Download manuscript - Creighton University

Running head: NEONATAL GOLDEN HOUR PROTOCOL
Assessment of the Need for Standardization of a Neonatal “Golden Hour” Protocol
Katie Eisele, Rebecca Lessard, Nicole Behring
Creighton University
1
2
THE NEONATAL GOLDEN HOUR
Abstract
Problem: The first 60 minutes of life are crucial moments. This time period is when an infant
shifts from intrauterine life, where the mother and the placenta are in control of the infant’s body,
to the outside world where the infant’s body takes over. Evidence based protocols, such as the
“Golden Hour” protocol, may help support the effectiveness and coordination in delivering high
quality of care through effective teamwork at the time of delivery.
The purpose of this scholarly project was to explore and assess the need for implementing a
consistent neonatal “Golden Hour” protocol. Through discovering areas that need greater focus
on admission, we can discover ways to improve and increase the use of a standardized care
protocol within the first 60 minutes of a premature infant’s life.
Methods: A retrospective chart review was conducted at three Midwestern community-based
level IIIA Neonatal Intensive Care Units (NICUs) where high-risk deliveries are attended.
Approximately 100 charts of infants born less than or equal to 30 weeks and/or less than or equal
to 1500 grams from the years 2012-2014 were reviewed. The data gathered assessed the need
for initiating a “Golden Hour” protocol in the delivery room and during admission.
Results: Data were collected on 95 infants from 3 Level III NICUs across the Midwest; 49
female and 46 male. The mean gestational age was 28 0/7 weeks, the minimum gestation 23 and
maximum gestation 33 4/7 weeks. Sixty-one infants (64%) had an initial blood glucose that did
not require a bolus of dextrose 10%. Nearly all infants (91%) had a normal blood pressure
reading within the first 2 hours of life. About half the infants (51%) had an initial temperature
reading between 36.5 – 37.5 degrees Celsius (normothermia); 36 infants had either hyperthermia
or cold stress within the first 2 hours. Seventy infants (74%) received their first dose of
surfactant within 2 hours; 25 infants (26%) received a second dose of surfactant. The average
oxygen days were 45 with a range of 0 to 192 days.
Conclusions: Both hypothermia and hypoglycemia appear to be problems in this population of
infants after delivery. Nearly all infants had IV access and thus received their first dose of
antibiotics, and dextrose as needed, within the first two hours of life. Improvement will need to
be made by providing nurses with education on temperature importance and stabilization in the
NICU. Another quality improvement project with a goal of admission temperature of 36.4-37˚
C. will be re-evaluated each month for improvement.
3
THE NEONATAL GOLDEN HOUR
Assessment of the Need for Standardization of a Neonatal “Golden Hour” Protocol
The neonatal “Golden Hour” focuses on the first 60 minutes after birth of an infant. The
first 60 minutes of life are crucial moments. This time period is when an infant shifts from
intrauterine life, where the mother and the placenta are in control of the infant’s body, to the
outside world where the infant’s body takes over. The transition period of an infant is dependent
upon the environment the infant is presented to and also upon the adaptability of the infant’s
body (Castrodale & Rinehart, 2014). Not all infants go through an effortless transition to
extrauterine life. The premature infant is exceptionally susceptible to adverse events that may
take place during this transitional period. A premature infant’s body system is underdeveloped
compared to a full term infant and may need assistance with the adaptation to extrauterine life.
Premature infants are a vulnerable population and are at a greater risk for morbidity and
mortality (Wyckoff, 2014). These include chronic lung disease (CLD), necrotizing enterocolitis
(NEC), neurodevelopmental impairments, visual disturbances, and increased infant mortality
(Qiu et al, 2012; Wallingford, Rubarth, Abbott, & Miers, 2012). The “Golden Hour”
incorporates multiple evidence-based practices that implement a systematic approach of the
scientific knowledge for each aspect of care for the very low birth weight (VLBW) infants
during resuscitation and stabilization (Bissinger & Annibale, 2010). The evidence-based
practices focus on thermoregulation, intraventricular hemorrhage prevention (IVH), CLD
prevention, and retinopathy of prematurity (ROP) prevention (Reynolds, Pilcher, Ring, Johnson,
& McKinley, 2009). By focusing on interventions within the first 60 minutes of life, survival
may increase and long-term complications may decrease (Reynolds, Pilcher, Ring, Johnson, &
McKinley, 2009). Although universal guidelines regarding best practices of resuscitation and
stabilization in infants are recommended, there is not a clear guideline as to implementing
4
THE NEONATAL GOLDEN HOUR
resuscitation and stabilization among VLBW infants (Soll & Pfister, 2011). There is growing
evidence indicating that certain interventions during the first hour of life can have a significant
impact on morbidity and mortality (Mehler et al, 2012). Many of the evidence-based practices
are being implemented during the resuscitation and stabilization of a VLBW infant in NICUs,
but there may not always be a consistent routine (McGrath, 2012; Roehr et al, 2010). The
purpose of this scholarly project is to explore and determine the need for implementing a
consistent neonatal “Golden Hour” protocol.
