Hospitalisation in short-stay units for adults with internal medicine diseases and conditions.

BACKGROUND: Short-stay units are hospital units that provide short-term care for selected patients. Studies have indicated that short-stay units might reduce admission rates, time of hospital stays, hospital readmissions and expenditure without compromising the quality of care. Short-stay units are often defined by a target patient category, a target function, and a target time frame. Hypothetically, short-stay units could be established as part of any department, but this review focuses on short-stay units that provide care for participants with internal medicine diseases and conditions. OBJECTIVES: To assess beneficial and harmful effects of short-stay unit hospitalisation compared with usual care in people with internal medicine diseases and conditions. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers up to 13 December 2017 together with reference checking, citation searching and contact with study authors to identify additional studies. We also searched several grey literature sources and performed a forward citation search for included studies. SELECTION CRITERIA: We included randomised trials and cluster-randomised trials, comparing hospitalisation in a short-stay unit with usual care (hospitalisation in a traditional hospital ward or other services). We defined a short-stay unit to be a hospital ward where the targeted length of stay in hospital for patients was five days or less. We included both multipurpose and specialised short-stay units. Participants were adults admitted to hospital with an internal medicine disease or condition. We excluded surgical, obstetric, psychiatric, gynaecological, and ambulatory participants. Trials were included irrespective of publication status, date, and language. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Two review authors independently extracted data and assessed the risk of bias of each included trial. We measured intervention effect sizes by meta-analyses for two primary outcomes, mortality and serious adverse events, and one secondary outcome, hospital readmission. We narratively reported the following important outcomes: quality of life, activities of daily living, non-serious adverse events, and costs. We used risk ratio differences of 15% for mortality and of 20% for serious adverse events for minimal relevant clinical consideration. We rated the certainty of the evidence and the strength of recommendations of the outcomes using the GRADE approach. MAIN RESULTS: We included 19 records reporting on 14 randomised trials with a total of 2872 participants. One trial was ongoing. Thirteen trials evaluated short-stay unit hospitalisation for six specific conditions (acute decompensated heart failure (one trial), asthma (one trial), atrial fibrillation (one trial), chest pain (seven trials), syncope (two trials), and transient ischaemic attack (one trial)) and one trial investigated participants presenting with miscellaneous internal medicine disease and conditions. The components of the intervention differed among the trials as dictated by the trial participants' condition. All included trials were at high risk of bias.The certainty of the evidence for all outcomes was very low. Consequently, it is uncertain whether hospitalisation in short-stay units compared with usual care reduces mortality (risk ratio (RR) 0.73, 95% confidence interval (CI) 0.47 to 1.15) 5 trials (seven additional trials reporting on 1299 participants reported no deaths in either group)); serious adverse events (RR 0.95, 95% CI 0.59 to 1.54; 7 trials (one additional trial with 108 participants reported no serious adverse events in either group)), and hospital readmission (RR 0.80, 95% CI 0.54 to 1.19, 8 trials (one additional trial with 424 participants did not report results for participants)). There was not enough information to confirm or refute that short-stay unit hospitalisation had relevant effects on quality of life, activities of daily living, non-serious adverse events, and costs. AUTHORS' CONCLUSIONS: Overall, the quantity and the certainty of the evidence was very low. Consequently, it is uncertain whether there are any beneficial or harmful effects of short-stay unit hospitalisation for adults with internal medicine diseases and conditions - more trials comparing the effects of short-stay units with usual care are needed. Such trials ought to be conducted with low risk of bias and low risks of random errors to improve the overall confidence in the evidence.

Factors Associated With Pediatric Hospital-Acquired Pressure Injuries.

