEUREKAHUMBOLDT481357NORTHBAY MEDICAL CENTERFAIRFIELDSOLANO450936MAYERS MEMORIAL HOSPITALFALL RIVER MILLSSHASTA370704FALLBROOK HOSP DISTRICT SKILLED NURSING FACILITYFALLBROOKSAN DIEGO370705FALLBROOK HOSPITAL DISTRICTFALLBROOKSAN DIEGO344029MERCY HOSPITAL - FOLSOMFOLSOMSACRAMENTO344035VIBRA HOSPITAL OF SACRAMENTOFOLSOMSACRAMENTO361223KAISER FND HOSP - FONTANAFONTANASAN BERNARDINO231013MENDOCINO COAST DISTRICT HOSPITALFORT BRAGGMENDOCINO121051REDWOOD MEMORIAL HOSPITALFORTUNAHUMBOLDT301175FOUNTAIN VALLEY REGIONAL HOSPITAL & MEDICAL CENTERFOUNTAIN VALLEYORANGE304039FOUNTAIN VALLEY RGNL HOSP AND MED CTR - WARNERFOUNTAIN VALLEYORANGE300225ORANGE COAST MEMORIAL MEDICAL CENTERFOUNTAIN VALLEYORANGE014034FREMONT HOSPITALFREMONTALAMEDA014132KAISER FND HOSP - FREMONTFREMONTALAMEDA010987WASHINGTON HOSPITAL - FREMONTFREMONTALAMEDA391010SAN JOAQUIN GENERAL HOSPITALFRENCH CAMPSAN JOAQUIN100899CHILDREN’S HOSPITAL CENTRAL CALIFORNIA- ST. AGNES HOSPITAL (CHCC)FRESNOFRESNO104008COMMUNITY BEHAVIORAL HEALTH CENTERFRESNOFRESNO100717COMMUNITY REGIONAL MEDICAL CENTER (CRMC)FRESNOFRESNO100718COMMUNITY SUBACUTE AND TRANSITIONAL CARE CENTERFRESNOFRESNO104089CRESTWOOD PSYCHIATRIC HEALTH FACILITY-FRESNOFRESNOFRESNOOSHPD #HOSPITAL NAMECITYCOUNTY105029FRESNO HEART AND SURGICAL HOSPITALFRESNOFRESNO104047FRESNO SURGICAL HOSPITALFRESNOFRESNO104062KAISER FND HOSP - FRESNOFRESNOFRESNO104023SAN JOAQUIN VALLEY REHABILITATION HOSPITALFRESNOFRESNO301342ST. JUDE MEDICAL CENTERFULLERTONORANGE121031JEROLD PHELPS COMMUNITY HOSPITALGARBERVILLEHUMBOLDT301283GARDEN GROVE HOSPITAL AND MEDICAL CENTERGARDEN GROVEORANGE190196KINDRED HOSPITAL SOUTH BAYGARDENALOS ANGELES190521MEMORIAL HOSPITAL OF GARDENAGARDENALOS ANGELES494047WOODLANDS PSYCHIATRIC HEALTH FACILITYGEYSERVILLESONOMA434138ST. LOUISE REGIONAL HOSPITALGILROYSANTA CLARA190323GLENDALE ADVENTIST MEDICAL CENTERGLENDALELOS ANGELES190522GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTERGLENDALELOS ANGELES190818USC VERDUGO HILLS HOSPITALGLENDALELOS ANGELES190298FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIALGLENDORALOS ANGELES190328GLENDORA COMMUNITY HOSPITALGLENDORALOS ANGELES291023SIERRA NEVADA MEMORIAL HOSPITALGRASS VALLEYNEVADA211006MARIN GENERAL HOSPITALGREENBRAEMARIN040802BIGGS GRIDLEY MEMORIAL HOSPITALGRIDLEYBUTTE164029ADVENTIST MEDICAL CENTERHANFORDKINGS160787CENTRAL VALLEY GENERAL HOSPITALHANFORDKINGS190431KAISER FND HOSP - SOUTH BAYHARBOR CITYLOS ANGELES190159GARDENS REGIONAL HOSPITAL AND MEDICAL CENTERHAWAIIAN GARDENSLOS ANGELES190523LOS ANGELES METROPOLITAN MED CTR-HAWTHORNE CAMPUSHAWTHORNELOS ANGELES010967ST. ROSE HOSPITALHAYWARDALAMEDA490964HEALDSBURG DISTRICT HOSPITALHEALDSBURGSONOMA334032HEMET VALLEY HEALTH CARE CENTERHEMETRIVERSIDE331194HEMET VALLEY MEDICAL CENTERHEMETRIVERSIDE350784HAZEL HAWKINS MEMORIAL HOSPITALHOLLISTERSAN BENITO351814HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNFHOLLISTERSAN BENITO190380SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOODHOLLYWOODLOS ANGELES301209HUNTINGTON BEACH HOSPITALHUNTINGTON BEACHORANGE190197COMMUNITY HOSPITAL OF HUNTINGTON PARKHUNTINGTON PARKLOS ANGELES331216JOHN F KENNEDY MEMORIAL HOSPITALINDIORIVERSIDE334457TELECARE RIVERSIDE COUNTY PSYCHIATRIC HEALTH FACILITYINDIORIVERSIDE190148CENTINELA HOSPITAL MEDICAL CENTERINGLEWOODLOS ANGELES304045HOAG HOSPITAL IRVINEIRVINEORANGE304460HOAG ORTHOPEDIC INSTITUTEIRVINEORANGE304306KAISER FND HOSP - ORANGE COUNTY - IRVINEIRVINEORANGE034002SUTTER AMADOR HOSPITALJACKSONAMADOROSHPD #HOSPITAL NAMECITYCOUNTY362041HI-DESERT MEDICAL CENTERJOSHUA TREESAN BERNARDINO210993KENTFIELD REHABILITATION & SPECIALTY HOSPITALKENTFIELDMARIN270777GEORGE L MEE MEMORIAL HOSPITALKING CITYMONTEREY370771RADY CHILDREN’S HOSPITAL SAN DIEGO AT SCRIPPS LA JOLLA (RCHSD)LA JOLLASAN DIEGO371256SCRIPPS GREEN HOSPITALLA JOLLASAN DIEGO374141UCSD-LA