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

Managed by California Perinatal Quality Care Collaborative (CPQCC)

Manual of DefinitionsFor Infants Born in 2015

Version 13October 2014

2015 Manual of Definitions – Neonatal Transport Data Collection Tool 1

Table of ContentsI. REFERRAL…………………………..

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Note to Imbedded NICUs…………………………………………………………………… 5Special Situation Overrides……………………………………………………………….. 5Transport Type………………………………………………………………………………. 6

Requested Delivery Attendance…………………………………………………………..EmergentUrgent………………………………………………………………………………………..Scheduled Neonatal………………………………………………………………………..Other…………………………………………………………………………………………

Indication for Transport……………………………………………………………………. 6Medical Dx/Rx Services……………………………………………………………………Surgery………………………………………………………………………………………Insurance…………………………………………………………………………………….Bed Availability………………………………………………………………………………

II. PATIENT IDENTIFICATION: HISTORY...…………………………………………………. 7

Birth weight…………………………………………………………………………………… 7Gestational Age……………………………………………………………………………… 7Sex……………………………………………………………………………………………… 7Prenatally Diagnosed Congenital Anomalies…………………………………………... 7Description of Prenatal Diagnosis of Major Birth Defects/Congenital Anomalies 8

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………………………………………

Mother’s Gravida……………………........................................................................... 8Antenatal Steroids……………………………………………………………………………

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Surfactant Given…………………………………………………………………………….. 8

III. TIME SEQUENCE………………………………………………...………………………….. 9

Date/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.......................................................................................................

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Date/Time Arrival of Team at Referral Hospital/Patient Bedside and Initial Transport Evaluation………………………………………………………………………..

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Date/Time Initial Transport Team Evaluation……………………………………….. 10Date/Time Arrival at Receiving NICU and Initial NICU Evaluation………………….. 10

IV. INFANT CONDITION……………………………………..................................................2015 Manual of Definitions – Neonatal Transport Data Collection Tool 2

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Date/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……………………………………..... 12

V. REFERRAL PROCESS…………………………………………………........................... 12

Referring Hospital…………………………………………………………………………… 12Was the Infant Previously Transported…………………………………………………. 13Previous Transfer Referring Hospital……………………………………………………. 13Location of Birth…………………………………………………………………………..,,, 13Transport Team On-Site Leader............................................................................... 13Transport Team From………………………………………………………………………. 14Mode of Transport…………………………………………………………………………… 14

VI. CLINICAL INFORMATION (ALL CALIFORNIA TRANSPORT FORM ONLY)………………………………………………………………………………..

VII. NON-CORE FORM - ADDITIONAL CLINICAL INFORMATION……………..

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VIII. REFERRING PHYSICIAN AND FACILITY INFORMATION…………………..

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

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

XI. INFORMATION MATERIALS TO BE SENT WITH TRANSPORT TEAM…………………………………………………………………………………

XII. TRANSPORT ISSUES WITH IMPROVEMENT POTENTIAL…………………

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APPENDICES

Please go to www.perinatal.org for all appendices under Neonatal Transport Data System 2014 materials


http://www.perinatal.org/

APPENDIX A: CPETS CORE FORM

APPENDIX B: BIRTH DEFECT CODES FOR CCNTF ITEM C.6

APPENDIX C: OSHPD FACILITY CODES

APPENDIX D: FAHRENHEIT TO CENTRIGRADE CONVERSION TAB

APPENDIX E: CPeTS/CPQCC Neonatal Transport Data Report Request 2015

APPENDIX F: CALIFORNIA PERINATAL TRANSPORT SYSTEM NEONATAL TRIPS SCORE CALCULATIONS FORM – 2015

CPeTS STAFF:

Ron Cohen, MD. Director, Northern Division

D. Lisa Bollman, RN, MSN, CPHQ Director, Southern Division

Michelle Padreddii, RN, BSN, Data Manager for Northern California

Kevin Van Otterloo, MPA Program Manager for Southern California


I. REFERRAL

Note: Items with “*” represent those that MUST be filled out on the online Transport form in order to propagate specific item numbers on the online Admission/Discharge (A/D) Form. The Admission/Discharge (A/D) related Items will be listed as “(A/D Item#)”.

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.1 Transport 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.2 Indication 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: HISTORY

C.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.4 Best Estimate of Gestational Age (A/D Item 3).Record the best available estimate of gestational age in weeks and days. Where sources disagree, use the following hierarchy: 1. Obstetric measures, based on last menstrual period, obstetrical parameters, or prenatal ultrasound as recorded in the maternal chart. 2. Neonatologist's estimate, based on physical or neurologic examination, combined physical and gestational age exam (Ballard/Dubowitz), or examination of the lens. Record gestational age in weeks and days. In cases when the best estimate of gestational age is an exact number of weeks, enter the number of weeks in the space provided for weeks and enter 0 in the space provided for days. Do not leave the number of days blank. C.5 Infant 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 Hips

C.7a Maternal Date of Birth2015 Manual of Definitions – Neonatal Transport Data Collection Tool 7

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.8a Antenatal Steroids (A/D Item 13).Note: Corticosteroids include Betamethasone, Dexamethasone, and Hydrocortisone.

Check Yes if corticosteroids were administered IM or IV to the mother during pregnancy at any time prior to delivery. Check No if no corticosteroids were administered IM or IV to the mother during pregnancy at any time prior to delivery.

Check Unk if this information cannot be obtained.

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.9 Surfactant 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 SEQUENCE

C.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).2015 Manual of Definitions – Neonatal Transport Data Collection Tool 8

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.12 Infant Birth Date and Time (A/D Item 4).Enter the date of birth using MM/DD/YYYY. Enter the time of birth using a 24-hour clock (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.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 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.15 Acceptance 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 CONDITION


This 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.21 Temperature (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.22 Heart 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.24 Oxygen Saturation (SaO2) (0 to 100). Indicate average oxygen saturation in percentage. If unknown, indicate UNK (Online only).

C.25 Respiratory Status. Write the number 1 (one) in the designated space if the infant was on the respirator at the time of referral for transport. Write the number 2 (two) in the designated space if the infant had severe respiratory complications, including: apnea, gasping, or was intubated but not on mechanical respirator. Write the number 3 (three) in the designated space for all other respiratory status (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.27 Respiratory 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. 2015 Manual of Definitions – Neonatal Transport Data Collection Tool 11

V. REFERRAL PROCESS

C.30 Referring 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 (www.cpqcc.org) when answering this question. If the referring hospital is not a CPQCC member hospital, this item is not applicable and may be left blank.

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 (www.cpqcc.org) when answering this question. If the birth hospital is not a CPQCC member hospital, this item is not applicable and may be left blank.

C.33 Transport Team On-Site Leader. Choose only one of the following responses: 2015 Manual of Definitions – Neonatal Transport Data Collection Tool 12

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 (www.aams.org). 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 Transport

C.35 Mode 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 Score

The 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 http://www.health-info-solutions.com/CPQCC-CPeTS/tripsmobile/tripsmobile.html( google TRIPS SCORE CALCULATOR ) .

VI. CLINICAL INFORMATION (ALL CALIFORNIA TRANSPORT FORM ONLY)

This information is helpful to provide continuity of care.

Infant name

Singleton/Multiple Births. (a)Check Singleton for any birth (b)Check Multiple for any birth involving more than a singleton infant and for any

multifetal gestation. 2015 Manual of Definitions – Neonatal Transport Data Collection Tool 14

http://www.health-info-solutions.com/CPQCC-CPeTS/tripsmobile/tripsmobile.html

(c) If Multiple Birth, indicate the infant’s birth order (first, second, etc) as well as the total number of infants actually delivered (count both live born and still born infants). For example, the second infant born of triplets would be entered as 2 of 3.

Note: Count both live births and stillbirths at the time of delivery but do not count fetuses which have been reabsorbed in utero and are not delivered.

Current Weight in grams

Diagnosis

Allergies. 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 Hospital

Gravida, Para, Abortions, Living

Rupture 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 severity

Infection. Includes intrauterine infections of the amniotic sac and fluid (amnionitis, chorioamnionitis) and those of the uterine wall (endometritis) as well as other infections such as which complicate the pregnancy or delivery. Includes Herpes, HIV, or other sexually-transmitted diseases (STD).

Preterm Labor. Uterine contractions resulting in dilation of the cervix at a gestational age of less than 37 completed weeks of gestation.

