"Golden Hour" quality improvement intervention and short-term outcome among preterm infants

Knowledge and practices of neonatal intensive care unit nurses concerning hypothermia in preterm infants: A descriptive cross-sectional study

AIM

To investigate the knowledge level and clinical practice of neonatal intensive care unit nurses on the whole process of hypothermia prevention in preterm infants.

DESIGN

A polycentric descriptive cross-sectional study was conducted in 23 hospitals in Shandong province involving 254 neonatal intensive care unit nurses.

METHODS

An evidence-based knowledge and clinical practice questionnaire on hypothermia prevention in preterm infants and a general information questionnaire were used to collect data. SPSS and EXCEL 24.0 database were used for data statistics and analysis.

RESULTS

Nearly one-third of nurses were unclear about the definition of mild hypothermia and heat preservation measures during labour management and resuscitation. Knowledge about the correct rate of amniotic fluid evaporation was low. The higher the hospital level and nurses' education level, professional title, work experience, and position, the higher the knowledge level. The clinical practice of nurses differed in terms of body temperature assessment tools, measurement sites, and measurement frequency for premature infants.

CONCLUSIONS

Nurses in neonatal intensive care units need to apply evidence-based knowledge and carry out practice interventions to ensure preterm infants' safe transition from the delivery room to the neonatal intensive care unit.

IMPACT

There have been few studies evaluating neonatal nurses' knowledge and practices with regards to the preventing hypothermia of premature infants from delivery room to neonatal intensive care unit. The study identifies the deficiencies and problems in temperature management that can be attributed to the knowledge level of nurses. The findings will help improve the current curriculum, teaching strategies, and the nurses' knowledge levels, preventing premature hypothermia in infants.

REPORTING METHOD

This study adhered to the STROBE statement for observational studies and obtained approval (KYLL-2023LW045) from the ethics committee of The Second Hospital of Shandong University. The other 22 third- and second-level hospitals, as our alliance members, recognized our chairperson status within the alliance and were willing to join our academic activities. Mutual responsibility for ethical filing between alliance units.

PUBLIC CONTRIBUTION

254 nurses were recruited from 23 tertiary and secondary public hospitals in Shandong province. No public or patient involvement. Members of the research group used the Questionnaire Star platform to prepare the electronic questionnaire, including obtaining informed consent, taking precautions for questionnaire completion, and using the aforementioned measurement tools. The project research team contacted the head nurses of 23 neonatal intensive care units in Shandong Province. After obtaining consent from the head nurses, they were asked to send the requirements and link of the electronic questionnaire to their WeChat management group. The nurses go through each question and make a choice which has two options of 'agree' or 'disagree.' Based on their answers, nurses were evaluated as having 'mastered' or 'not mastered' each item. Each 'mastered' item (correct answer) was given a score of 4; an item 'not mastered' (incorrect answer) was given a score of 0. The total score ranged from 0 to 100.

Quality improvement initiative to impact Golden Hour timeliness using a dedicated delivery team

OBJECTIVE

Golden Hour (GH) care impacts immediate and long-term outcomes for premature infants. We hypothesized that creation of a dedicated delivery team, the Stork Team, would improve delivery of GH care.

METHODS

A GH quality improvement initiative was created for infants born at <32 weeks and implemented in July 2018. Data were collected from GH checklists and the electronic medical record.

RESULTS

Following Stork Team implementation there was special cause variation noted in the minute of life (MOL) for administration of dextrose containing fluids and antibiotics. Dextrose containing fluid time improved from 111 to 67 MOL, with an increase in the percentage of patients receiving fluids by 60 MOL. Antibiotic administration improved from 180 to 82.5 MOL. GH checklist completion increased from 77% to 98% and time to isolette closure improved from 88 to 62 MOL.

CONCLUSION

Implementation of the Stork Team was associated with improvements in timeliness of GH care.

Quality improvement in the golden hour for premature infants: a scoping review

BACKGROUND AND OBJECTIVE

Evidence-based research has shown that golden hour quality improvement (QI) measures can improve the quality of care and reduce serious complications of premature infants. Herein, we sought to review golden hour QI studies to evaluate the impact on the outcome of preterm infants.

METHODS

A comprehensive literature search was conducted in PubMed, Embase, Cochrane Library, and SinoMed databases from inception to April 03, 2023. Only studies describing QI interventions in the golden hour of preterm infants were included. Outcomes were summarized and qualitative synthesis was performed.

