Background: Very low birth weight (VLBW) premature infants require multiple interventions within the first hour after birth, including airway management, central IV access, glucose-containing IV fluid administration, and temperature support. Timely and appropriate care has been shown to reduce morbidity and mortality. Recent publications have demonstrated an increased risk of mortality if these infants are hypothermic at NICU admission, and data from the Vermont Oxford Network showed that 35-40% of VLBW infants had admission hypothermia (<36.5 °C) in recent years. Implementation of a “Golden Hour” protocol has been reported to improve admission temperature. Local Problem: At our center, baseline chart review from April to September 2017 (n=17) showed an admission hypothermia rate of 47% of VLBW infants. Goal: Through implementation of a “Golden Hour” protocol, we will increase the number of inborn VLBW infants with admission normothermia (36.5 - 37.5 °C) to at least 80% of all VLBW infants. Additional goals include reductions in time to initiation of glucose-containing IV fluids and antibiotics when indicated. Methodology: The Plan-Do-Check-Act method was utilized for this ongoing QI project. Prior to PDCA Cycle 1, a multi-disciplinary working group consisting of physicians, nurses, and respiratory therapists was formed to review policies, procedures, and baseline data. Major interventions for PDCA Cycle 1 included implementation of a team-based strategy with specified roles (Figure 1) at times during the Golden Hour, as well as a new data collection worksheet to better track temperatures and other measures to guide future PDCA Cycles. PDCA Cycle 2 will include standardization of delivery room temperature policy and standardization of polyethylene bag and chemical warming mattress usage, which was found to be variable in usage during PDCA Cycle 1. Results: In PDCA Cycle 1 (October 2017 – December 2018, n=47), compared to baseline, our admission normothermia rate improved from 47% to 68% (Figure 2). We also had reduction in time to initiation of glucose-containing IV fluids and time to antibiotic administration (Table). This Cycle was longer than anticipated due to staff turnover at our military teaching hospital. We anticipate presenting PDCA Cycle 2 data in our poster presentation. Discussion/Conclusions: Using a team-based Golden Hour Protocol, we have improved our admission normothermia rates, and we have reduced average time to initiate glucose-containing IV fluids and antibiotics. Although these differences did not reach statistical significance, we feel they demonstrate clinically relevant improvements in quality of care for critically ill VLBW infants. Ideas for future PDCA Cycles include integrating ancillary departments (pharmacy, radiology) into this protocol, as well as standardizing unit practices related to GME trainees performing procedures on VLBW infants, in order to limit time spent with the incubator open in the event of prolonged procedural attempts.
Golden Hour team member roles chart. This chart was developed for this project and posted in the NICU and at deliveries to outline the roles of each team member during Golden Hour admissions.
Percentage of VLBW NICU admissions at our center with normothermia, hyperthermia, and hypothermia for PDCA Cycle 1, compared to baseline.
Comparison of outcome measures from baseline to PDCA Cycle 1. Mean differences did not reach statistical significance but showed a clinically relevant improvement.