Bleeding/Abruption/Previa. Bleeding related to complications with the placenta. Placental abruption refers to premature detachment of the placenta from the uterine wall. Placenta previa refers to low implantation of the placenta in the uterus, usually over the cervix.

Other Maternal. Other antenatal maternal complications affecting the infant’s health or the course of delivery. Specify the complication in the space provided.

Unknown. Information not obtainable.

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 2015 Manual of Definitions – Neonatal Transport Data Collection Tool 16

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 INFORMATION

Ventilator SettingsEnter the Type or Mode of ventilation along with Oxygen %, Pressures, Rate and Inspiratory/Expiratory times

Blood 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.

a. pHb. PCO2c. BE (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 Route

Enteral 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.2015 Manual of Definitions – Neonatal Transport Data Collection Tool 18

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 = 23:30

VIII. REFERRING PHYSICIAN AND FACILITY INFORMATION

Write 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 (www.cpqcc.org) when answering this question. If the referring hospital is not a CPQCC member hospital, this item is not applicable and may be left blank. Write the name of the 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)

X. COMMENTS


Please provide your comments in this section.

XI. INFORMATION/MATERIALS TO BE SENT WITH TRANSPORT TEAM

Information/Materials to be Sent with Transport Team.

Indicate all materials and information provided by referring hospital to transport team.

Chart (Patient Record).Check Maternal and/or Neonatal

Blood Specimen.Check Maternal and/or Neonatal

Imaging Copies.

Other.Specify all additional items transported with infant

XII. 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 provided.

Comments: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 2015 Manual of Definitions – Neonatal Transport Data Collection Tool 21

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 Transpor

t

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 YN Y N

Method of cooling C.35 Mode Ground Helicopter Fixed Wing C.22 Heart Rate DeathNo 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 YN 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 B2015 Manual of Definitions – Neonatal Transport Data Collection Tool 24

BIRTH 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 132015 Manual of Definitions – Neonatal Transport Data Collection Tool 25

502 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 Lung


APPENDIX COSHPD # HOSPITAL NAME CITY COUNTY010735 ALAMEDA HOSPITAL ALAMEDA ALAMEDA010989 ALAMEDA HOSPITAL AT WATERS EDGE ALAMEDA ALAMEDA010956 ALAMEDA HOSPITAL-SOUTH SHORE CONVALESCENT

HOSPITALALAMEDA ALAMEDA

190017 ALHAMBRA HOSPITAL MEDICAL CENTER ALHAMBRA LOS ANGELES250956 MODOC MEDICAL CENTER ALTURAS MODOC301097 ANAHEIM GENERAL HOSPITAL ANAHEIM ORANGE301098 ANAHEIM REGIONAL MEDICAL CENTER ANAHEIM ORANGE304409 KAISER FND HOSP - ORANGE COUNTY - ANAHEIM ANAHEIM ORANGE301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW ANAHEIM ORANGE301379 WEST ANAHEIM MEDICAL CENTER ANAHEIM ORANGE301188 WESTERN MEDICAL CENTER ANAHEIM ANAHEIM ORANGE074097 KAISER FND HOSP - ANTIOCH ANTIOCH CONTRA COSTA070934 SUTTER DELTA MEDICAL CENTER ANTIOCH CONTRA COSTA361343 ST. MARY MEDICAL CENTER IN APPLE VALLEY APPLE VALLEY SAN

BERNARDINO190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA ARCADIA LOS ANGELES121002 MAD RIVER COMMUNITY HOSPITAL ARCATA HUMBOLDT400466 MARIAN REGIONAL MEDICAL CENTER, ARROYO GRANDE ARROYO GRANDE SAN LUIS OBISPO400683 ATASCADERO STATE HOSPITAL ATASCADERO SAN LUIS OBISPO310791 SUTTER AUBURN FAITH HOSPITAL AUBURN PLACER190045 CATALINA ISLAND MEDICAL CENTER AVALON LOS ANGELES154101 BAKERSFIELD HEART HOSPITAL BAKERSFIELD KERN150722 BAKERSFIELD MEMORIAL HOSPITAL BAKERSFIELD KERN154160 CRESTWOOD PSYCHIATRIC HEALTH FACILITY 2 BAKERSFIELD KERN150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD BAKERSFIELD KERN154044 GOOD SAMARITAN HOSPITAL-SOUTHWEST D/P APH BAKERSFIELD KERN154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL BAKERSFIELD KERN150736 KERN MEDICAL CENTER BAKERSFIELD KERN150761 MERCY HOSPITAL - BAKERSFIELD BAKERSFIELD KERN154108 MERCY SOUTHWEST HOSPITAL BAKERSFIELD KERN150788 SAN JOAQUIN COMMUNITY HOSPITAL BAKERSFIELD KERN196035 KAISER FND HOSP - BALDWIN PARK BALDWIN PARK LOS ANGELES190049 KINDRED HOSPITAL BALDWIN PARK BALDWIN PARK LOS ANGELES331326 SAN GORGONIO MEMORIAL HOSPITAL BANNING RIVERSIDE364430 BARSTOW COMMUNITY HOSPITAL BARSTOW SAN

BERNARDINO190066 BELLFLOWER MEDICAL CENTER BELLFLOWER LOS ANGELES194044 BELLWOOD HEALTH CENTER BELLFLOWER LOS ANGELES010844 ALTA BATES SUMMIT MED CTR-HERRICK CAMPUS BERKELEY ALAMEDA010739 ALTA BATES SUMMIT MEDICAL CENTER BERKELEY ALAMEDA361110 BEAR VALLEY COMMUNITY HOSPITAL BIG BEAR LAKE SAN


BERNARDINO141273 NORTHERN INYO HOSPITAL BISHOP INYO331288 PALO VERDE HOSPITAL BLYTHE RIVERSIDEOSHPD # HOSPITAL NAME CITY COUNTY130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT BRAWLEY IMPERIAL301127 KINDRED HOSPITAL BREA BREA ORANGE301109 ANAHEIM GENERAL HOSPITAL - BUENA PARK CAMPUS BUENA PARK ORANGE190758 PROVIDENCE ST. JOSEPH MEDICAL CENTER BURBANK LOS ANGELES413500 BURLINGAME HEALTH CARE CENTER D/P SNF BURLINGAME SAN MATEO410852 MILLS-PENINSULA MEDICAL CENTER BURLINGAME SAN MATEO560508 ST. JOHN'S PLEASANT VALLEY HOSPITAL CAMARILLO VENTURA434051 CHILDRENS RECOVERY CENTER OF NORTHERN CALIFORNIA CAMPBELL SANTA CLARA190859 WEST HILLS HOSPITAL AND MEDICAL CENTER CANOGA PARK LOS ANGELES344170 CRESTWOOD PSYCHIATRIC HEALTH FACILITY-CARMICHAEL CARMICHAEL SACRAMENTO340950 MERCY SAN JUAN MEDICAL CENTER CARMICHAEL SACRAMENTO014233 EDEN MEDICAL CENTER CASTRO VALLEY ALAMEDA250955 SURPRISE VALLEY COMMUNITY HOSPITAL CEDARVILLE MODOC504081 TELECARE STANISLAUS COUNTY PHF CERES STANISLAUS190184 COLLEGE HOSPITAL CERRITOS LOS ANGELES321016 SENECA HEALTHCARE DISTRICT CHESTER PLUMAS044006 BUTTE COUNTY MENTAL HEALTH SERVICES CHICO BUTTE040828 ENLOE MEDICAL CENTER - COHASSET CHICO BUTTE040962 ENLOE MEDICAL CENTER- ESPLANADE CHICO BUTTE044011 ENLOE REHABILITATION CENTER CHICO BUTTE364050 CANYON RIDGE HOSPITAL CHINO SAN

BERNARDINO361144 CHINO VALLEY MEDICAL CENTER CHINO SAN

BERNARDINO370775 PARADISE VALLEY HSP D/P APH BAYVIEW BEH HLTH CHULA VISTA SAN DIEGO370658 SCRIPPS MERCY HOSPITAL CHULA VISTA CHULA VISTA SAN DIEGO370875 SHARP CHULA VISTA MEDICAL CENTER CHULA VISTA SAN DIEGO171049 ST. HELENA HOSPITAL - CLEARLAKE CLEARLAKE LAKE100005 CLOVIS COMMUNITY MEDICAL CENTER CLOVIS FRESNO100697 COALINGA REGIONAL MEDICAL CENTER COALINGA FRESNO105051 DEPARTMENT OF STATE HOSPITAL - COALINGA COALINGA FRESNO364231 ARROWHEAD REGIONAL MEDICAL CENTER COLTON SAN

