Assessment For Contact Number – please input numerical onlyOfficial email address of the hospital can be use as an alternative, use N/A if necessary. Hospital Name (Full)(required) Warning Address (Complete)(required) Warning Contact Number(required) Warning Chief/Director of the Hospital (Full Name)(required) Warning Mobile Number(required) Warning Email Address(required) Warning Paediatric Department Head (Full Name)(required) Warning Email Address(required) Warning Mobile Number(required) Warning Paediatrician / Neonatologist (Full Name)(required) Warning Email Address(required) Warning Mobile Number(required) Warning NICU Head/Supervisor (Full Name)(required) Warning Email Address(required) Warning Mobile Number(required) Warning Catchment Area Information(required) Warning Number of hospitals / health stations with birthing facilities(required) Warning Hospital Statistics Total Hospital Beds(required) Warning Total Number of Births (2019)(required) Warning Percentage by Caesarian Section(required) Warning Percentage by Forceps(required) Warning Percentage by Vacuum(required) Warning Total Still Birth of (2019)(required) Warning Number Admitted out-born neonates for 2019 (An infant who is delivered at a health care facility (or home) and then transferred to this hospital)(required) Warning Number of Babies admitted to NICU in 2019(required) Warning Number of babies who died in 2019(required) Warning Number of intramural babies admitted to NICU in 2019 (intramural – inborn babies born in this hospital)(required) Warning Number of babies who died in 2019(required) Warning Number of extramural babies admitted to NICU in 2019 (extramural – out-born babies born outside this hospital)(required) Warning Number of babies who died(required) Warning Does the number of babies who died include those who went home to die? (extramural – out-born babies born outside this hospital)(required) Warning Number of admissions to NICU for Jaundice in 2019(required) Warning Number of admission of inborn patients(required) Warning Number of admission of out-born patients(required) Warning Number of Kernicterus cases among inborn patients (Kernicterus are kind of preventable brain damage that can happen in newborns with jaundice)(required) Warning Number of Kernicterus cases among out-born patients (Kernicterus are kind of preventable brain damage that can happen in newborns with jaundice)(required) Warning Number of deaths of inborn patients due to jaundice(required) Warning Number of deaths of out-born patients due to jaundice(required) Warning Number of Exchange transfusion in 2019(required) Warning Number of inborn patients w/ exchange transfusion in 2019(required) Warning Number of out-born patients w/ exchange transfusion in 2019(required) Warning Number of successful exchange transfusions for babies in 2019(required) Warning In 2019, was the hospital unable to do exchange trans because of lack of blood?(required) Warning Data Collection Individual sheet kept for each patient?(required) Yes No Warning Retained after patient is no longer in hospital?(required) Yes No Warning Daily registry kept?(required) Yes No Warning If Yes, what are the data information collected ? (please check where applicable)(required) Sex/Gender Address Roomed in or admitted to NICU Admitting diagnosis Final diagnosis Procedure Done Attending Physician Date & Time of Discharge Disposition Warning How are records kept?(required) Paper/Manual Electronic/Computer Encoded Both Warning Software used for Electronic or Computer Recording(required) Warning Spiritus Vitae would like to access the data, will the hospital permit the organisation? (this is for assessment pruposes only)(required) Yes No Warning Infant Mortality Information Mortality Rate for the last: 3 Years(required) Warning 28 Days(required) Warning 7 Days(required) Warning 24 Hours(required) Warning What is included in numerator?(required) Warning What is included in denominator? (required) Warning Are there babies who are DAMA?(required) Warning If yes, how many per year?