Level III NICU Requirements 
(a) The Level III neonatal facility will:
1. provide comprehensive care for infants born at all gestational ages and birth weights, with mild to complex critical conditions or medical problems requiring sustained life support, hemodynamic support, and/or conventional mechanical ventilation2 ;
2. have the ability to provide high-frequency ventilation, inhaled nitric oxide (iNO) delivery, and/or therapeutic hypothermia or have policies and procedures in place to facilitate neonatal transfer to a higher level of care2 ;
3. provide care for infants who are back transferred for convalescent care2 ; and
4. have sufficient experience based on patient volume and a systematic process to assess the quality of care provided to each very low birth weight infant, including a method to track specific quality indicators including obstetrical and neonatal transfers, review aggregate data using accepted methodology, and develop action plans as needed to improve patient outcomes.2,14  
Neonatal Medical Director 
(b) The NMD will:
1. be a board eligible or certified neonatologist or equivalent;
i. if the neonatologist is certified by The American Board of Pediatrics, they will meet MOC requirements in neonatal-perinatal medicine;
2. complete annual continuing CME specific to neonatology; and
3. demonstrate a current status of NRP completion. 
Neonatologists 
(c) The NICU neonatologists will:
1. be a board eligible or certified neonatologist or equivalent;
i. if the neonatologist is certified by The American Board of Pediatrics, they will meet MOC requirements in neonatal-perinatal medicine;
2. complete annual CME specific to neonatology;
3. demonstrate a current status of NRP completion;
4. have credentials that are reviewed by the NMD at least every 2 years; and
5. preferably be on-site and immediately available 24/7 or on-call and available to arrive on-site within an appropriate time frame, as defined by the facility’s policies and procedures.
i. If a neonatologist is not on-site 24/7, a written policy will be in place that defines the criteria for notification and time frame for on-site presence, and a tracking mechanism for compliance is required. 
Privileged Care Providers 
(d) Privileged care providers with neonatal-specific training qualified to manage the care of infants with mild to complex critical conditions, including emergencies, will be on-site 24/7 and5 :
1. demonstrate a current status of NRP completion;
2. complete annual continuing education requirements specific to neonatology; and
3. have their credentials reviewed at least every 2 years by the NMD.
(e) At least 1 person with the skills to perform a complete neonatal resuscitation, including endotracheal intubation, establishment of vascular access, and administration of medications must be immediately available on-site 24/77 ; and
1. demonstrate a current status of NRP completion.
(f) The facility will establish a written policy for backup privileged care provider coverage that establishes flexibility for variable census and acuity. This policy will document the criteria for notification and time frame for on-site presence, be based on allocating the appropriate number of competent medical providers to a care situation, attend to a safe and high-quality work environment, and be operationally reviewed annually for adequacy and adherence.9  
Nursing Leadership 
(g) The level III NICU nurse leader will:
1. be an RN with experience and training in neonatal nursing and conditions, with nursing certification preferred5 ;
2. have at least a Bachelor of Science in Nursing, Master’s preferred;
3. demonstrate a current status of NRP completion;
4. have sufficient experience and expertise to create, and/or support, a program that provides care to infants who require level III NICU care;
5. be responsible for inpatient activities in the NICU(s) and, as appropriate, obstetrical, well newborn, and/or pediatric units;
6. coordinate with respective neonatal, pediatric, and obstetric care services, as appropriate;
7. provide oversight of annual neonatal-specific education which includes low-volume, high-risk procedures consistent with the care provided in the level III NICU; and
8. foster collaborative relationships with multidisciplinary team members, facility leadership, and higher-level facilities to create a diverse, equitable, and inclusive environment to improve the quality of care and patient care outcomes.5  
Clinical Nurse Staffing 
(h) A written nurse staffing plan is in place that establishes flexibility for variable census and acuity. This plan and actual staffing will be based on allocating the appropriate number of competent RNs to a care situation, attend to a safe and high-quality work environment, and be operationally reviewed annually for adequacy and adherence.9,10  
Clinical Nurse Staff 
(i) Each clinical nurse will:
1. be an RN, with nursing certification specific to the care environment preferred;
2. demonstrate a current status of NRP completion;
3. participate in annual simulation and skills verification, which includes low-volume, high-risk procedures consistent with the types of care provided in the level III NICU; and
4. promote a family-centered approach to care, including but not limited to skin-to-skin care, appropriate developmental positioning based on gestational age, lactation and breastfeeding support, and engagement of families in their infant’s care.
(j) If the facility utilizes LPNs or nonlicensed direct care providers to support the clinical nursing staff, the facility must:
1. have written criteria that define the LPNs’ or nonlicensed direct care providers’ scope of neonatal care;
2. provide annual education specific to the care of the neonatal population served; and
3. have a written staffing plan that establishes collaborative work assignments in accordance with the facility’s policies and procedures. 