JOLLA, JOHN M/SALLY B THORNTON HOSP & SULPIZO CARDIOLA JOLLASAN DIEGO370749ALVARADO PARKWAY INSTITUTE B.H.S.LA MESASAN DIEGO370714SHARP GROSSMONT HOSPITAL, WOMEN’S HEALTH CENTERLA MESASAN DIEGO190449KINDRED HOSPITAL - LA MIRADALA MIRADALOS ANGELES301234LA PALMA INTERCOMMUNITY HOSPITALLA PALMAORANGE301337MISSION HOSPITAL LAGUNA BEACHLAGUNA BEACHORANGE301317SADDLEBACK MEMORIAL HOSPITALLAGUNA HILLSORANGE361266MOUNTAINS COMMUNITY HOSPITALLAKE ARROWHEADSAN BERNARDINO150737KERN VALLEY HEALTHCARE DISTRICTLAKE ISABELLAKERN171395SUTTER LAKESIDE HOSPITALLAKEPORTLAKE190240LAKEWOOD REGIONAL MEDICAL CENTERLAKEWOODLOS ANGELES190034ANTELOPE VALLEY HOSPITALLANCASTERLOS ANGELES010983VALLEY MEMORIAL HOSPITALLIVERMOREALAMEDA390923LODI MEMORIAL HOSPITALLODISAN JOAQUIN390922LODI MEMORIAL HOSPITAL - WESTLODISAN JOAQUIN361245LOMA LINDA UNIV. MED. CENTER EAST CAMPUS HOSPITALLOMA LINDASAN BERNARDINO364502LOMA LINDA UNIVERSITY CHILDREN'S HOSPITALLOMA LINDASAN BERNARDINO361246LOMA LINDA UNIVERSITY MEDICAL CENTERLOMA LINDASAN BERNARDINO364451TOTALLY KIDS REHABILITATION HOSPITALLOMA LINDASAN BERNARDINO420491LOMPOC VALLEY MEDICAL CENTERLOMPOCSANTA BARBARA420552LOMPOC VALLEY MEDICAL CENTER COMPREHENSIVE CARE CENTER D/P SLOMPOCSANTA BARBARA424102THE CHAMPION CENTERLOMPOCSANTA BARBARA141338SOUTHERN INYO HOSPITALLONE PINEINYO190587COLLEGE MEDICAL CENTERLONG BEACHLOS ANGELES190477COLLEGE MEDICAL CENTER SOUTH CAMPUS D/P APHLONG BEACHLOS ANGELES190475COMMUNITY HOSPITAL LONG BEACHLONG BEACHLOS ANGELES194981LA CASA PSYCHIATRIC HEALTH FACILITYLONG BEACHLOS ANGELES190525LONG BEACH MEMORIAL MEDICAL CENTERLONG BEACHLOS ANGELES196168MILLER CHILDREN’S HOSPITAL AT LONG BEACH MEMORIAL HOSPITALLONG BEACHLOS ANGELES190053ST. MARY MEDICAL CENTERLONG BEACHLOS ANGELES191225TOM REDGATE MEMORIAL RECOVERY CENTERLONG BEACHLOS ANGELES301248LOS ALAMITOS MEDICAL CENTERLOS ALAMITOSORANGE190052BARLOW RESPIRATORY HOSPITALLOS ANGELESLOS ANGELES190125CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELESLOS ANGELESLOS ANGELESOSHPD #HOSPITAL NAMECITYCOUNTY190555CEDARS-SINAI MEDICAL CENTERLOS ANGELESLOS ANGELES190155CENTURY CITY DOCTORS HOSPITALLOS ANGELESLOS ANGELES190170CHILDREN’S HOSPITAL LOS ANGELESLOS ANGELESLOS ANGELES190256EAST LOS ANGELES DOCTORS HOSPITALLOS ANGELESLOS ANGELES190317GATEWAYS HOSPITAL AND MENTAL HEALTH CENTERLOS ANGELESLOS ANGELES190392GOOD SAMARITAN HOSPITAL, LOS ANGELESLOS ANGELESLOS ANGELES190382HOLLYWOOD PRESBYTERIAN MEDICAL CENTERLOS ANGELESLOS ANGELES190646KAISER FND HOSP - MENTAL HEALTH CENTERLOS ANGELESLOS ANGELES190429KAISER FND HOSP - SUNSET/LOS ANGELESLOS ANGELESLOS ANGELES190434KAISER FND HOSP - WEST LOS ANGELESLOS ANGELESLOS ANGELES194219KECK HOSPITAL OF USCLOS ANGELESLOS ANGELES190150KEDREN COMMUNITY MENTAL HEALTH CENTERLOS ANGELESLOS ANGELES190305KINDRED HOSPITAL - LOS ANGELESLOS ANGELESLOS ANGELES191228LAC/USC (LOS ANGELES COUNTY, UNIVERSITY SOUTHERN CALIFORNIA MEDICAL CENTER)LOS ANGELESLOS ANGELES190198LOS ANGELES COMMUNITY HOSPITALLOS ANGELESLOS ANGELES190854LOS ANGELES METROPOLITAN MEDICAL CENTERLOS ANGELESLOS ANGELES190796MATTEL CHILDREN’S HOSPITAL AT RONALD REAGAN UCLALOS ANGELESLOS ANGELES190681MIRACLE MILE MEDICAL CENTERLOS ANGELESLOS ANGELES190534OLYMPIA MEDICAL CENTERLOS ANGELESLOS ANGELES190307PACIFIC ALLIANCE MEDICAL CENTERLOS ANGELESLOS ANGELES190468PROMISE HOSPITAL OF EAST LOS ANGELES-EAST L.A. CAMPUSLOS ANGELESLOS ANGELES190930RESNICK NEUROPSYCHIATRIC HOSPITAL AT UCLALOS ANGELESLOS ANGELES190712SHRINERS HOSPITAL FOR CHILDRENLOS ANGELESLOS ANGELES190661SILVER LAKE MEDICAL CENTER-DOWNTOWN CAMPUSLOS ANGELESLOS ANGELES190762ST. VINCENT MEDICAL CENTERLOS ANGELESLOS ANGELES191216USC KENNETH NORRIS, JR. CANCER HOSPITALLOS ANGELESLOS ANGELES190878WHITE MEMORIAL MEDICAL CENTERLOS ANGELESLOS ANGELES240924MEMORIAL HOSPITAL LOS BANOSLOS BANOSMERCED430743EL CAMINO HOSPITAL LOS