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Perinatal Levels of Care Rewriting the Administrative Rules
The provision of risk appropriate care for pregnant women and newborn infants was first proposed in 1976. Providing risk appropriate care means ensuring that pregnant women are cared for and babies are born in a hospital with the expertise and resources to meet their medical needs. Illinois’ framework for risk appropriate care is implemented through the Regionalized Perinatal Health Care Code (77 Ill. Admin. Code 640), which requires every hospital to be designated at one of four levels of care based upon its functional capabilities and its capacity to serve pregnant women and newborns at risk for poor birth outcomes.
In 2012, the American Academy of Pediatrics (AAP) updated its policy statement on risk appropriate care, redefining the neonatal levels of care to provide:
- A basis for comparison of health outcomes, resource use, and health care costs;
- Standardized nomenclature for public health;
- Uniform definitions for pediatricians and other health professionals providing neonatal care; and
- A foundation for consistent standards of service by institutions; state health departments; and state, regional and national organizations focused on the improvement of perinatal care. (Barfield, 2012)
Below is a comparison of the patient population that is appropriate for each level of care, comparing Illinois’ current levels to the 2012 AAP guidelines
| Neonatal/Perinatal Level | Illinois Definition | AAP Definition |
|---|---|---|
| Level 0 | No perinatal services provided | Not Applicable |
| Level I | ≥ 36 weeks gestation; Infant ≥ 2500 Grams, no risk factors | ≥ 35 weeks gestation who are physiologically stable |
| Level II | ≥ 32 weeks gestation; ≥ 1500 grams; ≤ 6 hours ventilation | ≥ 32 weeks gestation; ≥ 1500 grams; < 24 hours ventilation |
| Level II with Extended Neonatal Capabilities | ≥ 30 weeks gestation; ≥ 1250 grams; assisted ventilation | Not Applicable |
| Level III | Complex healthcare issues | < 32 weeks; < 1500 grams; have medical or surgical conditions |
| Level IV | Not Applicable | Additional capabilities and experience in the care of the most complex and critically ill newborns infants |
In 2016, IDPH used the Centers for Disease Control and Prevention (CDC) Levels of Care Assessment Tool (LOCATe) to understand the Illinois perinatal system in relation to the AAP policy statement and to determine the impact of perinatal levels of care on infant mortality. LOCATe was designed as a brief, objective survey to assess hospital resources and personnel in relation to the AAP neonatal levels of care guidelines. We found that the availability of certain resources, such as not having on-site neonatologists, was a key difference between hospital levels in the current Illinois system and the AAP guidelines. Additionally, these resource differences were associated with variations in neonatal mortality for high-risk infants. For example, after linking LOCATe results to the birth and death certificates for births occurring in 2014, we found that neonatal mortality rates for very low birth weight infants (VLBW) were 150% to 300% higher for babies born in lower level facilities compared to Level III facilities, even after adjusting for infant medical conditions. Ensuring that high-risk infants receive care at a facility equipped to care for their medical needs is an important objective of the perinatal system.
In 2016, Illinois’ Perinatal Advisory Committee, a cross-disciplinary group of Illinois’ most highly trained and respected perinatal health professionals, recommended that IDPH implement the AAP’s 2012 guidelines for Neonatal Levels of Care.
In 2017, five work groups were established to assist with creating the new framework for Illinois’ Regionalized Perinatal Health program and identifying the necessary resource requirements to adopt a system more closely aligned with the AAP 2012 guidelines. The work groups will hold public meetings approximately once a month. The schedule of meetings can be found under the resources section of this page.
We anticipate that the workgroups will complete their work by early 2018 and implementation of the revised system will be finalized during 2019. Once completed, we anticipate that the revised system will result in an increase in the quality of care provided to pregnant women and newborns while simultaneously reducing infant and maternal morbidity and mortality. Please check back here for more updates as we move through this process.