Three of the Healthy People 2020 goals are to reduce fetal deaths, infant deaths, and child
deaths. These goals included reducing the rate of fetal and infant deaths during the perinatal
period (28 weeks of gestation to seven days after birth), reducing the rate of all infant deaths
including neonatal deaths and post neonatal deaths (between 28 days and one year of life), and
reducing the rate of death among children aged 1 to 4 years (U.S. Department of Health and
Human Services, 2014). Premature infants, either with or without premature related morbidities,
require increased medical care and costs throughout childhood (Beck et al, 2010). Since
prematurity is the leading cause of infant mortality, the second leading cause of child death, and
accounts for a significant increase in healthcare services and costs, special focus needs to be
placed on this population for the prevention of morbidities and mortalities (Beck et al, 2010;
CDC, n.d.).
According to the World Health Organization (WHO) (2012) there are 1.1 million infants
that die from preterm complications. Not only is prematurity the leading cause of infant
mortality, but it is also the second leading cause for child deaths (under 5 years of age) around
the world. Every year, there are more than 1 in 10 infants around the world that are born
5
THE NEONATAL GOLDEN HOUR
premature. Unfortunately, the U.S. is ranked one of the major contributing factors to the
international ranking of premature births, ranking 130 out of 184 premature births (CDC, n.d.).
The 2013 National Vital Statistics for the U.S. reports that in the year of 2010, 22% of
infants born at a very low birth weight (VLBW), less than 1,500 grams at birth, did not survive
the first year of life (Martin, et al, 2013). According to the CDC, in the year of 2008, disorders
related to prematurity and low birth weight (LBW) were the highest cause of infant mortality.
Infants born less than 32 weeks gestation made up the largest percentage of infant deaths,
accounting for 54% of all infant deaths. Infants born at an extremely low birth weight (ELBW),
less than 1,000 grams, had an average mortality of about 40% and infants born less than 1,500
grams (VLBW) had an average mortality of about 5-10%. The neonatal period (first 30 days
after birth) accounted for the highest range of infant deaths at 67%. The greatest cause within
the neonatal deaths was due to prematurity (CDC, n.d.).
According to the CDC, infants born less than 32 weeks gestation are at the greatest risk
for disability and death (CDC, n.d.) CLD, NEC, neurodevelopmental impairments, and visual
impairments can affect the infant’s whole life. The National Perinatal Information Center
(NPIC) (n.d.) focuses on morbidities related to CLD, sepsis, hypothermia, respiratory distress
syndrome (RDS), and retinopathy of prematurity (ROP).
Infants with CLD approximately double the length of stay (LOS) in a hospital compared
to an infant without CLD. Late onset sepsis (after 48 hours of age) is a major factor of morbidity
and mortality in VLBW infants (NPIC, n.d.). Early onset sepsis is also a major cause in
morbidity and mortality among premature infants (Doyle and Bradshaw, 2012). Early onset
sepsis in VLBW infants is not only associated with a higher mortality, but is also related to the
increased occurrence of RDS and intraventricular hemorrhage (IVH), which is another major
6
THE NEONATAL GOLDEN HOUR
morbidity and mortality among premature infants. The occurrence of moderate hypothermia is
associated with the increased risk of IVH. The incidence of moderate to severe hypothermia is
associated with mortality (NPIC, n.d.).
Premature births and LBW infants also lead to high medical costs. The average cost in
the U.S. related to medical and educational expenditures as well as lost productivity associated
with preterm birth in 2005, was over $26.2 billion (Beck, et al, 2010). The average amount of
medical costs within the first year of life for preterm infants is about 10 times greater than for
term infants (Caughey & Burchfield, 2014). Infants born prematurely continue to need more
healthcare services later in childhood than infants born at term gestation. The lower the
gestational age and/or weight at birth, the higher the medical care costs. Studies have proven
that infants with premature related morbidities use significantly more hospital resources than
premature infants without morbidities, including inpatient and outpatient hospital care, primary
care, social welfare services, and therapies. Greater healthcare costs during the fifth year of life
for children born less than 32 weeks gestation with premature related morbidities had a 4.4 fold
increase of health care costs compared to those born at term. Infants born less than 32 weeks
gestation without premature related morbidities were still at a 1.4 fold increase compared to
those born at term (Korvenranta, et al 2010).
Health insurance providers, healthcare providers, and the government are all concerned
about controlling the rising costs among premature infants (Caughey & Burchfield, 2014). A
large portion of Medicaid pay includes pregnancy and neonatal care, constituting a large volume
of cost towards preterm births. The goal of healthcare should be to increase quality of care,
increase access, and lower healthcare costs (Caughey & Burchfield, 2014). The overall
healthcare costs of premature infants are an obvious struggle. Since long term complications
7
THE NEONATAL GOLDEN HOUR
govern much of the cost of premature infants, a universal protocol that can improve neonatal
morbidities and mortalities may prove to be cost-effective.
Data suggested that standardized care during the first 60 minutes of life can have a
significant impact on the outcomes of LBW and VLBW infants by reducing neonatal
complications such as CLD, hypothermia, and hypoglycemia (Castrodale & Rinehart, 2014;
Reynolds, Pilcher, Ring, Johnson, & McKinley, 2009). Clinical practices have also been proven
to reduce morbidity and mortality related to these complications along with early treatment of
sepsis and parenteral nutrition (Reynolds, Pilcher, Ring, Johnson, & McKinley, 2009).