Nursing Orientation and Education 
(k) Level III NICU nursing orientation will incorporate didactic education, simulation, skills verification, and competency and will be tailored to the individual needs of the nurse based on clinical experience.9 
(l) The facility will document an annual educational needs assessment to determine the educational needs of the clinical nursing staff and ancillary team members.
(m) Annual nursing education will address the annual needs assessment and incorporate simulation and skill verification of low-volume, high-risk procedures consistent with the types of care provided in the level III NICU and include education related to serious safety events. 
Clinical Nurse Specialist 
(n) The clinical nurse specialist will:
1. be an RN, with neonatal nursing certification and clinical nurse specialist certification preferred5 ;
2. have at least a Bachelor of Science in Nursing, Master’s or Doctorate preferred5 ;
3. demonstrate a current status of NRP completion5 ;
4. foster continuous quality improvement in nursing care5 ;
5. develop and educate staff to provide evidence-based nursing care5 ;
6. be responsible for mentoring new staff and developing team building skills5 ;
7. provide leadership to multidisciplinary teams5 ;
8. facilitate case management of high-risk neonatal patients5 ; and
9. cultivate collaborative relationships with multidisciplinary team members and facility leadership to improve the quality of care and patient care outcomes.5 
(o) The roles and responsibilities of the NICU clinical nurse specialist can be allocated to multiple individuals to perform this role. 
Clinical Nurse Educator 
(p) The NICU clinical nurse educator will:
1. be an RN, with nursing certification specific to the care environment preferred;
2. have at least a Bachelor of Science in Nursing, Master’s preferred;
3. demonstrate a current status of NRP completion;
4. cultivate collaborative relationships with the neonatal nurse leader and facility leadership to improve the quality of care and patient care outcomes5 ; and
5. have experience and expertise to evaluate the educational needs of the clinical staff, develop didactic and skill-based educational tools, oversee education and skills verification, and evaluate retention of content, critical thinking skills, and competency relevant to level III neonatal care.9 
(q) The facility will have a dedicated individual with sufficient time allocated to perform the roles and responsibilities of the NICU clinical nurse educator. 
Neonatal Transport 
(r) If the facility has a neonatal critical care transport program, it will have an identified director of neonatal transport services.5  The director of neonatal transport services can be the neonatal medical director or another physician who is a pediatrician, board eligible or certified neonatologist, pediatric hospitalist, or pediatric medical subspecialist with expertise and experience in neonatal and infant transport.5 
1. If the facility does not have its own transport program, the facility must have policies and procedures in place to identify a local neonatal transport program to facilitate transport.5 
(s) Responsibilities of the director of neonatal transport services include the following:
1. train and supervise staff5 ;
2. provide appropriate review of all transport records5 ;
3. develop and implement policies and procedures for patient care during transport5 ;
4. develop guidelines for determining transport team composition and medical control and establish a mechanism to track adherence5 ;
5. establish policies and procedures to provide transport updates and outreach education5 ;
6. establish a program for evaluating performance by tracking data, identifying trends, and implementing quality improvement initiatives to address transport performance in a coordinated systematic approach within a culture of safety, equity, and prevention5 ; and
7. report neonatal transport data and neonatal-specific reviews back to the NPSQIP.
8. The director of neonatal transport services may delegate specific requirements to other person(s) or group(s) but retains the responsibility of certifying that these functions are addressed appropriately.5 
(t) The facility will:
1. establish minimum education, experience, and training requirements for all transport team members15 ;
2. select transport team members based on their experience and competence in the care of neonates and the transport team must collectively have the ability to provide a level of care that is similar to that of the admitting unit15 ; and
3. provide annual transport education to all transport team members that incorporates equipment training, didactic education, simulation, and skills verification of low-volume, high-risk procedures consistent with the types of care provided during neonatal transport.15  
Neonatal Outreach 
(u) The level III facility will provide multidisciplinary outreach education to referring facilities by assessing educational needs and evaluating clinical care and outcomes, including transport data, as part of collaboration with lower-level neonatal facilities, if applicable.5  
Pediatric Medical Subspecialists 
(v) The facility must have the ability to obtain pediatric medical subspecialist advice or formal consultation either on-site or by prearranged consultative agreement using telehealth technology and/or telephone consultation from a distant location from a broad range of pediatric medical subspecialists including, but not limited to2 :
1. cardiology, pulmonology, infectious disease, neurology, ophthalmology, endocrinology, hematology, gastroenterology, nephrology, and genetics or metabolism.