RESULTS

Ten studies were eligible for inclusion. All studies were from single centers, of which nine were conducted in the USA and one in Israel. Seven were pre-post comparative studies and three were observational studies. Most included studies were of medium quality (80%). The most common primary outcome was admission temperatures and glucose. Five studies (n = 2308) reported improvements in the admission temperature and three studies (n = 2052) reported improvements in hypoglycemia after QI. Four studies (n = 907) showed that the incidence of bronchopulmonary dysplasia (BPD) was lower in preterm infants after QI: 106/408 (26.0%) vs. 122/424(29.5%) [OR = 0.68, 95% CI 0.48-0.97, p = 0.04].

CONCLUSIONS

Our study showed that the golden hour QI bundle can improve the short-term and long-term outcomes for extremely preterm infants. There was considerable heterogeneity and deficiencies in the included studies, and the variation in impact on outcomes suggests the need to use standardized and validated measures. Future studies are needed to develop locally appropriate, high-quality, and replicable QI projects.

Maintaining normothermia immediately after birth in preterm infants <34 weeks' gestation: A systematic review and meta-analysis

AIM

To evaluate delivery room (DR) interventions to prevent hypothermia and improve outcomes in preterm newborn infants <34 weeks' gestation.

METHODS

Medline, Embase, CINAHL and CENTRAL were searched till 22nd July 2022. Randomized controlled trials (RCTs), non-RCTs and quality improvement studies were considered. A random effects meta-analysis was performed, and the certainty of evidence was evaluated using GRADE guidelines.

RESULTS

DR temperature of ≥23 °C compared to standard care improved temperature outcomes without an increased risk of hyperthermia (low certainty), whereas radiant warmer in servo mode compared to manual mode decreased mean body temperature (MBT) (moderate certainty). Use of a plastic bag or wrap (PBW) improved normothermia (low certainty), but with an increased risk of hyperthermia (moderate certainty). Plastic cap improved normothermia (moderate certainty) and when combined with PBW improved MBT (low certainty). Use of a cloth cap decreased moderate hypothermia (low certainty). Though thermal mattress (TM) improved MBT, it increased risk of hyperthermia (low certainty). Heated-humidified gases (HHG) for resuscitation decreased the risk of moderate hypothermia and severe intraventricular hemorrhage (very low to low certainty). None of the interventions was shown to improve survival, but sample sizes were insufficient.

CONCLUSIONS

DR temperature of ≥23 °C, radiant warmer in manual mode, use of a PBW and a head covering is suggested for preterm newborn infants <34 weeks' gestation. HHG and TM could be considered in addition to PBW provided resources allow, in settings where hypothermia incidence is high. Careful monitoring to avoid hyperthermia is needed.

Elaboration and implementation of a protocol for the Golden Hour of premature newborns using an Implementation Science lens

OBJECTIVE

describe the process of designing and implementing a care protocol for the first hour of life of premature newborns.

METHOD

a participatory research study using an implementation science framework, the Consolidated Framework for Implementation Research (CFIR) was employed to determine drivers and facilitators of implementation success of the Golden Hour protocol for newborns at a large university hospital in southeastern Brazil. A multi-professional team, including first line providers and managers participated in six stages of quality improvement: situational diagnosis; protocol elaboration; training protocol implementation; barrier and facilitator assessment; and protocol monitoring and review. Qualitative and monitoring data collected across these six stages were analyzed using descriptive statistics and content analysis.

RESULTS

the institution's Golden Hour protocol was organized by the multi-professional team based on a collective and dialogical approach. The protocol prioritized the infant's cardiopulmonary stability, as well as prevention of hypothermia, hypoglycemia and infection. After four months of implementation, the care team was evaluated the protocol as a good quality intervention, necessary for the service, low-cost and not very complex. One suggested improvement recommended was to carry out refresher training to address staff turnover.

CONCLUSION

implementation of the Golden Hour protocol introduced an appropriate and feasible neonatal care quality improvement process, which requires periodic refresher training to ensure greater adherence and better neonatal results.

Improving Golden Hour Care Coordination: Using Defined Roles to Improve Nurse Confidence and Care Coordination of Neonates Following Admission

STUDY AIM

To investigate whether use of admission lanyards improves nurse confidence, care coordination, and infant health outcomes during neonatal emergency admissions.