Recommended guidelines for the resuscitation and the stabilization of infants were
provided by many national organizations. These include the International Liaison Committee on
Resuscitation (ILCOR), American Academy of Pediatrics (AAP)/American Heart Association
(AHA) guidelines for the Neonatal Resuscitation Program (NRP), and the Vermont Network
(Bissinger & Annibale, 2010; McCarthy, Morley, Davis, Kanlin, & O’Donnell, 2013; Reynolds,
Pilcher, Ring, Johnson, & McKinley, 2009). ILCOR provides recommendations on the care of
the newborn in the delivery room, providing a stepwise approach (McCarthy, Morley, Davis,
Kamlin, & Colm, 2013). The NRP guidelines are based upon the latest evidence in neonatal
resuscitation. NRP guideline goals are to prevent the morbidity and mortality associated with
hypoxic-ischemic tissue injury, such as the brain, heart, and kidneys, and also to re-establish
adequate respirations and cardiac output (Chadha, 2010). The Vermont Network’s goal is to
improve patient outcomes by focusing on interventions in the first hour of life, termed as the
“Golden Hour” (Reynolds, Pilcher, Ring, Johnson, & McKinley, 2009). These national
guidelines combined with the provided research on evidence-based practices support the
8
THE NEONATAL GOLDEN HOUR
improvement of infant morbidity and mortality, but are not currently being placed into protocol
universally (McGrath, 2012).
Protocols, practice guidelines, and evidence-based practices used to increase quality of
care are respectable reasons for adopting a protocol. The importance of implementing the
“Golden Hour” protocol also includes teamwork, which should be done in collaboration and with
consistent care to help minimize long-term complications (Reynolds, Pilcher, Ring, Johnson, &
McKinley, 2009). The initial steps of stabilizing an infant can be very stressful. The
improvement of high-quality care has been accomplished through adherence to standardized
protocols (Roehr et al, 2010). Evidence-based protocols, such as the “Golden Hour” protocol,
may help support the effectiveness and coordination in delivering high quality of care through
effective teamwork (Roehr et al, 2010). The role of the provider is to act as a leader in initiating
these guidelines and evidence based practices. Providers are set in a leadership position, which
allows them to govern what protocols should or should not be put into place. Since the “Golden
Hour” protocol includes all aspects of care, including nursing, the neonatal nurse practitioner
(NNP) is in a perfect position to influence the use of the “Golden Hour” protocol. Part of an
NNP’s role is to focus on clinical care and outcomes and how they are governed. Increased
knowledge and skill allows the NNP to promote health, have a greater influence on the
improvement of the quality of healthcare delivered, and improve clinical outcomes through
policy processes and advocacy (AACN, 2011).
Although the “Golden Hour” has been shown to decrease infant morbidity and mortality
among VLBW infants, the utilization of a “Golden Hour” protocol has not been implemented
consistently in every NICU. The inconsistent care of premature infants within the first 60
minutes of life may increase the chances of neonatal morbidity and mortality.
9
THE NEONATAL GOLDEN HOUR
The purpose of this scholarly project was to explore and determine the need for
implementing a consistent neonatal “Golden Hour” protocol. Through discovering areas that
need greater focus on admission, we can discover ways to improve and increase the use of
standardized care within the first 60 minutes of a premature infant’s life.
Review of Literature
This review of literature discusses the specific reasons for standardized care within the
first 60 minutes of a premature infant’s life. Respiratory support, thermoregulation, sepsis, and
early nutrition all include evidence-based research that should be universally practiced.
Evidence Based Practice
The “Golden Hour” protocol incorporated multiple evidence-based practices that
implement a systematic approach of scientific knowledge for each aspect of care for VLBW
infants during resuscitation and stabilization (Bissinger & Annibale, 2010). The “Golden Hour”
protocol focused on a standardization of care including resuscitation and respiratory support,
thermoregulation, sepsis, and nutrition as well as preventing short and long term complications
in VLBW infants. VLBW infants are very vulnerable and have an increased possibility of
experiencing difficulty during stabilization directly after birth (Wyckoff, 2014). With the
increased number of premature infants born, and the younger the gestation, a greater emphasis
should be focused on providing efficient and coordinated care for VLBW infants. Castrodale
and Rinehart (2014) concluded that data suggests a positive impact on clinical measures of
temperature, glucose, and IV administration with the implementation of the “Golden Hour”
protocol. “Golden Hour” practices, including respiratory support, oxygen targeting, thermal
regulation, and teamwork discussed by Wallingford, Rubarth, Abbot, and Miers (2012) reported
a decrease in the incidence of CLD. Another study revealed a decrease in the incidence of ROP
10
THE NEONATAL GOLDEN HOUR
and CLD after the implementation of a “Golden Hour” protocol. The evidence based practices
implemented in the “Golden Hour” protocol included practices based on complications of
hypothermia, IVH, CLD, and ROP (Reynolds, Pilcher, Ring, Johnson, & McKinley, 2009).