GATOSLOS GATOSSANTA CLARA430915MISSION OAKS HOSPITALLOS GATOSSANTA CLARA462284EASTERN PLUMAS HOSPITAL-LOYALTON CAMPUS D/P SNFLOYALTONSIERRA190754ST. FRANCIS MEDICAL CENTERLYNWOODLOS ANGELES204019CHILDREN’S HOSPITAL CENTRAL CALIFORNIA, (CHCC)MADERAMADERA201281MADERA COMMUNITY HOSPITALMADERAMADERA260011MAMMOTH HOSPITALMAMMOTH LAKESMONO392287DOCTORS HOSPITAL OF MANTECAMANTECASAN JOAQUIN394009KAISER FND HOSP - MANTECAMANTECASAN JOAQUIN190500MARINA DEL REY HOSPITALMARINA DEL REYLOS ANGELES220733JOHN C FREMONT HEALTHCARE DISTRICTMARIPOSAMARIPOSA070924CONTRA COSTA REGIONAL MEDICAL CENTERMARTINEZCONTRA COSTA580996RIDEOUT MEMORIAL HOSPITALMARYSVILLEYUBA600001ROGUE REGIONAL MEDICAL CENTERMEDFORD?OSHPD #HOSPITAL NAMECITYCOUNTY414018MENLO PARK SURGICAL HOSPITALMENLO PARKSAN MATEO244027MARIE GREEN PSYCHIATRIC CENTER - P H FMERCEDMERCED240942MERCY MEDICAL CENTER - MERCEDMERCEDMERCED190385PROVIDENCE HOLY CROSS MEDICAL CENTERMISSION HILLSLOS ANGELES304113CHILDREN’S HOSPITAL OF ORANGE COUNTY (CHOC) AT MISSION HOSPITAL MISSION VIEJOORANGE301262MISSION HOSPITAL REGIONAL MEDICAL CENTERMISSION VIEJOORANGE500954CENTRAL VALLEY SPECIALTY HOSPITALMODESTOSTANISLAUS500852DOCTORS MEDICAL CENTER OF MODESTOMODESTOSTANISLAUS501016DOCTORS MEDICAL CENTER-BEHAVIORAL HEALTH DEPARTMENTMODESTOSTANISLAUS504042KAISER FND HOSP - MODESTOMODESTOSTANISLAUS500939MEMORIAL MEDICAL CENTER, MODESTOMODESTOSTANISLAUS504038STANISLAUS SURGICAL HOSPITALMODESTOSTANISLAUS190541MONROVIA MEMORIAL HOSPITALMONROVIALOS ANGELES361166MONTCLAIR HOSPITAL MEDICAL CENTERMONTCLAIRSAN BERNARDINO190081BEVERLY HOSPITALMONTEBELLOLOS ANGELES270744COMMUNITY HOSPITAL OF THE MONTEREY PENINSULAMONTEREYMONTEREY190315GARFIELD MEDICAL CENTERMONTEREY PARKLOS ANGELES190547MONTEREY PARK HOSPITALMONTEREY PARKLOS ANGELES334048KAISER FND HOSP - MORENO VALLEYMORENO VALLEYRIVERSIDE334487RIVERSIDE COUNTY REGIONAL MEDICAL CENTERMORENO VALLEYRIVERSIDE410828SETON COASTSIDEMOSS BEACHSAN MATEO470871MERCY MEDICAL CENTER MT. SHASTAMOUNT SHASTASISKIYOU430763EL CAMINO HOSPITALMOUNTAIN VIEWSANTA CLARA334589LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETAMURRIETARIVERSIDE334068SOUTHWEST HEALTHCARE SYSTEM-MURRIETAMURRIETARIVERSIDE281266NAPA STATE HOSPITALNAPANAPA281047QUEEN OF THE VALLEY HOSPITAL - NAPANAPANAPA370759PARADISE VALLEY HOSPITALNATIONAL CITYSAN DIEGO361458COLORADO RIVER MEDICAL CENTERNEEDLESSAN BERNARDINO301205HOAG MEMORIAL HOSPITAL, PRESBYTERIANNEWPORT BEACHORANGE301304NEWPORT BAY HOSPITALNEWPORT BEACHORANGE190568NORTHRIDGE HOSPITAL MEDICAL CENTERNORTHRIDGELOS ANGELES190766COAST PLAZA HOSPITALNORWALKLOS ANGELES190958DEPARTMENT OF STATE HOSPITAL-METROPOLITANNORWALKLOS ANGELES190570NORWALK COMMUNITY HOSPITALNORWALKLOS ANGELES214034NOVATO COMMUNITY HOSPITALNOVATOMARIN501352OAK VALLEY CARE CENTER D/P SNFOAKDALESTANISLAUS500967OAK VALLEY DISTRICT HOSPITAL (2-RH)OAKDALESTANISLAUS010937ALTA BATES SUMMIT MED CTR-SUMMIT CAMPUS-HAWTHORNEOAKLANDALAMEDA013626ALTA BATES SUMMIT MED CTR-SUMMIT CAMPUS-SUMMITOAKLANDALAMEDAOSHPD #HOSPITAL NAMECITYCOUNTY010776CHILDREN’S HOSPITAL & RESEARCH CENTER - OAKLANDOAKLANDALAMEDA010846HIGHLAND HOSPITALOAKLANDALAMEDA014326KAISER PERMANENTE - OAKLANDOAKLANDALAMEDA013687MPI CHEMICAL DEPENDENCY RECOVERY HOSPITALOAKLANDALAMEDA014207TELECARE HERITAGE PSYCHIATRIC HEALTH FACILITYOAKLANDALAMEDA010782THUNDER ROAD CHEMICAL DEPENDENCY RECOVERY HOSPITALOAKLANDALAMEDA370780TRI-CITY MEDICAL CENTEROCEANSIDESAN DIEGO560500OJAI MANOR CONVALESCENT HOSPITALOJAIVENTURA560501OJAI VALLEY COMMUNITY HOSPITALOJAIVENTURA364265KAISER FND HOSP - ONTARIOONTARIOSAN BERNARDINO361274KINDRED HOSPITAL ONTARIOONTARIOSAN BERNARDINO301140CHAPMAN MEDICAL CENTERORANGEORANGE300032CHILDREN’S HOSPITAL OF ORANGE COUNTY (CHOC )ORANGEORANGE304159HEALTHBRIDGE CHILDREN'S HOSPITAL-ORANGEORANGEORANGE301340ST. JOSEPH HOSPITAL - ORANGEORANGEORANGE301279UNIVERSITY