BERNARDINO060870 COLUSA REGIONAL MEDICAL CENTER COLUSA COLUSA074039 JOHN MUIR BEHAVIORAL HEALTH CENTER CONCORD CONTRA COSTA071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS CONCORD CONTRA COSTA331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA CORONA RIVERSIDE331152 CORONA REGIONAL MEDICAL CENTER-MAIN CORONA RIVERSIDE370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER CORONADO SAN DIEGO374321 VILLA CORONADO CONVALESCENT (DP/SNF) CORONADO SAN DIEGO301155 COLLEGE HOSPITAL COSTA MESA COSTA MESA ORANGE


301781 FAIRVIEW DEVELOPMENTAL CENTER COSTA MESA ORANGE190163 AURORA CHARTER OAK COVINA LOS ANGELES190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS COVINA LOS ANGELES084001 SUTTER COAST HOSPITAL CRESCENT CITY DEL NORTEOSHPD # HOSPITAL NAME CITY COUNTY197931 EXODUS RECOVERY P.H.F. CULVER CITY LOS ANGELES190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY CULVER CITY LOS ANGELES410817 SETON MEDICAL CENTER DALY CITY SAN MATEO574010 SUTTER DAVIS HOSPITAL DAVIS YOLO150706 DELANO REGIONAL MEDICAL CENTER DELANO KERN196403 KAISER FND HOSP - DOWNEY DOWNEY LOS ANGELES191306 LAC/RANCHO LOS AMIGOS NATIONAL REHAB CENTER DOWNEY LOS ANGELES190243 PIH HOSPITAL - DOWNEY DOWNEY LOS ANGELES190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL DUARTE LOS ANGELES130699 EL CENTRO REGIONAL MEDICAL CENTER EL CENTRO IMPERIAL491267 SONOMA DEVELOPMENTAL CENTER ELDRIDGE SONOMA371394 RADY CHILDREN’S HOSPITAL SAN DIEGO AT SCRIPPS

ENCINITAS (RCHSD)ENCINITAS SAN DIEGO

190280 ENCINO HOSPITAL MEDICAL CENTER ENCINO LOS ANGELES374382 PALOMAR MEDICAL CENTER ESCONDIDO SAN DIEGO370755 RADY CHILDREN’S NICU AT PALOMAR MEDICAL CENTER

(RCHSD)ESCONDIDO SAN DIEGO

120981 GENERAL HOSPITAL, THE EUREKA HUMBOLDT124004 SEMPERVIRENS P.H.F. EUREKA HUMBOLDT121080 ST. JOSEPH HOSPITAL - EUREKA EUREKA HUMBOLDT481357 NORTHBAY MEDICAL CENTER FAIRFIELD SOLANO450936 MAYERS MEMORIAL HOSPITAL FALL RIVER MILLS SHASTA370704 FALLBROOK HOSP DISTRICT SKILLED NURSING FACILITY FALLBROOK SAN DIEGO370705 FALLBROOK HOSPITAL DISTRICT FALLBROOK SAN DIEGO344029 MERCY HOSPITAL - FOLSOM FOLSOM SACRAMENTO344035 VIBRA HOSPITAL OF SACRAMENTO FOLSOM SACRAMENTO361223 KAISER FND HOSP - FONTANA FONTANA SAN

BERNARDINO231013 MENDOCINO COAST DISTRICT HOSPITAL FORT BRAGG MENDOCINO121051 REDWOOD MEMORIAL HOSPITAL FORTUNA HUMBOLDT301175 FOUNTAIN VALLEY REGIONAL HOSPITAL & MEDICAL CENTER FOUNTAIN VALLEY ORANGE

304039 FOUNTAIN VALLEY RGNL HOSP AND MED CTR - WARNER FOUNTAIN VALLEY ORANGE300225 ORANGE COAST MEMORIAL MEDICAL CENTER FOUNTAIN VALLEY ORANGE014034 FREMONT HOSPITAL FREMONT ALAMEDA014132 KAISER FND HOSP - FREMONT FREMONT ALAMEDA010987 WASHINGTON HOSPITAL - FREMONT FREMONT ALAMEDA391010 SAN JOAQUIN GENERAL HOSPITAL FRENCH CAMP SAN JOAQUIN100899 CHILDREN’S HOSPITAL CENTRAL CALIFORNIA- ST. AGNES

HOSPITAL (CHCC)FRESNO FRESNO


104008 COMMUNITY BEHAVIORAL HEALTH CENTER FRESNO FRESNO100717 COMMUNITY REGIONAL MEDICAL CENTER (CRMC) FRESNO FRESNO100718 COMMUNITY SUBACUTE AND TRANSITIONAL CARE CENTER FRESNO FRESNO104089 CRESTWOOD PSYCHIATRIC HEALTH FACILITY-FRESNO FRESNO FRESNOOSHPD # HOSPITAL NAME CITY COUNTY105029 FRESNO HEART AND SURGICAL HOSPITAL FRESNO FRESNO104047 FRESNO SURGICAL HOSPITAL FRESNO FRESNO104062 KAISER FND HOSP - FRESNO FRESNO FRESNO104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL FRESNO FRESNO301342 ST. JUDE MEDICAL CENTER FULLERTON ORANGE121031 JEROLD PHELPS COMMUNITY HOSPITAL GARBERVILLE HUMBOLDT301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER GARDEN GROVE ORANGE190196 KINDRED HOSPITAL SOUTH BAY GARDENA LOS ANGELES190521 MEMORIAL HOSPITAL OF GARDENA GARDENA LOS ANGELES494047 WOODLANDS PSYCHIATRIC HEALTH FACILITY GEYSERVILLE SONOMA434138 ST. LOUISE REGIONAL HOSPITAL GILROY SANTA CLARA190323 GLENDALE ADVENTIST MEDICAL CENTER GLENDALE LOS ANGELES190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER GLENDALE LOS ANGELES190818 USC VERDUGO HILLS HOSPITAL GLENDALE LOS ANGELES190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL GLENDORA LOS ANGELES190328 GLENDORA COMMUNITY HOSPITAL GLENDORA LOS ANGELES291023 SIERRA NEVADA MEMORIAL HOSPITAL GRASS VALLEY NEVADA211006 MARIN GENERAL HOSPITAL GREENBRAE MARIN040802 BIGGS GRIDLEY MEMORIAL HOSPITAL GRIDLEY BUTTE164029 ADVENTIST MEDICAL CENTER HANFORD KINGS160787 CENTRAL VALLEY GENERAL HOSPITAL HANFORD KINGS190431 KAISER FND HOSP - SOUTH BAY HARBOR CITY LOS ANGELES190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER HAWAIIAN

GARDENSLOS ANGELES

190523 LOS ANGELES METROPOLITAN MED CTR-HAWTHORNE CAMPUS

HAWTHORNE LOS ANGELES

010967 ST. ROSE HOSPITAL HAYWARD ALAMEDA490964 HEALDSBURG DISTRICT HOSPITAL HEALDSBURG SONOMA334032 HEMET VALLEY HEALTH CARE CENTER HEMET RIVERSIDE331194 HEMET VALLEY MEDICAL CENTER HEMET RIVERSIDE350784 HAZEL HAWKINS MEMORIAL HOSPITAL HOLLISTER SAN BENITO351814 HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF HOLLISTER SAN BENITO190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD HOLLYWOOD LOS ANGELES301209 HUNTINGTON BEACH HOSPITAL HUNTINGTON

BEACHORANGE

190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK HUNTINGTON PARK

LOS ANGELES

331216 JOHN F KENNEDY MEMORIAL HOSPITAL INDIO RIVERSIDE334457 TELECARE RIVERSIDE COUNTY PSYCHIATRIC HEALTH FACILITY INDIO RIVERSIDE


190148 CENTINELA HOSPITAL MEDICAL CENTER INGLEWOOD LOS ANGELES304045 HOAG HOSPITAL IRVINE IRVINE ORANGE304460 HOAG ORTHOPEDIC INSTITUTE IRVINE ORANGE304306 KAISER FND HOSP - ORANGE COUNTY - IRVINE IRVINE ORANGE034002 SUTTER AMADOR HOSPITAL JACKSON AMADOROSHPD # HOSPITAL NAME CITY COUNTY362041 HI-DESERT MEDICAL CENTER JOSHUA TREE SAN

