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) 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) Sex/Gender Address Roomed in or admitted to NICU Admitting diagnosis Final diagnosis Procedure Done Attending Physician Date & Time of Discharge Disposition 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 Number of Delivery Rooms(required) 1 2 3 4 5 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) Stable Electricity Continuous Clean Running Water Supply Oxygen Medical Air Oxygen Blender Adequate Clean Towels Suction Device Wall Clock or Monitoring Clock 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 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 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) Obstetrician Other doctor from OB Dept Paediatrician Nurses/Midwives Medical Student from Pedia Dept Medical Student from OB Dept Nursing/Midwifery Students 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 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 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) 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 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) How oxygen is provided?(required) Nasal Cannula Head Box or Hood Bag and Mask CPAP Ventilator 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) Antiseptic Cleaning Solution Antiseptic Bar Soap Antiseptic Liquid Soap Ordinary Bar Soap Ordinary Liquid Soap 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 Phototherapy (Overhead Type) Phototherapy (Firefly) Infant Warmer None 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) CPAP Machine that are still working(required) 1 2 3 4 5 None Phototherapy (Overhead Type) Machine that are still working(required) 1 2 3 4 5 None Phototherapy (Firefly Type) Machine that are still working(required) 1 2 3 4 5 None Infant Warmer Machine that are still working(required) 1 2 3 4 5 None 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 ? Submit Δ
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