METHODS

Admission lanyards that defined team roles, tasks, and responsibilities were evaluated in a mixed-methods, historically controlled, and nonrandomized intervention study. Methods included (i) 81 pre- and postintervention surveys to explore nurse confidence, (ii) 8 postintervention semistructured interviews to elicit nurse perceptions of care coordination and nurse confidence, and (iii) a quantitative comparison of infant care coordination and health outcomes for 71 infant admissions before and 72 during the intervention.

RESULTS

Nurse participants reported that using lanyards during neonatal admissions improved clarity of roles and responsibilities, communication, and task delegation, contributing to better admission flow, team leadership, accountability, and improved nurse confidence. Care coordination outcomes showed significantly improved time to stabilization for intervention infants. Radiographies for line placement were performed 14.4 minutes faster, and infants commenced intravenous nutrition 27.7 minutes faster from time of admission. Infant health outcomes remained similar between groups.

CONCLUSION

Admission lanyards were associated with improved nurse confidence and care coordination during neonatal emergency admissions, significantly reducing time to stabilization for infants, shifting outcomes closer to the Golden Hour.

Developing a Respiratory Quality Improvement Program to Prevent and Treat Bronchopulmonary Dysplasia in the Neonatal Intensive Care Unit

Improvements in respiratory care have resulted in improved outcomes for preterm infants over the past three decades. To target the multifactorial nature of neonatal lung diseases, neonatal intensive care units (NICUs) should consider developing comprehensive respiratory quality improvement programs that address all drivers of neonatal respiratory disease. This article presents a potential framework for developing a quality improvement program to prevent bronchopulmonary dysplasia in the NICU. Drawing on available research and quality improvement reports, the authors discuss key components, measures, drivers, and interventions that should be considered when building a respiratory quality improvement program devoted to preventing and treating bronchopulmonary dysplasia.

All Care is Brain Care: Neuro-Focused Quality Improvement in the Neonatal Intensive Care Unit

Neonates requiring intensive care are in a critical period of brain development that coincides with the neonatal intensive care unit (NICU) hospitalization, placing these infants at high risk of brain injury and long-term neurodevelopmental impairment. Care in the NICU has the potential to be both harmful and protective to the developing brain. Neuro-focused quality improvement efforts address 3 main pillars of neuroprotective care: prevention of acquired injury, protection of normal maturation, and promotion of a positive environment. Despite challenges in measurement, many centers have shown success with consistent implementation of best and potentially better practices that may improve markers of brain health and neurodevelopment.

Impact of simulation on multidisciplinary NICU teamwork during delivery and transport of extremely preterm infants

BACKGROUND AND OBJECTIVES

Multidisciplinary teamwork during delivery room (DR) resuscitation and timely transport to the neonatal intensive care unit (NICU) can reduce morbidity and mortality for infants born Extremely Preterm (EP). We aimed to assess the impact of a multidisciplinary high-fidelity simulation curriculum on teamwork during resuscitation and transport of EP infants.

METHODS

In a prospective study conducted at a Level III academic center, seven teams (each consisting of one NICU fellow, two NICU nurses, and one respiratory therapist) performed three high-fidelity simulation scenarios. Videotaped scenarios were graded by three independent raters using the Clinical Teamwork Scale (CTS). Times of completion of key resuscitation and transport tasks were recorded. Pre- and post- intervention surveys were obtained.

RESULTS

Overall, time of completion of key resuscitation and transport tasks decreased, with significant decreases in the time to attach the pulse oximeter, transfer of the infant to the transport isolette, and exit the DR. There was no significant difference in CTS scores from Scenario 1 to 3. Scenarios led by first-year fellows showed a trend towards improvement in all CTS categories. A comparison of teamwork scores pre- and post-simulation curriculum during direct observation of high-risk deliveries in real time revealed a significant increase in each CTS category.

CONCLUSION

A high-fidelity teamwork-based simulation curriculum decreased time to complete key clinical tasks in the resuscitation and transport of EP infants, with a trend towards increased teamwork in scenarios led by junior fellows. There was improvement of teamwork scores during high-risk deliveries on pre-post curriculum assessment.