BERNARDINO210993 KENTFIELD REHABILITATION & SPECIALTY HOSPITAL KENTFIELD MARIN270777 GEORGE L MEE MEMORIAL HOSPITAL KING CITY MONTEREY370771 RADY CHILDREN’S HOSPITAL SAN DIEGO AT SCRIPPS LA

JOLLA (RCHSD)LA JOLLA SAN DIEGO

371256 SCRIPPS GREEN HOSPITAL LA JOLLA SAN DIEGO374141 UCSD-LA JOLLA, JOHN M/SALLY B THORNTON HOSP &

SULPIZO CARDIOLA JOLLA SAN DIEGO

370749 ALVARADO PARKWAY INSTITUTE B.H.S. LA MESA SAN DIEGO370714 SHARP GROSSMONT HOSPITAL, WOMEN’S HEALTH CENTER LA MESA SAN DIEGO190449 KINDRED HOSPITAL - LA MIRADA LA MIRADA LOS ANGELES301234 LA PALMA INTERCOMMUNITY HOSPITAL LA PALMA ORANGE301337 MISSION HOSPITAL LAGUNA BEACH LAGUNA BEACH ORANGE301317 SADDLEBACK MEMORIAL HOSPITAL LAGUNA HILLS ORANGE361266 MOUNTAINS COMMUNITY HOSPITAL LAKE ARROWHEAD SAN

BERNARDINO150737 KERN VALLEY HEALTHCARE DISTRICT LAKE ISABELLA KERN171395 SUTTER LAKESIDE HOSPITAL LAKEPORT LAKE190240 LAKEWOOD REGIONAL MEDICAL CENTER LAKEWOOD LOS ANGELES190034 ANTELOPE VALLEY HOSPITAL LANCASTER LOS ANGELES010983 VALLEY MEMORIAL HOSPITAL LIVERMORE ALAMEDA390923 LODI MEMORIAL HOSPITAL LODI SAN JOAQUIN390922 LODI MEMORIAL HOSPITAL - WEST LODI SAN JOAQUIN361245 LOMA LINDA UNIV. MED. CENTER EAST CAMPUS HOSPITAL LOMA LINDA SAN

BERNARDINO364502 LOMA LINDA UNIVERSITY CHILDREN'S HOSPITAL LOMA LINDA SAN

BERNARDINO361246 LOMA LINDA UNIVERSITY MEDICAL CENTER LOMA LINDA SAN

BERNARDINO364451 TOTALLY KIDS REHABILITATION HOSPITAL LOMA LINDA SAN

BERNARDINO420491 LOMPOC VALLEY MEDICAL CENTER LOMPOC SANTA BARBARA420552 LOMPOC VALLEY MEDICAL CENTER COMPREHENSIVE CARE

CENTER D/P SLOMPOC SANTA BARBARA

424102 THE CHAMPION CENTER LOMPOC SANTA BARBARA141338 SOUTHERN INYO HOSPITAL LONE PINE INYO190587 COLLEGE MEDICAL CENTER LONG BEACH LOS ANGELES190477 COLLEGE MEDICAL CENTER SOUTH CAMPUS D/P APH LONG BEACH LOS ANGELES


190475 COMMUNITY HOSPITAL LONG BEACH LONG BEACH LOS ANGELES194981 LA CASA PSYCHIATRIC HEALTH FACILITY LONG BEACH LOS ANGELES190525 LONG BEACH MEMORIAL MEDICAL CENTER LONG BEACH LOS ANGELES196168 MILLER CHILDREN’S HOSPITAL AT LONG BEACH MEMORIAL

HOSPITALLONG BEACH LOS ANGELES

190053 ST. MARY MEDICAL CENTER LONG BEACH LOS ANGELES191225 TOM REDGATE MEMORIAL RECOVERY CENTER LONG BEACH LOS ANGELES301248 LOS ALAMITOS MEDICAL CENTER LOS ALAMITOS ORANGE190052 BARLOW RESPIRATORY HOSPITAL LOS ANGELES LOS ANGELES190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES LOS ANGELES LOS ANGELESOSHPD # HOSPITAL NAME CITY COUNTY190555 CEDARS-SINAI MEDICAL CENTER LOS ANGELES LOS ANGELES190155 CENTURY CITY DOCTORS HOSPITAL LOS ANGELES LOS ANGELES190170 CHILDREN’S HOSPITAL LOS ANGELES LOS ANGELES LOS ANGELES190256 EAST LOS ANGELES DOCTORS HOSPITAL LOS ANGELES LOS ANGELES190317 GATEWAYS HOSPITAL AND MENTAL HEALTH CENTER LOS ANGELES LOS ANGELES190392 GOOD SAMARITAN HOSPITAL, LOS ANGELES LOS ANGELES LOS ANGELES190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER LOS ANGELES LOS ANGELES190646 KAISER FND HOSP - MENTAL HEALTH CENTER LOS ANGELES LOS ANGELES190429 KAISER FND HOSP - SUNSET/LOS ANGELES LOS ANGELES LOS ANGELES190434 KAISER FND HOSP - WEST LOS ANGELES LOS ANGELES LOS ANGELES194219 KECK HOSPITAL OF USC LOS ANGELES LOS ANGELES190150 KEDREN COMMUNITY MENTAL HEALTH CENTER LOS ANGELES LOS ANGELES190305 KINDRED HOSPITAL - LOS ANGELES LOS ANGELES LOS ANGELES191228 LAC/USC (LOS ANGELES COUNTY, UNIVERSITY SOUTHERN

CALIFORNIA MEDICAL CENTER)LOS ANGELES LOS ANGELES

190198 LOS ANGELES COMMUNITY HOSPITAL LOS ANGELES LOS ANGELES190854 LOS ANGELES METROPOLITAN MEDICAL CENTER LOS ANGELES LOS ANGELES190796 MATTEL CHILDREN’S HOSPITAL AT RONALD REAGAN UCLA LOS ANGELES LOS ANGELES190681 MIRACLE MILE MEDICAL CENTER LOS ANGELES LOS ANGELES190534 OLYMPIA MEDICAL CENTER LOS ANGELES LOS ANGELES190307 PACIFIC ALLIANCE MEDICAL CENTER LOS ANGELES LOS ANGELES190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST L.A.

CAMPUSLOS ANGELES LOS ANGELES

190930 RESNICK NEUROPSYCHIATRIC HOSPITAL AT UCLA LOS ANGELES LOS ANGELES190712 SHRINERS HOSPITAL FOR CHILDREN LOS ANGELES LOS ANGELES190661 SILVER LAKE MEDICAL CENTER-DOWNTOWN CAMPUS LOS ANGELES LOS ANGELES190762 ST. VINCENT MEDICAL CENTER LOS ANGELES LOS ANGELES191216 USC KENNETH NORRIS, JR. CANCER HOSPITAL LOS ANGELES LOS ANGELES190878 WHITE MEMORIAL MEDICAL CENTER LOS ANGELES LOS ANGELES240924 MEMORIAL HOSPITAL LOS BANOS LOS BANOS MERCED430743 EL CAMINO HOSPITAL LOS GATOS LOS GATOS SANTA CLARA430915 MISSION OAKS HOSPITAL LOS GATOS SANTA CLARA462284 EASTERN PLUMAS HOSPITAL-LOYALTON CAMPUS D/P SNF LOYALTON SIERRA190754 ST. FRANCIS MEDICAL CENTER LYNWOOD LOS ANGELES


204019 CHILDREN’S HOSPITAL CENTRAL CALIFORNIA, (CHCC) MADERA MADERA201281 MADERA COMMUNITY HOSPITAL MADERA MADERA260011 MAMMOTH HOSPITAL MAMMOTH LAKES MONO392287 DOCTORS HOSPITAL OF MANTECA MANTECA SAN JOAQUIN394009 KAISER FND HOSP - MANTECA MANTECA SAN JOAQUIN190500 MARINA DEL REY HOSPITAL MARINA DEL REY LOS ANGELES220733 JOHN C FREMONT HEALTHCARE DISTRICT MARIPOSA MARIPOSA070924 CONTRA COSTA REGIONAL MEDICAL CENTER MARTINEZ CONTRA COSTA580996 RIDEOUT MEMORIAL HOSPITAL MARYSVILLE YUBA600001 ROGUE REGIONAL MEDICAL CENTER MEDFORD OSHPD # HOSPITAL NAME CITY COUNTY414018 MENLO PARK SURGICAL HOSPITAL MENLO PARK SAN MATEO244027 MARIE GREEN PSYCHIATRIC CENTER - P H F MERCED MERCED240942 MERCY MEDICAL CENTER - MERCED MERCED MERCED190385 PROVIDENCE HOLY CROSS MEDICAL CENTER MISSION HILLS LOS ANGELES304113 CHILDREN’S HOSPITAL OF ORANGE COUNTY (CHOC) AT