(w) If the pediatric medical subspecialist is available for on-site consultation, they will:
1. have credentials to consult at the facility including documented training, certification, competencies, and CME specific to their subspecialty; and
2. document consultations in the medical record within an appropriate time frame and as defined by the facility’s policies and procedures. 
Neonatal Surgical Program – Optional for Level III 
Pediatric Surgeons 
(x) Pediatric surgeons and pediatric surgical specialists will be available on-site or at another closely related NICU facility.5 
1. If pediatric surgery is not offered on-site at the facility, policies and procedures will be in place with a facility that provides surgical care to facilitate transfer of an infant when needed.
i. Infants requiring cardiovascular surgery or extracorporeal membrane oxygenation (ECMO) will be transferred to a facility that provides these services.
2. If pediatric surgery is accessible on-site, the surgeons will:
i. be available at the bedside within 1 hour of request or identified need16 ;
ii. have credentials to provide care at the facility, including documented training, certification, competencies, and continuing education specific to their pediatric surgery specialty16 ;
iii. establish a program for evaluating surgical performance by accurately tracking data, identifying trends, and implementing quality improvement initiatives to address surgical performance in a coordinated systematic approach within a culture of safety, equity, and prevention16 ; and
iv. report neonatal surgical and anesthesia care back to the NPSQIP. 
Anesthesiologists 
(y) If pediatric surgery is performed on-site, anesthesia providers with pediatric expertise must16 :
1. be on the medical staff and promptly available 24/7 to respond to the bedside within 1 hour of request or identified need16 ;
2. serve as the primary responsible anesthesia provider for all infants <24 mo of age and should serve as the primary anesthesiologist for children ≤5 y of age based on the American Society of Anesthesiologists (ASA) physical status classification16 ; and
3. be physically present for all neonatal surgical procedures for which they serve as the primary responsible anesthesia provider.16  
Laboratory Services 
(z) Laboratory services will have:
1. laboratory personnel on-site 24/7;
2. the ability to determine blood type, crossmatch, and perform antibody testing;
3. a blood bank capable of providing blood component therapy and irradiated, leukoreduced or CMV-negative blood;
i. policies and procedures will be in place to facilitate emergent access to blood and blood component therapy so that the NICU can provide hematologic interventions, if applicable;
4. the ability to perform neonatal blood gas monitoring;
5. the ability to perform analysis on small volume samples; and
6. access to perinatal pathology services, if applicable.
(aa) Low-volume specialty laboratory services may be provided by an outside laboratory, but the facility will have policies and procedures in place to maintain timely and direct communication of all critical value results. 
Pharmacy 
(bb) The facility will have at least 1 registered pharmacist with experience in neonatal and/or pediatric pharmacology who will:
1. be available for consultation on-site, or by telehealth or telephone, 24/7;
2. complete continuing education requirements specific to pediatric and neonatal pharmacology; and
3. participate in multidisciplinary care, including participation in patient care rounds.
(cc) The facility will have neonatal appropriate total parenteral nutrition (TPN) available 24/7, and:
1. the facility will have a written policy and procedure for the proper preparation and delivery of TPN.
(dd) The pharmacy will have policies and procedures in place to address drug shortages and to verify medications are appropriately allocated to the level III NICU, and:
1. have policies and procedures in place to verify neonatal competency for pharmacy staff supporting and preparing medications for neonatal patients. 
Diagnostic Imaging 
(ee) Radiology services will have:
1. appropriately trained radiology personnel continuously available on-site to meet routine diagnostic imaging needs and to address emergencies;
2. fluoroscopy available on-call 24/7;
i. if fluoroscopy is not offered on-site at the facility, policies and procedures will be in place to facilitate transfer of an infant to a higher level of care;
3. personnel appropriately trained in the following techniques will be on-call and/or available on-site to perform advanced imaging as requested:
i. ultrasonography, including cranial ultrasonography;
ii. computed tomography (CT); and
iii. magnetic resonance imaging (MRI); and
4. the ability to provide timely imaging interpretation by radiologists with pediatric expertise as requested.
(ff) The facility will provide pediatric echocardiography and have the ability to consult with a pediatric cardiologist for timely echocardiography interpretation as requested. 
Respiratory Therapy 
(gg) The respiratory care leader will:
1. be a full-time respiratory care practitioner, with neonatal and pediatric respiratory care certification preferred;
2. have sufficient time allocated to oversee the RTs who provide care in the level III NICU;
3. provide oversight of annual simulation and skills verification which includes neonatal respiratory care modalities and low-volume, high-risk neonatal respiratory procedures;
4. develop a written RT staffing plan that establishes flexibility for variable census and acuity. This plan and actual staffing will be based on allocating the appropriate number of competent RTs to a care situation, attend to a safe and high-quality work environment, and be operationally reviewed annually for adherence and to verify respiratory therapy staffing is adequate for patient care needs9 ; and
5. maintain appropriate staffing ratios for infants receiving supplemental oxygen and positive pressure ventilation.
