Att 6c_MPINC Facility Survey

mPINC 2018

2018

P

Form Approved

OMB #0920-0743

EXP.DATE: MM/DD/YYYY

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About this survey:

The Centers for Disease Control and Prevention (CDC) invites you to participate in a national survey of newborn feeding practices at hospitals in the United States and Territories that provided maternity care in the past year. The survey is being conducted for CDC by Battelle Health & Analytics, a national survey and research organization with extensive experience in the collection of health data. Participation of every hospital providing maternity care makes this survey representative of all maternity care hospitals in the United States and Territories. If your hospital provided maternity care at multiple locations, only report data for the specific physical location listed in your email invitation.

Your participation in the survey is completely voluntary. We will mail a hard copy of your hospital’s results to four (4) leadership positions at your hospital. These positions are the Director of Hospital Quality Improvement, Obstetrics Medical Director, Pediatrics Medical Director, and the Nurse Manager for Mother Baby Services.

Prior to submitting the survey, you will have the opportunity to provide your contact information so that you, the survey recipient, will receive one (1) electronic copy of your hospital’s results. Providing your contact information is voluntary; results will be mailed to your hospital if you do not provide an email address. Your contact information will in no way be connected to survey responses or scores.

How long will this survey take to complete?

The survey will take about 30 minutes to complete.

How will this information be used?

The purpose of this survey is to learn about newborn feeding practices at hospitals in the United States and Territories. After data collection is complete, your hospital will receive an individualized report containing a summary of survey results. Data will also be used to generate state-specific reports, national aggregate data tables, and may be used to answer other questions. Data may be released for additional approved purposes and may be shared with state health departments for the development of public health programs. Information from this survey will also assist CDC with program planning.

Are our survey responses kept confidential?

Your responses will be treated in a secure manner and will not be disclosed unless required by law. Your name, hospital name, and any other personal identifiers will not be included in either oral or written presentation of survey results. Responses will only be reported in summary form so individual responses cannot be identified.

Survey Instructions:

Thank you for participating in this survey. You have been identified as the survey recipient for your hospital, which means that only you have access to the unique link to complete and submit the 2018 mPINC survey for your hospital.

We are asking you to fill out the survey with data from the most recent calendar year (January 1, 2017 – December 31, 2017) or your hospital’s fiscal year. Unless otherwise specified, questions on the survey are asking about healthy newborns who are discharged to home (i.e., not transferred or admitted to the Special Care Nursery (SCN) or Neonatal Intensive Care Unit (NICU)).

This survey contains 6 core sections and an additional section for hospitals with an SCN or NICU. Each section should be completed by the most knowledgeable and appropriate staff. For example, the Mother-Baby Unit supervisor may be better able to answer one section, while the Lactation Services coordinator or NICU nurse manager may be better able to complete another section. See the table below for a list of people who may be helpful with completing different sections of the survey.

Titles of staff who may be appropriate to fill out sections of the survey include:

Mother-Baby Unit Manager / Supervisor

Labor and Delivery Unit Manager / Supervisor

Lactation Services Coordinator / Lactation Specialist

NICU Nurse Manager

Staff nurse

Database Manager / Coordinator

Maternal and Child Health Physician Leaders

Some questions ask you to enter exact percentages; however, if your hospital does not formally track this information, please provide your best estimate.

Click here to download a blank copy of the survey. This version should only be used as a worksheet to record responses prior to entering and submitting them online. No paper copies of the survey will be accepted.

You may wish to work on this survey over a period of time, particularly if it will be completed by multiple staff. You can view all sections and pages in the survey and you may go back and forth and edit responses as needed. Your responses will only be saved after you have clicked Next at the bottom of the page. If you cannot complete the survey all at one time, click Save, and return at a later time. When you return, you may continue where you left off. Before submitting you will be able to review the questions and your answers. You will be notified before your final submission if you have missed any items.

Survey Tips:

• Click here to download/print the survey.

• Move between sections of the survey on the Table of Contents page by clicking to the right of the section and then clicking Next.

• To move back and forth between questions within a section use the Next and Previous buttons.

• Do not click on your browser’s back or forward button while taking the survey.

• Throughout the survey there will be pop-ups providing you with definitions and explanations; access these by hovering your mouse over the underlined text.