PURPOSE: The purpose of this study was to identify associations among pediatric patient characteristics (age and gender), hospital characteristics, inpatient unit characteristics (unit type, pressure injury prevention practices, and nurse staffing measures), and hospital-acquired pressure injuries (HAPIs) in a group of pediatric patients and in those determined to be at risk for pressure injury. DESIGN: A descriptive, correlational analysis of data from a large dataset. SUBJECTS AND SETTING: The sample comprised 39,984 children aged 1 day to 18 years of age from 678 pediatric units in 271 participating hospitals across the United States. METHODS: Data related to pressure injuries and prevention among pediatric patients from the National Database of Nursing Quality Indicators (NDNQI) were analyzed. All data were collected during the year 2012. Descriptive statistics were used to summarize the study sample. Hierarchical logistic regression analysis was used to analyze patient age and gender, unit type, pressure injury risk, prevention and staffing measures, and hospital characteristics associated with HAPI. RESULTS: The likelihood of a HAPI was more than 9 times higher among patients who were determined to be at risk for pressure injuries (odds ratio [OR]: 9.42, 95% confidence interval [CI]: 7.28-12.17, P < .001) compared to patients deemed not at risk. Hospital-acquired pressure injury was more likely to occur on pediatric critical care units (OR: 2.59, 95% CI: 1.28-5.26, P = .009) and rehabilitation units (OR: 4.05, 95% CI: 1.21-13.55, P = .02). Patients from hospitals that only provided care for children (OR: 2.6, 95% CI: 1.42-4.78, P = .002) were also more likely to be associated with HAPI compared to hospitals that provided care for adults and children. Among the 11,203 pediatric patients deemed at risk for pressure injuries, 95.8% received one or more prevention interventions. There were no prevention interventions associated with a lower occurrence of HAPI. CONCLUSIONS: Study findings support pressure injury risk assessment among pediatric patients and elucidates important information regarding pediatric unit and hospital characteristics associated with HAPI.

A longitudinal analysis of nursing specialty certification by Magnet® status and patient unit type.

The objective of this study was to examine nursing specialty certification trends by Magnet® status and unit type. Research exploring organizational and unit attributes associated with higher specialty certification rates is timely given the beginning evidence that certification is associated with lower patient adverse events. The sample included 6047 units in 1249 National Database of Nursing Quality Indicators hospitals. Hierarchical linear modeling was used to predict growth in percentage of specialty-certified RNs within each unit type and Magnet status. Data (Bayesian Information Criteria = 224 583.30) demonstrated significant growth in specialty certification rates over time (P < .0001). Magnet-designated organizations had significantly different starting certification rates (P = .0002) and rates of change (P = .0002). Unit types also had significantly different starting certification rates (P < .0001) and different rates of change (P < .0001). Magnet recognition is associated with increases in specialty certification rates. Certification rates have risen faster in unit types such as pediatric critical care than in unit types such as adult step-down and adult surgical.

Group cohesion and social support of the nurses in a special unit and a general unit in Korea.

AIM: To identify the degree of group cohesion and social support of nurses in special and general units in hospitals in Korea, and to compare group cohesion and social support between the two groups. BACKGROUND: The level of commitment nurses have to their organizations has been shown to correlate with work group cohesion and social support. METHODS: The participants were 1751 nurses who were working in Korean hospitals. Data were collected using a structured questionnaire and were analysed using SAS. The statistical methods included: descriptive statistics, t-test, anova and Pearson's correlation coefficients. RESULTS: Group cohesion of nurses on special wards was significantly higher than for nurses on general wards. No significant difference was found between types of units in terms of social support. The degree of group cohesion was significantly different in terms of the respondents' clinical experience, position, religion, job satisfaction, number of supportive superiors and number of supportive peers. A statistically significant correlation was found between group cohesion scores and degree of social support. CONCLUSIONS AND IMPLICATIONS FOR NURSING MANAGEMENT: Hospital management can accomplish their goals more effectively through knowledge of the level of group cohesion, superior support and peer support for nursing staff in accordance with unit specialty.

Chest CT in COVID-19 pneumonia: A review of current knowledge.

The current COVID-19 pandemic has highlighted the essential role of chest computed tomography (CT) examination in patient triage in the emergency departments, allowing them to be referred to "COVID" or "non-COVID" wards. Initial chest CT examination must be performed without intravenous administration of iodinated contrast material, but contrast material administration is required when pulmonary embolism is suspected, which seems to be frequent in severe forms of the disease. Typical CT features consist of bilateral ground-glass opacities with peripheral, posterior and basal predominance. Lung disease extent on CT correlates with clinical severity. Artificial intelligence could assist radiologists for diagnosis and prognosis evaluation.

Work hours, work stress, and collaboration among ward staff in relation to risk of hospital-associated infection among patients.