MISSION HOSPITAL MISSION VIEJO ORANGE

301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER MISSION VIEJO ORANGE500954 CENTRAL VALLEY SPECIALTY HOSPITAL MODESTO STANISLAUS500852 DOCTORS MEDICAL CENTER OF MODESTO MODESTO STANISLAUS501016 DOCTORS MEDICAL CENTER-BEHAVIORAL HEALTH

DEPARTMENTMODESTO STANISLAUS

504042 KAISER FND HOSP - MODESTO MODESTO STANISLAUS500939 MEMORIAL MEDICAL CENTER, MODESTO MODESTO STANISLAUS504038 STANISLAUS SURGICAL HOSPITAL MODESTO STANISLAUS190541 MONROVIA MEMORIAL HOSPITAL MONROVIA LOS ANGELES361166 MONTCLAIR HOSPITAL MEDICAL CENTER MONTCLAIR SAN

BERNARDINO190081 BEVERLY HOSPITAL MONTEBELLO LOS ANGELES270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA MONTEREY MONTEREY190315 GARFIELD MEDICAL CENTER MONTEREY PARK LOS ANGELES190547 MONTEREY PARK HOSPITAL MONTEREY PARK LOS ANGELES334048 KAISER FND HOSP - MORENO VALLEY MORENO VALLEY RIVERSIDE334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER MORENO VALLEY RIVERSIDE410828 SETON COASTSIDE MOSS BEACH SAN MATEO470871 MERCY MEDICAL CENTER MT. SHASTA MOUNT SHASTA SISKIYOU430763 EL CAMINO HOSPITAL MOUNTAIN VIEW SANTA CLARA334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA MURRIETA RIVERSIDE334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA MURRIETA RIVERSIDE281266 NAPA STATE HOSPITAL NAPA NAPA281047 QUEEN OF THE VALLEY HOSPITAL - NAPA NAPA NAPA370759 PARADISE VALLEY HOSPITAL NATIONAL CITY SAN DIEGO361458 COLORADO RIVER MEDICAL CENTER NEEDLES SAN

BERNARDINO301205 HOAG MEMORIAL HOSPITAL, PRESBYTERIAN NEWPORT BEACH ORANGE


301304 NEWPORT BAY HOSPITAL NEWPORT BEACH ORANGE190568 NORTHRIDGE HOSPITAL MEDICAL CENTER NORTHRIDGE LOS ANGELES190766 COAST PLAZA HOSPITAL NORWALK LOS ANGELES190958 DEPARTMENT OF STATE HOSPITAL-METROPOLITAN NORWALK LOS ANGELES190570 NORWALK COMMUNITY HOSPITAL NORWALK LOS ANGELES214034 NOVATO COMMUNITY HOSPITAL NOVATO MARIN501352 OAK VALLEY CARE CENTER D/P SNF OAKDALE STANISLAUS500967 OAK VALLEY DISTRICT HOSPITAL (2-RH) OAKDALE STANISLAUS010937 ALTA BATES SUMMIT MED CTR-SUMMIT CAMPUS-

HAWTHORNEOAKLAND ALAMEDA

013626 ALTA BATES SUMMIT MED CTR-SUMMIT CAMPUS-SUMMIT OAKLAND ALAMEDAOSHPD # HOSPITAL NAME CITY COUNTY010776 CHILDREN’S HOSPITAL & RESEARCH CENTER - OAKLAND OAKLAND ALAMEDA010846 HIGHLAND HOSPITAL OAKLAND ALAMEDA014326 KAISER PERMANENTE - OAKLAND OAKLAND ALAMEDA013687 MPI CHEMICAL DEPENDENCY RECOVERY HOSPITAL OAKLAND ALAMEDA014207 TELECARE HERITAGE PSYCHIATRIC HEALTH FACILITY OAKLAND ALAMEDA010782 THUNDER ROAD CHEMICAL DEPENDENCY RECOVERY

HOSPITALOAKLAND ALAMEDA

370780 TRI-CITY MEDICAL CENTER OCEANSIDE SAN DIEGO560500 OJAI MANOR CONVALESCENT HOSPITAL OJAI VENTURA560501 OJAI VALLEY COMMUNITY HOSPITAL OJAI VENTURA364265 KAISER FND HOSP - ONTARIO ONTARIO SAN

BERNARDINO361274 KINDRED HOSPITAL ONTARIO ONTARIO SAN

BERNARDINO301140 CHAPMAN MEDICAL CENTER ORANGE ORANGE300032 CHILDREN’S HOSPITAL OF ORANGE COUNTY (CHOC ) ORANGE ORANGE304159 HEALTHBRIDGE CHILDREN'S HOSPITAL-ORANGE ORANGE ORANGE301340 ST. JOSEPH HOSPITAL - ORANGE ORANGE ORANGE301279 UNIVERSITY OF CALIFORNIA, IRVINE MEDICAL CENTER (UCI) ORANGE ORANGE040937 OROVILLE HOSPITAL OROVILLE BUTTE560838 PACIFIC SHORES HOSPITAL OXNARD VENTURA560529 ST. JOHN’S REGIONAL MEDICAL CENTER OXNARD VENTURA331164 DESERT REGIONAL MEDICAL CENTER PALM SPRINGS RIVERSIDE196405 PALMDALE REGIONAL MEDICAL CENTER PALMDALE LOS ANGELES434040 LUCILE PACKARD CHILDREN’S HOSPITAL AT STANFORD,

(LPCH)PALO ALTO SANTA CLARA

430905 STANFORD HOSPITAL PALO ALTO SANTA CLARA190432 KAISER FND HOSP - PANORAMA CITY PANORAMA CITY LOS ANGELES190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS PANORAMA CITY LOS ANGELES040875 FEATHER RIVER HOSPITAL PARADISE BUTTE190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN

CAMPUSPARAMOUNT LOS ANGELES

190462 AURORA LAS ENCINAS HOSPITAL PASADENA LOS ANGELES


190400 HUNTINGTON MEMORIAL HOSPITAL PASADENA LOS ANGELES361768 PATTON STATE HOSPITAL PATTON SAN

BERNARDINO332172 KINDRED HOSPITAL RIVERSIDE PERRIS RIVERSIDE491001 PETALUMA VALLEY HOSPITAL PETALUMA SONOMA301297 PLACENTIA LINDA HOSPITAL PLACENTIA ORANGE094002 EL DORADO COUNTY P H F PLACERVILLE EL DORADO090933 MARSHALL MEDICAL CENTER (1-RH) PLACERVILLE EL DORADO014050 VALLEYCARE MEDICAL CENTER PLEASANTON ALAMEDA194010 AMERICAN RECOVERY CENTER POMONA LOS ANGELES190137 CASA COLINA HOSPITAL FOR REHAB MEDICINE POMONA LOS ANGELES191014 LANTERMAN DEVELOPMENTAL CENTER POMONA LOS ANGELESOSHPD # HOSPITAL NAME CITY COUNTY190630 POMONA VALLEY HOSPITAL MEDICAL CENTER POMONA LOS ANGELES541123 PORTERVILLE DEVELOPMENTAL CENTER PORTERVILLE TULARE540798 SIERRA VIEW MEDICAL CENTER PORTERVILLE TULARE320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS PORTOLA PLUMAS370977 POMERADO HOSPITAL POWAY SAN DIEGO320986 PLUMAS DISTRICT HOSPITAL QUINCY PLUMAS364188 KINDRED HOSPITAL RANCHO RANCHO

