Assessment

For Contact Number – please input numerical only
Official email address of the hospital can be use as an alternative, use N/A if necessary.

Hospital Name (Full)(required)

Address (Complete)(required)

Contact Number(required)

Chief/Director of the Hospital (Full Name)(required)

Mobile Number(required)

Email Address(required)

Paediatric Department Head (Full Name)(required)

Email Address(required)

Mobile Number(required)

Paediatrician / Neonatologist (Full Name)(required)

Email Address(required)

Mobile Number(required)

NICU Head/Supervisor (Full Name)(required)

Email Address(required)

Mobile Number(required)

Catchment Area Information(required)

Number of hospitals / health stations with birthing facilities(required)

Hospital Statistics

Total Hospital Beds(required)

Total Number of Births (2019)(required)

Percentage by Caesarian Section(required)

Percentage by Forceps(required)

Percentage by Vacuum(required)

Total Still Birth of (2019)(required)

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)

Number of Babies admitted to NICU in 2019(required)

Number of babies who died in 2019(required)

Number of intramural babies admitted to NICU in 2019 (intramural – inborn babies born in this hospital)(required)

Number of babies who died in 2019(required)

Number of extramural babies admitted to NICU in 2019 (extramural – out-born babies born outside this hospital)(required)

Number of babies who died(required)

Does the number of babies who died include those who went home to die? (extramural – out-born babies born outside this hospital)(required)

Number of admissions to NICU for Jaundice in 2019(required)

Number of admission of inborn patients(required)

Number of admission of out-born patients(required)

Number of Kernicterus cases among inborn patients (Kernicterus are kind of preventable brain damage that can happen in newborns with jaundice)(required)

Number of Kernicterus cases among out-born patients (Kernicterus are kind of preventable brain damage that can happen in newborns with jaundice)(required)

Number of deaths of inborn patients due to jaundice(required)

Number of deaths of out-born patients due to jaundice(required)

Number of Exchange transfusion in 2019(required)

Number of inborn patients w/ exchange transfusion in 2019(required)

Number of out-born patients w/ exchange transfusion in 2019(required)

Number of successful exchange transfusions for babies in 2019(required)

In 2019, was the hospital unable to do exchange trans because of lack of blood?(required)

Data Collection

Individual sheet kept for each patient?(required)

Yes No

Retained after patient is no longer in hospital?(required)

Yes No

Daily registry kept?(required)

Yes No

If Yes, what are the data information collected ? (please check where applicable)(required)

How are records kept?(required)

Paper/Manual Electronic/Computer Encoded Both

Software used for Electronic or Computer Recording(required)

Spiritus Vitae would like to access the data, will the hospital permit the organisation? (this is for assessment pruposes only)(required)

Yes No

Infant Mortality Information

Mortality Rate for the last:

3 Years(required)

28 Days(required)

7 Days(required)

24 Hours(required)

What is included in numerator?(required)

What is included in denominator? (required)

Are there babies who are DAMA?(required)

If yes, how many per year?(required)

Are babies who are expected to die sent home?(required)

If yes, are these babies included in mortality rate?(required)

Delivery Suites

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

Room Temperature ºC(required)

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

Room Temperature ºC

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

Room Temperature ºC

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

Room Temperature ºC

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

Room Temperature ºC

Number of Operating Rooms(required)

1 2 3

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

Room Temperature ºC

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

Room Temperature ºC

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

Room Temperature ºC

Please check the following items if available in your Operating Room (please check where applicable)(required)

Please check the following items if available in your Delivery Room (please check where applicable)(required)

Equipment for Newborn Resuscitation (please check where applicable)(required)

Staffing

Number of Obstetrician(required)

Number of other Doctors(required)

Number of Nurses(required)

Number of Midwives(required)

Number of Medical Students

Number of Nursing Students

Number of Midwifery Students

Are obstetric Nurses rotated?(required)

Yes No

Resuscitation Training

Who performs resuscitation in your unit (please check where applicable)(required)

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

Others (please describe)

If only Inborn, where are the out-born babies treated?(required)

Do you include in 'Inborn' babies who are born ON THE WAY to your hospital?(required)

Yes No

Is there separate room for outborn ?(required)

Yes No

Is there separate room for preterm babies?(required)

Yes No

Is there separate room for babies with infection or suspected infection?(required)

Yes No

Is there separate room for babies receiving phototherapy?(required)

Yes No

Is there separate room for exchange transfusion?(required)

Yes No

Treatment Room

Number of beds (N/A if none)(required)

Lowest Room Temperature ºC (N/A if none)(required)

Number of hand basins (N/A if none)(required)

Alcohol or Hand Sanitizer at each bedside?(required)