OF CALIFORNIA, IRVINE MEDICAL CENTER (UCI)ORANGEORANGE040937OROVILLE HOSPITALOROVILLEBUTTE560838PACIFIC SHORES HOSPITALOXNARDVENTURA560529ST. JOHN’S REGIONAL MEDICAL CENTEROXNARDVENTURA331164DESERT REGIONAL MEDICAL CENTERPALM SPRINGSRIVERSIDE196405PALMDALE REGIONAL MEDICAL CENTERPALMDALELOS ANGELES434040LUCILE PACKARD CHILDREN’S HOSPITAL AT STANFORD, (LPCH)PALO ALTOSANTA CLARA430905STANFORD HOSPITALPALO ALTOSANTA CLARA190432KAISER FND HOSP - PANORAMA CITYPANORAMA CITYLOS ANGELES190524MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUSPANORAMA CITYLOS ANGELES040875FEATHER RIVER HOSPITALPARADISEBUTTE190599PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUSPARAMOUNTLOS ANGELES190462AURORA LAS ENCINAS HOSPITALPASADENALOS ANGELES190400HUNTINGTON MEMORIAL HOSPITALPASADENALOS ANGELES361768PATTON STATE HOSPITALPATTONSAN BERNARDINO332172KINDRED HOSPITAL RIVERSIDEPERRISRIVERSIDE491001PETALUMA VALLEY HOSPITALPETALUMASONOMA301297PLACENTIA LINDA HOSPITALPLACENTIAORANGE094002EL DORADO COUNTY P H FPLACERVILLEEL DORADO090933MARSHALL MEDICAL CENTER (1-RH)PLACERVILLEEL DORADO014050VALLEYCARE MEDICAL CENTERPLEASANTONALAMEDA194010AMERICAN RECOVERY CENTERPOMONALOS ANGELES190137CASA COLINA HOSPITAL FOR REHAB MEDICINEPOMONALOS ANGELES191014LANTERMAN DEVELOPMENTAL CENTERPOMONALOS ANGELESOSHPD #HOSPITAL NAMECITYCOUNTY190630POMONA VALLEY HOSPITAL MEDICAL CENTERPOMONALOS ANGELES541123PORTERVILLE DEVELOPMENTAL CENTERPORTERVILLETULARE540798SIERRA VIEW MEDICAL CENTERPORTERVILLETULARE320859EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUSPORTOLAPLUMAS370977POMERADO HOSPITALPOWAYSAN DIEGO320986PLUMAS DISTRICT HOSPITALQUINCYPLUMAS364188KINDRED HOSPITAL RANCHORANCHO CUCAMONGASAN BERNARDINO330120BETTY FORD CENTER AT EISENHOWER, THERANCHO MIRAGERIVERSIDE331168EISENHOWER MEDICAL CENTERRANCHO MIRAGERIVERSIDE521041ST. ELIZABETH COMMUNITY HOSPITALRED BLUFFTEHAMA450949MERCY MEDICAL CENTER, REDDINGREDDINGSHASTA454013PATIENTS' HOSPITAL OF REDDINGREDDINGSHASTA454068RESTPADD PSYCHIATRIC HEALTH FACILITYREDDINGSHASTA451019SHASTA COUNTY P H FREDDINGSHASTA450940SHASTA REGIONAL MEDICAL CENTERREDDINGSHASTA454012VIBRA HOSPITAL OF NORTHERN CALIFORNIAREDDINGSHASTA364014LOMA LINDA UNIVERSITY BEHAVIORAL MEDICINE CENTERREDLANDSSAN BERNARDINO364268LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITALREDLANDSSAN BERNARDINO361308REDLANDS COMMUNITY HOSPITALREDLANDSSAN BERNARDINO410804KAISER FND HOSP - REDWOOD CITYREDWOOD CITYSAN MATEO410891LUCILE PACKARD CHILDREN’S SPECIAL CARE NURSERY AT SEQUOIA HOSPITAL, (LPCH)REDWOOD CITYSAN MATEO100797ADVENTIST MEDICAL CENTER - REEDLEYREEDLEYFRESNO196404JOYCE EISENBERG KEEFER MEDICAL CENTERRESEDALOS ANGELES074093KAISER FND HOSP - RICHMOND CAMPUSRICHMONDCONTRA COSTA150782RIDGECREST REGIONAL HOSPITALRIDGECRESTKERN334025KAISER FND HOSP - RIVERSIDERIVERSIDERIVERSIDE331293PARKVIEW COMMUNITY HOSPITALRIVERSIDERIVERSIDE331312RIVERSIDE COMMUNITY HOSPITALRIVERSIDERIVERSIDE331314RIVERSIDE COUNTY REGIONAL MEDICAL CENTER - D/P APHRIVERSIDERIVERSIDE331226VISTA BEHAVIORAL HOSPITALRIVERSIDERIVERSIDE190020BHC ALHAMBRA HOSPITALROSEMEADLOS ANGELES190410SILVER LAKE MEDICAL CENTER-INGLESIDE CAMPUSROSEMEADLOS ANGELES314024KAISER PERMANENTE - ROSEVILLEROSEVILLEPLACER311000SUTTER ROSEVILLE MEDICAL CENTER ROSEVILLEPLACER314029TELECARE PLACER COUNTY PSYCHIATRIC HEALTH FACILITYROSEVILLEPLACER344188CRESTWOOD PSYCHIATRIC HEALTH FACILITY-SACRAMENTOSACRAMENTOSACRAMENTO344021HERITAGE OAKS HOSPITALSACRAMENTOSACRAMENTO340913KAISER FND HOSP - SACRAMENTOSACRAMENTOSACRAMENTO342344KAISER FND HOSP - SOUTH SACRAMENTOSACRAMENTOSACRAMENTO340947MERCY GENERAL HOSPITALSACRAMENTOSACRAMENTOOSHPD #HOSPITAL NAMECITYCOUNTY340951METHODIST HOSPITAL OF SACRAMENTOSACRAMENTOSACRAMENTO344011SACRAMENTO MENTAL HEALTH TREATMENT CENTERSACRAMENTOSACRAMENTO344114SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF.SACRAMENTOSACRAMENTO342392SIERRA