(hh) Respiratory care practitioners assigned to the NICU will:
1. be a respiratory care practitioner with documented experience and training in the respiratory support of newborns and infants, with neonatal and pediatric respiratory care certification preferred;
2. be on-site 24/7 and immediately available to supervise assisted ventilation, assist in resuscitation, and attend deliveries;
3. demonstrate a current status of NRP completion;
4. participate in annual simulation and respiratory skills verification, which includes low-volume, high-risk procedures consistent with the types of respiratory care provided in the NICU; and
5. have their credentials reviewed by the respiratory care leader annually for adequacy and adherence. 
Dietitian 
(ii) At least 1 registered dietitian or nutritionist who has specialized training in neonatal nutrition will have dedicated time allotted to serve the NICU and will5 :
1. collaborate with the medical team to establish feeding protocols, develop patient-specific feeding plans, and help determine nutritional needs at discharge;
2. establish policies and procedures to verify proper preparation and storage of human milk and formula;
3. participate in multidisciplinary care, including participation in patient care rounds; and
4. have policies and procedures for dietary consultation for infants in the NICU. 
Neonatal Nutrition 
(jj) The facility will:
1. provide a specialized area or room, with limited access and away from the bedside, to accommodate mixing of formula or additives to human milk5 ;
2. develop standardized feeding protocols for the advancement of feedings based on the availability of, and family preference for human milk, donor human milk, fortification of human milk and formula; and
3. have policies and procedures in place for accurate verification and administration of human milk and formula, and to avoid misappropriation. 
Lactation and Breastfeeding Support 
(kk) The facility will:
1. have personnel with the knowledge and skills to support lactation available at all times;
2. have an IBCLC available for on-site consultation on weekdays and accessible by telehealth or telephone 24/7; and
3. operationally review IBCLC personnel on an annual basis to establish adequately trained lactation coverage based on the specific need and volume of the neonatal population served.11  
Neonatal Therapists 
(ll) The facility will provide on-site consultative services by qualified neonatal therapists to address the 6 core practice domains (environment, family and psychosocial support, sensory system, neurobehavioral system, neuromotor and musculoskeletal systems, and oral feeding and swallowing) and to provide the appropriate care for the neonatal population served.12 
(mm) The facility will have on-site access to the following neonatal therapists who have dedicated time allocated to serve the NICU:
1. an occupational and/or physical therapist with neonatal expertise, and neonatal therapy certification preferred5 ; and
2. a speech language pathologist with neonatal expertise, skilled in the evaluation and management of neonatal feeding and swallowing concerns, and neonatal therapy certification preferred.5 
i. If swallow studies are not offered on-site at the facility, policies and procedures will be in place to facilitate neonatal transfer to a higher level of care.
(nn) The facility will operationally review neonatal therapist personnel on an annual basis to maintain adequate multidisciplinary neonatal therapist coverage based on the specific need and volume of the neonatal population served.12  
Social Worker 
(oo) The NICU social worker will:
1. be a Master’s prepared medical social worker with perinatal and/or pediatric experience.5 
(pp) The facility will:
1. provide 1 social worker for every 30 beds providing level III neonatal care and/or specialty and subspecialty perinatal care5 ;
2. have a written description that clearly identifies the responsibilities and functions of the NICU social worker; and
3. have social services available for each family with an infant in the NICU as needed. 
Pastoral Care 
(qq) Personnel skilled in pastoral care will be available as needed and by family request, and will represent, or have the ability to consult, multiple religious affiliations representative of the population served.5  
Retinopathy of Prematurity 
(rr) The facility must have a process in place to appropriately identify infants at risk for retinopathy of prematurity to guarantee timely examination and treatment by having13 :
1. documented policies and procedures for the monitoring, treatment, and follow-up of retinopathy of prematurity5,13 ; and
2. the ability to perform on-site retinal examinations, or off-site interpretation of digital photographic retinal images, by a pediatric ophthalmologist or retinal specialist with expertise in retinopathy of prematurity.5,13  
Discharge and Follow-up 
(ss) Systems will be in place to establish preparation for NICU discharge, including postdischarge follow-up by general and subspecialty pediatric care providers, home care arrangements and community service resources, and enrollment in a developmental follow-up program as needed.
1. The facility will:
i. have written medical, neurodevelopmental, and psychosocial criteria that automatically warrant high-risk neonatal follow-up with appropriate developmental follow-up services; and
ii. provide developmental follow-up services or have a written referral agreement with a developmental follow-up clinic or practice, when possible, to provide neurodevelopmental services for the neonatal population served. 