Time to improve documentation of neonatal resuscitation: a narrative review

A complete, objective and systematic documentation of delivery room resuscitation is important for research, for quality improvement, for teaching and as a reference for postresuscitation care. However, documentation during neonatal resuscitation is usually paper-based, retrospective, inaccurate and unreliable. In this narrative review, we discuss the strengths and pitfalls of current documentation methods in neonatal resuscitation, as well as the challenges of introducing new or emerging technologies in this field. In particular, we discuss innovations in electronic and automated medical records, video recording and Smartphones and Tablet Apps. Given the lack of a consensus standard, we finally propose a list of items that should be part of any neonatal resuscitation documentation method.

Advancements in neonatology through quality improvement

In the past 3 decades, quality improvement methodology has often been employed in medicine to improve patient outcomes. Neonatal medicine has seen an increase in publications using improvement science to ensure the application of potentially better practices to decrease complications and increase survival without major disability. This article reviews quality improvement studies that have impacted neonatal mortality and morbidity, as well as specific disease processes including bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, and retinopathy of prematurity. Using improvement science, studies have substantially reduced neonatal mortality and the major complications of preterm birth.

Golden Hour Education, Standardization, and Team Dynamics: A Literature Review

The "golden hour" is the critically important first 60 minutes in an extremely low birth weight neonate's life that can impact both short- and long-term outcomes. The golden hour concept involves several competing stabilization priorities that should be conducted systematically by highly specialized health care providers in both the hospital and transport settings for improvement in patient outcomes. Current literature supports utilizing an experienced team in the golden hour process to improve patient outcomes through standardization, improved efficiency, and positive team dynamics. Although a variety of teaching methods exist to train individuals in the care of extremely low birth weight infants, the literature supports the incorporation of low- or high-fidelity simulation-based training. In addition, initial and ongoing educational requirements of individuals caring for a golden hour-eligible infant in the immediate post-delivery phase, as well as ongoing care in the days and weeks to follow, are justified. Instituting standard golden hour educational requirements on an ongoing basis provides improved efficiency in team function and patient outcomes. The goal of this literature review was to determine whether implementation of golden hour response teams in both the inpatient and transport setting has shown improved outcomes and should be considered for neonatal intensive care units admitting or transporting golden hour eligible infants.

Implementing the Golden Hour Protocol to Improve the Clinical Outcomes in Preterm Infants

Purpose: Since premature infants are sensitive to the changes in blood glucose levels and body temperature, maintaining these parameters is important to avoid the risk of infections. The authors implemented the Golden Hour protocol (GHP) that aims to close the final incubator within one hour of birth by implementing early treatment steps for premature infants after birth, such as maintaining body temperature, securing airway, and rapidly administering glucose fluid and prophylactic antibiotics by securing breathing and rapid blood vessels. This study investigated the effect of GHP application on the short- and long-term clinical outcomes.Methods: We retrospectively analyzed the medical records between 2017 and 2018 before GHP application and between 2019 and 2020 after GHP application in preterm infants aged 24 weeks or older and those aged less than 33 weeks who were admitted to the neonatal intensive care unit.Results: Overall, 117 GHP patients and 81 patients without GHP were compared and analyzed. Peripheral vascularization time and prophylactic antibiotic administration time were shortened in the GHP-treated group (P=0.007 and P=0.008). In the short-term results, the GHP-treated group showed reduced hypothermia upon arrival at the neonatal intensive care unit (P=0.002), and the blood glucose level at 1 hour of hospitalization was higher (P=0.012). Furthermore, the incidence of neonatal necrotizing enteritis decreased (P=0.043). As a long-term result, the incidence of BPD was reduced (P=0.004).Conclusion: We confirmed that applying GHP improved short- and long-term clinical outcomes in premature infants aged <33 weeks age of gestation, and we expect to improve the treatment quality by actively using it for postnatal treatment.

Blood pressure changes during the first 24 hours of life and the association with the persistence of a patent ductus arteriosus and occurrence of intraventricular haemorrhage