VISTA HOSPITALSACRAMENTOSACRAMENTO344017SUTTER CENTER FOR PSYCHIATRYSACRAMENTOSACRAMENTO341051SUTTER GENERAL HOSPITALSACRAMENTOSACRAMENTO341052SUTTER MEDICAL CENTER SACRAMENTOSACRAMENTOSACRAMENTO341006UNIVERSITY OF CALIFORNIA, DAVIS CHILDREN’S HOSPITAL (UCD)SACRAMENTOSACRAMENTO274043NATIVIDAD MEDICAL CENTER SALINASMONTEREY270875SALINAS VALLEY MEMORIAL HEALTHCARE SYSTEMSALINASMONTEREY050932MARK TWAIN MEDICAL CENTERSAN ANDREASCALAVERAS364121BALLARD REHABILITATION HOSPSAN BERNARDINOSAN BERNARDINO361323COMMUNITY HOSPITAL OF SAN BERNARDINOSAN BERNARDINOSAN BERNARDINO361339ST. BERNARDINE MEDICAL CENTERSAN BERNARDINOSAN BERNARDINO301325SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTESAN CLEMENTEORANGE370652ALVARADO HOSPITAL MEDICAL CENTERSAN DIEGOSAN DIEGO374063ALVARADO HOSPITAL MEDICAL CENTERSAN DIEGOSAN DIEGO374024AURORA SAN DIEGOSAN DIEGOSAN DIEGO370730KAISER FND HOSP - SAN DIEGOSAN DIEGOSAN DIEGO370721KINDRED HOSPITAL - SAN DIEGOSAN DIEGOSAN DIEGO370787PROMISE HOSPITAL OF SAN DIEGOSAN DIEGOSAN DIEGO370673RADY CHILDREN’S HOSPITAL SAN DIEGO (RCHSD)SAN DIEGOSAN DIEGO374055SAN DIEGO COUNTY PSYCHIATRIC HOSPITALSAN DIEGOSAN DIEGO370744SCRIPPS MERCY HOSPITAL, SAN DIEGOSAN DIEGOSAN DIEGO370695SHARP MARY BIRCH HOSPITAL FOR WOMENSAN DIEGOSAN DIEGO374049SHARP MCDONALD CENTERSAN DIEGOSAN DIEGO370694SHARP MEMORIAL HOSPITALSAN DIEGOSAN DIEGO370745SHARP MESA VISTA HOSPITALSAN DIEGOSAN DIEGO370782UNIVERSITY OF CALIFORNIA, SAN DIEGO MEDICAL CENTER (UCSD)SAN DIEGOSAN DIEGO374094VIBRA HOSPITAL OF SAN DIEGOSAN DIEGOSAN DIEGO190673SAN DIMAS COMMUNITY HOSPITALSAN DIMASLOS ANGELES380826CALIFORNIA PACIFIC MED CTR-CALIFORNIA EASTSAN FRANCISCOSAN FRANCISCO380933CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUSSAN FRANCISCOSAN FRANCISCO380929CALIFORNIA PACIFIC MED CTR-PACIFIC CAMPUSSAN FRANCISCOSAN FRANCISCO380964CALIFORNIA PACIFIC MEDICAL CENTER - ST. LUKE'S CAMPUSSAN FRANCISCOSAN FRANCISCO380777CALIFORNIA PACIFIC MEDICAL CENTER (CPMC)SAN FRANCISCOSAN FRANCISCO382715CHINESE HOSPITALSAN FRANCISCOSAN FRANCISCO380842JEWISH HOMESAN FRANCISCOSAN FRANCISCO380857KAISER PERMANENTE - SAN FRANCISCOSAN FRANCISCOSAN FRANCISCOOSHPD #HOSPITAL NAMECITYCOUNTY380865LAGUNA HONDA HOSPITAL AND REHABILITATION CENTERSAN FRANCISCOSAN FRANCISCO380868LANGLEY PORTER PSYCHIATRIC INSTITUTESAN FRANCISCOSAN FRANCISCO380939SAN FRANCISCO GENERAL HOSPITAL (SFGH)SAN FRANCISCOSAN FRANCISCO380960ST. FRANCIS MEMORIAL HOSPITALSAN FRANCISCOSAN FRANCISCO380965ST. MARY'S MEDICAL CENTER, SAN FRANCISCOSAN FRANCISCOSAN FRANCISCO380895UCSF MEDICAL CENTER AT MOUNT ZIONSAN FRANCISCOSAN FRANCISCO381154UNIVERSITY OF CALIFORNIA, SAN FRANCISCO MEDICAL CENTER (UCSF)SAN FRANCISCOSAN FRANCISCO190200SAN GABRIEL VALLEY MEDICAL CENTERSAN GABRIELLOS ANGELES434220CRESTWOOD PSYCHIATRIC HEALTH FACILITY-SAN JOSESAN JOSESANTA CLARA430779GOOD SAMARITAN HOSPITAL (HCA), SAN JOSE SAN JOSESANTA CLARA431506KAISER FND HOSP - SAN JOSESAN JOSESANTA CLARA430837O’CONNOR HOSPITALSAN JOSESANTA CLARA430705REGIONAL MEDICAL CENTER OF SAN JOSESAN JOSESANTA CLARA430883SANTA CLARA VALLEY MEDICAL CENTER (SCVMC)SAN JOSESANTA CLARA010811FAIRMONT HOSPITALSAN LEANDROALAMEDA014337KAISER PERMANENTE - SAN LEANDROSAN LEANDROALAMEDA010887KINDRED HOSPITAL - SAN FRANCISCO BAY AREASAN LEANDROALAMEDA013619SAN LEANDRO HOSPITALSAN LEANDROALAMEDA014226TELECARE WILLOW ROCK CENTERSAN LEANDROALAMEDA400480FRENCH HOSPITAL MEDICAL CENTERSAN LUIS OBISPOSAN LUIS OBISPO404046SAN LUIS OBISPO CO PSYCHIATRIC HEALTH FACILITYSAN LUIS OBISPOSAN LUIS OBISPO400524SIERRA VISTA REGIONAL MEDICAL CENTERSAN LUIS OBISPOSAN LUIS OBISPO410742MILLS HEALTH CENTERSAN MATEOSAN MATEO410782SAN MATEO MEDICAL CENTERSAN MATEOSAN MATEO070904DOCTORS MEDICAL CENTER - SAN PABLOSAN PABLOCONTRA COSTA190680PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDROSAN