CPQCC Data Center. CPQCC Satellite NICUs Version 16.1, April 28,

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CPQCC Data Center CPQCC s Version 16.1, April 28, 2016-1 -

Dear CPQCC Participant, You are receiving this memo because you are one of the nine s participating in CPQCC. We are addressing the special circumstances affecting s and the implications for the CPQCC data collection and reporting. These changes were first introduced into the CPQCC Network Database on March 1, 2010 1, and updated on April 16, 2010 2, January 24, 2011 3, March 3, 2012 4 and April 28, 2016 5. I. s Definition Starting with the 2010 CPQCC Network Database, a (or an Embedded NICU) is defined as a NICU owned and managed by one organization (Main NICU) located within a delivery facility owned and managed by another hospital ( ). CPQCC uses OSHPD IDs to capture an infant s location: birth location (birthlocation, Item 7c and C.32), transport location (xferlocation, Item 59), hospital that discharged infant home (last, Item 52), referring location (T_referring, Item C.30) and previous transport referring hospital (T_prev, Item C.31). As for most s, OSHPD reporting is consolidated with OSHPD reporting of the main NICU, s typically do not have their own OSHPD ID. Starting in May 2012, in order to capture correct infant location variables we introduced fake OSHPD IDs for all s in the CPQCC Manual of Definitions. 3 Note that we currently use fake OSHPD IDs for military hospitals, birthing centers that do not report to OSHPD and non-hospital or out-of-state hospital locations as well. 3 We continue to update this list according to member requests for the specific setup or member requests for the addition of non-cpqcc member s of their main NICU. 5 Table 1: CPQCC s below shows for each of the 11 s that are currently incorporated into the CPQCC data collection, the associated main NICU and the hospital where the Satellite is located. The location codes (OSHPD IDs or fake OSHPD IDs) are shown in parenthesis for each location. - 2 -

Table 1: CPQCC s SATELLITE NICU MAIN NICU CO-LOCATED Children s of Children s Mission Orange County (CHOC) of Orange County, Regional Medical at Mission (304113) CHCC (300032) Center (301262) Lucille Packard Children s Special Care Nursery at Sequoia, LPCH (750002) Lucille Packard Children s Special Care Nursery at Washington, LPCH (750003) San Diego at Scripps La Jolla (750005) San Diego at Scripps Encinitas (750004) Lucille Packard Children s at Stanford, LPCH (434040) Lucille Packard Children s at Stanford, LPCH (434040) San Diego San Diego Sequoia (410891) Washington Fremont (010987) Scripps Memorial La Jolla (370771) Scripps Memorial Encinitas (371394) COMMENTS This NICU is no longer owned by LPCH and is therefore no longer a Satellite. NICU at Palomar Medical Center (750006) NICU at Rancho Springs Medical Center in Murrieta (750007) 4 San Diego San Diego Palomar Medical Center (370755) Rancho Springs Medical Center in Murrieta (334068) - 3 -

SATELLITE NICU MAIN NICU CO-LOCATED NICU at Scripps Mercy San Scripps Mercy San Diego San Diego Diego (750010) 5 COMMENTS New in 2016 NICU at Scripps Mercy Chula Vista (750011) 5 San Diego Scripps Mercy Chula Vista New in 2016 Valley Children s at St. Agnes Medical Center (750001) Children s Central California, CHCC (204019) St. Agnes Medical Center (100899) Valley Children s at Adventist Medical Center, Hanford (750008) 4 Valley Children s at Mercy Medical Center, Merced (750009) 5 Children s Central California, CHCC (204019) Children s Central California, CHCC (204019) Adventist Medical Center, Hanford (160787) Mercy Medical Center, Merced (240942) Non-CPQCC Member Non-CPQCC Member II. Coding Instructions in www.cpqccdata.org A. Item 7a. Location of Birth 1 1. Inborn Infant. For s the Inborn option is not available. 2. Infant Born at. Infants who are delivered at the and then transferred to the are considered infants Born at the. Select Born at (s Only) from the drop-down box 5 if your center is a and the infant was delivered in the hospital. This includes any location within the hospital, e.g., Labor & Delivery, Antepartum unit, - 4 -

Emergency Room. For non-s, the Infant born at is not available. 3. Outborn Infant. Select Outborn if the infant was born in another facility OR at any location outside the hospital OR home at any time after birth. Any infant requiring ambulance transport is considered Outborn. When completing the Admission/Discharge data forms for Outborn infants, use all information available from the hospital from which the infant was transported to your center as well as from your own center. Specifically: Outborn should always be used for an infant who was previously home. Infants who are delivered at the Main NICU and then transported to a Main NICU s are considered Outborn infants for the. infants who are born at the hospital are coded as follows: Item 7a. If a is entering data for an infant born at the who is then transferred to the Satellite NICU, code the infant as Born at in Item 7a. Location of Birth. NOTE: For non-s the last option (Born at ) is not available; for s the Inborn option is not available. - 5 -

