Golden Hour Bundle of Interventions Boosts Outcomes for High-Risk Preterm Infants

WASHINGTON — A multidisciplinary quality improvement (QI) team successfully and safely adhered to a golden hour bundle of interventions for high-risk preterm infants, a researcher said here.

Adherence to the bundle also led to reduced rates of severe hypothermia and reduced time to antibiotic administration, as well as a boost to early initiation of IV fluid (IVF) among the study infants, according to Justin Kotliar, MD, of NewYork Presbyterian-Weill Cornell in New York City.

“Golden hour refers to practicing evidence-based interventions in the first 60 minutes of care to improve short- and long-term neonatal outcomes,” Kotliar said in a presentation at the American Academy of Pediatrics annual meeting.

Very low birth rate infants are at high risk of mortality and morbidities, including hypothermia, hypoglycemia, intraventricular hemorrhage, and bronchopulmonary dysplasia, he noted, and golden hour bundles can help to standardize the quality and consistency of complex care needed at birth.

The study by Kotliar and colleagues involved a multidisciplinary QI team performing sequential interventions in inborn newborns , who were less than 32 weeks or ≤1,500 grams at a level IV neonatal ICU (NICU).

Baseline data were collected from January 2020 to November 2021. The primary goal was to increase overall adherence to the elements of the golden hour bundle to 50% by July 2023, Kotliar reported. Secondary aims were to reduce the rates of severe hypothermia by 25%, reduce the time to antibiotic administration by 25%, and increase the initiation of IVF within the golden hour by 25%, also by July 2023.

There were 255 infants in the study — 163 pre-golden hour bundle and 92 post-golden hour bundle. Adherence to the golden hour bundle was 86%.

Subsequent to adherence to the golden hour bundle, there was a center line change in the rates of severe hypothermia from 25% to 4%, he reported. Mean time to antibiotic administration decreased from 132 minutes to 78 minutes. And the percentage of infants receiving IVF within the golden hour increased from 30% to 71%.

Balance measures included hyperthermia and admission temperature in preterm newborns who did not meet inclusion criteria, he noted, and there were no cases of hyperthermia or increased rates of hypothermia in excluded preterm newborns.

Primary drivers tied to sequential interventions were workflow, culture, and practices, Kotliar said. Secondary drivers included communication with labor and delivery; pharmacy and radiology teams; supply readiness and accessibility; and timely IV access, among others.

“This project has five PDSA [plan-do-study-act] cycles,” Kotliar said, outlining a series of interventions under each respective cycle.

Sequential interventions in the first cycle included introducing an admission checklist and flow sheet, educating NICU staff on the golden hour bundle, collaborating with the pharmacy to expedite antibiotic preparation and delivery, and standardizing the use of battery pack warmers and thermometers. Those in the second cycle included introducing the golden hour documentation sheet, and alerting team members via electronic health records for anticipated golden hour admission. Additionally, those in the third cycle were introducing thermoregulation guidelines, and auditing NICU staff and assessing feedback.

Interventions in the fourth cycle included updating practice to include triplet deliveries, and integrating family care partners. Finally, those in the fifth cycle included implementing knowledge-based surveys.

Plans for future work include sustaining improvement in the outcome areas, Kotliar reported. This will include the development of knowledge-based surveys and the integration of families in additional PDSA cycles.

The golden hour interventions, he added, are also slated to be incorporated as part of a larger bronchopulmonary dysplasia prevention initiative.

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