1. Maryland Perinatal System Standards, Revised 2004 Summary of Efforts by the Perinatal Clinical Advisory Committee, Department of Health & Mental Hygiene

2. 2 Maryland Perinatal System Standards, 2004 Consensus document developed by a 33-member committee representing 16 Maryland professional organizations 3 rd major updating of Maryland perinatal standards that have been in existence since 1995 Consistent with Guidelines for Perinatal Care, 5 th Edition, 2002 issued by AAP/ACOG Consistent with AAP 2004 Policy Statement on Levels of Neonatal Care Standards facilitate consistent service provision, represent professional consensus, informs the public, and permits comparisons for outcomes among institutions

3. 3 Perinatal Standards: National Perspective 1972 – March of Dimes formed the Committee on Perinatal Health (COPH) 1976 – COPH issued Toward Improving the Outcome of Pregnancy (TIOP I) that defined standards for perinatal regionalization 1985 – Robert Wood Johnson Foundation Report on perinatal regionalization demonstrated improved pregnancy outcomes 1993 – COPH updated Toward Improving the Outcome of Pregnancy (TIOP II) 2002 – Guidelines for Perinatal Care, 5 th Edition, issued by AAP and ACOG supports TIOP II standards

4. 4 Perinatal Standards: Maryland’s Perspective 1989 – Maryland AAP’s Fetus and Newborn Committee developed nursery guidelines 1995 – DHMH Secretary’s Perinatal Clinical Advisory Committee issued voluntary Maryland Guidelines for Perinatal Care 1998 – Perinatal Clinical Advisory Committee updated Maryland Perinatal System Standards –Level III and IV standards adopted by MIEMSS for maternal-neonatal transport purposes and MHCC for certificate of need purposes 2004 – Perinatal Clinical Advisory Committee updated Maryland Perinatal System Standards

5. 5 Perinatal Outcomes: Maryland Infant mortality rate declined by 11% from the early 1990’s to early 2000’s – (9.1/1000 in 92-96 to 8.2/1000 in 97-01) Neonatal mortality rate declined by 5% Postneonatal mortality rate declined by 22% VLBW-specific neonatal mortality rates improved –For all hospitals: 148/1000 to 132/1000 –For Level III & IV hospitals: 142/1000 to 129/1000 –Fewer Level III and IV hospitals now have NMR’s greater than 200/1000 (4 to 1)

6. 6 Birth Weight-Adjusted Neonatal Mortality Rates, By Maryland Level III & IV Hospital 1994-19951999-2000

7. 7 Maryland Perinatal Clinical Advisory Committee, 2004 American Academy of Pediatrics, Maryland Chapter American College of Nurse-Midwives, Maryland Chapter American College of Obstetricians & Gynecologists, Maryland Chapter Association of Women’s Health, Obstetric & Neonatal Nurses Association of Social Workers, Maryland Chapter Department of Health and Mental Hygiene Maryland Academy of Family Physicians Maryland Association of County Health Officers Maryland Health Care Commission

8. 8 Maryland Perinatal Clinical Advisory Committee, 2004 Maryland Hospital Association Maryland Institute for Emergency Medical Services Systems Maryland Commission on Infant Mortality Prevention Maryland Perinatal Association Maryland Society of Anesthesiologists Med-Chi Obstetrical and Gynecologic Society of Maryland

9. 9 Definitions of Levels of Care, 2004: Level I Basic care to pregnant women and infants Delivery room and normal newborn care for stable infants  35 weeks gestation Maternal care limited to term and near-term gestations Other than emergency stabilization, neonatal units do not provide mechanical ventilation No pediatric subspecialty or surgical specialty services Do not receive primary infant or maternal referrals

10. 10 Definitions of Levels of Care, 2004: Level IIA Specialty care to pregnant women and infants Delivery room and specialized care for stable infants  1,500 grams or  32 weeks gestation Maternal care limited to term and preterm gestations Neonatal units may provide conventional mechanical ventilation only in stabilization situations No pediatric subspecialty or neonatal surgical specialty services Do not receive primary infant or maternal referrals

11. 11 Definitions of Levels of Care, 2004: Level IIB Specialty care to pregnant women and infants Delivery room and acute specialized care for stable infants  1,500 grams or  32 weeks gestation Maternal care limited to term and preterm gestations Neonatal units may provide conventional mechanical ventilation, limited in technique and duration May provide limited pediatric subspecialty services No neonatal surgical specialty services Do not receive primary infant or maternal referrals

12. 12 Definitions of Levels of Care, 2004: Level IIIA Subspecialty care to pregnant women and infants Acute delivery room & neonatal intensive care unit (NICU) care for infants  1,000 grams or  28 weeks gestation Maternal care spans the range of normal term gestation care to the management of moderate prematurity and moderately complex maternal complications Neonatal units provide conventional mechanical ventilation and offer continuous availability of neonatologists May provide some pediatric subspecialty services No neonatal surgical specialty services May provide maternal or neonatal transport

13. 13 Definitions of Levels of Care, 2004: Level IIIB Subspecialty care to pregnant women and infants Acute delivery room and neonatal intensive care unit (NICU) care for infants of all birth weights and gestational ages Maternal care spans the range of normal term gestation care to the management of extreme prematurity and moderately complex maternal complications Neonatal units provide multiple modes of neonatal ventilation and offer continuous availability of neonatologists Provide some pediatric subspecialty services May provide some neonatal surgical specialty services May provide maternal or neonatal transport

14. 14 Definitions of Levels of Care, 2004: Level IIIC Subspecialty care to pregnant women and infants Acute delivery room and neonatal intensive care unit (NICU) care for infants of all birth weights and gestational ages Maternal care spans the range of normal term gestation care to that of highly complex or critically ill mothers Neonatal units provide advanced modes of neonatal ventilation and life support and offer continuous availability of neonatologists Extensive pediatric subspecialty services and pediatric subspecialty surgical services are available, including cardiothoracic open-heart surgery and neurosurgery Provides maternal and neonatal transport