CUCAMONGASAN BERNARDINO

330120 BETTY FORD CENTER AT EISENHOWER, THE RANCHO MIRAGE RIVERSIDE331168 EISENHOWER MEDICAL CENTER RANCHO MIRAGE RIVERSIDE521041 ST. ELIZABETH COMMUNITY HOSPITAL RED BLUFF TEHAMA450949 MERCY MEDICAL CENTER, REDDING REDDING SHASTA454013 PATIENTS' HOSPITAL OF REDDING REDDING SHASTA454068 RESTPADD PSYCHIATRIC HEALTH FACILITY REDDING SHASTA451019 SHASTA COUNTY P H F REDDING SHASTA450940 SHASTA REGIONAL MEDICAL CENTER REDDING SHASTA454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA REDDING SHASTA364014 LOMA LINDA UNIVERSITY BEHAVIORAL MEDICINE CENTER REDLANDS SAN

BERNARDINO364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL REDLANDS SAN

BERNARDINO361308 REDLANDS COMMUNITY HOSPITAL REDLANDS SAN

BERNARDINO410804 KAISER FND HOSP - REDWOOD CITY REDWOOD CITY SAN MATEO410891 LUCILE PACKARD CHILDREN’S SPECIAL CARE NURSERY AT

SEQUOIA HOSPITAL, (LPCH)REDWOOD CITY SAN MATEO

100797 ADVENTIST MEDICAL CENTER - REEDLEY REEDLEY FRESNO196404 JOYCE EISENBERG KEEFER MEDICAL CENTER RESEDA LOS ANGELES074093 KAISER FND HOSP - RICHMOND CAMPUS RICHMOND CONTRA COSTA150782 RIDGECREST REGIONAL HOSPITAL RIDGECREST KERN334025 KAISER FND HOSP - RIVERSIDE RIVERSIDE RIVERSIDE331293 PARKVIEW COMMUNITY HOSPITAL RIVERSIDE RIVERSIDE


331312 RIVERSIDE COMMUNITY HOSPITAL RIVERSIDE RIVERSIDE331314 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER - D/P APH RIVERSIDE RIVERSIDE331226 VISTA BEHAVIORAL HOSPITAL RIVERSIDE RIVERSIDE190020 BHC ALHAMBRA HOSPITAL ROSEMEAD LOS ANGELES190410 SILVER LAKE MEDICAL CENTER-INGLESIDE CAMPUS ROSEMEAD LOS ANGELES314024 KAISER PERMANENTE - ROSEVILLE ROSEVILLE PLACER311000 SUTTER ROSEVILLE MEDICAL CENTER ROSEVILLE PLACER314029 TELECARE PLACER COUNTY PSYCHIATRIC HEALTH FACILITY ROSEVILLE PLACER344188 CRESTWOOD PSYCHIATRIC HEALTH FACILITY-SACRAMENTO SACRAMENTO SACRAMENTO344021 HERITAGE OAKS HOSPITAL SACRAMENTO SACRAMENTO340913 KAISER FND HOSP - SACRAMENTO SACRAMENTO SACRAMENTO342344 KAISER FND HOSP - SOUTH SACRAMENTO SACRAMENTO SACRAMENTO340947 MERCY GENERAL HOSPITAL SACRAMENTO SACRAMENTOOSHPD # HOSPITAL NAME CITY COUNTY340951 METHODIST HOSPITAL OF SACRAMENTO SACRAMENTO SACRAMENTO344011 SACRAMENTO MENTAL HEALTH TREATMENT CENTER SACRAMENTO SACRAMENTO344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF. SACRAMENTO SACRAMENTO342392 SIERRA VISTA HOSPITAL SACRAMENTO SACRAMENTO344017 SUTTER CENTER FOR PSYCHIATRY SACRAMENTO SACRAMENTO341051 SUTTER GENERAL HOSPITAL SACRAMENTO SACRAMENTO341052 SUTTER MEDICAL CENTER SACRAMENTO SACRAMENTO SACRAMENTO341006 UNIVERSITY OF CALIFORNIA, DAVIS CHILDREN’S HOSPITAL

(UCD)SACRAMENTO SACRAMENTO

274043 NATIVIDAD MEDICAL CENTER SALINAS MONTEREY270875 SALINAS VALLEY MEMORIAL HEALTHCARE SYSTEM SALINAS MONTEREY050932 MARK TWAIN MEDICAL CENTER SAN ANDREAS CALAVERAS364121 BALLARD REHABILITATION HOSP SAN BERNARDINO SAN

BERNARDINO361323 COMMUNITY HOSPITAL OF SAN BERNARDINO SAN BERNARDINO SAN

BERNARDINO361339 ST. BERNARDINE MEDICAL CENTER SAN BERNARDINO SAN

BERNARDINO301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE SAN CLEMENTE ORANGE370652 ALVARADO HOSPITAL MEDICAL CENTER SAN DIEGO SAN DIEGO374063 ALVARADO HOSPITAL MEDICAL CENTER SAN DIEGO SAN DIEGO374024 AURORA SAN DIEGO SAN DIEGO SAN DIEGO370730 KAISER FND HOSP - SAN DIEGO SAN DIEGO SAN DIEGO370721 KINDRED HOSPITAL - SAN DIEGO SAN DIEGO SAN DIEGO370787 PROMISE HOSPITAL OF SAN DIEGO SAN DIEGO SAN DIEGO370673 RADY CHILDREN’S HOSPITAL SAN DIEGO (RCHSD) SAN DIEGO SAN DIEGO374055 SAN DIEGO COUNTY PSYCHIATRIC HOSPITAL SAN DIEGO SAN DIEGO370744 SCRIPPS MERCY HOSPITAL, SAN DIEGO SAN DIEGO SAN DIEGO370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN SAN DIEGO SAN DIEGO374049 SHARP MCDONALD CENTER SAN DIEGO SAN DIEGO370694 SHARP MEMORIAL HOSPITAL SAN DIEGO SAN DIEGO


370745 SHARP MESA VISTA HOSPITAL SAN DIEGO SAN DIEGO370782 UNIVERSITY OF CALIFORNIA, SAN DIEGO MEDICAL CENTER

(UCSD)SAN DIEGO SAN DIEGO

374094 VIBRA HOSPITAL OF SAN DIEGO SAN DIEGO SAN DIEGO190673 SAN DIMAS COMMUNITY HOSPITAL SAN DIMAS LOS ANGELES380826 CALIFORNIA PACIFIC MED CTR-CALIFORNIA EAST SAN FRANCISCO SAN FRANCISCO380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS SAN FRANCISCO SAN FRANCISCO380929 CALIFORNIA PACIFIC MED CTR-PACIFIC CAMPUS SAN FRANCISCO SAN FRANCISCO380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST. LUKE'S CAMPUS SAN FRANCISCO SAN FRANCISCO380777 CALIFORNIA PACIFIC MEDICAL CENTER (CPMC) SAN FRANCISCO SAN FRANCISCO382715 CHINESE HOSPITAL SAN FRANCISCO SAN FRANCISCO380842 JEWISH HOME SAN FRANCISCO SAN FRANCISCO380857 KAISER PERMANENTE - SAN FRANCISCO SAN FRANCISCO SAN FRANCISCOOSHPD # HOSPITAL NAME CITY COUNTY380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER SAN FRANCISCO SAN FRANCISCO380868 LANGLEY PORTER PSYCHIATRIC INSTITUTE SAN FRANCISCO SAN FRANCISCO380939 SAN FRANCISCO GENERAL HOSPITAL (SFGH) SAN FRANCISCO SAN FRANCISCO380960 ST. FRANCIS MEMORIAL HOSPITAL SAN FRANCISCO SAN FRANCISCO380965 ST. MARY'S MEDICAL CENTER, SAN FRANCISCO SAN FRANCISCO SAN FRANCISCO380895 UCSF MEDICAL CENTER AT MOUNT ZION SAN FRANCISCO SAN FRANCISCO381154 UNIVERSITY OF CALIFORNIA, SAN FRANCISCO MEDICAL

