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2724150000THERAPEUTIC HYPOTHERMIA PROGRAM CHECKLIST* & PLANNINGUse this check list to: assess your practice, identify needs, describe your current scope of practice and provide rationale for any deficiencies.Section*(CCS-NL)Criteria Met (Y/N/NA)Yes: Describe current practiceNo: Describe plan for meeting standardAPROGRAMBe a CA CCS Paneled NICU*Meet AAP criteria for Level III Care*Use a servo-regulated device(Name model/manufacturer)Birth rate and/or catchment area supports an average of 6 treated patients per year*Active Program:Include birth rate data, number of patients treated in last 3 years New Program: If starting a program, document # of patients referred for cooling in last 3 yearsIf less than 12 patients/year – formal relationship with regional center*AWritten & Approved Clinical Guidelines for providing Therapeutic Hypothermia for Infants with Moderate to Severe HIEDate:AClinical Guidelines includes: method for patient selectionpatient managementneuromonitoring standardsneuroimaging standardsAEstablished plan to review:Adverse eventsPerform Quality Assurance reviewConduct Quality Improvement initiativesPERSONNELATeam to oversee training of all providersANeonatologistNameAPediatric NeurologistNameAClinical Nurse SpecialistNameDDevelopmental Care TeamOT:PT:Developmental Specialists:DLactation SupportDescribe hours of service, number of FTE, services providedDPalliative CareDo you have a written neonatal-specific palliative care clinical guideline?What are your standards for ensuring staff well-being (debriefing, etc)?DSpiritual Care/ChaplainDescribe availability or hoursMEDICAL & DIAGNOSTICSB-1Physician CoveragePhysician coverage – NeonatologistPhysician coverage – NeurologistPhysician coverage – NeurophysiologistPhysician coverage – NeuroradiologistPhysician coverage – HRIFDoes every TH infant get a Neuro consultation within the first 12 hours life?% In-Person vs On-PhoneDoes every TH infant get a clinical assessment by a Pediatric Neurologist within 24 hours of birth?% by 24 hoursDoes your Pediatric Neurologist perform clinical examinations during TH, review neuro-monitoring, review neuro-imaging?B-2NEURO-MONITORINGAre all infants undergoing TH are monitoring continuously with cEEG or aEEG?% aEEG% cEEGAge at initiationDo you have cEEG available on-site, during normal work hours?Describe process to order/activate; average time to initiate after order placedAre your cEEG recordings reviewed within 24 hours by a neurophysiologist or a child neurologist with neonatal EEG expertise?Is aEEG used in your NICU?If used: a) how were your providers trained? ((See worksheet))b) provide example of standardized documentationB-3NEURO-IMAGINGDo you have on-site MRI with DWI capabilities?Are MRI’s performed on all infants undergoing TH before discharge?% completedReason for any variance below 100%% done as outpatientIs sedation used for your MRI’s?% completed with/without sedationAre your MRI’s reviewed by a neuroradiologist with neonatal expertise?Describe trainingDescribe plan for training or staff recruitmentUse of tele-medicine?B-4TRANSFER FOR HIGHER LEVEL OF CAREDo you provide HFV, ECMO, iNO?Established relationship with referral center?In the last 3 years have you transferred infants for a Higher LOC?Provide list of patients and reasons for referral for higher LOCB-5HIGH RISK INFANT FOLLOW UPDo all infants have a referral to HRIF upon discharge?Do all infants have an appointment for HRIF upon discharge?Referral to Pediatric Neurologist for infants with: seizures, going home on AED’s, and documented brain injury on MRIDocument % of appointments on DCCTRAINING & COMPETENCYAll providers have completed a minimum of 8 hours of training(Use “Education Documentation” checklist for each member of your team who provides cooling)Annual competency has been documentedList where annual competency records are stored and outline of relevant content from the last 3 years DANCILLARY SERVICESSee earlier sectionsEOUTREACHDo you have cultrally‐sensitive, family-centered handouts for parents that explain HIE and THAre you a referral center for TH patients?Document education provided and to whom and what dates. Be sure to include OB + General Pediatric Providers who attend deliveries. Cover topics related to: Identification and timely referralRisk factors for encephalopathyEligibility criteria for coolingM&M ReviewOther activitiesFQUALITY ASSURANCE Protocol to monitor quality of careBlood gas screeningCooling provided according to center’s policy and criteriaAssurance that infants get recommended monitoring, imaging, and follow‐up% monitored% imaged%follow up with HRIF%follow up with NeurologyMonitor temperature controlAvg. Time to Target TempFrequency of out of range tempsAdverse EventsEX:Bradycardia (requiring treatment)Coagulopathy (requiring treatment)Pressure UlcersSub-Cutaneous Fat NecrosisOther parameters ................
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