The Golden Hour, Implementing a Team Approach to Resuscitation of the Very Low Birth Weight Infant

The Golden Hour

Implementing a Team Approach to Resuscitation of the Very Low Birth Weight (VLBW) Infant

Most infants transition from intrauterine life to extrauterine life without the need for intervention. There are situations when an infant does need assistance during this time. The Neonatal Resuscitation Program (NRP) was developed by the American Academy of Pediatrics and the American Heart Association and endorsed in 1987. The course has been widely taught in the United States and has become the standard of care in newborn resuscitation. A subset of these newborns is very low birth weight (VLBW) infants, who weigh less than 1500 grams, are among the most medically fragile patients in hospitals today. At birth, these infants require extensive assistance in lifesaving therapies such as ventilation, chest compression, and medications to support heart rate. Given their size and gestational age, the tolerance for deviation of treatment is extremely critical.

Management in the first hour of a premature infant’s life may have significant life-long implications. Resuscitation during this time has been characterized as intense, chaotic, and prone to error and miscommunication, and requiring coordination of multiple caregivers. Experts believe good teamwork among health care providers may improve the quality of care. The initial management of VLBW infants needs to be optimized in collaboration with all members of the health care team. The organization of the teamwork and task assignments in preparing for and responding to the delivery of a VLBW infant is crucial. A highly structured mechanism for ensuring this optimal management is a program called "The Golden Hour."

Components of this program include:

• Structure communication which facilitates awareness between team members
• Early surfactant administration
• Protocolized initial ventilation
• Early attention to thermoregulation and developmentally supportive care

Implementing complex protocols such as The Golden Hour in the actual clinical setting is a challenge. The aviation industry developed Crew Resource Management (CRM), a program designed to improve teamwork and prevent and manage error. Data from other medical specialties such as emergency medicine have demonstrated the benefit of using this methodology to improve team performance. Like the aviation industry, practicing complex scenarios and improving provider perceptions of working together have been useful in health care. In addition, debriefings in a supportive environment enhance the self-efficacy of personnel which is believed to be a key in achieving optimal human performance.

Performing a complex task such as resuscitation of a VLBW infant requires interdisciplinary participants capable of performing multiple tasks using specialized equipment. Uniformity of practice is more likely to lead to:

• Consistency in provider skill sets
• Ease of training new practitioners
• Identification of outlying practices based on evidence based research
• Increased ease of comparing alternative practices

Outcome measures would include:

• Evaluation of resuscitation measures such as apnea and bradycardia, oxygen saturation, and temperature
• Time to surfactant administration
• Initial ABG values
• Qualitative measures such as personnel, equipment readiness, and teamwork