OBJECTIVES: To examine the association between work hours, work stress, and collaboration among the ward personnel, and the risk of hospital-associated infection among patients. DESIGN: Cross-sectional data on hospital infections were collected between March and June 2004. These data were linked with ward-level responses to a personnel survey collected during the same time period. SETTING: Medical records of patients in 60 non-psychiatric bed wards in 6 Finnish hospitals. PARTICIPANTS: One thousand ninety-two patients and 1159 staff survey responses. MEASUREMENTS: Prevalence surveillance was performed by 4 infection control nurses, using standard criteria. Data on several potential risk factors for infection were collected: sex, age, patient type (surgical vs. other), hospital type (university vs. regional hospital), unit type, number of patients in the ward, exposure to invasive devices, International Classification of Diseases version 10 diagnosis, chemotherapy, radiotherapy, and use of corticosteroids. Staff working conditions were measured by survey scales. RESULTS: Ninety-nine cases (9.1%) of hospital-associated infection were found. Multilevel logistic regression analyses, adjusted for hospital factors and patient-related risk factors, showed that long work hours among staff were associated with increased risk of infection [odds ratio (OR) 2.74, 95% confidence interval (CI): 1.07-7.04]. Other staff-related correlates of infection were high work stress, as indicated by high imbalance between efforts and rewards (OR: 2.47; 95% CI: 1.38-4.42), low trust between work unit members (OR: 2.37; 95% CI: 1.27-4.43), injustice in the distribution of work (OR: 1.81; 95% CI: 1.04-3.16), and poor collaboration between ward supervisors (OR: 2.46; 95% CI: 1.38-4.38). CONCLUSIONS: Long work hours, high work stress, and poor collaboration among the ward staff are associated with hospital-associated infection among patients.

Point-prevalence study of antimicrobial use in public hospitals in southern Sri Lanka identifies opportunities for improving prescribing practices.

A point-prevalence study of antimicrobial use among inpatients at 5 public hospitals in Sri Lanka revealed that 54.6% were receiving antimicrobials: 43.1% in medical wards, 68.0% in surgical wards, and 97.6% in intensive care wards. Amoxicillin-clavulanate was most commonly used for major indications. Among patients receiving antimicrobials, 31.0% received potentially inappropriate therapy.

Combination of acute stroke unit and short-term stroke ward with early supported discharge decreases mortality and complications after acute ischemic stroke.

BACKGROUND: The stroke unit has been established as a standard care for stroke. However, it has not been widely established in developing countries due to the lack of understanding and limited resources. OBJECTIVE: To compare the complications and mortality of stroke patients admitted in the stroke unit and short-term ward with those admitted in the general medical ward. MATERIAL AND METHOD: The authors prospectively collected data of acute stroke patients who were admitted after the set up of the stroke unit and stroke short-term ward in 2003, and compared with the data of those who were admitted in a general medical ward in 2001. All acute stroke patients who presented within seven days of the onset were admitted and those who had final diagnosis of ischemic stroke or transient ischemic attack (TIA) were studied. Patients in the stroke unit were taken care of by a multidisciplinary team approach under clinical guidelines and a care map. The short-term ward is a part of the general medical ward and stroke patients were treated by a multidisciplinary team followed by homecare treatment. The endpoints were mortality rate, neurological and medical complications during admissions, and the mean length of stay. RESULTS: Seven hundred and ninety-four patients were studied. Three hundred and eighty-seven patients were admitted in 2001 and 407 patients in 2003. Among patients presented 2003, three hundred and one cases were treated in the acute stroke unit whereas 106 were admitted in the short-term ward. There was no difference in stroke risk factors and stroke subtypes between the two groups, except for dyslipidemia and cigarette smoking, which were more prevalent in patients admitted in 2003. Patients in the stroke unit and the short-term ward had significantly less mortality than those in the general medical ward (8.9 and 2.1%). Overall complications in the stroke unit and the short-term ward were 16.8%, compared to 26% of those admitted into the general medical ward. Significantly less brain edema, hemorrhagic infarction, urinary tract infection, pneumonia, and pressure sore were also observed. The length of hospital stay of the patients admitted in 2001 and 2003 was 11.26 and 8.09 days, respectively. CONCLUSION: Combination of organized acute stroke unit and short-term ward with early supported discharge reduces the mortality and complications of ischemic stroke patients during admission as well as the length of stay when compared to the general medical ward. The present study reassures that the combination is useful for hospitals in developing countries, which have limited number of beds in their stroke units.

