Section 640.APPENDIX H  Written Protocol for Consultation/Transfer/Transport

Section 640.EXHIBIT A  Level I:  Patients for consultation with ________________ (Level III hospital or Administrative Perinatal Center)

1)         Maternal Conditions

A)        Previous Pregnancy Problems:

i)          Premature infant

ii)         Perinatal death or mental retardation

iii)        Isoimmunization

iv)        Difficult deliveries

v)         Congenital malformations

vi)        Mid-trimester loss

B)        Current Pregnancy Problems:

i)          Any medical disorder (e.g., diabetes mellitus, hemoglobinopathy, chronic hypertension, heart disease, renal disease)

ii)         Drug addiction

iii)        Multiple gestation

iv)        Intrauterine growth retardation

v)         Preterm labor less than or equal to 36 weeks

vi)        Postdate greater than or equal to 42 weeks

vii)       Third trimester bleeding

viii)      Abnormal genetic evaluation

ix)        Pregnancy induced hypertension

2)         Neonatal Conditions

A)        Gestation less than or equal to 36 weeks, weight less than or equal to 2500 grams

B)        Small-for-gestational age (less than 10^th percentile)

C)        Sepsis

D)        Seizures

E)        Congenital heart disease

F)         Multiple congenital anomalies

G)        Apnea

H)        Respiratory distress

I)         Neonatal asphyxia

J)         Handicapping conditions or developmental disabilities that threaten life or subsequent development

K)        Severe anemia

L)        Hyperbilirubinemia, not due to physiologic cause

M)       Polycythemia

3)         Consultation and transfer to a Level III or Administrative Perinatal Center shall occur for the following conditions:

A)        Premature labor or premature birth less than 34 weeks gestation.

B)        Birth weight less than or equal to 2000 grams.

(Source:  Amended at 35 Ill. Reg. 2583, effective January 31, 2011)