(required) Warning Are babies who are expected to die sent home?(required) Warning If yes, are these babies included in mortality rate?(required) Warning Delivery Suites Number of Delivery Rooms(required) 1 2 3 4 5 Warning Delivery Room #1 Space in (sq. meter)(required) 20 to 30 sq. meter 30 to 40 sq. meter 40 to 50 sq. meter more than 50 sq. meter Warning Room Temperature ºC(required) Warning Delivery Room #2 Space in (sq. meter) 20 to 30 sq. meter 30 to 40 sq. meter 40 to 50 sq. meter more than 50 sq. meter Warning Room Temperature ºC Warning Delivery Room #3 Space in (sq. meter) 20 to 30 sq. meter 30 to 40 sq. meter 40 to 50 sq. meter more than 50 sq. meter Warning Room Temperature ºC Warning Delivery Room #4 Space in (sq. meter) 20 to 30 sq. meter 30 to 40 sq. meter 40 to 50 sq. meter more than 50 sq. meter Warning Room Temperature ºC Warning Delivery Room #5 Space in (sq. meter) 20 to 30 sq. meter 30 to 40 sq. meter 40 to 50 sq. meter more than 50 sq. meter Warning Room Temperature ºC Warning Number of Operating Rooms(required) 1 2 3 Warning Operating Room #1 Space in (sq. meter)(required) 20 to 30 sq. meter 30 to 40 sq. meter 40 to 50 sq. meter more than 50 sq. meter Warning Room Temperature ºC Warning Operating Room #2 Space in (sq. meter) 20 to 30 sq. meter 30 to 40 sq. meter 40 to 50 sq. meter more than 50 sq. meter Warning Room Temperature ºC Warning Operating Room #3 Space in (sq. meter) 20 to 30 sq. meter 30 to 40 sq. meter 40 to 50 sq. meter more than 50 sq. meter Warning Room Temperature ºC Warning Please check the following items if available in your Operating Room (please check where applicable)(required) Stable Electricity Continuous Clean Running Water Supply Oxygen Medical Air Oxygen Blender Adequate Clean Towels Suction Device Wall Clock or Monitoring Clock Warning Please check the following items if available in your Delivery Room (please check where applicable)(required) Stable Electricity Continuous Clean Running Water Supply Oxygen Medical Air Oxygen Blender Adequate Clean Towels Suction Device Wall Clock or Monitoring Clock Warning Equipment for Newborn Resuscitation (please check where applicable)(required) Resuscitation table with heater Bag & Mask – Term Bag & Mask – Pre-term Laryngoscope Scale Oximeter or Monitor Drugs for Reanimation Warning Staffing Number of Obstetrician(required) Warning Number of other Doctors(required) Warning Number of Nurses(required) Warning Number of Midwives(required) Warning Number of Medical Students Warning Number of Nursing Students Warning Number of Midwifery Students Warning Are obstetric Nurses rotated?(required) Yes No Warning Resuscitation Training Who performs resuscitation in your unit (please check where applicable)(required) Obstetrician Other doctor from OB Dept Paediatrician Nurses/Midwives Medical Student from Pedia Dept Medical Student from OB Dept Nursing/Midwifery Students Warning NICU Which babies are treated in NICU (please check where applicable)(required) Babies born in the hospital All babies born 28 days old regardless if inborn or out-born Others Warning Others (please describe) Warning If only Inborn, where are the out-born babies treated?(required) Warning Do you include in ‘Inborn’ babies who are born ON THE WAY to your hospital?(required) Yes No Warning Is there separate room for outborn ?(required) Yes No Warning Is there separate room for preterm babies?(required) Yes No Warning Is there separate room for babies with infection or suspected infection?(required) Yes No Warning Is there separate room for babies receiving phototherapy?(required) Yes No Warning Is there separate room for exchange transfusion?(required) Yes No Warning Treatment Room Treatment Room #1(required) 20 to 30 sq. meter 30 to 40 sq. meter 40 to 50 sq. meter more than 50 sq. meter None Warning Number of beds (N/A if none)(required) Warning Lowest Room Temperature ºC (N/A if none)(required) Warning Number of hand basins (N/A if none)(required) Warning Alcohol or Hand Sanitizer at each bedside?(required) Yes No Warning Alcohol or Hand Sanitiser at the center of the room?