PEDROLOS ANGELES190362PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTERSAN PEDROLOS ANGELES210992KAISER FND HOSP - SAN RAFAELSAN RAFAELMARIN074017SAN RAMON REGIONAL MEDICAL CENTERSAN RAMONCONTRA COSTA074011SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDINGSAN RAMONCONTRA COSTA301258COASTAL COMMUNITIES HOSPITALSANTA ANAORANGE301167KINDRED HOSPITAL - SANTA ANASANTA ANAORANGE301566WESTERN MEDICAL CENTER, SANTA ANASANTA ANAORANGE420514COTTAGE HOSPITAL, SANTA BARBARASANTA BARBARASANTA BARBARA424047COTTAGE REHABILITATION HOSPITALSANTA BARBARASANTA BARBARA420483GOLETA VALLEY COTTAGE HOSPITALSANTA BARBARASANTA BARBARA424002SANTA BARBARA PSYCHIATRIC HEALTH FACILITYSANTA BARBARASANTA BARBARA434153KAISER PERMANENTE - SANTA CLARASANTA CLARASANTA CLARA434218KAISER PERMANENTE P.H.F - SANTA CLARASANTA CLARASANTA CLARA440755DOMINICAN HOSPITALSANTA CRUZSANTA CRUZ444012SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZSANTA CRUZSANTA CRUZOSHPD #HOSPITAL NAMECITYCOUNTY444029TELECARE SANTA CRUZ PHFSANTA CRUZSANTA CRUZ420493MARIAN REGIONAL MEDICAL CENTERSANTA MARIASANTA BARBARA190687SANTA MONICA-UCLA MEDICAL CENTER & ORTHOPEDIC HOSPITALSANTA MONICALOS ANGELES190756ST. JOHN’S HEALTH CENTER SANTA MONICALOS ANGELES560521VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITALSANTA PAULAVENTURA494048AURORA BEHAVIORAL HEALTHCARE-SANTA ROSA, LLCSANTA ROSASONOMA494019KAISER FND HOSP - SANTA ROSASANTA ROSASONOMA491064SANTA ROSA MEMORIAL HOSPITALSANTA ROSASONOMA490907SANTA ROSA MEMORIAL HOSPITAL-SOTOYOMESANTA ROSASONOMA494106SUTTER MEDICAL CENTER OF SANTA ROSASANTA ROSASONOMA374497EDGEMOOR GERIATRIC HOSPITALSANTEESAN DIEGO491338PALM DRIVE HOSPITALSEBASTOPOLSONOMA100793ADVENTIST MEDICAL CENTER-SELMASELMAFRESNO190708SHERMAN OAKS HOSPITALSHERMAN OAKSLOS ANGELES560525SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORESIMI VALLEYVENTURA420522SANTA YNEZ VALLEY COTTAGE HOSPITALSOLVANGSANTA BARBARA491076SONOMA VALLEY HOSPITALSONOMASONOMA552209SONORA REGIONAL MEDICAL CENTER - FAIRVIEWSONORATUOLUMNE554011SONORA REGIONAL MEDICAL CENTER - GREENLEYSONORATUOLUMNE551035SONORA REGIONAL MEDICAL CENTER D/P SNF (UNIT 6 AND 7)SONORATUOLUMNE190352GREATER EL MONTE COMMUNITY HOSPITALSOUTH EL MONTELOS ANGELES090793BARTON MEMORIAL HOSPITALSOUTH LAKE TAHOEEL DORADO410806KAISER FND HOSP - SOUTH SAN FRANCISCOSOUTH SAN FRANCISCOSAN MATEO281078ST. HELENA HOSPITALST. HELENANAPA390846DAMERON HOSPITAL ASSOCIATION (DHA)STOCKTONSAN JOAQUIN394003SAN JOAQUIN COUNTY P.H.F.STOCKTONSAN JOAQUIN392232ST. JOSEPH'S BEHAVIORAL HEALTH CENTERSTOCKTONSAN JOAQUIN391042ST. JOSEPH’S MEDICAL CENTER, STOCKTONSTOCKTONSAN JOAQUIN334018MENIFEE VALLEY MEDICAL CENTERSUN CITYRIVERSIDE190696PACIFICA HOSPITAL OF THE VALLEYSUN VALLEYLOS ANGELES184008BANNER LASSEN MEDICAL CENTERSUSANVILLELASSEN191231OLIVE VIEW UCLA MEDICAL CENTERSYLMARLOS ANGELES190517PROVIDENCE TARZANA MEDICAL CENTERTARZANALOS ANGELES190782TARZANA TREATMENT CENTERTARZANALOS ANGELES150808TEHACHAPI HOSPITALTEHACHAPIKERN334564TEMECULA VALLEY HOSPITALTEMECULARIVERSIDE400548TWIN CITIES COMMUNITY HOSPITALTEMPLETONSAN LUIS OBISPO560492LOS ROBLES REGIONAL HOSPITAL & MEDICAL CENTERTHOUSAND OAKSVENTURA564121THOUSAND OAKS SURGICAL HOSPITAL, A CAMPUS OF LOS ROBLES HOSPTHOUSAND OAKSVENTURAOSHPD #HOSPITAL NAMECITYCOUNTY190232DEL AMO HOSPITALTORRANCELOS ANGELES191227HARBOR UCLA MEDICAL CENTERTORRANCELOS ANGELES190470PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER - TORRANCETORRANCELOS ANGELES190702PROVIDENCE LITTLE COMPANY OF MARY TRANSITIONAL CARE CENTERTORRANCELOS ANGELES194967STAR VIEW ADOLESCENT - P H FTORRANCELOS ANGELES190422TORRANCE MEMORIAL MEDICAL CENTERTORRANCELOS ANGELES391056SUTTER TRACY COMMUNITY HOSPITALTRACYSAN JOAQUIN291053TAHOE FOREST HOSPITALTRUCKEENEVADA540816TULARE REGIONAL MEDICAL CENTERTULARETULARE500867EMANUEL MEDICAL