What to do if you have questions:

If you have any questions about the survey, please call the Battelle Survey Line toll free at 1 (866) 826-4176. If you have any questions about your rights as a research participant, please contact the Human Protections Administrator of the Battelle Institutional Review Board toll free at 1 (877) 810-9530 ext. 500.

What to do when you have completed the survey:

When you get to the end of the survey, you can review your answers. When you are satisfied with your answers, return to the table of contents and click Complete Survey. This action will send the survey to a secure database. Once you have submitted the survey, you will not be able to return to the survey. You will have the opportunity to download a completed copy of the survey for your records after it is submitted. Please note that you must select Complete Survey to complete the survey process and receive a Benchmark Report for your hospital. Surveys that are not submitted are considered incomplete and will not be eligible to receive a hospital Benchmark Report.

Thank you for your contribution!

SURVEY ITEMS

Hovers, skip patterns, & notes

SECTION A: Hospital Data

This section is about deliveries and general hospital information. Mouse over underlined text for a definition or more information.

A1

What type of facility is your hospital? (select 1 option only)

• government hospital

• non-profit hospital

• private hospital

• military hospital

A2

Is your hospital a teaching hospital (e.g., medical residents, nursing students)?

YES
NO

A3

Is your hospital currently designated as “Baby-Friendly” by the Baby-Friendly Hospital Initiative (BFHI)?

YES
NO

Frequently asked questions

A4

Are any of the following employment benefits offered to hospital staff (as hospital policy)?

	Yes	No
A private place, other than a bathroom, to express or feed breast milk
On-site access to an electric breast pump
[Reasonable break time] to express or feed breast milk
Flexible work hours / scheduling of shifts to express or feed breast milk
On-site child care
Paid maternity leave (other than accrued sick or personal leave)
Paid paternity leave (other than accrued sick or personal leave)
In-person support from a lactation care provider (e.g., IBCLC, CLC, CBC)

Reasonable break time: adequate time to travel to the designated lactation area, express milk or breastfeed, clean up, and return to their work area

A5

Do women who deliver at your hospital have the opportunity to receive prenatal breastfeeding education (in either group or individual settings) provided by your hospital and/or a hospital-affiliated clinic or service?

YES
NO
Not Sure

Complete the following items using data from the past calendar or fiscal year:
A6 [Total live births]: ____________	Total number of live births includes vaginal and Cesarean (C-Section) deliveries. For multiple births, count each newborn as a separate live birth.
A7 [Total live births delivered by Cesarean section]: ____________ If cesarean births are not performed at your hospital, record “0”	Total number of live birth Cesarean (C-Section) deliveries that were performed at your hospital, including in the perinatal services area, an operating room, or any other location within the hospital. Those who enter 0 will not see any future cesarean-related items (C2)
A8 How many healthy newborns at your hospital have their umbilical cord clamped more than one minute after birth?

A9

Throughout their hospital stay, what percent of healthy newborns are fed the following?

	Enter %	Select one
[ONLY breast milk]	_____ %	Actual Estimate
Breast milk AND any formula, water, or glucose water	_____ %	Actual Estimate
No breast milk	_____ %	Actual Estimate
Total sums to 100%	100%

[ONLY breast milk]:

• no water or formula at any time during hospitalization

• no glucose water or sucrose solution except for during painful procedures

A10

Among breastfed newborns who are supplemented, and not in a special care nursery or neonatal intensive care unit, how many receive donor human milk?

Not offered at our hospital	Few (0-19%)	Some (20-49%)	Many (50-79%)	Most (80% +)

Although most of the survey is about early postpartum care practices for healthy mother-baby dyads, the following 2 items address a special population of newborns.

A11

How many newborns diagnosed with Neonatal Abstinence Syndrome (NAS) . . .

					Not Applicable
. . .are breastfed or provided with expressed human milk?
. . .[are rooming-in?]
. . .practice [skin-to-skin] or [Kangaroo Care]?
. . . are cared for in your specialty unit (Special Care Nursery, Neonatal Intensive Care Unit, Regional Neonatal Intensive Care Unit)?

(No skip pattern)

Rooming-in is a practice where mother and newborn are in close proximity.

Skin-to-skin: The naked newborn is placed prone directly on the mother’s bare chest or abdomen, with or without a cap/blanket.

