Multidisciplinary NICU Golden Hour Program at UPMC Magee-Womens Hospital Works to Enhance Short and Long-Term Outcomes in Extremely Premature Neonates

While neonatology, research and clinical practice have made extraordinary leaps in the ability to care for and save the lives of very premature babies, it is still an incredibly fragile and complex patient population, one that requires the expertise of multiple disciplines in a highly coordinated and collaborative setting in order to achieve optimal short and long-term outcomes improving survival without major complications.

As the medicine surrounding caring for premature and extremely premature infants has progressed, so too has the understanding of how the care provided during the first hour of life can impact both short- and long-term patient outcomes.

The Golden Hour project, a multidisciplinary collaborative quality improvement program between Newborn Medicine, Obstetrics and Gynecology, Radiology, and Pharmacy divisions and departments at UPMC Magee-Womens Hospital, is designed to standardize and optimize the care during the first hour of life of extremely premature neonates who are born at or less than 29-weeks’ gestation. The program officially launched in May 2022 after a yearlong development process that included extensive literature review, examination and optimization of internal care and communications processes, and adapting and modifying best practices and new operational ideas to fit the unique environment at one of the busiest delivery hospitals such as UPMC Magee-Womens hospital.

Leading the program and its development are John Ibrahim, MD, FAAP, assistant professor of pediatrics in the Division of Newborn Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine; and Michelle S. Lamary, MPAS, PA-C, who is a neonatal advanced practice provider and chair of the Small Baby Program at UPMC Magee-Womens Hospital.

“What happens during the first hour and hours after birth for these babies has significant influence over morbidity, mortality, and potential long-term complications that can affect their quality of life in the future” says Ms. Lamary.

The Golden Hour program involves the neonatal intensive care unit (NICU) and Obstetrics (OB) team meeting prior to each extremely premature delivery, counselling and discussing with parents the plans of care for their extremely premature neonate and preparing all necessary equipment and assigning roles in the delivery rooms.

The program works to decrease the incidence and impact of short-term complications, including hypothermia and hypoglycemia, expediting the establishment of IV access for fluids delivery and isolette closure.

The program also focuses on decreasing the incidence and severity of extreme prematurity- related complications, such as intraventricular hemorrhage, bronchopulmonary dysplasia, sepsis, and retinopathy of prematurity, all that can significantly influence long-term outcomes.

“You can’t implement or successfully run a program like this without taking a multidisciplinary approach; the cases are simply too complex,” says Dr. Ibrahim. “What works to our advantage at UPMC Magee-Womens Hospital is the full complement of clinical services from experienced nurses, respiratory therapists, advanced care providers, and physicians who are adept at handling high volume, high-risk pregnancies and deliveries, as well as coordinating the care needed between multiple disciplines, hospitals, and intensive care units."

Programmatic Pillars and Measures of Success

Transitioning from intrauterine to extrauterine life is a big deal for a newborn, and it's a complex process, even more so for extremely premature infants who are at risk for more severe complications and a protracted NICU course.

As Ms. Lamary and Dr. Ibrahim explain, the program has set benchmarks for several critical processes and guidelines that significantly influence outcomes down the road.

Guidelines have been revised and standardized to optimize delivery room temperatures and implement use of IV fluid warmers to reduce the risk of hypothermia, in addition to designating specific roles for each provider in the delivery room and providing extensive education to healthcare providers at all levels including pharmacy staff, radiology technicians, nurses, nurse practitioners, and physicians.

"We examined our processes for establishing IV access and also worked with our radiology teams to improve our time for getting imaging at the bedside to confirm endotracheal tube and central line placement," says Ms. Lamary.

Keeping these babies as warm as possible and getting the IV glucose supply going during the first hour of life has direct links to morbidity and mortality in the future, so the team worked to develop standards that expedite these early critical care processes.

"Just within the first couple of months of officially rolling out the program, we cut our average isolette closure times by nearly half, to an average of approximately 67 minutes. Isolette closure is the last step of the initial stabilization of those vulnerable neonates when they reach the NICU. This was a tremendous marker of the early success of the protocols and guidelines built into the program," says Dr. Ibrahim.

Standardized Order Sets

Another crucial component of the program was the development of a specific and standardized order set for the Golden Hour, one that expedites admission orders while minimizing the potential for error and time delays.

"UPMC Magee is one of the busiest delivery hospitals in the country," says Dr. Ibrahim. "We collectively see some of the most premature, as well as complicated cases, and the geography we cover is quite large. So, the communication efforts between all these different care groups are complex, but also a key part in optimizing the care of very premature babies. Everyone must know in advance exactly what to do, when, and why.”

Measuring Quality and Planning for Advances in Care

Since the Golden Hour program is also a quality improvement project at its heart, the program is tracking a wide swath of metrics on patient measures and outcomes.

“Of course,” says Ms. Lamary, “we’re interested in how the program is doing and how our metrics are improving over time, and how our patient outcomes are improving over time, but we’re also interested in applying those findings to the evolution of the program. Nothing we’ve created so far is set in stone. If we find a better way to do something, or the data points us in that direction, that’s where we will go.  We have seen wonderful success so far, and that is largely credited not only to the multidisciplinary team involved in creating these guidelines, but also to our wonderful NICU doctors, advanced practice providers, and nurses who have really embraced this program and made it successful so far.”

The same goes for planned updates or additions to the program over time. One such update is the addition of a shuttle – an apparatus that will allow power to be delivered to resuscitation equipment without needing a wall receptacle, allowing for resuscitations and transport from the delivery room to the NICU without a bed change for the first week of life. This is important for several reasons, one of which is that these babies can lose heat when transported, increasing the risk of hypothermia.

"We have been very fortunate to collaborate with our colleagues from various disciplines throughout this process and have especially benefitted from the support of our nursing leadership teams in both the NICU and Women Care Birth Center,” says Katie Schwabenbauer, MD, interim NICU medical director at UPMC Magee.

Another initiative in the works will allow these infants to be directly admitted into their NICU rooms, bypassing the NICU triage area. This will encourage a timely admission process and will provide these infants with the care they need in a focused environment.

"The leadership team also meets monthly to discuss the program, review every admission of extremely premature neonates, analyzing data and discussing how or where we can make improvements, immediately or in the future," says Dr. Ibrahim. 

Learn more about the Newborn Medicine Program at UPMC, and the work happening in the Neonatal Intensive Care Units.