Beneficial Effects of Guided Imagery or Clinical Massage on the Status of Patients in a Progressive Care Unit.

BACKGROUND: Patients in the progressive care unit typically experience high levels of pain and anxiety and exhibit difficulty sleeping. OBJECTIVE: To determine whether either clinical massage or guided imagery could reduce pain and anxiety and improve sleep. METHODS: This study included 288 inpatients on 2 floors of a progressive care unit. On 1 floor, each patient was offered daily a 15-minute complimentary clinical massage, whereas the patients on the other floor were provided access to a 30-minute guided-imagery recording. Patients were asked to rate their pain and anxiety levels immediately before and after the massage intervention or were asked whether the guided-imagery intervention was helpful for pain, anxiety, or insomnia. RESULTS: The massage intervention showed an immediate and significant reduction in self-reported pain and anxiety (P < .001); likewise, a significant number of patients self-reported that guided imagery helped alleviate pain, anxiety, and insomnia (P < .001). CONCLUSION: The results of this study indicate that clinical massage and guided imagery can benefit patients in the progressive care unit.

The contribution of a comprehensive stroke unit to the outcome of Chinese stroke patients.

INTRODUCTION: There are significant differences in stroke patterns and risk factors for cerebrovascular disease between Chinese subjects and Caucasians. The outcome of stroke unit care in a Chinese population has not been described in the medical literature. The present study aims to evaluate the outcome of stroke unit care in Chinese subjects. METHODS: By prospective comparative research, Chinese patients treated in the stroke unit were group-matched with those treated in the general medical ward by age, gender, premorbid functional status (by the Barthel Index), National Institute of Health Stroke Scale score, and stroke types. From April 2001 to April 2002, a total of 188 patients in the stroke unit group and 177 patients in the general ward group were recruited in the study. The main outcome measures included mortality at 28 and 120 days, and the length of inpatient stay. RESULTS: Stroke unit care significantly reduced mortality of patients with acute stroke after 28 and 120 days. After 28 days, mortality was 3.3 percent and 17.2 percent for the stroke unit group and general ward group, respectively (p-value is equal to or less than 0.01); whereas after 120 days, mortality was 5.0 percent and 24.7 percent for the stroke unit group and general ward group, respectively (p-value is equal to or less than 0.001). The stroke unit care was demonstrated, by logistic regression analysis, to have contributed to the reduction of mortality at 120 days (p-value is 0.014). At 28 days, there was only a trend for stroke unit care to contribute to the reduction of mortality by logistic regression analysis (p-value is 0.067). By Kaplan-Meier survival curves (log rank statistic is 10.46, p-value is 0.001) and a Cox regression (hazard ratio 0.253, 95 percent confidence interval 0.085 to 0.754, p-value is 0.014), the stroke unit care was further found to reduce mortality significantly. The mean length of inpatient stay of the stroke unit group was 37.1 days, while that of the general medical ward group was 69.3 days (p-value is equal to or less than 0.001). CONCLUSION: Chinese subjects receiving comprehensive stroke unit care are associated with less mortality and shorter length of hospital stay than those having conventional care in general medical wards.

Timing of aspirin and secondary preventative therapies in acute stroke: support for use of stroke units.

BACKGROUND: We aimed to study the timing of aspirin prescription in ischaemic stroke comparing patients admitted to an acute stroke unit (ASU) directly or via a general medical ward. We also analysed prescription of secondary preventive therapies in stroke patients in an ASU. METHODS: Retrospective analysis was made of medical notes and prescription records of 69 patients admitted to an ASU over a three month period to establish timing of aspirin prescription with respect to onset of stroke symptoms, CT brain scan and route of admission to the ASU. RESULTS: CT brain scans were obtained at a median of 2.1 days post stroke (IQ range 1.3-4.3). Patients directly admitted to the ASU received aspirin earlier post admission compared to those admitted via a medical ward (0.7 vs 2.2 days, p < 0.01) and were also more likely to receive aspirin prior to CT scan being performed (57% vs 19%, p = 0.02). 86% of stroke patients were discharged on an antiplatelet therapy, 79% on a statin, 37% on a thiazide diuretic and 32% on an ACE inhibitor or angiotensin II antagonist. CONCLUSION: Aspirin was given more promptly in acute stroke and more commonly prior to CT scanning in an ASU compared to a medical ward. Statin therapy is used extensively in stroke but there is a much lower rate of initiation of other secondary preventive therapies (e.g. anti-hypertensive therapy) in hospital. These findings demonstrate a hesitancy in early use of aspirin amongst general physicians and lends support for the use of stroke units.