Very low birthweight (VLBW) infants are at risk of intraventricular haemorrhage (IVH) and delayed closure of ductus arteriosus. We investigated mean arterially recorded blood pressure (MAP) changes during the first day of life in VLBW infants as potential risk factors for a patent ductus arteriosus (PDA) and IVH. This retrospective cohort study exploring MAP changes during adaption and risk factors for a PDA and IVH comprised 844 VLBW infants admitted to the Helsinki University Children’s Hospital during 2005–2013. For each infant, we investigated 600 time-points of MAP recorded 4–24 hours after birth. Based on blood pressure patterns revealed by a data-driven method, we divided the infants into two groups. Group 1 (n = 327, mean birthweight = 1019 g, mean gestational age = 28 + ^1/7 weeks) consisted of infants whose mean MAP was lower at 18–24 hours than at 4–10 hours after birth. Group 2 (n = 517, mean birthweight = 1070 g, mean gestational age = 28 + ^5/7 weeks) included infants with a higher mean MAP at 18–24 hours than at 4–10 hours after birth. We used the group assignments, MAP, gestational age at birth, relative size for gestational age, surfactant administration, inotrope usage, invasive ventilation, presence of respiratory distress syndrome or sepsis, fluid intake, and administration of antenatal steroids to predict the occurrence of IVH and use of pharmacological or surgical therapy for a PDA before 42 weeks of gestational age. Infants whose mean MAP is lower at 18–24 hours than at 4–10 hours after birth are more likely to undergo surgical ligation of a PDA (odds ratio = 2.1; CI 1.14–3.89; p = 0.018) and to suffer from IVH (odds ratio = 1.83; CI 1.23–2.72; p = 0.003).

Observational study using video recordings to explore the first hour after admission to a neonatal intensive care unit

AIM

To explore the admission process to our neonatal intensive care unit.

METHODS

A first phase quality improvement initiative was conducted. We utilised observational video recording of a convenience sample of inborn admissions. Two remote GoPro cameras were placed, one giving an overview of activity and the other focussed on the infant. Recordings captured the first hour after admission including transfer to the neonatal intensive care unit by the birthing team. The video footage of each case study was reviewed by a multidisciplinary panel using an agreed semi-quantitative analysis of events.

RESULTS

Ten admissions to the neonatal intensive care unit were video recorded between June and October 2018. Gestational age 28² -40¹ . A focus on maintaining airway support was inconsistent as was the ability to provide continuous monitoring of vital signs. Overall leadership of the process was lacking and handover often appeared fragmented. Median temperature on admission was 36² (35⁴ -37³ ) °C. Vascular access and fluid management occurred at a median of 36 (13-67) minutes.

CONCLUSIONS

Planning and approval for this study were protracted, particularly negotiating the use of video recording. Anecdotally, this delay is thought to have contributed to an improvement in managing admissions, particularly when maintaining airway support and monitoring. However, our baseline data have highlighted a lack of leadership, fragmented handover, low admission temperatures and broad time frames to achieve vascular access. A guideline to streamline handover and nursery transition is currently being implemented; a subsequent evaluation cycle is planned.

Neonatal Golden Hour: A survey of Australian and New Zealand Neonatal Network units' early stabilisation practices for very preterm infants

AIM

To identify current 'Golden Hour' practices for initial stabilisation of very preterm infants <32 weeks' gestational age (GA) within tertiary neonatal intensive care units (NICUs) in the Australian and New Zealand Neonatal Network (ANZNN).

METHODS

A 76-question survey regarding delivery room (DR) and NICU stabilisation practices was distributed electronically to directors of tertiary perinatal NICUs in the ANZNN in January 2019. Responses were categorised into GA subgroups: 23-24, 25-27 and 28-31 weeks' GA.

RESULTS

The response rate was 100% (24/24 units). Delayed cord clamping (DCC) was practised 'always' or 'often' by 21 units (88%). All units used oximetry to target oxygen saturations, and 23/24 (96%) commenced resuscitation in <40% oxygen. Ten units (42%) routinely used DR electrocardiography monitoring. CPAP was preferred as primary respiratory support in one-third of units for infants born 23-24 weeks' GA, compared with 19 units (79%) at 25-27 weeks' GA and 23 units (96%) at 28-31 weeks' GA. DR skin-to-skin care was uncommon, particularly at lower GAs. Five units (21%) used minimally invasive surfactant therapy for non-intubated infants at 23-24 weeks' GA, 13 units (54%) at 25-27 weeks' GA and 16 units (67%) at 28-31 weeks' GA.

CONCLUSIONS

Most Golden Hour stabilisation practices align with international guidelines. Consistency exists with respect to DCC, oxygen saturation targeting and primary CPAP use for infants 25 weeks' GA and above. Where evidence is less certain, practices vary across ANZNN NICUs. Time targets for stabilisation measures may help standardise practice for this population.

