The Golden Hour
A TIPQC Project
Ajay J. Talati, MD
Professor, Pediatrics and OB/GYN
UTHSC
• Minutes after birth are the critical minutes of
life
• NRP (neonatal resuscitation program) has
made a significant improvement in
standardizing care of this time frame world
wide
• However, the effectiveness of NRP has not
been tested
• Individual variations in management make it
difficult to assess outcomes
• Standardizing management improves
outcomes
– Avoids chaos
– Decreases variation
– Outcomes can be compared
– Mistakes can be identified easily
• NRP
– Requires a skilled team ready at all times
– Has a standard resuscitation protocol
– Special situations to consider
• NRP
– Does not require a preparatory check list
– Has multiple options for doing the same thing
– Does not require any assessment of outcomes
The Golden Hour
Prenatal
consultexchange
information
Update family
Disposition
Debrief with OB
staff
Foot prints, ID
Transfer to NICU
NICU team
getting
ready
-30
-15
Checklist and
equipment check
Define roles
Timeout called
ABG, CxR done
IVF started
Initial glucose
Antibiotics/orders
written
UAC/UVC placed
Family updated
10 min Apgar
10 min sats, titrate O2,
Surfactant <29 wk
0
15
Start Apgar clock
Resusc per NRP
Pulseox at 2 min
5 min Apgar, temp
5 min sats
30
45
Initial assessment,
vitals, Accucheck
Temp, Vit K,
erythromycin
60
PDSA
Potentially better practices
• Use of checklists to facilitate team
communication
• Development of a local consensus pulmonary
management strategy
• Optimization of initial thermal management
• Effective and efficient implementation of
delivery room pulse oximetry to guide
titration of supplemental oxygen during
resuscitation and stabilization
Goals
• To improve resuscitation and stabilization of a
newborn by improving
– A. Team readiness
– B. Thermoregulation
– C. Optimizing respiratory care
– D. Performance improvement of the team in
delivery room and first hour
AIMS
• Team readiness– To establish a checklist and measure the number
of times checklist is being completed prior to
delivery
– 75% of high risk deliveries should have the
checklist completed
Pre-Resuscitation Checklist
Leader (MD or NNP):_________________________MD(s)__________________________________
RN(s):_____________________________________RT(s):__________________________________
Gestational Age:_______________Reason for Call:________________________________________
__ Introductions/Roles
__ Discuss Plan
___ special considerations?
___ Additional personnel/equipment?
___ “If any team member sees any developing problem or concern, I want to have it brought to my attention as soon as
possible.” Please repeat all orders from Leader (ex. “PIP is now 20”)
Pre-Resuscitation Checklist
Lead Resuscitator
___ Ensure briefing completed and introductions done.
___ Ensure RT checklist done
___ Ensure RN checklist done
Respiratory Therapist
___ Brings surfactant and tubing for <29 weeks.
___ Set up Neopuff (20/5 and FiO2 50%, flow 8-10)
___ Sets up Ambu bag, appropriate masks, checks air/oxygen connection and “ON”
___ Intubation equipment checked, appropriate size ETTs available, CO2 detectors
___ Suction set at 80-100 mmHg, catheters, meconium aspirator, if needed
___ Pulse oximeter turned “on” and probe out of packaging
___ Tidal volume machine
Nursing
___ If baby crashing, call 2nd RN/MD, ensure line available, Epi is drawn up, syringes are labeled.
___ Tackle box checked
___ Radiant warmer on MANUAL and pre-heat, probe and cover available, hat available, warming mattress
___ Stethoscope
___ wrap or plastic bag, warming mattress for <32 weeks
___ EKG leads
Debrief
Did we have all the information we need to admit this patient? Yes/No
What did we do well? (MD, RN, RT)_____________________________________________________________
_________________________________________________________________________________________
What can we improve upon?__________________________________________________________________
Do we need follow up on any items?___________________________________________________________
Check all that apply:
___Pre-warmed Transport Incubator
___Pre-warmed Blanket
___Neo-wrap used
___Chemical warming pad used
Delivery Room Skin temp:__________
___Pre-heated “Panda” Radiant Warmer
___Infant Cap “ON”
___Plastic Bag used
Admission Temp:___________
Room Temp:___________
Evidence
• Checklists are utilized in many high-risk
industries (notably the aviation industry)
• Utilization of a safety checklist improves
surgical outcomes and reduces morbidity and
mortality (“Safe Surgery”) (Robbins, 2011)
• Use of checklists facilitates communication
and teamwork (Carney et al, 2010)
Aim – to administer Surfactant in a timely fashion
• Develop guidelines specific to the NICU
• To give surfactant to >90% neonates within the established
guidelines
• Tools: Obtain baseline data for 3 months
• Establish guidelines
• Educate Respiratory therapists/ nurses/NNPs/residents
The Regional One guidelines:
– Prophylactic surfactant to all infants <29 weeks in the DR
(within 20 min)
– Rescue to all infants meeting criteria for HMD within one
hour of diagnosis (needing respiratory support with >30%FiO2 and
chest xray suggestive of HMD)
Evidence
•
HMD varies due to GA, severity of the disease, PDA, presence of infection,
antenatal steroid use, and surfactant administration
•
~60% of preterm infant <28 wks develop RDS (Warren, J.B., and Anderson, J.M, 2009)
•
Surfactant replacement therapy is considered the standard of care for infants with
RDS for several years.