Kangaroo Care refers to skin-to-skin care where a newborn, often premature, is placed prone directly on the mother's, father's, or other's bare chest or abdomen. The caregiver is then wrapped in a blanket or other cloth to secure the newborn against his or her chest.

A12

Are the following included in a written policy about management of Neonatal Abstinence Syndrome (NAS) at your hospital?

	Yes	No
Verbal screening for maternal substance use (e.g., asking in the medical history)
Toxicology screening for maternal substance use (e.g., urine, meconium, hair, cord blood)
Use of a standardized tool to evaluate NAS symptoms (e.g., Modified Neonatal Abstinence Scoring System, Finnegan Score)
Promotion of breastfeeding or provision of expressed human milk as a nonpharmacological treatment of NAS
Promotion of [rooming-in] as a nonpharmacological treatment of NAS
Promotion of [skin-to-skin contact] or [Kangaroo Care] as a nonpharmacological treatment of NAS
Pharmacologic treatment of NAS

(no skip pattern)

Rooming-in is a practice where mother and newborn are in close proximity.

Kangaroo Care refers to skin-to-skin care where a newborn, often premature, is placed prone directly on the mother's, father's, or other's bare chest or abdomen. The caregiver is then wrapped in a blanket or other cloth to secure the newborn against his or her chest.

Skin-to-skin contact: The naked newborn is placed prone directly on the mother’s bare chest or abdomen, with or without a cap/blanket.

SECTION B: SPECIAL CARE NURSERY (SCN) AND / OR NEONATAL INTENSIVE CARE UNIT (NICU)

This section is about practices in your hospital’s SCN and / or NICU. Mouse over underlined text for a definition or more information. The primary contact should consult with an SCN or NICU colleague before answering these questions.

B1

What is the highest level of neonatal care provided at your hospital? Click for:

[Definitions, Capabilities, and Provider Types: Neonatal Levels of Care]

The remaining questions in Section B only apply if your hospital has Level II-Level IV neonatal care.

Level I: Well newborn nursery
Level II: Special care nursery
Level III: Neonatal Intensive Care Unit
Level IV: Regional Neonatal Intensive Care Unit

Pop up with the AAP table: “Definitions, Capabilities, and Provider Types: Neonatal Levels of Care”

If level 1 is selected, pop up should appear stating, “You’ve selected Level 1. The rest of the questions in this section do not apply. Click OK to return to the Table of Contents. If you selected Level 1 by mistake, please close the window, return to the question and correct your answer.”

This section is only available to those who have a Level 2-4 SCN or NICU from Item B1. If they select Level 1 for B1, skip the remaining items in Section B and go right to Section C.

You’ve selected Level 1. The rest of the questions in this section do not apply. Click Next to return to the Table of Contents. If you selected Level 1 by mistake, please click Previous, return to the question and correct your answer

B2

How many mothers with newborns in your hospital’s SCN or NICU . . .

. . .are advised to provide human milk as a component of their newborn’s medical care?
. . .are advised to breastfeed or express their milk 8 or more times every 24 hours to establish and maintain their milk supply?
. . .begin expressing and collecting their milk within 1 hour of their newborn’s birth (among healthy, stable mothers)?
. . .are shown techniques for cleaning breast pump equipment?
. . .receive written instructions for cleaning breast pump equipment?
. . .receive written instructions for safe storage and transport of expressed milk?

B3

Among SCN/NICU newborns eligible for [Kangaroo Care], how many practice Kangaroo Care?

Not offered at our hospital	Few (0-19%)	Some (20-49%)	Many (50-79%)	Most (80% +)

Kangaroo Care refers to skin-to-skin care where a newborn, often premature, is placed prone directly on the mother's, father's, or other's bare chest or abdomen. The caregiver is then wrapped in a blanket or other cloth to secure the newborn against his or her chest.

If “Not offered” is selected, B4 is skipped

B4

At discharge from your SCN/NICU, what percent of infants are receiving the following [enteral feedings]?

Answer this question based on the enteral feedings received during the 24 hour period prior to discharge, transfer, or death. Do not consider [parenteral] feedings when answering this item. For example, for infants discharged on [IV TPN] as well as human milk, the correct response would be “Human Milk Only” since human milk was the only enteral feeding.

