All California Neonatal Transport Form

Referral: Information required at initial contact between referring and receiving center/providers to facilitate transport.
T.1 Transport type c DR Attendance Requested c ASAP Neonatal c Scheduled Neonatal c Other ______
T.2 Indication c Medical Dx/Rx Services c Growth/Discharge Planning c Surgery cChronic Care c Insurance
T.3 Date/Time(D/T) Referral: @ T.4 Acceptance @
T.5 Maternal Admission to Labor & Delivery/Hospital Date/Time @
Patient Identification/History: Information to be obtained prior to transport.
Infant’s Name______c Singleton c Multiple __of __ T.6 Birth D/T ______@______Ins. ______
T.7 Birth wt. ______gms Current wt. ______gms T.8 Gestational Age __ __wks__ days T.9 c M cF cUnk
T.10 Prenatally Diagnosed Congenital Anomalies c Y c N c Unk Describe:
Mother’s Name Birth Date Age __ __ yrs MedRec#
T.11 G __ P c AB c L c ROM Date/Time @ Duration __ __ hrs Fluid c Clear c Meconium
Antenatal Conditions
c None c Unk
c Hypertension
c Diabetes
c Infection
c Preterm Labor
c Bleeding/Abrupt/Previa
c Other: ______/ Significant Antepartum/Intrapartum Issues: / Delivery
c Spont. Vag
c Op. Vag
cVacuum
c Forceps
c Cesarean
c Primary
c Repeat / Apgar Scores
Score N/D Unk
1 __ __ c c
5 __ __ c c
10__ __ c c
15__ __ c c
______
______
Antibiotics cY Specify______cN cUnk
T.12 Steroids cY cN (last dose) @
T.13 Surfactant Given cY cN cUnk
c DR c NSY cNICU(first dose) @
Infant Condition Clinical Information
Modified TRIPS Score: to be recorded on referral, within 15 minutes of arrival at referring hospital and admit to NICU. / Date Time Results
Referral
a / Initial TT Eval b / NICU Admit c / Hgb/HCT @
T.14 Time (24 hour) / Bld. Cult. @
T.15 Responsivenessª / Bilirubin @
Respiratory / T.16 Rate / Screening: HearingcYcNc Unk MetaboliccYcNcUnk
T.17 O2 Saturation / Subs Exp cY cNcUkn
T.18 Status­ / Imaging: CXR @
Oxygen Index*
T.19 / MAP / Other (specify)
FiO2 / IV Access/Fluids (type, rate, site)
PAO2 / Bld. Trans. @ (type,vol)
Vital Signs / T.20 HR / Last Urine @ Stool @
T.21 BP Sys/ Dia,
Mean / Feeding (type/rt/vol) First Last
T.22 Pressors / cY cN / cYcN / cY cN / Meds given within last 24° c Eye care c Vit. K
T.23 Temp. C° / Date/Time Med Dose Rt.
T.24 Blood Glucose
Bld. Gas / T.25 Resp. Support«
pH
PCO2 / Allergies cY type c N cUnk
BE / Surgery cY c N Indication cNEC c CHD c Other
ªResponsiveness: 0=Death 1=None, Seizure, Muscle Relaxant
2=Lethargic, no cry 3=Vigorously withdraws, cry.
«Resp Support: None, Hood/NC. NCPAP, ETT
­Respiratory Status: 1=Respirator 2= Severe (apnea, gasping,
intubated but not on respirator) 3=Other
*Oxygen Index completed if pt. is on vent.
DeathcNo cYes @ c Prior to team arrival
c Prior to departure c Prior to arrival at NICU**
Referral Process
T.26 Referring Hospital Name
Code Telephone Number
Referring OB
Referring Peds
Informant
T.27 Previously Transported? ¨Y ¨N From: Hospital Name Code
T.28 Birth Hospital (if not listed above) Hospital Name Code
Receiving Hospital Accepting Physician
T.29 Trans. Team On-Site Leader cSub-specialist MD cPeds cOther MD/Resident cNNP cTransport Spec. cNurse
Present prior to transport team arrival ¨Y ¨N @
T.30 Team From c Receiving Hospital cContract Service (CPQCC TT ID ) c Referring Hospital
T.31 Mode cGround cHelicopter cFixed Wing Indication Transport Carrier

Timeline

Date Time Comments

T.32 Transport Team Departure for Referring Hospital @
T.33 Transport Team Arrival at Referring Hospital @
Transport Team Departure from Referring Hospital @
Transport Team Arrival at Receiving Facility @
Information/Materials To Be Sent With Transport Team (check all provided)
Chart (pt. record) ¨Maternal ¨Neonatal Blood Specimen ¨Maternal ¨Neonatal ¨Placenta ¨Imagining copies
¨Other, specify
Care Providers name /title signature D/T of arrival
Referring Hospital @
@
Transport Team @
@
@
@
Comments
**SPECIAL INSTRUCTIONS: 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.

Confidential Neonatal Transport Issues with Improvement Potential Form

¨Delay in transport, describe: ______
Related to¨Amb./vehicle issues ¨Traffic ¨Missed opportunity for maternal transport ¨Delay in transferring infant
¨Transport Team Difficulties, describe: ______
¨ Required elements of neonatal transport form incomplete, describe: ______
¨Equipment Difficulties, describe: ______
¨Unplanned Intervention During Transport, describe: ______
Related to ¨Airway ¨Vascular Access ¨Return to Referring Hospital ¨Other ______
¨CPR during transport
¨Death prior to admission to receiving NICU**
¨None
¨Other, describe
Comments
Referred for Joint Mortality/Morbidity Review ¨Y ¨N ¨ Unk Date of Review
Outcome of Review: ¨Policy/Procedure Change ¨Joint QI Project ¨Education Offering ¨Consultation
¨ Other: describe
Follow up:
**SPECIAL INSTRUCTIONS: 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.

Referring Hospital, Transport Team/Receiving Hospital, Bold: essential data base components, Plain: hospital preference.