CENTERTURLOCKSTANISLAUS304079HEALTHSOUTH TUSTIN REHABILITATION HOSPITALTUSTINORANGE301357NEWPORT SPECIALTY HOSPITALTUSTINORANGE231396UKIAH VALLEY MEDICAL CENTERUKIAHMENDOCINO361318SAN ANTONIO COMMUNITY HOSPITALUPLANDSAN BERNARDINO484044KAISER FND HOSP - VACAVILLEVACAVILLESOLANO484001NORTH BAY VACAVALLEY HOSPITALVACAVILLESOLANO190949HENRY MAYO NEWHALL MEMORIAL HOSPITALVALENCIALOS ANGELES484062CRESTWOOD SOLANO PSYCHIATRIC HEALTH FACILITYVALLEJOSOLANO480989KAISER FND HOSP - REHABILITATION CENTER VALLEJOVALLEJOSOLANO481015ST. HELENA HOSPITAL CENTER FOR BEHAVIORAL HEALTHVALLEJOSOLANO481094SUTTER SOLANO MEDICAL CENTERVALLEJOSOLANO190814SOUTHERN CALIFORNIA HOSPITAL AT VAN NUYS D/P APHVAN NUYSLOS ANGELES190812VALLEY PRESBYTERIAN HOSPITALVAN NUYSLOS ANGELES560203AURORA VISTA DEL MAR HOSPITALVENTURAVENTURA560473COMMUNITY MEMORIAL HOSPITAL OF VENTURAVENTURAVENTURA560481VENTURA COUNTY MEDICAL CENTER (VCMC)VENTURAVENTURA364144DESERT VALLEY HOSPITALVICTORVILLESAN BERNARDINO361370VICTOR VALLEY GLOBAL MEDICAL CENTERVICTORVILLESAN BERNARDINO544009KAWEAH DELTA MENTAL HEALTH HOSPITAL D/P APHVISALIATULARE540734KAWEAH DELTA HEALTHCARE DISTRICTVISALIATULARE544075KAWEAH DELTA REHABILITATION HOSPITALVISALIATULARE540827KAWEAH DELTA SKILLED NURSING FACILITYVISALIATULARE070988JOHN MUIR HEALTH, WALNUT CREEK CAMPUSWALNUT CREEKCONTRA COSTA070990KAISER PERMANENTE - WALNUT CREEKWALNUT CREEKCONTRA COSTA444013WATSONVILLE COMMUNITY HOSPITALWATSONVILLESANTA CRUZ531059TRINITY HOSPITALWEAVERVILLETRINITY190636CITRUS VALLEY MEDICAL CENTERWEST COVINALOS ANGELES190857DOCTORS HOSPITAL OF WEST COVINA, INCWEST COVINALOS ANGELES190458KINDRED HOSPITAL - SAN GABRIEL VALLEYWEST COVINALOS ANGELES564018LOS ROBLES HOSPITAL & MEDICAL CENTER - EAST CAMPUSWESTLAKE VILAGEVENTURAOSHPD #HOSPITAL NAMECITYCOUNTY301380KINDRED HOSPITAL WESTMINSTERWESTMINSTERORANGE190631PRESBYTERIAN INTER. HOSPITAL (PIH) HEALTH HOSPITALWHITTIERLOS ANGELES190883WHITTIER HOSPITAL MEDICAL CENTERWHITTIERLOS ANGELES334001SOUTHWEST HEALTHCARE SYSTEM-WILDOMARWILDOMARRIVERSIDE230949FRANK R HOWARD MEMORIAL HOSPITALWILLITSMENDOCINO110889GLENN MEDICAL CENTERWILLOWSGLENN571086WOODLAND MEMORIAL HOSPITALWOODLANDYOLO191450KAISER FND HOSP - WOODLAND HILLSWOODLAND HILLSLOS ANGELES190552MOTION PICTURE AND TELEVISION HOSPITALWOODLAND HILLSLOS ANGELES474007FAIRCHILD MEDICAL CENTERYREKASISKIYOU510882FREMONT MEDICAL CENTERYUBA CITYSUTTER514033NORTH VALLEY BEHAVIORAL HEALTHYUBA CITYSUTTER514030SUTTER SURGICAL HOSPITAL-NORTH VALLEYYUBA CITYSUTTER514001SUTTER-YUBA PSYCHIATRIC HEALTH FACILITYYUBA CITYSUTTER70056430TH MEDICAL GROUP HOSPITAL??70059760TH MEDICAL GROUP HOSPITAL??700431722ND MEDICAL GROUP??70010395TH MEDICAL GROUP - EDWARDS AIR FORCE BASE??890096CALIFORNIA - CLINIC??890097CALIFORNIA - EMERGENCY ROOM??890000CALIFORNIA - HOME BIRTH??890095CALIFORNIA - MD OFFICE??890099CALIFORNIA - OTHER IN/PATIENT SETTING??890094CALIFORNIA - OTHER OUT/PATIENT SETTING??700501NAVAL HOSPITAL - CAMP PENDLETON??700112NAVAL HOSPITAL - LEMOORE??700461NAVAL HOSPITAL - TWENTYNINE PALM??700502NAVAL MEDICAL CENTER (BALBOA)??777777NOT APPLICABLE??880096OUT OF STATE - CLINIC??880097OUT OF STATE - EMERGENCY ROOM??880000OUT OF STATE - HOME BIRTH??880095OUT OF STATE - MD OFFICE??880099OUT OF STATE - OTHER IN/PATIENT SETTING??880094OUT OF STATE - OTHER OUT/PATIENT SETTING ??900099SAFE SURRENDER??999999UNKNOWN??700330US ARMY AIR FORCE HOSPITAL??700473US ARMY HOSPITAL??700474US INFIMARY AIR FORCE BASE??700602US NAVAL HOSPITAL??700659US NAVAL STATION HOSPITAL??700664USAF HOSPITAL - MARYSVILLE??APPENDIX D-FAHRENHEIT TO CENTRIGRADE CONVERSION TABLECPeTS/CPQCC Neonatal Transport Data Report Request 2015Name of Person Requesting DataHospital Affiliation/RegionFull Hospital AddressE-mail Address to send report toDate Needed (allow 2 weeks)Please be as specific as possible when requesting