	Enter %	Select one
Human milk only	_____  %	Actual Estimate
Formula only	_____  %	Actual Estimate
Human milk in combination with either fortifier or formula	_____  %	Actual Estimate
No enteral feedings (e.g., infants discharged receiving [IV TPN] alone without any enteral feedings	_____  %	Actual Estimate
Total sums to 100%	100%

Enteral: given by any method including breast, bottle, gavage tube, gastrostomy tube, feeding cup, etc.

Parenteral: given intravenously

IV TPN: Intravenous Total Parenteral Nutrition

B5

How many infants receive donor human milk at any time while cared for in your hospital’s SCN/NICU?

	Not available	Few (0-19%)	Some (20-49%)	Many (50-79%)	Most (80% +)
Infants < 1500 grams
Infants ≥ 1500 grams

SECTION C: CARE PRACTICES

This section is about early postpartum care practices for all healthy mother-baby dyads, REGARDLESS OF FEEDING METHOD. Mouse over underlined text for a definition or more information.

C1

After vaginal delivery, how many newborns remain in uninterrupted [skin-to-skin contact] with their mothers beginning immediately after birth . . .

. . .if breastfeeding, until the first breastfeeding is completed?
. . .if not breastfeeding, for at least one hour?

skin-to-skin contact: The naked newborn is placed prone directly on the mother’s bare chest or abdomen, with or without a cap/blanket.

C2

After Cesarean-delivery, how many newborns remain in uninterrupted [skin-to-skin contact] with their mothers as soon as the mother is responsive and alert after birth?

. . .if breastfeeding, until the first breastfeeding is completed?
. . .if not breastfeeding, for at least one hour?

skin-to-skin contact: The naked newborn is placed prone directly on the mother’s bare chest or abdomen, with or without a cap/blanket.

This item is skipped if no cesareans (A7 = 0)

C3

How many vaginally-delivered newborns are separated from their mothers [before] starting [rooming-in]?

Few (0-19%)	Some (20-49%)	Many (50-79%)	Most (80% +)	Rooming-in is not an option at our hospital

Before: Prior to or during transfer from Labor / Delivery care to Postpartum / Nursery care

Rooming-in is a practice where mother and newborn are in close proximity.

C4

What percent of newborns stay in the room with their mothers for at least 23 hours per day (not including those separated for medical reasons)?

Enter %	Select one
_________%	Actual Estimate

C5

How many newborns receive continuous [observed monitoring] throughout the first two hours immediately following birth?

Observed monitoring includes for positioning, color, and breathing

C6

Where are newborns usually located during each of the following situations? Click one location per situation. For situations addressed in multiple locations in your hospital, choose the most frequently-used location.

	Mother's Room	Nursery, procedure room, or newborn observation unit
Pediatric exams/rounds
Hearing screening
Phototherapy
Pulse oximetry screening (congenital heart defect screening)
Routine labs/blood draws/injections
Newborn bath

C7

Does your hospital have a protocol that requires frequent observations of [high-risk] mother-infant dyads by nurses to ensure safety of the infant while they are together?

YES
NO

Examples of high-risk include: low Apgar scores, late preterm, infants who required resuscitation, difficult delivery, or medications given to the mother that may make her drowsy or sedated or affect the newborn.

SECTION D: FEEDING PRACTICES

This section is about infant feeding practices for healthy BREASTFED newborns. Mouse over underlined text for a definition or more information.

D1

How many healthy breastfed newborns are given pacifiers by staff?
Do not include the use of pacifiers for painful procedures – e.g., circumcision – in your response.

D2

How many healthy breastfed newborns are ever fed any breast milk, infant formula, glucose water, or water from a traditional bottle and nipple? 

D3

What percent of healthy, term breastfed newborns are fed any of the following?

	Enter %	Select one
Infant formula	_____ %	Actual Estimate
Water or glucose water Do not include the use of glucose water for painful procedures – e.g. circumcision – in your response.	_____ %	Actual Estimate
Any supplemental feedings (infant formula, water, or glucose water) as part of standing orders	_____ %	Actual Estimate
Not expected to sum to 100%

D4

What are the 3 most common situations that lead to recommendations or requests for formula for healthy breastfed newborns during the hospital stay? (Free text)

1

2

3

D5

Does your hospital perform routine blood glucose monitoring of full-term healthy newborns who are NOT at risk for hypoglycemia?  