Lack of Standardization
Although the “Golden Hour” has been shown to improve short and long term
complications in the VLBW infants, there is still a lack of standardization as to what the “Golden
Hour” protocol should entail. A study by El-Naggar and McNamara (2012) discovered that there
were high variations in the delivery room resuscitation practices and inconsistencies in the
current NRP guidelines. Evidence suggests an increase in neonatal morbidity and mortality
related to hypothermia, but the approach to temperature control in the delivery room remains a
significant concern (El-Naggar & McNamara, 2012). Also, there is lack of uniformity on the
delivery of respiratory support and the measurement of effectiveness of the respiratory support
(El-Naggar & McNamara, 2012). Two studies done by Roehr et al (2010) and Dani et al (2013)
discovered that in certain areas in the nation, NICUs frequently reflect evidence based practices
and written protocols in accordance with national guidelines, but with variation. Although the
guidelines and evidence based practices are recommended for all and utilized by most, many of
the practices are being performed individually. By combining these evidence based practices
into one systematic approach, all aspects of the infant can be treated within a timely manner and
may have a positive impact on the short and long term outcomes of VLBW infants.
Respiratory Support
The majority of VLBW infants require gentle assistance to allow transition and
adaptation from intrauterine to extrauterine life, while only a few VLBW infants require full
resuscitation (Mehler et al, 2012). Improved rates of survival and morbidity can be achieved
11
THE NEONATAL GOLDEN HOUR
through efficient delivery room management with the gentle support in a premature infant’s
transition and adaptation to extrauterine life (Mehler et al, 2012). Data was collected on infants
born before 28 weeks gestation in 2002-2004 that were assessed at 24 months of age using the
Bayley Scales of Infant Development second edition or the Vineland Adaptive Behavior Scales.
The study revealed that 49% of VLBW infants had CLD, and that CLD accounts for an
association between CLD and developmental delay (Laughon et al., 2009). The smallest
exposure to oxygen and mechanical ventilation has been associated with a contribution to CLD
in a premature infant (Reynolds, Pilcher, Ring, Johnson, and McKinley, 2009). A randomized
study was conducted with the goal to reduce adverse pulmonary outcomes, oxidative stress, and
inflammation of infants born between 24 to 28 weeks gestation. These infants were resuscitated
with fraction of inspired oxygen (Fi02) of 30% to 90% (Vento et al., 2009). Results revealed
that infants who received low-oxygen needed fewer days of supplemental oxygen, fewer days of
mechanical ventilation, and showed a decrease in bronchopulmonary dysplasia (BPD) at
discharge (Vento et al., 2009). Thus, resuscitation of VLBW infants with lower oxygen showed
to cause less oxidative stress, inflammation, the need for oxygen, and decreased risk of BPD
(Vento et al., 2009). Depending on the severity of respiratory distress the premature infant is
experiencing, surfactant administration should be decided. The prophylactic administration of
surfactant given to a premature infant has been shown to improve the survival of premature
infants by reducing respiratory distress and the severity of CLD. Rojas et al. (2007), looked at
providing early surfactant therapy without mandatory ventilation by using CPAP, and its overall
improvement in decreasing the need for mechanical ventilation in preterm infants (Rojas et al.,
2007). Results of 279 infants showed a lower need for mechanical ventilation in the treatment
group, and a 49% incidence rate of CLD in the treatment group compared to 59% in the control
12
THE NEONATAL GOLDEN HOUR
group (Rojas et al., 2007). Dunn, et al, (2014) reports that both prophylactic treatment of
surfactant and selective treatment of surfactant after evidence of significant RDS have reduced
the number of pneumothoraces , neonatal mortality, and the combination of death or CLD. Dunn
et al (2014) concluded that the approach of using nCPAP leads to a reduction in the number of
infants who are intubated, and may be recommended as a less invasive and possibly more costeffective method of delivering respiratory support. The consideration of early CPAP as an
alternative to intubation and surfactant in premature infants is also supported by the NICHD
Neonatal Research Network SUPPORT study group of the Eunice Kennedy Schriver NICHD
(2010), which compared the treatment method of early CPAP versus intubation and surfactant
administration in extremely low birth weight infants (ELBW).
Thermoregulation
Thermoregulation was another important aspect of decreasing morbidity and mortality
among VLBW infants (Billimoria, Chawla, Bajaj, & Natarajan, 2013; El-Naggar & McNamara,
2012). Neonatal resuscitation guidelines recommended practice to minimize heat loss in the
delivery room (Te Pas, Lopriore, Dito, Morley, and Walther, 2010). The standard of care was to
use humidified and heated gas in the NICU, but resuscitation guidelines did not require this type
of therapy use during stabilization at birth (Te Pas et al., 2010). This study looked at “cold”
versus “heated” oxygen during stabilization and found that there was a difference in the mean
rectal temperature of infants that had “heated” versus “cold” oxygen (Te Pas et al., 2010). Also,
the infants that received heat oxygen achieved normothermia, whereas those that received cold
oxygen did not (Te Pas et al., 2010). Special attention to thermoregulation can save an infant
from lifetime effects. Hypothermia in a premature infant can lead to morbidity and mortality by
causing altered pulmonary vasomotor tone, acid-base imbalances, hypotension, and hypovolemia
13
THE NEONATAL GOLDEN HOUR
(Reynolds, Pilcher, Ring, Johnson, and McKinley, 2009). Hypothermia has also been related to
an increased risk of IVH, late onset sepsis, and RDS (Billimoria, Chawla, Bajaj, & Natarajan,
2013). Hypothermia can be reduced within the first 60 minutes of life by increasing the
temperature in the delivery room, pre-warming the bed and linens, using a chemical mattress for
additional heat, immediately drying the infant and removing wet linens or immediately placing
the infant in a plastic bag without drying to reduce evaporative cooling, applying two caps to the
head, and promoting a tucked position (Reynolds, Pilcher, Ring, Johnson, and McKinley, 2009).