Differences in psychosocial and behavioral profiles between heart failure patients admitted to cardiology and geriatric wards.

BACKGROUND: Heart failure represents a growing epidemic, primarily in the elderly. Development and implementation of management programs designed for use in daily clinical practice remains a major challenge. AIMS: This study aimed at profiling a hospitalized heart failure population in view of medical, behavioral, educational, psychosocial and health resources utilization parameters stratified by admission to cardiology and geriatric wards. METHODS AND RESULTS: Using a descriptive comparative design, 109 European heart failure patients admitted to cardiology (42%) and geriatric wards (58%) were included. Significant differences (all P<0.0001) were identified between the two groups. Patients admitted to cardiology had a mean age of 68.5, 33% were women, and the mean ejection fraction was 38%. Patients admitted to geriatrics had a mean age of 85, 68% were women, and the mean ejection fraction was 56%. Sixty-six percent were admitted for cardiac reasons. Medical, educational, behavioral, psychosocial and health resources utilization data were retrieved from medical files as well as by patient and family interviews. Results showed significant differences between groups. Patients admitted to geriatric wards received significantly less ACE inhibition and beta-blockers. Moreover, these patients were significantly less knowledgeable, showed poorer self-management, poorer hearing, more cognitive impairment, a higher degree of depressive symptomatology, more problems with ADL and IADL, and used significantly more home health care services compared to patients admitted to cardiology wards. CONCLUSION: The characteristics of the heart failure population at large are quite different from those of populations included in large-scale therapeutic trials. Findings from this study provide options for tailored management strategies for both profiled subgroups.

Identification of depression by medical and surgical general hospital physicians.

Little information is available about identification of mental distress by general hospital physicians (GHPs). We compared, among patients admitted in a General Hospital, depressed patients with patients identified as depressed by the GHPs. A random sample of 1,039 patients were screened with the 12-item General Health Questionnaire. Afterwards, all high scorers and a probability sample of low scorers were interviewed with a variety of measures, including the Composite International Diagnostic Interview-Primary Care version (CIDI-PHC). GHPs recorded the presence of depression on a Physician Encounter Form. Patients were more likely to have depression detected on medical than surgical wards. Of the 195 patients who had a depression, the GHPs assessed 32.5% as depressed. A number of factors associated with CIDI diagnoses were not significantly associated with being identified by the GHPs - female gender, two or more life events in the previous year, and a previous history of depression. The identification by the GHPs was associated with a higher probability of contacts with medical professionals and of antidepressant drug prescriptions during the year which followed the first interview.

Hospitalized patients and alcohol: who is being missed?

Research and clinical experience have shown that alcohol use disorders are neither sufficiently identified nor addressed in hospitalized patients. This study sought to quantify and localize these missed opportunities. The setting was an urban medical center with a Level 1 trauma designation. The only eligibility requirement was a Blood Alcohol Level (BAL) greater than 300 ng/dl upon hospital admission, a "nonsubtle" value more than three times the legal intoxication limit. Charts [58] were retrospectively reviewed for treating service (medical, trauma services, or psychiatric) and evidence of psychological signs or behavioral symptoms of withdrawal. Also assessed were the presence or absence of withdrawal monitoring, withdrawal prophylaxis orders, inpatient addictions consultation, and referral for addictions aftercare. Numerous patients with admission BALs >300 failed to be identified as needing assessment for alcohol-related disorders. Patients admitted to medical or psychiatric services were significantly more likely to be diagnosed than those on trauma services (P =.02). Patients on medical or psychiatric services were also more likely to be assessed for withdrawal and referred for after-care (P <.0001) than those cared for on trauma services. The delivery of care for alcohol-related disorders was deficient, particularly for patients with traumatic injuries, even among patients severely intoxicated at admission. Failure to identify such patients represented a missed opportunity to address this vital contributor to trauma. It is suggested that both the origins of this shortfall and its resolution depend not just upon trauma providers but upon the entire medical system.

Child-onset growth hormone deficiency in adulthood. Transfer of patients from pediatric to adult endocrinology units.