YES
NO

SECTION E: EDUCATION AND SUPPORT OF MOTHERS

This section is about information taught to mothers and caregivers about feeding and caring for their newborn and support provided to mothers by staff. Mouse over underlined text for a definition or more information.

E1

How many mothers and support persons are taught strategies for [safe sleep] with their newborn at the hospital (regardless of feeding method)?

Safe sleep practices: infants are placed on their backs on a firm, flat surface that is free of any items.

E2

How many breastfeeding mothers are taught or shown how to . . .

. . .recognize and respond to their newborn’s [feeding cues]?
. . .position and latch their newborn for breastfeeding?
. . .assess effective breastfeeding by observing their newborn’s latch and the presence of audible swallowing?
. . .assess effective breastfeeding by observing their newborn’s elimination patterns (i.e., urine and stool output and stool character)?
. . .breastfeed [as often and as long] as their newborn wants, [without restrictions]?
. . .hand express their breast milk?

Feeding cues: Signs the baby is ready to feed, including increased alertness, flexion of the extremities, mouth and tongue movements, cooing sounds, rooting, bringing fist toward the mouth, or sucking on fingers / hand.

As often and as long: Also known as 'cue-based' or 'on-demand' feeding.

Without restrictions: Without setting a schedule for how long baby should be at the breast and/or the amount of time that should pass between feeds.

E3

When breastfeeding mothers request infant formula, how often do staff counsel them about the possible consequences to the health of their infant and the success of breastfeeding?

RARELY	SOMETIMES	OFTEN	ALMOST ALWAYS
(0-19%)	(20-49%)	(50-79%)	(80% +)

E4

Among mothers whose newborns are fed any formula, how many are taught . . .

. . .appropriate [formula feeding techniques]?
. . .how to safely prepare and feed formula?

Feeding in response to hunger cues and holding the baby closely during the feed, allowing for eye-to-eye contact.

E5

Do your discharge criteria for breastfeeding newborns require. . .

	YES	NO
. . . direct observation of effective positioning, latch, and milk transfer?
. . . direct observation of at least one effective feeding at the breast within the 8 hours prior to discharge?
. . . scheduling of the first follow-up visit with a health care provider?

E6

What discharge support does your hospital routinely provide to breastfeeding mothers?

	Yes	No
[In-person follow-up visits/appointments for lactation support]
Personalized phone calls to mothers to ask about breastfeeding (not automated calls)
[Formalized, coordinated referrals to lactation providers in the community when additional support or follow-up is needed]
[Breastfeeding information and resources]

In-person follow-up visits:

Breastfeeding assessments, support, and weight checks at a post-discharge home, hospital, clinic, or office visit; breastfeeding-specific support group in a hospital wellness center

Formalized, coordinated referrals:

Scheduling an appointment on the mother’s behalf with a lactation provider, WIC peer counselor, or home visiting program; providing a referral for insurance coverage; providing access to lactation support via interactive smartphone app or other online/remote support; writing a prescription for lactation support

Breastfeeding information and resources: Educational booklets/pamphlets, informational smartphone app or other online information, list of community resources, breastfeeding assessment sheet/feeding log, warm-lines

E7

Does your hospital collaborate with [WIC] in any of the following ways?

	Yes	No
Our hospital has enabled WIC staff/peer counselors to provide bedside breastfeeding support
Our hospital staff help schedule WIC appointments
Our hospital routinely communicates WIC client birth information to WIC
WIC and our hospital have a [written agreement] to promote breastfeeding through outreach or collaboration
Other ___________________

WIC: The Special Supplemental Nutrition Program for Women, Infants, and Children

Written agreement: Such as a memorandum of understanding (MOU)

SECTION F: STAFFING

This section is about maternity-care staff and providers who work in your maternity-care unit, as well as staff and provider responsibilities and training. Mouse over underlined text for a definition or more information.

F1

How many nurses have met the following requirements?

	FEW (0-19%)	SOME (20-49%)	MANY (50-79%)	MOST (80%+)
Minimum 15 hours of [didactic breastfeeding education]
Minimum 5 hours [competency-based clinical training]

didactic breastfeeding education: Lectures, conferences, classroom, and online courses.

competency-based clinical training: Training and mentorship necessary to attain competence in managing and supporting breastfeeding.

F2

How often does your hospital require that nurses complete [continuing education] on breastfeeding support and lactation management?