Maintaining a stable temperature has been shown to reduce the need for surfactant, reduce the
incidence of severe IVH and decrease the incidence of culture-proven sepsis and symptomatic
PDA (patent ductus arteriosus) (Billimoria, Chawla, Bajaj, and Natarajan, 2013). De Carolis et
al. (2013) completed a study in two periods. The first period, preterm infants were provided
routine thermal care like being placed on a radiant warmer, drying and transport to NICU (De
Carolis et al., 2013). In the second period, additional interventions were provided like
transwarmer mattresses, hats, and infants born less than 28 weeks were placed in polyethylene
wraps, heated and humidified oxygen was used if ventilation was required, and prewarmed fluids
if volume expanders were administered (De Corlis et al., 2013). The study found that the first
period had more hypothermic infants compared to the second period, and that temperatures were
more stable between 7:00 am to 1:00 pm when a dedicated team attended deliveries (De Corlis et
al., 2013).
Sepsis
Sepsis among premature infants has been known to be a major cause for infant morbidity
and mortality. Early administration of antimicrobial therapy has demonstrated reduced mortality
related to early-onset sepsis (EOS). Doyle and Bradshaw (2012) reported a study demonstrating
14
THE NEONATAL GOLDEN HOUR
that on adult patients with EOS, every hour an antibiotic administration was delayed, there was a
decrease in survival of almost 8%. The 2008 guidelines recommend that broad-spectrum
antimicrobial therapy should be administered within the first hour sepsis is suspected (Doyle and
Bradshaw, 2012). Clinical practices have also been proven to reduce morbidity and mortality
related to these complications along with early treatment of sepsis and parenteral nutrition
(Reynolds, Pilcher, Ring, Johnson, & McKinley, 2009).
Early Nutrition
Early nutrition with amino acid supplementation was used to help promote protein
deposition and increased lean body mass that more closely resembles fetal energy production and
growth (Valentine et al, 2009). The early administration of amino acids and parenteral nutrition
in premature infants has not only been proven safe, but has also been proven to decrease the
incidence of hypernatremia, hypokalemia, hyperglycemia, osteopenia of prematurity (OOP), and
a decreased need for phosphate supplementation (Aroor et al, 2012). Also, data suggested that
long-term developmental outcomes of premature infants may be correlated with early protein
intake (Aroor et al, 2012). A study by Ehrenkranz, et al (2011), also concluded that aggressive
parenteral and enteral nutrition was associated with decreased rates of mortality and short term
morbidities, and was related to improved growth and neurodevelopmental outcomes.
Summary
The improvement of short and long term complications may take place through the use of
a standardized protocol, such as the neonatal “Golden Hour”. The standardization of a protocol
for the neonatal “Golden Hour” may help with timely support and management of an infant
throughout transition to extrauterine life. Gentle respiratory support that is given based on the
needs of the infant can help decrease the incidence of CLD (Reynolds, Pilcher, Ring, Johnson, &
15
THE NEONATAL GOLDEN HOUR
McKinley, 2009). Special attention to thermoregulation can help improve an infant’s stability
and decrease lifetime effects (Billimoria, Chawla, Bajaj, & Natarajan, 2013; Reynolds, Pilcher,
Ring, Johnson, and McKinley, 2009). Early prophylactic treatment for sepsis can reduce
mortality (Doyle & Bradshaw, 2012). Even early nutrition administration with amino acids can
improve stability, growth, and neurodevelopmental outcomes (Ehrenkranz, et al, 2011). All
these aspects play a significant role in the infant’s risks of morbidity and mortality. Although
decreasing morbidity and mortality is a goal for many neonatal providers, a protocol based on
these aspects is not universally implemented. Discovering barriers to these practices as a
protocol may help develop a consistent practice with a positive outcome for the infant.
Theoretical Framework
Synactive formulation of development is the conceptualization of how an individual
infant developmentally appears to handle the experience of the world around them (Als, 1982).
Each stage in development and each moment of functioning, along with several subsystems of
functioning, are present side by side in development (Als, 1982). These systems include the
autonomic system, motor system, state-organizational system, attention and interaction system,
and self-regulatory and balancing system. The autonomic system can be observed in patterns of
respiration, color changes, and hiccups. The motor system can be observed in the infant’s
posture, tone and movements. The organizational state can be observed in how the infant has the
ability to become alert, attentive, and then how the infant processes this information to take in
the cognitive and social-emotional aspects. The regulatory system is represented by how the
infant maintains a balanced, stable and relaxed state and/or how the infant can return to this state
(Als, 1982).
16
THE NEONATAL GOLDEN HOUR
This quality improvement project was focused on the VLBW infant and how important
that first hour can be. This critical time period sets the infant up for the capability to be able to
develop and handle the world around them. These subsystem states of development may be
greatly impacted by unsatisfactory management and set the infant up for their short and longterm morbidities and/or mortality. Thus, the overall goal was to use evidence-based practice in
the development of a standardized protocol of care which will aid with the future development of
these infants.