(required) Yes No Warning Is there a thermometer on the wall?(required) Yes No Warning Does the room have access to clean running water?(required) Yes No Warning Is there a Clock in the room?(required) Yes No Warning Is the room fitted with wall type connection for oxygen?(required) Yes No Warning Is the room accessible for cylinder oxygen tank?(required) Yes No Warning Is the room accessible for medical air supply?(required) Yes No Warning Can oxygen be blended?(required) Yes No Warning Is there a suction device in the room?(required) Yes No Warning Treatment Room #2 20 to 30 sq. meter 30 to 40 sq. meter 40 to 50 sq. meter more than 50 sq. meter Warning Number of beds Warning Lowest Room Temperature ºC Warning Number of hand basins Warning Alcohol or Hand Sanitiser at each bedside? Yes No Warning Alcohol or Hand Sanitiser at the center of the room? Yes No Warning Is there a thermometer on the wall? Yes No Warning Does the room have access to clean running water? Yes No Warning Is there a Clock in the room? Yes No Warning Is the room fitted with wall type connection for oxygen? Yes No Warning Is the room accessible for cylinder oxygen tank? Yes No Warning Is the room accessible for medical air supply? Yes No Warning Can oxygen be blended? Yes No Warning Is there a suction device in the room? Yes No Warning Treatment Room #3 20 to 30 sq. meter 30 to 40 sq. meter 40 to 50 sq. meter more than 50 sq. meter Warning Number of beds Warning Lowest Room Temperature ºC Warning Number of hand basins Warning Alcohol or Hand Sanitiser at each bedside? Yes No Warning Alcohol or Hand Sanitiser at the center of the room? Yes No Warning Is there a thermometer on the wall? Yes No Warning Does the room have access to clean running water? Yes No Warning Is there a Clock in the room? Yes No Warning Is the room fitted with wall type connection for oxygen? Yes No Warning Is the room accessible for cylinder oxygen tank? Yes No Warning Is the room accessible for medical air supply? Yes No Warning Can oxygen be blended? Yes No Warning Is there a suction device in the room? Yes No Warning If your hospital has more than 3 treatment room with similar configuration from above (please check where is applicable) Treatment Room #4 Treatment Room #5 Treatment Room #6 Warning Treatment Room Staffing Number of Neonatologist(required) Warning Number of Paediatrician(required) Warning Other Doctors Warning Number of Nurses(required) Warning Number of Medical Students(required) Warning Number of Nursing Students(required) Warning Are NICU nurses rotated?(required) Yes No Warning How long does the medical student stays in the NICU?(required) Warning Clinician’s language or dialect (mode of communication)(required) Warning NICU Equipment that are working (please check where applicable)(required) Mechanical Ventilator Bubble CPAP Pulse Oximeter Incubator Portable suction machine for newborn Ambubag for newborn Infant warmer Phototherapy – LED Phototherapy – Blue light Phototherapy – Other Warning Is there protocol for routine maintenance of equipment?(required) Yes No Warning If Yes, please describe the protocol of maintenance Warning For Phototherapy Non-LED Frequency of changing bulbs Warning Cost of changing bulbs for a machine (estimate only) Warning Are there periods you have to treat infants with machine after bulbs have expired? Warning Oxygen Therapy Oxygen Supply Reliability?(required) In-line (room is fitted with wall type oxygen connection) On demand (per request as needed stock is always available) Warning Medical Air Supply Reliability?(required) In-line (room is fitted with wall type oxygen connection) On demand (per request as needed stock is always available) Warning Endotracheal tubes supply reliability?(required) Available immediately (stock in room) Per request (supply coming from supply office always available) Warning How oxygen is provided?(required) Nasal Cannula Head Box or Hood Bag and Mask CPAP Ventilator Warning O2 Flow rate if thru nasal cannula(required) Warning O2 Flow rate if thru headbox(required) Warning Resuscitation Training Resuscitation Training Provided to NICU staff?