BehringEiseleLessard_Manuscript_05162015

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 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 THE NEONATAL GOLDEN HOUR 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 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 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 hours Seventy infants (74%) received their first dose of surfactant within hours; 25 infants (26%) received a second dose of surfactant The average oxygen days were 45 with a range of 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 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 THE NEONATAL GOLDEN HOUR 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 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 THE NEONATAL GOLDEN HOUR including neonatal deaths and post neonatal deaths (between 28 days and one year of life), and reducing the rate of death among children aged to 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 years of age) around the world Every year, there are more than in 10 infants around the world that are born 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.) THE NEONATAL GOLDEN HOUR 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 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 THE NEONATAL GOLDEN HOUR 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 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, THE NEONATAL GOLDEN HOUR 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 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 THE NEONATAL GOLDEN HOUR 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 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” THE NEONATAL 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 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 10 THE NEONATAL GOLDEN HOUR resuscitation (Mehler et al, 2012) Improved rates of survival and morbidity can be achieved 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 12 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 that on adult patients with EOS, every hour an antibiotic administration was delayed, there was a 13 THE NEONATAL GOLDEN HOUR 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, & 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 14 THE NEONATAL GOLDEN HOUR 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) 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 15 THE NEONATAL GOLDEN HOUR 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 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 16 THE NEONATAL GOLDEN HOUR 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 and The most common five minute APGAR was and The range for 10 minute APGARS was to with 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 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 hyperthermia or cold stress within the first hours Seventy infants received their first dose of surfactant within 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 17 THE NEONATAL GOLDEN HOUR 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 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 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(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 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.) 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