At least once per year
Less than once per year
Not required

Participation in educational and training activities that improve the care that is provided by maternity staff to mothers and infants.

F3

How often are nurses [formally assessed] for clinical competency in breastfeeding support and lactation management?

At least once per year
Less than once per year
Not required

Systematic evaluation of staff’s hands-on ability to support breastfeeding mothers, and may include demonstration of competency at an annual skills lab or observation by a lactation specialist.

F4

Are nurses required to demonstrate competency in the following skills?

	Yes	No
Placement and monitoring of the newborn [skin-to-skin] with the mother immediately following birth
Assisting with effective newborn positioning and latch for breastfeeding
Assessment of milk transfer during breastfeeding
Assessment of maternal pain related to breastfeeding
Teaching hand expression of breast milk
Teaching safe formula preparation and feeding
Counseling the parents/caregivers on [safe sleep practices] for their newborn during the hospital stay
Counseling the mother on the importance of exclusive breastfeeding for 6 months

skin-to-skin: the naked newborn is placed prone directly on the mother’s bare chest or abdomen, with or without a cap/blanket.

Safe sleep practices: infants are placed on their backs on a firm, flat surface that is free of any items.

F5

How many of the following health care providers who care for breastfeeding mothers and newborns complete a minimum of 3 hours of [breastfeeding management education]?

	Not Applicable (none on staff)	FEW (0-19%)	SOME (20-49%)	MANY (50-79%)	MOST (80%+)
Obstetricians
Pediatricians
Family Practice Physicians
Certified Nurse Midwives
Nurse Practitioners / Advance Practice Registered Nurses Not including RNs
Medical Residents

Educational activities that give health care providers an understanding and knowledge of the benefits of exclusive breastfeeding, physiology of lactation, how their field of practice impacts lactation, and how to find out about safe medications for use during lactation.

F6

How many full time equivalents (FTEs) are International Board Certified Lactation Consultants (IBCLCs) dedicated exclusively to in-patient lactation care?

_ _._ _ FTEs (if less than1 FTE, please record as a decimal.

For example, 40 hours per week = 1 FTE,

20 hours per week = .5 FTEs,

and 10 hours per week = .25 FTEs.)

SECTION G: POLICIES AND PROCEDURES

This section is about hospital policies and procedures. Mouse over underlined text for a definition or more information.

G1

Does your hospital record (keep track of) [exclusive breastfeeding] throughout the entire hospitalization?

YES
NO

Human milk is the only food provided and includes expressed human milk from the mother or from a donor milk bank. Medicines, minerals, and vitamins may also be given, but no formula, water, or other preparations.

G2

Which of the following are included in a written policy (or policies) at your hospital?

		Yes	No
Policy requiring…	documentation of medical justification or informed parental consent for giving [non breast milk feedings] to breastfed newborns
	formal assessment of staff’s clinical competency in breastfeeding support
	formal, in-service, breastfeeding-related staff training
	documentation of prenatal breastfeeding education
	staff to teach mothers breastfeeding techniques, including how to manage common difficulties
	staff to show mothers how to express breast milk
	placement of newborns skin-to-skin with their mother at birth or soon thereafter
	purchase of infant formula and related breast milk substitutes by the hospital at fair market value
	staff to provide mothers with resources for breastfeeding support after discharge
	Staff to teach mothers about strategies for [safe sleep] while [rooming-in] at the hospital
	the option for mothers to room-in with their newborns
Policy prohibiting…	distribution of marketing/education materials, samples, or gift packs by the facility that include or promote breast milk substitutes (infant formula), infant feeding supplies, or infant formula coupons

Non breast milk feedings: formula, water, glucose water

Safe sleep practices: infants are placed on their backs on a firm, flat surface that is free of any items.

Rooming-in is a practice where mother and newborn are in close proximity.

G3

How many health care providers who have any contact with pregnant women, mothers, and/or newborns have been oriented on the hospital’s infant feeding policies?

Our hospital does not have official infant feeding practice policies.	Few (0-19%)	Some (20-49%)	Many (50-79%)	Most (80% +)

G4

How does your hospital acquire each of the following:

	HOSPITAL PURCHASES at [fair market price]	HOSPITAL RECEIVES free of charge	UNKNOWN or unsure
Infant formula
Bottles, nipples, pacifiers

Consistent with hospital-wide vendor policy

G5

Does your hospital give mothers any of the following items free of charge, as gifts or free samples (not including items prescribed as part of medical care)?