Item 7b. For Small Babies, Item 7b. Age in Days at Admission to the is set to 1. Item 7c. Once Born at in Item 7a is selected, the system automatically sets Item 7c. Select the hospital of birth to the s OSHPD ID number. The birth location is grayed out, and it cannot be changed by the Data Contact. B. CPeTS Form: Items C.30, C.31, 52 and 59 - OSHPD List 2, 4 After the initial system update that introduced revised data capture for s, it was brought to our attention that Main NICUs wanted to be able to distinguish an infant that was transported to the s Well-baby nursery FROM an infant that was transported to the at the. Prior to the systems update in January 2011, Data Contacts were instructed to use the OSHPD ID of the regardless of the location of transport. Subsequently, we updated the hospital code list for the following Items: C.30, C.31, 52 and 59. Specifically, we used the fake OSHPD ID codes created for the s (see Table 1: CPQCC s). 5 This change did not affect the OSHPD list for the Birth Location (Items C.32 and 7C). Finally, note that the CPeTS form supports easy data entry of the referring location for infants born at a hospital (see screenshot below) 5. - 6 -

Here are situational examples of how the systems update affects data entry: SITUATION SITUATION A: Infant is born at the, is transferred to the Satellite NICU, then transported to the Main NICU, and then back-transported to the Satellite NICU. 2015/2016 ITEM 5 Main NICU enters data C.30 REFERRING (OSHPD) C.31B. PREVIOUS TRANSFER REFERRING (OSHPD) C.32. LOCATION OF BIRTH (OSHPD) -- NO CHANGE 7A. LOCATION OF BIRTH 7C. BIRTH (OSHPD) -- NO CHANGE Not applicable Outborn enters data ; CPeTS Form not required ; CPeTS Form not required ; CPeTS Form not required Born at - 7 - SITUATION B: Infant is born at the, is transferred to a non-cpqcc member Satellite NICU, then transported to the Main NICU, and then back-transported to the non- CPQCC member Satellite NICU. Main NICU enters data Non-CPQCC Not Applicable Outborn Non-CPQCC does not enter data 59. Main NICU Non-CPQCC

SITUATION SITUATION A: Infant is born at the, is transferred to the Satellite NICU, then transported to the Main NICU, and then back-transported to the Satellite NICU. TRANSPORTED TO (OSHPD) SITUATION B: Infant is born at the, is transferred to a non-cpqcc member Satellite NICU, then transported to the Main NICU, and then back-transported to the non- CPQCC member Satellite NICU. For Situation B (Infant is born at the, is transferred to a non-cpqcc member, then transported to the Main NICU, and then back-transported to the non-cpqcc member ), if available member Centers should enter the fake OSHPD ID of the non- CPQCC. If no such code is available, the OSHPD code Other In-Patient Setting California (890099) should be used. C. CCS Supplemental Form 1 Starting with the 2010 CCS Supplemental Form, the following revisions were implemented: In Section A, Total Live Births by Birth weight in your Center is replaced by Total Live Births from the. 5 In Section A, Delivery Room Deaths is replaced by Delivery Room Deaths from the. 5 In Section B, Inborn admissions to your NICU is replaced by Infants born at. 5 In Section B, Outborn 4 Admissions to your NICU 5 should include infants who are transported into your NICU from all hospitals other than the hospital. 5-8 -

In Section D, Total Live Births by Gestational in your Center is replaced by Total Live Births from by Gestational Age at. 5 Per the request of the CPQCC Data Center, CCS released a revised support letter on [Date] 5 addressed to the CCS-approved Satellite NICUs to help facilitate the retrieval and reporting of data from the Co- Located. The CPQCC Data Center will continue to facilitate this process every year. Below is an excerpt: 5 The CPQCC Data Center has informed us that some administrations do not grant their local NICU data reporting team access to certain required data elements. These locally restricted elements include: total live births by birthweight AND gestational age, delivery room deaths by birthweight, and inborn admissions by birthweight AND gestational age to the NICU. Every CCS-approved NICU operates in a CCS-approved. Therefore, there are no HIPAA compliance issues with reporting these data. 5 CCS has worked directly with each to retrieve the data from the and continues in this process. 5 This letter is located on the CPQCC Data Center/Downloads page (link below) and can be used 5 to help facilitate the timely submission of the CCS Supplemental Form by the April 1 st deadline if requested by Centers. https://www.cpqcc.org/perinatal-programs/cpqcc-datacenter/downloads III. Technical Assistance If you have any questions, concerns or recommendations, please log in to the CPQCC Help Desk (cpqccsupport.org) and create a ticket. - 9 -