(required) Yes No Warning When is the most recent training conducted? Warning Is the training provided to other hospitals’ staff?(required) Yes No Warning How often is the training being conducted in the hospital?(required) Once a year Every 6 Months Every 3 Months Warning Infection Control Is there a separate room for cleaning the equipment?(required) Yes No Warning Is the autoclave working?(required) Yes No Warning Is there a protocol for cleaning equipment?(required) Yes No Warning Is there a protocol for cleaning clinical area?(required) Yes No Warning Is there a training for infection control for staff?(required) Yes No Warning Is there a training for infection control for staff?(required) Yes No Warning How often is the training being conducted in the hospital?(required) Once a year Every 6 Months Every 3 Months Warning When is that latest training conducted?(required) Warning Is there a training for infection control for visitors?(required) Yes No Warning Is there adequate supply of Alcohol or Hand Sanitiser?(required) Yes No Warning Medical alcohol (70%) supply reliability ?(required) Available Immediately Per Request (Supply Office has always stand by stock) Alcohol supply often run out of stock budget allocation for alcohol is very limited Warning Is NICU equipped with a hand washing area ?(required) Yes No Warning Is NICU equipped with clean water supply?(required) Yes No Warning Is NICU hand washing area equipped with cleaning agent ?(required) Antiseptic Cleaning Solution Antiseptic Bar Soap Antiseptic Liquid Soap Ordinary Bar Soap Ordinary Liquid Soap Warning How staff dry their hands ?(required) Paper Towel Cloth Towel Electric Hand Dryer Warning Is there an instruction on how to wash hands properly posted near the sink ?(required) Yes No Warning Is there a bathroom close or inside NICU(required) Yes No Warning Is the bathroom have adequate supply of clean water ?(required) Yes No Warning Is the bathroom equipped with functional toilet ?(required) Yes No Warning Is it possible to clean the CPAP inside the NICU sink ? (required) Yes No Warning If No, please indicate where do you wash the CPAP ? Warning Is the hospital imposing breastfeeding exclusively ?(required) Yes No Warning Please describe how milk is provided to babies in NICU ? Warning Laboratory Testing Is Total Serum Bilirubin conducted ?(required) Yes No Warning Is Un-cojugated Bilirubin conducted ?(required) Yes No Warning Is Infection Screening – WBC conducted ?(required) Yes No Warning Is Infection Screening – CRP conducted ?(required) Yes No Warning Is Blood Culture & Antibiotic Sensitivity conducted ?(required) Yes No Warning The test are conducted where ?(required) At the hospital Off-site, at a hospital facility Off-site, at a private facility Warning Is there a possibility that some test are not conducted because its expensive ?(required) Yes No Warning If Yes, which type of test (please indicate)(required) Warning Jaundice on Postnatal Wards Usual Length of Stay (day of birth=0 night) Uncomplicated delivery(required) Warning Usual Length of Stay (day of birth=0 night) Caesarean Section(required) Warning Postnatal Wards Name of Ward #1(required) Warning Number of Beds?(required) Warning Ward #1 Space in (sq. meter estimate only)(required) 20 to 30 sq. meter 30 to 40 sq. meter 40 to 50 sq. meter above 50 sq. meter Warning Name of Ward #2 Warning Number of Beds? Warning Ward #2 Space in (sq. meter estimate only) 20 to 30 sq. meter 30 to 40 sq. meter 40 to 50 sq. meter above 50 sq. meter Warning Name of Ward #3 Warning Number of Beds? Warning Ward #3 Space in (sq. meter estimate only) 20 to 30 sq. meter 30 to 40 sq. meter 40 to 50 sq. meter above 50 sq. meter Warning Name of Ward #4 Warning Number of Beds? Warning Ward #4 Space in (sq. meter estimate only) 20 to 30 sq. meter 30 to 40 sq. meter 40 to 50 sq. meter above 50 sq. meter Warning Do mothers routinely share beds (overcrowding) ? Yes No Warning Screening for Jaundice Is there a routine blood typing for mothers & babies ?