The Golden Hour: a quality improvement initiative for extremely premature infants in the neonatal intensive care unit

Abstract

Background: Following delivery, extremely premature infants are vulnerable to rapid development of hypothermia and hypoglycemia. To reduce local rates of these morbidities, a multidisciplinary team developed a protocol standardizing evidence-based care practices during the first hour after birth.

Methods: Using quality improvement methodology, the Golden Hour protocol was implemented for all inborn infants <27 weeks' gestation. Data were collected (2012-2017) over three phases; pre-protocol (n = 80), Phase I (n = 42), and Phase II (n = 92).

Results: There were no significant differences in infant characteristics. Improvements in hypothermia (59% vs 26% vs 38%; p = 0.001), hypoglycemia (18% vs 7% vs 4%; p = 0.012), and minutes to completion of stabilization [median (Q1,Q3) 110 (89,138) vs 111 (94,135) vs 92 (74,129); p = 0.0035] were observed.

Conclusions: Implementation of an evidence-based, Golden Hour protocol is an effective intervention for reducing hypothermia and hypoglycemia in extremely premature infants.

Fig. 1

Golden Hour algorithm initial airway management was based on the infant’s gestational age and assessment of risk factors for respiratory failure. Choices included intubation with surfactant administration (In/In), intubation for surfactant administration with immediate extubation to CPAP (In/Out), or CPAP without surfactant administration. AA amino acid, CBC w/diff complete blood count with differential, CPAP continuous positive airway pressure, CR cardiorespiratory, D10%W dextrose 10% in water; ETT endotracheal tube, FiO₂ fraction of inspired oxygen, HUC hospital unit coordinator; NCCC Newborn Critical Care Center, NNP neonatal nurse practitioner, OB obstetrician, PAL peripheral arterial line, PEEP positive end expiratory pressure, PIP positive inspiratory pressure, PIV peripheral intravenous line, POC point-of-care, RN registered nurse, RT respiratory therapist, STAT immediately, UAC/UVC umbilical arterial and venous catheters

Fig. 2

Golden Hour statistical process control charts a Change in admission temperatures over time b Change in time to completion of admission stabilization over time. LCL lower control limit, UCL upper control limit