Methods
A retrospective chart review was conducted at a three Midwestern community-based
level IIIA NICUs where the nurses attend high risk deliveries. Approximately 100 charts of
infants born less than or equal to 30 weeks and/or less than or equal to 1500 grams from the
years 2012-2014 were reviewed. The information was collected on an Excel spreadsheet (See
Appendix A & B) and consisted of information gathered on gestational age at birth, birth weight,
discharge weight, length of stay, delivery room resuscitation, Apgar scores, personnel present at
the delivery, and any respiratory management, blood sugar management, blood pressure
management, and thermal regulation management up to two hours after birth. The data gathered
assessed the need for initiating a “Golden Hour” protocol in the delivery room and during
admission. Each situation was assigned an ID number. Once the information was collected the
infant data were de-identified. Institutional Review Board approval was obtained prior to
collection of any information. The information was stored in a locked cabinet and on a password
protected computer in the researcher’s office. Limitations of this study included the accessibility
of chart information from each institution and the data collected was dependent on the
consistency of charting at each institution.
17
THE NEONATAL GOLDEN HOUR
Data Analysis
Data from this quality improvement project were used to describe the sample and
frequency of interventions. The data were evaluated for any needed improvement in care.
The data from each individual unit were evaluated as to whether the personnel in these
units had the ability to adequately maintain temperature, provide rapid respiratory support,
maintain blood sugar, and maintain blood pressure after birth. This quality improvement
assessment plan was aimed at assessing current practice in the units. Following the
assessment, the management of each facility will decide if there is a need to implement a
standardized “Golden Hour” Protocol at the individual units.
Results
Data were collected on 95 infants from three different Level III NICUs across the
Midwest; sample included 49 female and 46 male infants. The mean gestational age was 28 0/7
weeks, the minimum gestational age was 23 weeks, and maximum gestation age was 33 4/7
weeks. The average birth weight was 1097 grams with a range of 400 to 1490 grams. The
discharge weight ranged from 670 grams to 6685 grams. The average days of service were 68 to
192 days. Most infants (88) received PPV/CPAP or intubation in the delivery room. The most
common one minute APGAR was 6 and 7. The most common five minute APGAR was 7 and 8.
The range for 10 minute APGARS was 2 to 9 with 8 being the most common number recorded.
Delivery room attendance most often involved an NNP or NNP/MD. There were 54 infants that
required intubation on admission or were already intubated. Sixty-one infants had an initial
blood glucose that did not require a bolus of dextrose 10%. Nearly all infants (86) had a normal
blood pressure reading within the first 2 hours of life. Over half the infants (48) had an initial
temperature reading between 36.5 – 37.5 degrees Celsius (normothermia); 36 infants had either
18
THE NEONATAL GOLDEN HOUR
hyperthermia or cold stress within the first 2 hours. Seventy infants received their first dose of
surfactant within 2 hours; 25 infants received a second dose of surfactant. The average oxygen
days were 45 with a minimum of zero and a maximum of 192. Nearly all infants had IV access
and thus received their first dose of antibiotics within the first two hours of life.
Discussion
The “Golden Hour” or first two hours of life is the most vulnerable for the VLBW infant.
It requires an entire team of well-trained personnel. Decisions made in this vulnerable time
period can result in a smooth transition to extrauterine life or can hasten the infant’s demise. The
main outcome requiring intervention in most infants was temperature control. This area will
require additional training at all facilities to improve the outcomes of their “Golden Hour”
procedures. Improvement can be done through providing NICU staff with education on
temperature control and stabilization of an infant in the delivery room and upon admission to the
NICU. This can be provided through S.T.A.B.L.E. training. Once all staff are trained, a second
quality improvement project can be done with a goal that 100% of infants will have a
temperature between 36.4 and 37 degrees Celsius upon admission. All infants less than 1500
grams at birth or less than or equal to 30 weeks gestation at birth will have all admission
temperatures recorded. Each month, the quality improvement project can be re-evaluated for
improvement and the need for further improvement or education. Follow-up can be done with
quarterly education.
Improvement in temperature control can start in the delivery room by increasing the
temperature in the delivery room, pre-warming the bed and linens, using a chemical mattress for
additional heat, immediately drying the infant and removing wet linens or immediately placing
19
THE NEONATAL GOLDEN HOUR
the infant in a plastic bag without drying to reduce evaporative cooling, applying two caps to the
head, and promoting a tucked position (Reynolds, Pilcher, Ring, Johnson, and McKinley, 2009).
Conclusion
Both hypothermia and hypoglycemia appear to be problems in this population of infants
after delivery. Nearly all infants had IV access and thus received their first dose of antibiotics,
and dextrose as needed, within the first two hours of life. Improvement will need to be made by
providing nurses with education on temperature importance and stabilization in the NICU.
Another quality improvement project with a goal of admission temperature of 36.4-37˚ C. will be
re-evaluated each month for improvement.
20
THE NEONATAL GOLDEN HOUR
References
Als, H. (1982). Toward a Synactive Theory of Development: Promise for the Assessment and
Support of the Infant Individuality. Infant Mental Health Journal, 3, 229-243.