•
Early surfactant has been shown to drastically decrease need for mechanical
ventilation and BPD (AAP statement, 2010)
•
Recent studies show that nasal CPAP is an acceptable alternative (SUPPORT Trial, AAP
policy statement, Pediatrics Vol. 133 No. 1 January 1, 2014)
•
Different approaches to surfactant administration may vary depending on the
population your specific unit serves and that units geographical population.
Aim : To optimize oxygenation in DR
• Oxygen saturations - 90% infants between 8085% at 5 min (NRP 6th edition, 2011)
• Tools:
– Place pulse oximeter on right arm by 2 min
after birth
– Use blended oxygen in DR
– Start at 40% FiO2 (21-99%)
– Wean/increase gradually to achieve desired
oxygen saturations
Evidence
• Administration of supplemental oxygen is no longer considered a benign
practice
• Recent studies have shown that even brief exposure to hyperoxia may
adversely affect outcomes
• Hyperoxia should be avoided by resuscitating infants with optimal oxygen
therapy
• We also know that visual assessment of color change is challenging and
highly variable depending on clinician
• NRP 6th edition have guidelines for pulse oximetry and FiO2 titration
should be based on pulse oximetry
• Our own data show that optimizing oxygen saturations (90%-95%)
decrease the risk for ROP and BPD in preterm infants (EPAS2009:2837.315)
Appropriate ventilation
• Desired PCO2 between 40-55 torr by one hour
age for infants with mechanical ventilation
• Achieve goal in 90% infants undergoing
mechanical ventilation
• Tools:
– Obtain ABG within the first hour after birth
– Wean based on Tidal volume monitoring
– Use TcPCO2 immediately after birth
Thermoregulation
Evidence
• Hypothermia and cold stress increase
metabolic rate and caloric consumption
• Several studies show that cold stress in VLBW
babies is associated with increased
morbidities
• Our data show that when incidence of
hypothermia decreased, survival and BPD
improved in our unit
Aim : to maintain temperature on neonate in euthermic
state after birth
• Thermorgulation– 90% VLBW infants should be between 36.5oc-37.5oc
• Tools:
– Obtain baseline data (we should have this already)
– Identify source of heat loss (i.e. transport etc)
– Adjust OR/DR temp
– Use hat/prewarmed towels
– Wrap/bag for VLBW infants
– Warming mattress
Performance improvement
• Measure: Use Survey??
• Tools:
– Use checklist for briefing/debriefing
– Direct observer/debriefing
– Videotaping for quality improvement
– Simulations/videotaping for quality improvement
Other potentially better practices
• Cord clamping – delay it 30-45 seconds
• Initial glucose to be measured by 1 hour (in
VLBW infants)
• Family contact and update within 1 hour after
birth for infants admitted to NICU
• Optimize IV fluid and antibiotic start time
Measures
• Individual as indicated with each practice
• Composite measure of physiologic parameters
at one hour age
– Develop a grid ?
– Scoring system?
Keypoints
• We are over 2 years into the project after kick-off
• Practical data capture and entry challenges (sorted
over the time)
• Thermal management- excellent sustainment
• Surfactant by unit protocol, better than expected
for the first 18 months, but declining in the past 6
months (effect of AAP policy statement?)
• Already seeing statewide reductions in time to
specific interventions
• Oxygen management- significant challenge
Project Development Team Leaders:
Ajay J. Talati, UTHSC, Memphis
Kelley Smith, RN, Regional One Health,
Memphis
Clare Stanton, RN, Baptist Hospital, Nashville
Melanie Ford, RN, Baptist Hospital, Nashville
Lynn Rosas, NNP, Methodist Hospitals,
Pediatrix Medical Group, Memphis
M. Bruce Jenkins, MD, Pediatrix Medical
Group, Memphis
Peter Grubb, MD, Medical Director, TIPQC
Special thanks to Brenda Barker
and Tennessee Department of Health