Level III NICU Requirements 
(a) The Level III neonatal facility will:
1. provide comprehensive care for infants born at all gestational ages and birth weights, with mild to complex critical conditions or medical problems requiring sustained life support, hemodynamic support, and/or conventional mechanical ventilation2 ;
2. have the ability to provide high-frequency ventilation, inhaled nitric oxide (iNO) delivery, and/or therapeutic hypothermia or have policies and procedures in place to facilitate neonatal transfer to a higher level of care2 ;
3. provide care for infants who are back transferred for convalescent care2 ; and
4. have sufficient experience based on patient volume and a systematic process to assess the quality of care provided to each very low birth weight infant, including a method to track specific quality indicators including obstetrical and neonatal transfers, review aggregate data using accepted methodology, and develop action plans as needed to improve patient outcomes.2,14  
Neonatal Medical Director 
(b) The NMD will:
1. be a board eligible or certified neonatologist or equivalent;
i. if the neonatologist is certified by The American Board of Pediatrics, they will meet MOC requirements in neonatal-perinatal medicine;
2. complete annual continuing CME specific to neonatology; and
3. demonstrate a current status of NRP completion. 
Neonatologists 
(c) The NICU neonatologists will:
1. be a board eligible or certified neonatologist or equivalent;
i. if the neonatologist is certified by The American Board of Pediatrics, they will meet MOC requirements in neonatal-perinatal medicine;
2. complete annual CME specific to neonatology;
3. demonstrate a current status of NRP completion;
4. have credentials that are reviewed by the NMD at least every 2 years; and
5. preferably be on-site and immediately available 24/7 or on-call and available to arrive on-site within an appropriate time frame, as defined by the facility’s policies and procedures.
i. If a neonatologist is not on-site 24/7, a written policy will be in place that defines the criteria for notification and time frame for on-site presence, and a tracking mechanism for compliance is required. 
Privileged Care Providers 
(d) Privileged care providers with neonatal-specific training qualified to manage the care of infants with mild to complex critical conditions, including emergencies, will be on-site 24/7 and5 :
1. demonstrate a current status of NRP completion;
2. complete annual continuing education requirements specific to neonatology; and
3. have their credentials reviewed at least every 2 years by the NMD.
(e) At least 1 person with the skills to perform a complete neonatal resuscitation, including endotracheal intubation, establishment of vascular access, and administration of medications must be immediately available on-site 24/77 ; and
1. demonstrate a current status of NRP completion.
(f) The facility will establish a written policy for backup privileged care provider coverage that establishes flexibility for variable census and acuity. This policy will document the criteria for notification and time frame for on-site presence, be based on allocating the appropriate number of competent medical providers to a care situation, attend to a safe and high-quality work environment, and be operationally reviewed annually for adequacy and adherence.9  
Nursing Leadership 
(g) The level III NICU nurse leader will:
1. be an RN with experience and training in neonatal nursing and conditions, with nursing certification preferred5 ;
2. have at least a Bachelor of Science in Nursing, Master’s preferred;
3. demonstrate a current status of NRP completion;
4. have sufficient experience and expertise to create, and/or support, a program that provides care to infants who require level III NICU care;
5. be responsible for inpatient activities in the NICU(s) and, as appropriate, obstetrical, well newborn, and/or pediatric units;
6. coordinate with respective neonatal, pediatric, and obstetric care services, as appropriate;
7. provide oversight of annual neonatal-specific education which includes low-volume, high-risk procedures consistent with the care provided in the level III NICU; and
8. foster collaborative relationships with multidisciplinary team members, facility leadership, and higher-level facilities to create a diverse, equitable, and inclusive environment to improve the quality of care and patient care outcomes.5  
Clinical Nurse Staffing 
(h) A written nurse staffing plan is in place that establishes flexibility for variable census and acuity. This plan and actual staffing will be based on allocating the appropriate number of competent RNs to a care situation, attend to a safe and high-quality work environment, and be operationally reviewed annually for adequacy and adherence.9,10  
Clinical Nurse Staff 
(i) Each clinical nurse will:
1. be an RN, with nursing certification specific to the care environment preferred;
2. demonstrate a current status of NRP completion;
3. participate in annual simulation and skills verification, which includes low-volume, high-risk procedures consistent with the types of care provided in the level III NICU; and
4. promote a family-centered approach to care, including but not limited to skin-to-skin care, appropriate developmental positioning based on gestational age, lactation and breastfeeding support, and engagement of families in their infant’s care.
(j) If the facility utilizes LPNs or nonlicensed direct care providers to support the clinical nursing staff, the facility must:
1. have written criteria that define the LPNs’ or nonlicensed direct care providers’ scope of neonatal care;
2. provide annual education specific to the care of the neonatal population served; and
3. have a written staffing plan that establishes collaborative work assignments in accordance with the facility’s policies and procedures. 
