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Reducing Golden Hour Admission Times for Extremely Preterm Infants: An Improvement Science Initiative
Insights
This study significantly reduced the critical Golden Hour admission time for extremely preterm infants by 50%, from 117 to 59 minutes. This quality improvement initiative improved infant stabilization and care in the neonatal intensive care unit (NICU).
Area of Science:
- Neonatal Medicine
- Quality Improvement in Healthcare
- Perinatal Care
Background:
- The Golden Hour is a critical period for extremely preterm infants (<28 weeks' gestation), where timely stabilization can prevent severe morbidities like intraventricular hemorrhage and bronchopulmonary dysplasia.
- University of Virginia data revealed average Golden Hour admission times of 117 minutes for these infants, indicating a substantial need for process optimization.
Purpose of the Study:
- To implement a quality improvement initiative aimed at reducing the Golden Hour admission time for infants <28 weeks' gestation by 25% (to ≤87 minutes) within one year.
- To enhance the efficiency and stability of care delivery during the critical first hour of life for extremely preterm neonates.
Main Methods:
- Utilized the Institution for Healthcare Improvement (IHI) methodology, employing two Plan-Do-Study-Act (PDSA) cycles to address delays.
- PDSA 1 introduced a dedicated admission coordinator, standardized flowsheet, and visual timer; PDSA 2 focused on line-placement efficiency with auditory cues, team huddles, and earlier isolette closure.
- Statistical Process Control (SPC) charts (XbarS, XmR) monitored admission time, process measures (glucose, IV dextrose, X-ray, surfactant), and balancing measures (temperature, glucose, severe IVH rates).
Main Results:
- Achieved a 50% reduction in average Golden Hour admission time, decreasing it from 117 to 59 minutes among 106 infants.
- Improved the proportion of admissions meeting the target time (<87 minutes) from 8% to 100%, exceeding the study's aim.
- Demonstrated decreased process variability and maintained stable balancing measures, indicating improved efficiency without compromising infant safety.
Conclusions:
- Two sequential PDSA cycles successfully and sustainably reduced Golden Hour admission time by 50% without adverse effects.
- Structured team roles, real-time feedback mechanisms, and workflow redesign were key drivers for creating a more efficient and stable care process.
- This systematic quality improvement initiative effectively optimized Golden Hour care and is potentially replicable in other Neonatal Intensive Care Units (NICUs).
Objective:
The Golden Hour is the first 60 minutes of life for extremely preterm infants and represents a critical window where timely stabilization can reduce morbidity such as intraventricular hemorrhage and bronchopulmonary dysplasia. At the University of Virginia, average Golden Hour admission times for infants <28 weeks' gestation were 117 minutes, indicating a major opportunity for improvement. This study aimed to reduce admission time by 25% (to ≤87 min) for infants <28 weeks' gestational age within 1 year of implementation.
Study Design:
Using the Institution for Healthcare Improvement methodology, a multidisciplinary team identified key drivers of delay and implemented two Plan-Do-Study-Act (PDSA) cycles. PDSA 1 introduced a designated admission coordinator, structured flowsheet, and visible timer to enhance team awareness. PDSA 2 focused on line-placement efficiency, adding an auditory time, team huddles after 15 minutes, and earlier isolette closure to promote thermoregulation. Statistical process control (SPC) charts (XbarS, XmR) were used to evaluate changes. The outcome measure was time from admission to isolette closure. Process measures were time to glucose, IV dextrose, X-ray, and surfactant administration. Balancing measures were admission temperature, glucose levels, and severe intraventricular hemorrhage (IVH) rates.
Results:
Among 106 infants, the average admission time decreased from 117 to 59 minutes, resulting in a 50% reduction. The proportion of admissions meeting the SMART aim (<87 min) improved from 8 to 100%. Process variability decreased on both XbarS and XmR charts. Balancing measures remained stable.
Conclusion:
Two sequential PDSA cycles achieved and sustained a 50% reduction in Golden Hour admission time without adverse effects. Structured team roles, real-time feedback, and workflow redesign produced a more efficient and stable process. This initiative demonstrates that systematic QI can meaningfully optimize Golden Hour care and may be replicable across NICUs.
Key Points:
· This is the first reported quality improvement initiative to use admission time as a primary outcome within the neonatal Golden Hour framework.. · The results show a significant and sustained 50% reduction in admission time-from 117 minutes to 59 minutes-exceeding the SMART aim.. · Key drivers of change included defined team roles, visual and auditory cues, and standardization of the umbilical line placement workflow, which can be readily adapted for use in other NICUs seeking to test improvements during Golden Hour admissions..