Treatment with growth hormone (GH) in adult-onset GH deficiency (AO-GHD) reverses its many metabolic alterations, modifying body composition, bone mass, several cardiovascular risk factors, and improving quality of life. In adult patients with a previous diagnosis of child-onset GH deficiency (CO-GHD), the lack of treatment also produces similar alterations, reversed by GH treatment. In patients with multiple pituitary hormone deficiency, the lack of GH is considered definitive, but in isolated GHD, the need for re-evaluation of the deficit is mandatory. The 'gold standard' test is insulin-induced hypoglycemia, after a wash-out period, and the criterion for GH therapy should be a GH (polyclonal-RIA assay) response less than 3 ng/ml. The initial recommended GH dose is lover than in children, and the dosage must be adjusted to maintain IGF-I levels in the normal range. We propose that decisions about patient recruitment, assessment, confirmation or reevaluation, information about new perspectives, disadvantages and benefits of GH therapy, and the beginning of treatment should be made in cooperation by pediatric and adult endocrinologists, so the patient receives all information from both medical teams, before being transferred to the adult endocrinology department.

[Utilization and comparison study of antipsychotics at the Department of Psychiatry and Psychotherapy of the Semmelweis University and the Galfi Bela Hospital]. / Antipszichotikumok felhasználásának utilizációs vizsgálata és összehasonlítása a Semmelweis Egyetem Pszichiátriai és Pszichoterápiás Klinikáján és a Gálfi Béla Gyógyító és Rehabilitációs Kht. Szakkórházában.

The authors examined the use of antipsychotics at the Department of Psychiatry and Psychotherapy of the Semmelweis University and at the Gálfi Béla Hospital by reviewing retrospectively the drug ordering practice in the period of 1998-2002. The aim of the study was to analyse the utilization aspects of the use of antipsychotic medication. The study also aimed to identify the main trends of prescribing preference and to compare the use of antipsychotics in the two institutions. Data showed that in accordance with the latest professional guidelines the use of novel antipsychotics is increasing. Based on analysis of the antipsychotic use in both clinical practices there were characteristic patterns found that show that the conventional antipsychotic use is still notable. The purpose of the present study was to follow the temporal development trends and present state of antipsychotic use which could result in a cost-effective drug therapy.

Diabetic foot units in Spain: knowing the facts using a questionnaire.

OBJECTIVE: To ascertain the number of diabetic foot units (DFUs) in Spain, the specialists working in them, and the population covered by them. MATERIAL AND METHODS: The Spanish Group on the Diabetic Foot (SGDF) prepared and agreed a questionnaire based on the recommendations of the 2011 International Consensus on the Diabetic Foot (ICDF). From October to December 2012, the questionnaire was sent to members of three scientific societies formed by professionals involved in the care of patients with diabetes mellitus. Population coverage of the responding centers and DFUs was estimated using the 2012 population census. RESULTS: Seventy five questionnaires were received, 64 of them from general hospitals, which accounted for 13% of the general hospitals of the National Health System. It was calculated that they provided coverage to 43% of the population. Thirty four centers answered that they had a DFU. Specialized diabetic foot care was only provided to 25% of the population. The number of different professionals working at diabetic foot units was 6.3±2.7. Classification of DFUs based on their complexity was as follows: 5 basic units (14.7%), 20 intermediate units (58.8%), and 9 excellence units (26.5%). CONCLUSIONS: The number of DFUs reported in this study in Spain is low, and allow for foot care of only one out of every four patients with diabetes. Spanish health system needs to improve diabetic foot care by creating new DFUs and improving the existing ones.

[Health care levels and minimum recommendations for neonatal care]. / Niveles asistenciales y recomendaciones de mínimos para la atención neonatal.

A policy statement on the levels of care and minimum recommendations for neonatal healthcare was first proposed by the Standards Committee and the Board of the Spanish Society of Neonatology in 2004. This allowed us to define the level of care of each center in our country, as well as the health and technical requirements by levels of care to be defined. This review takes into account changes in neonatal care in the last few years and to optimize the location of resources. Facilities that provide care for newborn infants should be organized within a regionalized system of perinatal care. The functional capabilities of each level of care should be defined clearly and uniformly, including requirements for equipment, facilities, personnel, ancillary services, training, and the organization of services (including transport) needed to cover each level of care.