reports. Please check all applicable and complete one set of information for each report requested. Send completed request to Lisa@ Select One From BelowSelect One Transport TypeCPQCC Member Facility NumberAll TransportsNon-CPQCC Facility OSHPD NumberDelivery Room RequestedPerinatal Region (specify)EmergentSelect One UrgentTransport InScheduledTransport OutSelect One Transport Provider TypeSelect One Data YearReceiving Facility2014Referring Facility2013Contract Service2012Select One From BelowSelect One Transport TypeCPQCC Member Facility NumberAll TransportsNon-CPQCC Facility OSHPD NumberDelivery Room RequestedPerinatal Region EmergentSelect One UrgentTransport InScheduledTransport OutSelect One Transport Provider TypeSelect One Data YearReceiving Facility2014Referring Facility2013Contract Service2012Select One From BelowSelect One Transport TypeCPQCC Member Facility NumberAll TransportsNon-CPQCC Facility OSHPD NumberDelivery Room RequestedPerinatal Region EmergentSelect One UrgentTransport InScheduledTransport OutSelect One Transport Provider TypeSelect One Data YearReceiving Facility2014Referring Facility2013Contract Service2012Revised 10/2014APPENDIX FCALIFORNIA PERINATAL TRANSPORT SYSTEM NEONATAL TRIPS SCORE CALCULATIONS FORM – 2015 To calculate a TRIPS Score for a neonate being transported in California: Obtain TRIPS score information from the CORE Neonatal Transport form (maybe entered on Table A or B) Use point scores from Table C to calculate total score Identify Risk of Mortality in first 7 days following transport using Table D. To use an electronic application to identify California TRIPS Score and associated risk please visit: Table A: California TRIPS Score: to be recorded on referral, within 15 minutes of arrival at referring hospital and admit to NICU.*ReferralInitial Transport NICU Admit Time (24 hour)C.14C.18C.19C.20 Responsiveness222C.21 Temperature C°37.637.737.8Too low to registerYesYesYesWas the infant cooled? Y XX NY XX NY XX NMethod of coolingC.22 Heart Rate165172170C.23 Respiratory Rate806060C.24 Oxygen Saturation848990C.25 Respiratory Status 211C.26 Inspired Oxygen Concentration1009590C.27 Respiratory Support 333C.28 Blood Pressure Systolic / Diastolic, Mean28/1732/2234/23Too low to registerYesYesYesC.29 Pressors XX Y NXX YNXX Y NResponsiveness: 0=Death 1=None, Seizure, Muscle Relaxant 2=Lethargic, no cry 3=Vigorously withdraws, cryMethod of cooling: Passive, Selective Head, Selective Body, Other, UnknownRespiratory Status: 1=Respirator 2= Severe (apnea, gasping, intubated not on respirator) 3=OtherRespiratory Support: 0 = None, 1 = Hood/Nasal Cannula. 2 = Nasal Continuous Positive Airway Pressure, 3 = Endotracheal Tube *Shaded areas not used for TRIPS Score calculationsTable B: TRIPS Score Components Used for Identifying Risk of Mortality within 7 Days After TransportValuePointsC.20 Responsiveness210C.21 Temperature C°37.76C.25 Respiratory Status 120C.26 Inspired Oxygen Concentration95C.28 Blood Pressure Systolic/ Diastolic, Mean32/228C.29 Pressors YES5 TOTAL SCORE49Table C: Model Used for Calculating California TRIPSRisk Factor?TRIPS PointsResponsivenessNone, seizure, muscle relaxant (1)14Lethargic, no cry (2)10Vigorously Withdraws, Cry (3)0Temperature (°C) 36.1 to 37.60<36.1 or >37.66Respiratory StatusNone or mild respiratory symptoms (3)0Moderate (apnea, gasping, not on respirator) (2)21Severe (on respirator) (1)? with FiO2 < 5015 with FiO2 50 to <7518 with FiO2 75-10020Systolic Blood Pressure (mmHg)under 202420-301930-408>400PressorsNot Used0Used5 49Table D: California TRIPS Score Risk PointsRisk of Death within 7 Days of Transport0 to 80.4 to 0.9%9 to 160.9 to 1.9%17 to 242.1 to 4.0%25 to 344.4 to 10.2%35 to 4411.1 to 23.4%45 to 7025.2 to 80.1% ................
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