P3D265: Implementation of the NICU “golden Hour” – a Quality Improvement Project for Preterm Infants

Purpose/Objectives: Prematurity remains the leading cause of neonatal and childhood morbidity and mortality in the United States and developed world with increasing rates of death or health complications directly correlating to degree of prematurity and lower birth weights. These infants are at increased risk of complications such as hypothermia, hypoglycemia, and infection that directly impact health outcomes. The NICU “Golden Hour” refers to a series of team-oriented, task-driven evidence-based interventions applied during the initial hours of life with the goal of improving both short term and long-term outcomes. Utilizing these principals, our team aims to improve efficacy and standardization of the NICU admissions process at our medical center.

Our primary objective was to standardize interventions and initial care of very preterm and very low birthweight newborns. Secondary objectives were to decrease time to interventions such as time to IV fluid administration and time to first dose of antibiotics. We also aimed to improve time from delivery room to NICU, and reduced hypothermia rates at both admission and one hour.

Design/Methods: Using quality improvement methodology, the Golden Hour protocol was implemented at Tripler Army Medical Center in February of 2021. All infants with an estimated gestational age less than 32 weeks and/or a birthweight of less than 1500 grams met inclusion criteria for the Golden Hour Protocol. With the implementation of golden hour, a standardized order set was created for all infants meeting criteria on admission. Frequent in-service meetings and education was provided to all levels of the care team in the NICU. Times to interventions were tracked on a flow sheet with intervention goals that were brought to deliveries.

Results: The pre (n=40) and post-implementation (n=48) cohorts showed no statistical differences in gender, birthweight, or gestational age. We saw no difference in time to starting antibiotics, however there was a decrease in time to intravenous fluids from 115.5 to 73.2 minutes (p=0.0005). Post-protocol group demonstrated increased time from birth to NICU admission going from 23.6 to 26.3 minutes (p=0.0087). Patient temperature between both groups did not show change, both at time of admission and one hour post admission. When looking at rates of intraventricular hemorrhages we saw a significant reduction in rates of clinically significant IVH (grades 2-4) with an OR of 0.14 [95% CI 0.03-0.717] post-protocol.

Conclusion/Discussion: While implementation of our protocol did not result in differences in time to antibiotics or admission temperatures it was associated with statistically significant decreases in time to intravenous fluids administration and rates of significant IVH. Although we were unable to meet all desired treatment goals, these results suggest that the standardization of care and attention to early intervention in the low birth weight and severely premature results in significantly improved health outcomes for these neonates.