CENTER (UCSF)SAN FRANCISCO SAN FRANCISCO

190200 SAN GABRIEL VALLEY MEDICAL CENTER SAN GABRIEL LOS ANGELES434220 CRESTWOOD PSYCHIATRIC HEALTH FACILITY-SAN JOSE SAN JOSE SANTA CLARA430779 GOOD SAMARITAN HOSPITAL (HCA), SAN JOSE SAN JOSE SANTA CLARA431506 KAISER FND HOSP - SAN JOSE SAN JOSE SANTA CLARA430837 O’CONNOR HOSPITAL SAN JOSE SANTA CLARA430705 REGIONAL MEDICAL CENTER OF SAN JOSE SAN JOSE SANTA CLARA430883 SANTA CLARA VALLEY MEDICAL CENTER (SCVMC) SAN JOSE SANTA CLARA010811 FAIRMONT HOSPITAL SAN LEANDRO ALAMEDA014337 KAISER PERMANENTE - SAN LEANDRO SAN LEANDRO ALAMEDA010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA SAN LEANDRO ALAMEDA013619 SAN LEANDRO HOSPITAL SAN LEANDRO ALAMEDA014226 TELECARE WILLOW ROCK CENTER SAN LEANDRO ALAMEDA400480 FRENCH HOSPITAL MEDICAL CENTER SAN LUIS OBISPO SAN LUIS OBISPO404046 SAN LUIS OBISPO CO PSYCHIATRIC HEALTH FACILITY SAN LUIS OBISPO SAN LUIS OBISPO400524 SIERRA VISTA REGIONAL MEDICAL CENTER SAN LUIS OBISPO SAN LUIS OBISPO410742 MILLS HEALTH CENTER SAN MATEO SAN MATEO410782 SAN MATEO MEDICAL CENTER SAN MATEO SAN MATEO070904 DOCTORS MEDICAL CENTER - SAN PABLO SAN PABLO CONTRA COSTA190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO SAN PEDRO LOS ANGELES190362 PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE

CENTERSAN PEDRO LOS ANGELES

210992 KAISER FND HOSP - SAN RAFAEL SAN RAFAEL MARIN074017 SAN RAMON REGIONAL MEDICAL CENTER SAN RAMON CONTRA COSTA


074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING SAN RAMON CONTRA COSTA301258 COASTAL COMMUNITIES HOSPITAL SANTA ANA ORANGE301167 KINDRED HOSPITAL - SANTA ANA SANTA ANA ORANGE301566 WESTERN MEDICAL CENTER, SANTA ANA SANTA ANA ORANGE420514 COTTAGE HOSPITAL, SANTA BARBARA SANTA BARBARA SANTA BARBARA424047 COTTAGE REHABILITATION HOSPITAL SANTA BARBARA SANTA BARBARA420483 GOLETA VALLEY COTTAGE HOSPITAL SANTA BARBARA SANTA BARBARA424002 SANTA BARBARA PSYCHIATRIC HEALTH FACILITY SANTA BARBARA SANTA BARBARA434153 KAISER PERMANENTE - SANTA CLARA SANTA CLARA SANTA CLARA434218 KAISER PERMANENTE P.H.F - SANTA CLARA SANTA CLARA SANTA CLARA440755 DOMINICAN HOSPITAL SANTA CRUZ SANTA CRUZ444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ SANTA CRUZ SANTA CRUZOSHPD # HOSPITAL NAME CITY COUNTY444029 TELECARE SANTA CRUZ PHF SANTA CRUZ SANTA CRUZ420493 MARIAN REGIONAL MEDICAL CENTER SANTA MARIA SANTA BARBARA190687 SANTA MONICA-UCLA MEDICAL CENTER & ORTHOPEDIC

HOSPITALSANTA MONICA LOS ANGELES

190756 ST. JOHN’S HEALTH CENTER SANTA MONICA LOS ANGELES560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA

HOSPITALSANTA PAULA VENTURA

494048 AURORA BEHAVIORAL HEALTHCARE-SANTA ROSA, LLC SANTA ROSA SONOMA494019 KAISER FND HOSP - SANTA ROSA SANTA ROSA SONOMA491064 SANTA ROSA MEMORIAL HOSPITAL SANTA ROSA SONOMA490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME SANTA ROSA SONOMA494106 SUTTER MEDICAL CENTER OF SANTA ROSA SANTA ROSA SONOMA374497 EDGEMOOR GERIATRIC HOSPITAL SANTEE SAN DIEGO491338 PALM DRIVE HOSPITAL SEBASTOPOL SONOMA100793 ADVENTIST MEDICAL CENTER-SELMA SELMA FRESNO190708 SHERMAN OAKS HOSPITAL SHERMAN OAKS LOS ANGELES560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE SIMI VALLEY VENTURA420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL SOLVANG SANTA BARBARA491076 SONOMA VALLEY HOSPITAL SONOMA SONOMA552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW SONORA TUOLUMNE554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY SONORA TUOLUMNE551035 SONORA REGIONAL MEDICAL CENTER D/P SNF (UNIT 6 AND

7)SONORA TUOLUMNE

190352 GREATER EL MONTE COMMUNITY HOSPITAL SOUTH EL MONTE LOS ANGELES090793 BARTON MEMORIAL HOSPITAL SOUTH LAKE

TAHOEEL DORADO

410806 KAISER FND HOSP - SOUTH SAN FRANCISCO SOUTH SAN FRANCISCO

SAN MATEO

281078 ST. HELENA HOSPITAL ST. HELENA NAPA390846 DAMERON HOSPITAL ASSOCIATION (DHA) STOCKTON SAN JOAQUIN394003 SAN JOAQUIN COUNTY P.H.F. STOCKTON SAN JOAQUIN392232 ST. JOSEPH'S BEHAVIORAL HEALTH CENTER STOCKTON SAN JOAQUIN


391042 ST. JOSEPH’S MEDICAL CENTER, STOCKTON STOCKTON SAN JOAQUIN334018 MENIFEE VALLEY MEDICAL CENTER SUN CITY RIVERSIDE190696 PACIFICA HOSPITAL OF THE VALLEY SUN VALLEY LOS ANGELES184008 BANNER LASSEN MEDICAL CENTER SUSANVILLE LASSEN191231 OLIVE VIEW UCLA MEDICAL CENTER SYLMAR LOS ANGELES190517 PROVIDENCE TARZANA MEDICAL CENTER TARZANA LOS ANGELES190782 TARZANA TREATMENT CENTER TARZANA LOS ANGELES150808 TEHACHAPI HOSPITAL TEHACHAPI KERN334564 TEMECULA VALLEY HOSPITAL TEMECULA RIVERSIDE400548 TWIN CITIES COMMUNITY HOSPITAL TEMPLETON SAN LUIS OBISPO560492 LOS ROBLES REGIONAL HOSPITAL & MEDICAL CENTER THOUSAND OAKS VENTURA564121 THOUSAND OAKS SURGICAL HOSPITAL, A CAMPUS OF LOS

ROBLES HOSPTHOUSAND OAKS VENTURA

OSHPD # HOSPITAL NAME CITY COUNTY190232 DEL AMO HOSPITAL TORRANCE LOS ANGELES191227 HARBOR UCLA MEDICAL CENTER TORRANCE LOS ANGELES190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER -

TORRANCETORRANCE LOS ANGELES

190702 PROVIDENCE LITTLE COMPANY OF MARY TRANSITIONAL CARE CENTER

TORRANCE LOS ANGELES

194967 STAR VIEW ADOLESCENT - P H F TORRANCE LOS ANGELES190422 TORRANCE MEMORIAL MEDICAL CENTER TORRANCE LOS ANGELES391056 SUTTER TRACY COMMUNITY HOSPITAL TRACY SAN JOAQUIN291053 TAHOE FOREST HOSPITAL TRUCKEE NEVADA540816 TULARE REGIONAL MEDICAL CENTER TULARE TULARE500867 EMANUEL MEDICAL CENTER TURLOCK STANISLAUS304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL TUSTIN ORANGE301357 NEWPORT SPECIALTY HOSPITAL TUSTIN ORANGE231396 UKIAH VALLEY MEDICAL CENTER UKIAH MENDOCINO361318 SAN ANTONIO COMMUNITY HOSPITAL UPLAND SAN

BERNARDINO484044 KAISER FND HOSP - VACAVILLE VACAVILLE SOLANO484001 NORTH BAY VACAVALLEY HOSPITAL VACAVILLE SOLANO190949 HENRY MAYO NEWHALL MEMORIAL HOSPITAL VALENCIA LOS ANGELES484062 CRESTWOOD SOLANO PSYCHIATRIC HEALTH FACILITY VALLEJO SOLANO480989 KAISER FND HOSP - REHABILITATION CENTER VALLEJO VALLEJO SOLANO481015 ST. HELENA HOSPITAL CENTER FOR BEHAVIORAL HEALTH VALLEJO SOLANO481094 SUTTER SOLANO MEDICAL CENTER VALLEJO SOLANO190814 SOUTHERN CALIFORNIA HOSPITAL AT VAN NUYS D/P APH VAN NUYS LOS ANGELES190812 VALLEY PRESBYTERIAN HOSPITAL VAN NUYS LOS ANGELES560203 AURORA VISTA DEL MAR HOSPITAL VENTURA VENTURA560473 COMMUNITY MEMORIAL HOSPITAL OF VENTURA VENTURA VENTURA560481 VENTURA COUNTY MEDICAL CENTER (VCMC) VENTURA VENTURA364144 DESERT VALLEY HOSPITAL VICTORVILLE SAN