Yes No

Alcohol or Hand Sanitiser at the center of the room?(required)

Yes No

Is there a thermometer on the wall?(required)

Yes No

Does the room have access to clean running water?(required)

Yes No

Is there a Clock in the room?(required)

Yes No

Is the room fitted with wall type connection for oxygen?(required)

Yes No

Is the room accessible for cylinder oxygen tank?(required)

Yes No

Is the room accessible for medical air supply?(required)

Yes No

Can oxygen be blended?(required)

Yes No

Is there a suction device in the room?(required)

Yes No

Treatment Room #2

20 to 30 sq. meter 30 to 40 sq. meter 40 to 50 sq. meter more than 50 sq. meter

Number of beds

Lowest Room Temperature ºC

Number of hand basins

Alcohol or Hand Sanitiser at each bedside?

Yes No

Alcohol or Hand Sanitiser at the center of the room?

Yes No

Is there a thermometer on the wall?

Yes No

Does the room have access to clean running water?

Yes No

Is there a Clock in the room?

Yes No

Is the room fitted with wall type connection for oxygen?

Yes No

Is the room accessible for cylinder oxygen tank?

Yes No

Is the room accessible for medical air supply?

Yes No

Can oxygen be blended?

Yes No

Is there a suction device in the room?

Yes No

Treatment Room #3

20 to 30 sq. meter 30 to 40 sq. meter 40 to 50 sq. meter more than 50 sq. meter

Number of beds

Lowest Room Temperature ºC

Number of hand basins

Alcohol or Hand Sanitiser at each bedside?

Yes No

Alcohol or Hand Sanitiser at the center of the room?

Yes No

Is there a thermometer on the wall?

Yes No

Does the room have access to clean running water?

Yes No

Is there a Clock in the room?

Yes No

Is the room fitted with wall type connection for oxygen?

Yes No

Is the room accessible for cylinder oxygen tank?

Yes No

Is the room accessible for medical air supply?

Yes No

Can oxygen be blended?

Yes No

Is there a suction device in the room?

Yes No

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

Treatment Room Staffing

Number of Neonatologist(required)

Number of Paediatrician(required)

Other Doctors

Number of Nurses(required)

Number of Medical Students(required)

Number of Nursing Students(required)

Are NICU nurses rotated?(required)

Yes No

How long does the medical student stays in the NICU?(required)

Clinician's language or dialect (mode of communication)(required)

Is there protocol for routine maintenance of equipment?(required)

Yes No

If Yes, please describe the protocol of maintenance

For Phototherapy Non-LED

Frequency of changing bulbs

Cost of changing bulbs for a machine (estimate only)

Are there periods you have to treat infants with machine after bulbs have expired?

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)

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)

Endotracheal tubes supply reliability?(required)

Available immediately (stock in room) Per request (supply coming from supply office always available)

O2 Flow rate if thru nasal cannula(required)

O2 Flow rate if thru headbox(required)

Resuscitation Training

Resuscitation Training Provided to NICU staff?(required)

Yes No

When is the most recent training conducted?

Is the training provided to other hospitals' staff?(required)

Yes No

How often is the training being conducted in the hospital?(required)

Once a year Every 6 Months Every 3 Months

Infection Control

Is there a separate room for cleaning the equipment?(required)

Yes No

Is the autoclave working?(required)

Yes No

Is there a protocol for cleaning equipment?(required)

Yes No

Is there a protocol for cleaning clinical area?(required)

Yes No

Is there a training for infection control for staff?(required)

Yes No

Is there a training for infection control for staff?(required)

Yes No

How often is the training being conducted in the hospital?(required)

Once a year Every 6 Months Every 3 Months

When is that latest training conducted?(required)

Is there a training for infection control for visitors?(required)

Yes No

Is there adequate supply of Alcohol or Hand Sanitiser?(required)

Yes No

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

Is NICU equipped with a hand washing area ?(required)

Yes No

Is NICU equipped with clean water supply?(required)

Yes No

Is NICU hand washing area equipped with cleaning agent ?(required)

How staff dry their hands ?(required)

Paper Towel Cloth Towel Electric Hand Dryer

Is there an instruction on how to wash hands properly posted near the sink ?(required)

Yes No

Is there a bathroom close or inside NICU(required)

Yes No

Is the bathroom have adequate supply of clean water ?(required)

Yes No

Is the bathroom equipped with functional toilet ?(required)

Yes No

Is it possible to clean the CPAP inside the NICU sink ? (required)

Yes No

If No, please indicate where do you wash the CPAP ?

Is the hospital imposing breastfeeding exclusively ?(required)

Yes No

Please describe how milk is provided to babies in NICU ?