	Yes	No
Infant formula (including formula discharge packs)
Feeding bottles, bottle nipples, nipple shields, or pacifiers
Coupons, discounts, or educational materials from companies that make or sell infant formulas or feeding products.

SECTION H: EXIT / COMPLETION

H1

Select the positions or titles of the people who have participated in completing this survey, including your own. Click all that apply.

Mother-Baby Unit Manager / Supervisor
Labor and Delivery Unit Manager / Supervisor
Maternity Care Services Director / Manager
Lactation Services Coordinator
Lactation Care Provider (i.e., IBCLC, CLC, CBC)
Clinical Nurse Specialist
Director of Obstetrics and Gynecology
Director of Perinatal Care
Director of Pediatrics
Medical Director
NICU Nurse Manager
Staff physician
Staff midwife
Staff nurse
Database Manager / Coordinator
Other, specify_________________
I prefer not to answer

H2

Contact information for mPINC reports

We will mail a hard copy of your hospital’s results to four (4) leadership positions at your hospital. These positions are the Director of Hospital Quality Improvement, Obstetrics Medical Director, Pediatrics Medical Director, and the Nurse Manager for Mother Baby Services.

• In addition, we would like to email a copy of your hospital’s results. To protect the confidentiality of your hospital’s scores, we cannot send electronic copies of the benchmark report to personal email addresses (e.g., Yahoo, Gmail, Hotmail). Please enter your name, position, and official hospital email address so that we may email your hospital’s results. You, the survey recipient, will receive one (1) electronic copy of your hospital’s results. Your contact information will in no way be connected to survey responses or scores.

Survey Recipient Name	Position	Email

H3

Comments

Free text

Thank you for your time!

Definitions, Capabilities, and Provider Types: Neonatal Levels of Care

Level of Care	Capabilities	Provider Types1
Level I Well newborn nursery	Provide neonatal resuscitation at every delivery Evaluate and provide postnatal care to stable term newborn infants Stabilize and provide care for infants born 35–37 wk gestation who remain physiologically stable Stabilize newborn infants who are ill and those born at <35 wk gestation until transfer to a higher level of care	Pediatricians, family physicians, nurse practitioners, and other advanced practice registered nurses
Level II Special care nursery	Level I capabilities plus: Provide care for infants born ≥32 wk gestation and weighing ≥1500 g who have physiologic immaturity or who are moderately ill with problems that are expected to resolve rapidly and are not anticipated to need subspecialty services on an urgent basis Provide care for infants convalescing after intensive care Provide mechanical ventilation for brief duration (<24 h) or continuous positive airway pressure or both Stabilize infants born before 32 wk gestation and weighing less than 1500 g until transfer to a neonatal intensive care facility	Level I health care providers plus: Pediatric hospitalists, neonatologist, and neonatal nurse practitioners.
Level III NICU	Level II capabilities plus: Provide sustained life support Provide comprehensive care for infants born <32 wks gestation and weighing <1500 g and infants born at all gestational ages and birth weights with critical illness Provide prompt and readily available access to a full range of pediatric medical subspecialists, pediatric surgical specialists, pediatric anesthesiologists, and pediatric ophthalmologists Provide a full range of respiratory support that may include conventional and/or high-frequency ventilation and inhaled nitric oxide Perform advanced imaging, with interpretation on an urgent basis, including computed tomography, MRI, and echocardiography	Level II health care providers plus: Pediatric medical subspecialists, pediatric anesthesiologists, pediatric surgeons, and pediatric ophthalmologists.2
Level IV Regional NICU	Level III capabilities plus: Located within an institution with the capability to provide surgical repair of complex congenital or acquired conditions Maintain a full range of pediatric medical subspecialists, pediatric surgical subspecialists, and pediatric anesthesiologists at the site Facilitate transport and provide outreach education	Level III health care providers plus: Pediatric surgical subspecialists

Source: American Academy of Pediatrics (2012). Levels of Neonatal Care. [Policy Statement]. Pediatrics, 130, 587-597.

1 Includes all providers with relevant experience, training, and demonstrated competence.

2 At the site or at a closely related institution by prearranged consultative agreement.

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