Documentation during neonatal resuscitation: a systematic review

OBJECTIVE

Accurate documentation in healthcare is necessary for ethical, legal, research and quality improvement purposes. In this review, we aimed to evaluate the accuracy of methods of documentation of delivery room resuscitations.

METHODS

A systematic literature search in MEDLINE was conducted to identify original studies that reported the quality of documentation records during newborn resuscitation in the delivery room. Data extracted from the studies included population characteristics, methodology, documentation protocols, use of gold standard and main results (initial assessment of heart rate and peripheral oxygen saturation, respiratory support and supplementary oxygen).

RESULTS

In total, 197 records were screened after initial database search, of which seven studies met the inclusion criteria and were finally included in this review. Four studies were chart reviews and three studies compared conventional documentation methods with video recording. Only one study tested an intervention to improve documentation. Documentation was often inaccurate and important resuscitation events and interventions were poorly recorded. Lack of uniformity among studies preclude pooled analysis, but it seems that complex or advanced procedures were more accurately reported than basic interventions.

CONCLUSIONS

There is little literature regarding accuracy of documentation during neonatal resuscitation, but current quality of documentation seems to be unsatisfactory. There is a need for consensus guidelines and innovative solutions in newborn resuscitation documentation.

Impact of neonatal resuscitation changes on outcomes of very-low-birth-weight infants

The improvement of delivery room care, according to the 2015 International Consensus, may affect neonatal outcome, especially in very-low-birth-weight infants. We aimed to investigate the current practice of neonatal resuscitation by year and analyze the association with neonatal outcomes. A total of 8142 very-low-birth-weight infants, registered in the Korean Neonatal Network between 2014 and 2017 were included. A significant decreasing trend of intubation (64.5% vs 55.1%, P < 0.0001) and markedly increasing trend of positive pressure ventilation (PPV) (11.5% vs 22.9%, P < 0.0001) were noted. The annual PPV rate differed significantly by gestation (P < 0.0001). The highest level of resuscitation was also shown as an independent risk factor for mortality within 7 days and for bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), and periventricular leukomalacia. PPV and intubation were associated with significantly decreased risk of mortality and morbidities compared to epinephrine use. When considering association, the incidence of mortality within 7 days, IVH, PVL, and BPD or mortality showed significant differences by combination of year, gestational age, and level of resuscitation. According to updated guidelines, changes in the highest level of resuscitation significantly associated with reducing mortality and morbidities. More meticulous delivery room resuscitation focusing on extreme prematurity is needed.

A systematic review of reports of quality improvement for bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is the most common morbidity of preterm infants, and its incidence has not responded to research and intervention efforts to the same degree as other major morbidities associated with prematurity. The complexity of neonatal respiratory care as well as persistent inter-institutional variability in BPD rates suggest that BPD may be amenable to quality improvement (QI) efforts. We present a systematic review of QI for BPD in preterm infants. We identified 22 reports from single centers and seven from collaborative efforts published over the past two decades. In almost all of the reports, respiratory QI interventions successfully reduced BPD or other key respiratory measures, particularly for infants with birth weight over 1000 g. Several themes and lessons from existing reports may help inform future efforts in both research and QI to impact the burden of BPD.

Retinopathy of Prematurity: How to Prevent the Third Epidemics in Developing Countries

Retinopathy of prematurity (ROP) is vasoproliferative disease affecting preterm infants and is a leading cause of avoidable childhood blindness worldwide. The world is currently experiencing the third epidemic of ROP, where majority of the cases are from middle-income countries. Over 40% of the world's premature infants were born in India, China, Bangladesh, Pakistan, and Indonesia. Together with other neighboring nations, this region has unique challenges in ROP management. Key aspects of the challenges including heavier and more mature infants developing severe ROP. Current strategies include adoption of national screening guidelines, telemedicine, integrating vision rehabilitation and software innovations in the form of artificial intelligence. This review overviews some of these aspects.