Laboratory Testing

Is Total Serum Bilirubin conducted ?(required)

Yes No

Is Un-cojugated Bilirubin conducted ?(required)

Yes No

Is Infection Screening – WBC conducted ?(required)

Yes No

Is Infection Screening – CRP conducted ?(required)

Yes No

Is Blood Culture & Antibiotic Sensitivity conducted ?(required)

Yes No

The test are conducted where ?(required)

At the hospital Off-site, at a hospital facility Off-site, at a private facility

Is there a possibility that some test are not conducted because its expensive ?(required)

Yes No

If Yes, which type of test (please indicate)(required)

Jaundice on Postnatal Wards

Usual Length of Stay (day of birth=0 night) Uncomplicated delivery(required)

Usual Length of Stay (day of birth=0 night) Caesarean Section(required)

Postnatal Wards

Name of Ward #1(required)

Number of Beds?(required)

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

Name of Ward #2

Number of Beds?

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

Name of Ward #3

Number of Beds?

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

Name of Ward #4

Number of Beds?

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

Do mothers routinely share beds (overcrowding) ?

Yes No

Screening for Jaundice

Is there a routine blood typing for mothers & babies ?(required)

Yes No

Does hospital identify all babies with ABO haemolytic disease ?(required)

Yes No

Does hospital identify all babies with Rh(D) haemolytic disease ?(required)

Yes No

Is prophylactic phototherapy given to babies with ABO/Rh haemolytic disease ?(required)

Yes No

Does hospital routinely screen all babies on postnatal ward for jaundice ?(required)

Yes No

If Yes, when is screening performed ?

Date of Birth Only Everyday Date of Discharge Only Other, describe

If Others, please describe

If Yes, how is screening performed ?(required)

Kramer's Rule Informal Visual Assessment Other, describe

If Others, please describe

If No, how are babies with physiologic jaundice identified ?

Phototherapy on Post Natal Wards

Is phototherapy provided in postnatal wards ?(required)

Yes No

Is TSB available?(required)

Yes No

If Yes, is TSB available?(required)

Sometimes Always

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)

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

Location of Equipment

Ward #1 type of Phototherapy(required)

LED Blue Light Ordinary White Fluorescent Type

Ward #2 type of Phototherapy

LED Blue Light Ordinary White Fluorescent Type

Ward #3 type of Phototherapy

LED Blue Light Ordinary White Fluorescent Type

Ward #3 type of Phototherapy

LED Blue Light Ordinary White Fluorescent Type

Are multiple babies treated on same machine ?(required)

Yes No

Average duration of Phototherapy Treatment ?(required)

Responsible for supervision of phototherapy in PostnatalWard #1

Responsible for supervision of phototherapy in PostnatalWard #2

Responsible for supervision of phototherapy in PostnatalWard #3

Referrals to Higher Level Hospitals

Hospital refer neonates to Higher Level Hospitals (required)

Yes No

If Yes, which hospital ?

How long does it take to get to these hospital/s ?

Which neonates do you most frequently refer ?(required)

Preterm Severe respiratory distress Surgical Others

If other, please describe

How are neonates transferred

Hospital Ambulance Parents, describe transport

Do doctor/nurses accompany infant ?(required)

Yes No

Does hospital get follow-up info on transferred infant ?(required)

Yes No

Donated Devices (very important)

Donated Equipments by (East Meets West Foundation)(required)

CPAP Machine (Number of Units, 0 if none)(required)

Phototherapy Overhead Type (Number of Units, 0 if none)(required)

Phototherapy Firefly Type (Number of Units, 0 if none)(required)

Infant Warmer (Number of Units, 0 if none)(required)

Hospital Power Supply

Voltage Supply(required)

220 Volts 60 Hz 220 Volts 50 hz

Voltage Supply

Single Phase Three Phase

Power Transformer

In house use only Connected to public distribution

Electricity supply reliability

99% 75% 50% 25%

Is there a generator during power cuts ?(required)

Yes No

If yes, what is the percentage of time it has fuel ?

Always On Demand

Number of AC Outlet in NICU ?

Number of AC Outlet in rooming in ward ?

MTTS@Facebook

Hospital Statistics

Data Collection

Infant Mortality Information

Mortality Rate for the last:

Delivery Suites

Staffing

Resuscitation Training

NICU

Treatment Room

Treatment Room Staffing

For Phototherapy Non-LED

Oxygen Therapy

Resuscitation Training

Infection Control

Laboratory Testing

Jaundice on Postnatal Wards

Postnatal Wards

Screening for Jaundice

Phototherapy on Post Natal Wards

Location of Equipment

Referrals to Higher Level Hospitals

Donated Devices (very important)

Hospital Power Supply