Nursing Orientation and Education 
(k) Level III NICU nursing orientation will incorporate didactic education, simulation, skills verification, and competency and will be tailored to the individual needs of the nurse based on clinical experience.9 
(l) The facility will document an annual educational needs assessment to determine the educational needs of the clinical nursing staff and ancillary team members.
(m) Annual nursing education will address the annual needs assessment and incorporate simulation and skill verification of low-volume, high-risk procedures consistent with the types of care provided in the level III NICU and include education related to serious safety events. 
Clinical Nurse Specialist 
(n) The clinical nurse specialist will:
1. be an RN, with neonatal nursing certification and clinical nurse specialist certification preferred5 ;
2. have at least a Bachelor of Science in Nursing, Master’s or Doctorate preferred5 ;
3. demonstrate a current status of NRP completion5 ;
4. foster continuous quality improvement in nursing care5 ;
5. develop and educate staff to provide evidence-based nursing care5 ;
6. be responsible for mentoring new staff and developing team building skills5 ;
7. provide leadership to multidisciplinary teams5 ;
8. facilitate case management of high-risk neonatal patients5 ; and
9. cultivate collaborative relationships with multidisciplinary team members and facility leadership to improve the quality of care and patient care outcomes.5 
(o) The roles and responsibilities of the NICU clinical nurse specialist can be allocated to multiple individuals to perform this role. 
Clinical Nurse Educator 
(p) The NICU clinical nurse educator will:
1. be an RN, with nursing certification specific to the care environment preferred;
2. have at least a Bachelor of Science in Nursing, Master’s preferred;
3. demonstrate a current status of NRP completion;
4. cultivate collaborative relationships with the neonatal nurse leader and facility leadership to improve the quality of care and patient care outcomes5 ; and
5. have experience and expertise to evaluate the educational needs of the clinical staff, develop didactic and skill-based educational tools, oversee education and skills verification, and evaluate retention of content, critical thinking skills, and competency relevant to level III neonatal care.9 
(q) The facility will have a dedicated individual with sufficient time allocated to perform the roles and responsibilities of the NICU clinical nurse educator. 
Neonatal Transport 
(r) If the facility has a neonatal critical care transport program, it will have an identified director of neonatal transport services.5  The director of neonatal transport services can be the neonatal medical director or another physician who is a pediatrician, board eligible or certified neonatologist, pediatric hospitalist, or pediatric medical subspecialist with expertise and experience in neonatal and infant transport.5 
1. If the facility does not have its own transport program, the facility must have policies and procedures in place to identify a local neonatal transport program to facilitate transport.5 
(s) Responsibilities of the director of neonatal transport services include the following:
1. train and supervise staff5 ;
2. provide appropriate review of all transport records5 ;
3. develop and implement policies and procedures for patient care during transport5 ;
4. develop guidelines for determining transport team composition and medical control and establish a mechanism to track adherence5 ;
5. establish policies and procedures to provide transport updates and outreach education5 ;
6. establish a program for evaluating performance by tracking data, identifying trends, and implementing quality improvement initiatives to address transport performance in a coordinated systematic approach within a culture of safety, equity, and prevention5 ; and
7. report neonatal transport data and neonatal-specific reviews back to the NPSQIP.
8. The director of neonatal transport services may delegate specific requirements to other person(s) or group(s) but retains the responsibility of certifying that these functions are addressed appropriately.5 
(t) The facility will:
1. establish minimum education, experience, and training requirements for all transport team members15 ;
2. select transport team members based on their experience and competence in the care of neonates and the transport team must collectively have the ability to provide a level of care that is similar to that of the admitting unit15 ; and
3. provide annual transport education to all transport team members that incorporates equipment training, didactic education, simulation, and skills verification of low-volume, high-risk procedures consistent with the types of care provided during neonatal transport.15  
Neonatal Outreach 
(u) The level III facility will provide multidisciplinary outreach education to referring facilities by assessing educational needs and evaluating clinical care and outcomes, including transport data, as part of collaboration with lower-level neonatal facilities, if applicable.5  
Pediatric Medical Subspecialists 
(v) The facility must have the ability to obtain pediatric medical subspecialist advice or formal consultation either on-site or by prearranged consultative agreement using telehealth technology and/or telephone consultation from a distant location from a broad range of pediatric medical subspecialists including, but not limited to2 :
1. cardiology, pulmonology, infectious disease, neurology, ophthalmology, endocrinology, hematology, gastroenterology, nephrology, and genetics or metabolism.