Perinatal quality improvement bundle to decrease hypothermia in extremely low birthweight infants with birth weight less than 1000 g: single-center experience over 6 years

Normothermia (36.5°C–37. 5°C) at the time of admission to the neonatal intensive care unit (NICU) in extremely low birthweight (ELBW) infants (birth weight <1000 g) is associated with decreased morbidity and mortality, decreased length of stay and hospital costs. We designed a thermoregulation bundle to decrease hypothermia (<36.5°C) in ELBW infants with a multidisciplinary perinatal quality improvement initiative that included the following key interventions: dedicated delivery room (DR)/operating room (OR) for all preterm deliveries of ≤32 weeks with DR/OR temperature set 24/7 at 74°F by the hospital engineering staff, use of exothermic mattress, preheated radiant warmer set at 100% for heat prior to delivery, servo-controlled mode after the neonate is placed on the warmer, and use of plastic wrap, head cap and warm towels. A total of 200 ELBW infants were admitted to our NICU between January 1, 2014 and December 31, 2019. Hypothermia (<36.5°C) occurred in 2.5% of infants, normothermia (36.5°C–37.5°C) in 91% of infants and transitional hyperthermia (>37.5°C) in 6.5% of ELBW infants. No case of moderate hypothermia (32°C–36°C) was seen in our infants. Our target rate of less than 10% hypothermia was reached in ELBW infants over the last 2 years with no cases of moderate hypothermia in 6 years. Eliminating hypothermia among ELBW remains a challenge and requires team effort and continuous quality improvement efforts.

The Golden Hour: a quality improvement initiative for extremely premature infants in the neonatal intensive care unit

BACKGROUND

Following delivery, extremely premature infants are vulnerable to rapid development of hypothermia and hypoglycemia. To reduce local rates of these morbidities, a multidisciplinary team developed a protocol standardizing evidence-based care practices during the first hour after birth.

METHODS

Using quality improvement methodology, the Golden Hour protocol was implemented for all inborn infants <27 weeks' gestation. Data were collected (2012-2017) over three phases; pre-protocol (n = 80), Phase I (n = 42), and Phase II (n = 92).

RESULTS

There were no significant differences in infant characteristics. Improvements in hypothermia (59% vs 26% vs 38%; p = 0.001), hypoglycemia (18% vs 7% vs 4%; p = 0.012), and minutes to completion of stabilization [median (Q1,Q3) 110 (89,138) vs 111 (94,135) vs 92 (74,129); p = 0.0035] were observed.

CONCLUSIONS

Implementation of an evidence-based, Golden Hour protocol is an effective intervention for reducing hypothermia and hypoglycemia in extremely premature infants.

Delivery room interventions to prevent bronchopulmonary dysplasia in preterm infants: a protocol for a systematic review and network meta-analysis

INTRODUCTION

As gestational age decreases, incidence of bronchopulmonary dysplasia (BPD) and chronic lung disease increases. There are many interventions used in the delivery room to prevent acute lung injury and consequently BPD in these patients. The availability of different treatment options often poses a practical challenge to the practicing neonatologist when it comes to making an evidence-based choice as the multitude of pairwise systematic reviews including Cochrane reviews that are currently available only provide a narrow perspective through head-to-head comparisons.

METHODS AND ANALYSIS

We will conduct a systematic review of all randomised controlled trials evaluating delivery room interventions within the first golden hour after birth for prevention of BPD. The primary outcome includes BPD. Secondary outcomes include death at 36 weeks of postmenstrual age or before discharge; severe intraventricular haemorrhage (grade 3 or 4 based on the Papile criteria); any air leak syndromes (including pneumothorax or pulmonary interstitial emphysema); retinopathy of prematurity (any stage) and neurodevelopmental impairment at 18-24 months. We will search from their inception to August 2018, the following databases: Medline, EMBASE and Cochrane Central Register of Controlled Trials as well as grey literature resources. Two reviewers will independently screen titles and abstracts, review full texts, extract information and assess the risk of bias and the confidence in the estimate (with Grading of Recommendations Assessment, Development and Evaluation approach). This review will use Bayesian network meta-analysis approach which allows the comparison of the multiple delivery room interventions for prevention of BPD. We will perform a Bayesian network meta-analysis to combine the pooled direct and indirect treatment effect estimates for each outcome, effectiveness and safety of delivery room interventions for prevention of BPD.

ETHICS AND DISSEMINATION

The proposed protocol is a network meta-analysis, which has been registered on PROSPERO International prospective register of systematic reviews (CRD42018078648). The results will provide an evidence-based guide to choosing the right sequence of early postnatal interventions that will be associated with the least likelihood of inducing lung injury and BPD in preterm infants. Furthermore, we will identify knowledge gaps and will encourage further research for other therapeutic options. Therefore, its results will be disseminated through peer-reviewed publications and conference presentations. Due to the nature of the design, no ethics approval is necessary.