The four levels of neonatal designation consist of:

The four levels of neonatal designation consist of: 1. Level I – Well Care – The Level I neonatal designated facility must: a. Provide neonatal resuscitation at every delivery. b. Evaluate and provide postnatal care to stable term newborn infants. c. Stabilize and provide care for infants born at 35-37 weeks gestation who remain physiologically stable. d. Stabilize newborn infants who are ill and those born at less than 35 weeks gestation until transfer to a facility that can provide the appropriate level of care. e. Maintain a staff of providers including pediatricians, family physicians, nurse practitioners with newborn training, registered nurses with newborn training, including being current with Neonatal Resuscitation Program Certification and S.T.A.B.L.E. 2. Level II – Special Care – The Level II neonatal designated facility must: a. Prove all basic care services of a Level I neonatal designated facility. b. Provide care for mothers and their infants of generally more than or equal to 32 weeks gestational age and birth weight more than or equal to 1500 grams who have physiologic immaturity or problems that are expected to resolve rapidly and are not anticipated to require subspecialty services on an urgent basis. c. Provide care for infants’ convalescent care after intensive care. Provide mechanical ventilation for brief duration (less than 24 hours) and/or continuous positive airway pressure. e. Stabilize infants born before 32 weeks’ gestation and weighing less than 1500 grams until transfer to a Level III or Level IV neonatal intensive care facility. f. Maintain a staff of providers including pediatric hospitalists, neonatologists, and neonatal nurse practitioners. g. Referral to a higher level of care for all infants when needed for pediatric surgical or medical subspeciality intervention. h. Level II nurseries must have equipment (e.g., portable x-ray machine, blood gas analyzer) and personnel (e.g., physicians, specialized nurses, respiratory therapists, radiology technicians) to provide ongoing care of admitted infants as well as to address emergencies. 3. Level III – Neonatal Intensive Care – The Level III neonatal designated facility must: a. Provision of all Level I and Level II services. b. Level III NICUs are defined by having continuously available personnel (neonatologists, neonatal nurses, and respiratory therapists) and equipment to provide life support for as long as necessary. c. Provide comprehensive care for infants born less than 32 weeks gestation and weighing less than1500 grams and infants born at all gestational ages and birth weights with critical illness. d. Provide prompt and readily available access to a full range of pediatric medical subspecialists, pediatric surgical specialists, pediatric anesthesiologists or anesthesiologists with experience in neonatal surgical care and pediatric ophthalmologists, on site or by prearranged consultative agreements. e. Provide a full range of respiratory support and physiologic monitoring that may include conventional and/or high-frequency ventilation and inhaled nitric oxide. f. Perform advanced imaging with interpretation on an urgent basis, including computed tomography, MRI and echocardiography. g. Social and family support, including social services and pastoral care. h. If geographic constraints for land transportation exist, the Level III facility should ensure availability of rotor and fixed-wing transport services to transfer infants requiring subspecialty intervention from other regions and facilities. i. Consultation and transfer agreements with both lower-level referring hospitals and regional centers, including back-transport agreements. j. Prompt diagnosis and appropriate referral of all conditions requiring surgical intervention. Major surgery should be performed by pediatric surgical specialists (including anesthesiologists with pediatric expertise) on–site within the hospital or at a closely related institution, ideally in close geographic proximity if possible. Level III facilities should be able to offer complete care, management, and evaluation for high-risk neonates 24 hours a day. A neonatologist should be available either in- house or on-call with the capacity to be in-house in a timely manner, 24 hours a day. k. Level III facilities should maintain a sufficient volume of infants less than 1500 grams to meet professionally accepted guidelines to achieve adequate experience and expertise. l. Enrollment in the Vermont Oxford Network to report and monitor data regarding outcomes of infants born less than 32 weeks and weighing less than 1500 grams. m. Participation in and evaluation of quality improvement initiatives. 4. Level IV – Advanced Neonatal Intensive Care – The Level IV neonatal designated facility must: a. Provide all level III capabilities listed above. b. Located within an institution with the capability to provide surgical repair of complex congenital or acquired conditions. c. Maintain a full range of pediatric medical subspecialists, pediatric surgical subspecialists and pediatric anesthesiologists at the site. d. Facilitate transport and provide outreach education including community taught NRP and S.T.A.B.L.E. classes.