(w) If the pediatric medical subspecialist is available for on-site consultation, they will:
1. have credentials to consult at the facility including documented training, certification, competencies, and CME specific to their subspecialty; and
2. document consultations in the medical record within an appropriate time frame and as defined by the facility’s policies and procedures. 
Neonatal Surgical Program – Optional for Level III 
Pediatric Surgeons 
(x) Pediatric surgeons and pediatric surgical specialists will be available on-site or at another closely related NICU facility.5 
1. If pediatric surgery is not offered on-site at the facility, policies and procedures will be in place with a facility that provides surgical care to facilitate transfer of an infant when needed.
i. Infants requiring cardiovascular surgery or extracorporeal membrane oxygenation (ECMO) will be transferred to a facility that provides these services.
2. If pediatric surgery is accessible on-site, the surgeons will:
i. be available at the bedside within 1 hour of request or identified need16 ;
ii. have credentials to provide care at the facility, including documented training, certification, competencies, and continuing education specific to their pediatric surgery specialty16 ;
iii. establish a program for evaluating surgical performance by accurately tracking data, identifying trends, and implementing quality improvement initiatives to address surgical performance in a coordinated systematic approach within a culture of safety, equity, and prevention16 ; and
iv. report neonatal surgical and anesthesia care back to the NPSQIP. 
Anesthesiologists 
(y) If pediatric surgery is performed on-site, anesthesia providers with pediatric expertise must16 :
1. be on the medical staff and promptly available 24/7 to respond to the bedside within 1 hour of request or identified need16 ;
2. serve as the primary responsible anesthesia provider for all infants <24 mo of age and should serve as the primary anesthesiologist for children ≤5 y of age based on the American Society of Anesthesiologists (ASA) physical status classification16 ; and
3. be physically present for all neonatal surgical procedures for which they serve as the primary responsible anesthesia provider.16  
Laboratory Services 
(z) Laboratory services will have:
1. laboratory personnel on-site 24/7;
2. the ability to determine blood type, crossmatch, and perform antibody testing;
3. a blood bank capable of providing blood component therapy and irradiated, leukoreduced or CMV-negative blood;
i. policies and procedures will be in place to facilitate emergent access to blood and blood component therapy so that the NICU can provide hematologic interventions, if applicable;
4. the ability to perform neonatal blood gas monitoring;
5. the ability to perform analysis on small volume samples; and
6. access to perinatal pathology services, if applicable.
(aa) Low-volume specialty laboratory services may be provided by an outside laboratory, but the facility will have policies and procedures in place to maintain timely and direct communication of all critical value results. 
Pharmacy 
(bb) The facility will have at least 1 registered pharmacist with experience in neonatal and/or pediatric pharmacology who will:
1. be available for consultation on-site, or by telehealth or telephone, 24/7;
2. complete continuing education requirements specific to pediatric and neonatal pharmacology; and
3. participate in multidisciplinary care, including participation in patient care rounds.
(cc) The facility will have neonatal appropriate total parenteral nutrition (TPN) available 24/7, and:
1. the facility will have a written policy and procedure for the proper preparation and delivery of TPN.
(dd) The pharmacy will have policies and procedures in place to address drug shortages and to verify medications are appropriately allocated to the level III NICU, and:
1. have policies and procedures in place to verify neonatal competency for pharmacy staff supporting and preparing medications for neonatal patients. 
Diagnostic Imaging 
(ee) Radiology services will have:
1. appropriately trained radiology personnel continuously available on-site to meet routine diagnostic imaging needs and to address emergencies;
2. fluoroscopy available on-call 24/7;
i. if fluoroscopy is not offered on-site at the facility, policies and procedures will be in place to facilitate transfer of an infant to a higher level of care;
3. personnel appropriately trained in the following techniques will be on-call and/or available on-site to perform advanced imaging as requested:
i. ultrasonography, including cranial ultrasonography;
ii. computed tomography (CT); and
iii. magnetic resonance imaging (MRI); and
4. the ability to provide timely imaging interpretation by radiologists with pediatric expertise as requested.
(ff) The facility will provide pediatric echocardiography and have the ability to consult with a pediatric cardiologist for timely echocardiography interpretation as requested. 
Respiratory Therapy 
(gg) The respiratory care leader will:
1. be a full-time respiratory care practitioner, with neonatal and pediatric respiratory care certification preferred;
2. have sufficient time allocated to oversee the RTs who provide care in the level III NICU;
3. provide oversight of annual simulation and skills verification which includes neonatal respiratory care modalities and low-volume, high-risk neonatal respiratory procedures;
4. develop a written RT staffing plan that establishes flexibility for variable census and acuity. This plan and actual staffing will be based on allocating the appropriate number of competent RTs to a care situation, attend to a safe and high-quality work environment, and be operationally reviewed annually for adherence and to verify respiratory therapy staffing is adequate for patient care needs9 ; and
5. maintain appropriate staffing ratios for infants receiving supplemental oxygen and positive pressure ventilation.