BERNARDINO


361370 VICTOR VALLEY GLOBAL MEDICAL CENTER VICTORVILLE SAN BERNARDINO

544009 KAWEAH DELTA MENTAL HEALTH HOSPITAL D/P APH VISALIA TULARE540734 KAWEAH DELTA HEALTHCARE DISTRICT VISALIA TULARE544075 KAWEAH DELTA REHABILITATION HOSPITAL VISALIA TULARE540827 KAWEAH DELTA SKILLED NURSING FACILITY VISALIA TULARE070988 JOHN MUIR HEALTH, WALNUT CREEK CAMPUS WALNUT CREEK CONTRA COSTA070990 KAISER PERMANENTE - WALNUT CREEK WALNUT CREEK CONTRA COSTA444013 WATSONVILLE COMMUNITY HOSPITAL WATSONVILLE SANTA CRUZ531059 TRINITY HOSPITAL WEAVERVILLE TRINITY190636 CITRUS VALLEY MEDICAL CENTER WEST COVINA LOS ANGELES190857 DOCTORS HOSPITAL OF WEST COVINA, INC WEST COVINA LOS ANGELES190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY WEST COVINA LOS ANGELES564018 LOS ROBLES HOSPITAL & MEDICAL CENTER - EAST CAMPUS WESTLAKE VILAGE VENTURAOSHPD # HOSPITAL NAME CITY COUNTY301380 KINDRED HOSPITAL WESTMINSTER WESTMINSTER ORANGE190631 PRESBYTERIAN INTER. HOSPITAL (PIH) HEALTH HOSPITAL WHITTIER LOS ANGELES190883 WHITTIER HOSPITAL MEDICAL CENTER WHITTIER LOS ANGELES334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR WILDOMAR RIVERSIDE230949 FRANK R HOWARD MEMORIAL HOSPITAL WILLITS MENDOCINO110889 GLENN MEDICAL CENTER WILLOWS GLENN571086 WOODLAND MEMORIAL HOSPITAL WOODLAND YOLO191450 KAISER FND HOSP - WOODLAND HILLS WOODLAND HILLS LOS ANGELES190552 MOTION PICTURE AND TELEVISION HOSPITAL WOODLAND HILLS LOS ANGELES474007 FAIRCHILD MEDICAL CENTER YREKA SISKIYOU510882 FREMONT MEDICAL CENTER YUBA CITY SUTTER514033 NORTH VALLEY BEHAVIORAL HEALTH YUBA CITY SUTTER514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY YUBA CITY SUTTER514001 SUTTER-YUBA PSYCHIATRIC HEALTH FACILITY YUBA CITY SUTTER700564 30TH MEDICAL GROUP HOSPITAL 700597 60TH MEDICAL GROUP HOSPITAL 700431 722ND MEDICAL GROUP 700103 95TH MEDICAL GROUP - EDWARDS AIR FORCE BASE 890096 CALIFORNIA - CLINIC 890097 CALIFORNIA - EMERGENCY ROOM 890000 CALIFORNIA - HOME BIRTH 890095 CALIFORNIA - MD OFFICE 890099 CALIFORNIA - OTHER IN/PATIENT SETTING 890094 CALIFORNIA - OTHER OUT/PATIENT SETTING 700501 NAVAL HOSPITAL - CAMP PENDLETON 700112 NAVAL HOSPITAL - LEMOORE 700461 NAVAL HOSPITAL - TWENTYNINE PALM 700502 NAVAL MEDICAL CENTER (BALBOA) 777777 NOT APPLICABLE 880096 OUT OF STATE - CLINIC


880097 OUT OF STATE - EMERGENCY ROOM 880000 OUT OF STATE - HOME BIRTH 880095 OUT OF STATE - MD OFFICE 880099 OUT OF STATE - OTHER IN/PATIENT SETTING 880094 OUT OF STATE - OTHER OUT/PATIENT SETTING 900099 SAFE SURRENDER 999999 UNKNOWN 700330 US ARMY AIR FORCE HOSPITAL 700473 US ARMY HOSPITAL 700474 US INFIMARY AIR FORCE BASE 700602 US NAVAL HOSPITAL 700659 US NAVAL STATION HOSPITAL 700664 USAF HOSPITAL - MARYSVILLE

APPENDIX D-FAHRENHEIT TO CENTRIGRADE CONVERSION TABLE


CPeTS/CPQCC Neonatal Transport Data Report Request 2015Name of Person Requesting DataHospital Affiliation/RegionFull Hospital Address

E-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 [email protected] Select One From Below Select One Transport Type

CPQCC Member Facility Number All TransportsNon-CPQCC Facility OSHPD Number Delivery Room RequestedPerinatal Region (specify) Emergent

Select One UrgentTransport In ScheduledTransport Out Select One Transport Provider Type

Select One Data Year Receiving Facility2015 Manual of Definitions – Neonatal Transport Data Collection Tool 42

2014 Referring Facility2013 Contract Service2012

Select One From Below Select One Transport TypeCPQCC Member Facility Number All TransportsNon-CPQCC Facility OSHPD Number Delivery Room RequestedPerinatal Region Emergent


Select One Data Year Receiving Facility2014 Referring Facility2013 Contract Service2012

Select One From Below Select One Transport TypeCPQCC Member Facility Number All TransportsNon-CPQCC Facility OSHPD Number Delivery Room RequestedPerinatal Region Emergent


Select One Data Year Receiving Facility2014 Referring Facility2013 Contract Service2012

Revised 10/2014APPENDIX F

CALIFORNIA 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: http://www.health-info-solutions.com/CPQCC-CPeTS/tripsmobile/tripsmobile.html

Table A: California TRIPS Score: to be recorded on referral, within


15 minutes of arrival at referring hospital and admit to NICU.*Referral Initial

Transport NICU Admit

Time (24 hour) C.14 C.18 C.19

C.20 Responsiveness 2 2 2C.21 Temperature C° 37.6 37.7 37.8Too low to register Yes Yes Yes

Was the infant cooled? Y XX N Y XX N Y XX N

Method of coolingC.22 Heart Rate 165 172 170

C.23 Respiratory Rate 80 60 60

C.24 Oxygen Saturation 84 89 90

C.25 Respiratory Status 2 1 1C.26 Inspired Oxygen Concentration

100 95 90

C.27 Respiratory Support 3 3 3C.28 Blood Pressure Systolic / Diastolic, Mean

28/17 32/22 34/23

Too low to register Yes Yes Yes

C.29 Pressors XX Y N XX YN XX Y N

Responsiveness: 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 calculations

Table B: TRIPS Score Components Used for Identifying Risk of Mortality within 7 Days After Transport

Value Points

C.20 Responsiveness 2 10C.21 Temperature C° 37.7 6C.25 Respiratory Status 1 20C.26 Inspired Oxygen Concentration 95C.28 Blood Pressure Systolic/ Diastolic, Mean

32/22 8


C.29 Pressors YES 5

TOTAL SCORE 49

Table C: Model Used for Calculating California TRIPS

Risk Factor

TRIPS Points

Responsiveness None, seizure, muscle relaxant (1) 14Lethargic, no cry (2) 10Vigorously Withdraws, Cry (3) 0

Temperature (°C)

36.1 to 37.6 0<36.1 or >37.6 6

Respiratory Status

None or mild respiratory symptoms (3) 0Moderate (apnea, gasping, not on respirator) (2) 21

Severe (on respirator) (1) with FiO2 < 50 15 with FiO2 50 to <75 18

with FiO2 75-100 20Systolic Blood Pressure (mmHg)

under 20 2420-30 1930-40 8>40 0

Pressors Not Used 0

Used 5

49

Table D: California TRIPS Score Risk Points Risk of Death within

7 Days of Transport0 to 8 0.4 to 0.9%

9 to 16 0.9 to 1.9%17 to 24 2.1 to 4.0%25 to 34 4.4 to 10.2%35 to 44 11.1 to 23.4%

45 to 70 25.2 to 80.1%


all california neonatal transport cpets manual.docx · web viewin general, apgar scores are...

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