American Association of Colleges of Nursing (AACN). (2011). The essentials of master’s
education in nursing. Retrieved from http://www.aacn.nche.edu/educationresources/MastersEssentials11.pdf
Aroor, A.R., Krishnan, L., Reyes, Z., Fazallulah, M., Ahmed, M., Khan, A.A., Al-Farsi, Y.
(2012). Early versus late parenteral nutrition in very low birth weight neonates. SQU
Medical Journal, 12(1) 33-40.
Beck, S., Wojdyla, D., Say, L., Pilar Betran, A., Merialdi, M., Harris Requejo, J., Rubens, C.,
Menon, R., Van Look, P.F.A. (2010). The worldwide incidence of preterm birth: a
systematic review of maternal mortality and morbidity. World Health Organization.
Retrieved from http://www.who.int/bulletin/volumes/88/1/08-062554/en/
Billimoria, Z., Chawla, S., Bajaj, M., Natarajan, G. (2013). Improving admission temperature in
extremely low birth weight infants: a hospital-based multi-intervention quality
improvement project. Journal of Perinatal Medicine, 41(4) 455-460. DOI: 10.1515/jpm2012-0259
Bissinger, R.L., Annibale, D.J. (2010). Thermoregulation in very low-birth-weight infants during
the golden hour: Results and implications. Advances in Neonatal Care, 10(5) 230-238.
Castrodale, V., Rinehart, S. (2014). The golden hour: Improving the stabilization of the very low
birth-weight infant. Advances in Neonatal Care, 14(1) 9-14.
21
THE NEONATAL GOLDEN HOUR
Caughey, A.B., Burchfield, D.J. (2014). Costs and cost-effectiveness of periviable care.
Seminars in Perinatology, 38(1) 56-62. DOI:
http://dx.doi.org/10.1053/j.semperi.2013.07.010
Centers for Disease Control and Prevention (CDC) (n.d.). Infant mortality in the US: Where we
stand. U.S. Department of Health and Human Services. Retrieved from
www.cdc.gov/cdcgrandrounds/pdf/gr_infant_mortality_final_oct16.pdf
Chadha, I.A. (2010). Neonatal resuscitation: Current issues. Indian Journal of Anesthesia, 54(5)
428-438. DOI: 10.4103/0019-5049.71042
Dani, C., Bresci, C., Lista, G., Martano, C., Messina, F., Migliori, C., Vento, G. (2013). Neonatal
respiratory support strategies in the intensive care unit: an Italian survey. Eur J Pediatr,
172, 331-336. DOI: 10.1007/s00431-012-1885-3
De Carolis, M., Rubortone, S., Bersani, I., Lacerenza, S., Costa, F., Garufi, C., & Romagnoli, C.
(2013). Heat loss prevention in the delivery room in term and preterm infants. The
Turkish Journal of Pediatrics, 55, 63-68.
Doyle, K.J., Bradshaw, W.T. (2012). Sixty golden minutes. Neonatal Network, 31(5) 289-294.
DOI: 10.1891/0730-0832.31.5.289
Dunn, M.S., Kaempf, J., Klerk, A., Klerk, Rose, Reilly, M., Howard, D., Ferrelli, K., O’Conor,
J., Soll, R.F. Randomized trial comparing 3 approaches to the initial respiratory
management of preterm neonates. Pediatrics, 128(5) e1069-e1076. DOI:
10.1542/peds.2010-3848
Ehrenkranz, R.A., Das, A., Wrage, L.A., Poindexter, B.B., Higgines, R.D., Stoll, B.J., Oh, W.
(2011). Early nutrition mediates the influence of severity of illness on extremely LBW
infants. Pediatric Research, 69, 522-529. DOI: 10.1203/PDR.0b013e318217f4f1
22
THE NEONATAL GOLDEN HOUR
El-Naggar, W., McNamra, P.J. (2012). Delivery room resuscitation of preterm infants in Canada:
Current practice and views of neonatologist at level III centers. Journal of Perinatology,
32, 491-497.
Korvenranta, E., Lehtonen, L., Rautava, L., Hakkinen, U., Andersson, S., Gissler, M., Hallman,
M., Leipala, J., Peltola, M., Tammela, O., Linna, M. (2012). Impact of very preterm birth
on health care costs at five years of age. American Academy of Pediatrics, 125(5) e1109e1114 DOI: 10.1542/peds.2009-2882
Laughon, M., O’Shea, M., Allred, E., Bose, C., Kuban, K., Van Marter, L., Ehrenkranz, R., &
Leviton, A. (2009). Chronic lung disease and development delay at 2 years of age in
children born before 28 weeks gestation. Pediatrics, 124, 637-648.
doi:10.1542/peds.2008.2874.
Martin, J.A., Hamilton, B.E., Osterman, M.J.K., Curtin, S.C., Mathews, M.A., Mathews, T.J.