(hh) Respiratory care practitioners assigned to the NICU will:
1. be a respiratory care practitioner with documented experience and training in the respiratory support of newborns and infants, with neonatal and pediatric respiratory care certification preferred;
2. be on-site 24/7 and immediately available to supervise assisted ventilation, assist in resuscitation, and attend deliveries;
3. demonstrate a current status of NRP completion;
4. participate in annual simulation and respiratory skills verification, which includes low-volume, high-risk procedures consistent with the types of respiratory care provided in the NICU; and
5. have their credentials reviewed by the respiratory care leader annually for adequacy and adherence. 
Dietitian 
(ii) At least 1 registered dietitian or nutritionist who has specialized training in neonatal nutrition will have dedicated time allotted to serve the NICU and will5 :
1. collaborate with the medical team to establish feeding protocols, develop patient-specific feeding plans, and help determine nutritional needs at discharge;
2. establish policies and procedures to verify proper preparation and storage of human milk and formula;
3. participate in multidisciplinary care, including participation in patient care rounds; and
4. have policies and procedures for dietary consultation for infants in the NICU. 
Neonatal Nutrition 
(jj) The facility will:
1. provide a specialized area or room, with limited access and away from the bedside, to accommodate mixing of formula or additives to human milk5 ;
2. develop standardized feeding protocols for the advancement of feedings based on the availability of, and family preference for human milk, donor human milk, fortification of human milk and formula; and
3. have policies and procedures in place for accurate verification and administration of human milk and formula, and to avoid misappropriation. 
Lactation and Breastfeeding Support 
(kk) The facility will:
1. have personnel with the knowledge and skills to support lactation available at all times;
2. have an IBCLC available for on-site consultation on weekdays and accessible by telehealth or telephone 24/7; and
3. operationally review IBCLC personnel on an annual basis to establish adequately trained lactation coverage based on the specific need and volume of the neonatal population served.11  
Neonatal Therapists 
(ll) The facility will provide on-site consultative services by qualified neonatal therapists to address the 6 core practice domains (environment, family and psychosocial support, sensory system, neurobehavioral system, neuromotor and musculoskeletal systems, and oral feeding and swallowing) and to provide the appropriate care for the neonatal population served.12 
(mm) The facility will have on-site access to the following neonatal therapists who have dedicated time allocated to serve the NICU:
1. an occupational and/or physical therapist with neonatal expertise, and neonatal therapy certification preferred5 ; and
2. a speech language pathologist with neonatal expertise, skilled in the evaluation and management of neonatal feeding and swallowing concerns, and neonatal therapy certification preferred.5 
i. If swallow studies are not offered on-site at the facility, policies and procedures will be in place to facilitate neonatal transfer to a higher level of care.
(nn) The facility will operationally review neonatal therapist personnel on an annual basis to maintain adequate multidisciplinary neonatal therapist coverage based on the specific need and volume of the neonatal population served.12  
Social Worker 
(oo) The NICU social worker will:
1. be a Master’s prepared medical social worker with perinatal and/or pediatric experience.5 
(pp) The facility will:
1. provide 1 social worker for every 30 beds providing level III neonatal care and/or specialty and subspecialty perinatal care5 ;
2. have a written description that clearly identifies the responsibilities and functions of the NICU social worker; and
3. have social services available for each family with an infant in the NICU as needed. 
Pastoral Care 
(qq) Personnel skilled in pastoral care will be available as needed and by family request, and will represent, or have the ability to consult, multiple religious affiliations representative of the population served.5  
Retinopathy of Prematurity 
(rr) The facility must have a process in place to appropriately identify infants at risk for retinopathy of prematurity to guarantee timely examination and treatment by having13 :
1. documented policies and procedures for the monitoring, treatment, and follow-up of retinopathy of prematurity5,13 ; and
2. the ability to perform on-site retinal examinations, or off-site interpretation of digital photographic retinal images, by a pediatric ophthalmologist or retinal specialist with expertise in retinopathy of prematurity.5,13  
Discharge and Follow-up 
(ss) Systems will be in place to establish preparation for NICU discharge, including postdischarge follow-up by general and subspecialty pediatric care providers, home care arrangements and community service resources, and enrollment in a developmental follow-up program as needed.
1. The facility will:
i. have written medical, neurodevelopmental, and psychosocial criteria that automatically warrant high-risk neonatal follow-up with appropriate developmental follow-up services; and
ii. provide developmental follow-up services or have a written referral agreement with a developmental follow-up clinic or practice, when possible, to provide neurodevelopmental services for the neonatal population served. 
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