(required) Yes No Warning Does hospital identify all babies with ABO haemolytic disease ?(required) Yes No Warning Does hospital identify all babies with Rh(D) haemolytic disease ?(required) Yes No Warning Is prophylactic phototherapy given to babies with ABO/Rh haemolytic disease ?(required) Yes No Warning Does hospital routinely screen all babies on postnatal ward for jaundice ?(required) Yes No Warning If Yes, when is screening performed ? Date of Birth Only Everyday Date of Discharge Only Other, describe Warning If Others, please describe Warning If Yes, how is screening performed ?(required) Kramer's Rule Informal Visual Assessment Other, describe Warning If Others, please describe Warning If No, how are babies with physiologic jaundice identified ? Warning Phototherapy on Post Natal Wards Is phototherapy provided in postnatal wards ?(required) Yes No Warning Is TSB available?(required) Yes No Warning If Yes, is TSB available?(required) Sometimes Always Warning If TSB is ‘sometimes’ or ‘always’, how is it measured ?(required) Bilirubinometer in the postnatal ward Bilirubinometer in the sick baby nursery Laboratory (turnaround time) Warning Which babies can receive phototherapy in the postnatal wards ?(required) Uncomplicated physiological jaundice (TSB not approaching exchange transfusion levels) Babies with haemolytic disease (TSB not approaching exchange transfusion levels) Babies with TSB approaching exchange transfusion levels Warning Location of Equipment Ward #1 type of Phototherapy(required) LED Blue Light Ordinary White Fluorescent Type Warning Ward #2 type of Phototherapy LED Blue Light Ordinary White Fluorescent Type Warning Ward #3 type of Phototherapy LED Blue Light Ordinary White Fluorescent Type Warning Ward #3 type of Phototherapy LED Blue Light Ordinary White Fluorescent Type Warning Are multiple babies treated on same machine ?(required) Yes No Warning Average duration of Phototherapy Treatment ?(required) Warning Responsible for supervision of phototherapy in PostnatalWard #1 Warning Responsible for supervision of phototherapy in PostnatalWard #2 Warning Responsible for supervision of phototherapy in PostnatalWard #3 Warning Referrals to Higher Level Hospitals Hospital refer neonates to Higher Level Hospitals (required) Yes No Warning If Yes, which hospital ? Warning How long does it take to get to these hospital/s ? Warning Which neonates do you most frequently refer ?(required) Preterm Severe respiratory distress Surgical Others Warning If other, please describe Warning How are neonates transferred Hospital Ambulance Parents, describe transport Warning Do doctor/nurses accompany infant ?(required) Yes No Warning Does hospital get follow-up info on transferred infant ?(required) Yes No Warning Donated Devices (very important) Donated Equipments by (East Meets West Foundation)(required) CPAP Machine Phototherapy (Overhead Type) Phototherapy (Firefly) Infant Warmer None Warning CPAP Machine (Number of Units, 0 if none)(required) Warning Phototherapy Overhead Type (Number of Units, 0 if none)(required) Warning Phototherapy Firefly Type (Number of Units, 0 if none)(required) Warning Infant Warmer (Number of Units, 0 if none)(required) Warning CPAP Machine that are still working(required) 1 2 3 4 5 None Warning Phototherapy (Overhead Type) Machine that are still working(required) 1 2 3 4 5 None Warning Phototherapy (Firefly Type) Machine that are still working(required) 1 2 3 4 5 None Warning Infant Warmer Machine that are still working(required) 1 2 3 4 5 None Warning Hospital Power Supply Voltage Supply(required) 220 Volts 60 Hz 220 Volts 50 hz Warning Voltage Supply Single Phase Three Phase Warning Power Transformer In house use only Connected to public distribution Warning Electricity supply reliability 99% 75% 50% 25% Warning Is there a generator during power cuts ?(required) Yes No Warning If yes, what is the percentage of time it has fuel ? Always On Demand Warning Number of AC Outlet in NICU ? Warning Number of AC Outlet in rooming in ward ? Warning Warning. Submit Δ
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