(2013). Births: Final data for 2012. U.S. Department of Health and Human Services:
National Vital Statistics Reports, 62(9). Retrieved from
http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_09.pdf
McCarthy, L.K., Morley, C.J., Davis, P.G., Kamlin, C.O.F., O’Donnell, C.P.F. (2013). Timing of
interventions in the delivery room: Does reality compare with neonatal resuscitation
guidelines? The Journal of Pediatrics, 163(6) 1553-1557. Retrieved from
http://dx.doi.org/10.1016/j.jpeds.2013.06.007
McGrath, J.M. (2012). Is evidence-based practice routine in the golden hour? The Journal of
Perinatal & Neonatal Nursing, 26(1) 57-68. DOI: 10.1097/JPN.0b013e318259ffec
Mehler, K., Grimme, J., Abel, J., Huensler, C., Roth, B., Kribs, A. (2012). Outcome of extremely
low gestational age newborns after introduction of a revised protocol to assist preterm
23
THE NEONATAL GOLDEN HOUR
infants in their transition to extrauterine life. Acta Paediatrica, 101, 1232-1239. DOI:
10.1111/apa.12015
National Perinatal Information Center (NPIC). (n.d.) V.12.1 Special Report: very low birth
weight neonates. Retrieved from
http://www.npic.org/Services/V121_Special_Report_SAMPLE.pdf
NICHD Neonatal Research Network and the SUPPORT Study Group (2010). Early CPAP
versus surfactant in extremely preterm infants. The New England Journal of Medicine,
362, 1970-1979.
Qiu, X., Lodha, A., Shah, P.S., Sankaran, K., Seshia, M.K.M., Yee, W., Jefferies, A., Lee, S.K.
(2012). Neonatal outcomes of small for gestational age preterm infants in Canada.
American Journal of Perinatology, 29(2) 87-94. DOI: 10.1055/s-0031-1295647
Reynolds, R.D., Pilcher, J., Ring, A., Johnson, R., McKinley, P. (2009). The neonatal golden
hour: Standardized evidence-based process and multidisciplinary teamwork improve
outcomes and decrease mortality. Advance Healthcare Network, 28(4) 211-219.
Retrieved form http://nursing.advanceweb.com/Continuing-Education/CE-Articles/TheNeonatal-Golden-Hour.aspx
Roehr, C.C., Grobe, S., Rudiger, M., Hummler, H., Nelle, M., Proquitte, H., Hammer, H.,
Schmalisch, G. (2010). Delivery room management of very low birth weight infants in
Germany, Austria and Switzerland: A comparison of protocols. European Journal of
Medical Research, 15, 493-503.
Rojas, M., Lozano, J., Rojas, M., Laughon, M., Bose, C., Rondon, M., Charry., L., Bastidas, J.,
Perez, L., Rojas, C., Ovalle, O., Celis, L., Garcia-Harker, J., & Jaramillo, M. (2009).
24
THE NEONATAL GOLDEN HOUR
Very early surfactant without mandatory ventilation in premature infants treated with
early continuous positive airway pressure: A randomized, controlled trial. Pediatrics,
123, 137-144. doi:10.1542/peds.2007-3501.
Soll, R.F., Pfister, R.H. (2011). Evidence-based delivery room care of the very low birth weight
infant. Neonatology, 99, 349-354. DOI: 10.1159/000326844
Te Pas, A., Lopriore, E., Dito, I., Morley, C., & Walther, F. (2010). Humidified and heated
air during stabilization at birth improves temperature in preterm infants. Pediatrics,
125, e1427-e1433. doi:10.1542/peds.2009-2656.
U.S. Department of Health and Human Services (2014). Maternal, infant, and child health:
Morbidity and mortality. Healthy People 2020. Retrieved from
http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=2
Valentine, C.J., Fernandez, S., Rogers, L.K., Gulati, P., Hayes, J., Lore, P., Puthoff, T., Jones,
A., Collins, K., Curtiss, J., Hutson, K., Welty, S.E. (2009). Early amino-acid
administration improves preterm infant weight. Journal of Perinatology, 29, 428-432.
DOI: 10.1038/jk.2009.51
Vento, M., Cheung, P-Y., Aguar, M. (2009). The first golden minutes of the extremely-lowgestational-age neonate: A gentle approach. Neonatology, 95, 286-298. DOI:
10.1159/000178770
Vento, M., Moro, M., Escrig, R., Arruza, L., Villar, G., Izquierdo, I., Roberts, L., Arduini, A.,
Escobar, J., Sastre, J., & Asensi. (2009). Preterm resuscitation with low oxygen causes
less oxidative stress, inflammation, and chronic lung disease. Pediatrics, 124,
E439-e450. doi:10.1542/peds.2009-0434
25
THE NEONATAL GOLDEN HOUR
Wallingford, B., Rubarth, L., Abbott, A., Miers, L.J. (2012). Implementation and evaluation of
“golden hour” practices in infants younger than 33 weeks’ gestation. Retrieved from
http://www.medscape.com/viewarticle/765544
World Health Organization (WHO). (2012). Born too soon: The global action report on preterm
births. Retrieved from
http://www.who.int/pmnch/media/news/2012/201204_borntoosoon-report.pdf
Wyckoff, M.H. (2014). Initial resuscitation and stabilization of the periviable neonate: The
golden-hour approach. Seminars in Perinatology, 38, 12-16. Retrieved from
http://dx/doi.org/10.1053/j.semiperi.2013.07.003
26
THE NEONATAL GOLDEN HOUR
Appendix A.
Demographics
Appendix B.
Results