September 27, 2010 — Editor's note: According to the March of Dimes, 1 of every 10 babies born in the United States is admitted to a neonatal intensive care unit because of prematurity or other medical condition. The care given during the critical "golden hour," particularly in very-low-birth-weight infants, has immediate and far-reaching effects. These infants face challenges that carry risks for short- and long-term injury, life-long developmental delay, and even death. A discussion of the golden hour was featured at the National Association of Neonatal Nurses 26th Annual Educational Conference, held from September 19 to 22 in Las Vegas, Nevada.
To find out more about this critical newborn period, Medscape Medical News interviewed Robin Bissinger, PhD, APRN, NNP-BC. Dr. Bissinger has been practicing as a certified neonatal nurse practitioner for 20 years. She is the director of the graduate program at the Medical University of South Carolina in Charleston, and past president of the National Association of Neonatal Nurses. She has collaborated at the state level in South Carolina within the SC Neonatal Medicine Consortium. Dr. Bissinger is the guest editor of the October 2010 issue of Advances in Neonatal Care, which focuses on the care of the neonate during the golden hour.
Medscape: What are the incidence, morbidity, and mortality rates of very-low-birth-weight (VLBW) infants in the United States?
Dr. Bissinger: The incidence of preterm birth in the United States increased from 10.7% in 1990 to 12.8% in 2006. The incidence of infants born with VLBW (<1500 g) is 1.5% of all births, an increase of 25% during the same period. Preterm birth is associated with significant mortality, morbidity, and healthcare costs. Advances in neonatal care have led to improved survival of the most premature infants. However, the mortality for VLBW infants in the United States remains at 14%. In 2006, the Institute of Medicine estimated the annual cost of preterm births in the United States to be $26 billion, or approximately $51,600 per preterm infant. Although VLBW infants represent only 12% of premature births, they account for 30% of total dollars spent on newborn healthcare. These higher costs reflect the significantly higher severity of morbidities that impact VLBW infants during the neonatal intensive care unit (NICU) stay.
Medscape: What is the actual time span of the golden hour (GH) for VLBW infants?
Dr. Bissinger: The first hours of neonatal life parallels concepts upon which the GH of trauma care is based. In trauma care, the GH refers to the time of first encounter to admission to the emergency department. There may be a GH of care for VLBW infants that begins with the first encounter at delivery until admission to the NICU.
The GH initiative goes beyond looking to change one clinical outcome. Instead, it looks at a process for providing care to implement multiple evidence-based practice initiative "bundles" that could improve short- and long-term outcomes for VLBW infants. During these initial hours, the clinician is faced with complex decisions based on multiple systems that require attention — knowing that care in these first minutes of life can translate into life-long medical problems.
Medscape: What GH resuscitation strategies have been developed at the Medical University of South Carolina (MUSC)?
The GH Guideline developed at the MUSC incorporates processes of neonatal resuscitation based on the Neonatal Resuscitation Program (NRP) guidelines. Expanding on NRP guidelines, the [MUSC] GH Guideline is based on the unique needs of the VLBW infant at birth and evidence-based strategies, including thermoregulation, respiratory support, cardiovascular stability, fluid and electrolyte management, and infection control.
The body temperature of premature infants drops precipitously after birth. Hypothermia after admission is a risk factor for mortality in preterm infants and is associated with acid–base abnormalities, respiratory distress, necrotizing enterocolitis, and intraventricular hemorrhages. We significantly decrease cold stress in VLBW infants who are at increased risk for hypothermia by controlling environmental temperature and using wraps.
An early complication of extreme prematurity is respiratory distress caused by surfactant deficiency. We significantly reduced the incidence of chronic lung disease by standardizing practice, ensuring early administration of surfactant, and developing a ventilation weaning protocol to ensure early extubation.
Postnatal growth restriction remains a significant problem in VLBW infants (<1500 g). Even 1 day of starvation can be detrimental to the premature infant. One strategy is to optimize protein intake early in the infant's neonatal course. With the introduction of protein within the first 2 hours of life and early administration of lipids, we have been able to decrease extrauterine growth retardation at discharge, demonstrating that the care in the first hours of life will impact long-term growth and outcomes.
Medscape: What suggestions do you have for staff development and the implementation of evidence-based GH protocols?
Dr. Bissinger: The promise of the GH in neonatal care lies not only in evidence-based treatment, but also in team structure, communication, and proficiency. Healthcare providers are faced with a multitude of tasks (cognitive, procedural, communicative, and managerial) that must be completed in a relatively short time. Neonatal resuscitation is complex and takes place in an extremely dynamic and complex environment. In this type of environment, communication and team function can become important factors in success. Team training exercises and simulations can help to ensure that well-functioning teams perform to a level that maximizes or even exceeds the skills of its individual team members. Interdisciplinary training and team development that challenge hierarchical barriers are an effective approach to improve outcomes and reduce medical errors.
Medscape: What is the most important take-home point about GH protocols?
Dr. Bissinger: The GH concept is a bundle of interventions that address the needs of the VLBW infant at birth and during stabilization. It provides a framework for training and team development that improves outcomes and care to some of our most vulnerable babies. Standardizing care to ensure consistency in practice also improves care to these fragile infants. It is essential that we continue to work as healthcare teams to decrease morbidity and mortality for all infants in the United States.
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Cite this: The Golden Hour -- A Resuscitation Strategy for Very-Low-Birth-Weight Infants: An Expert Interview With Robin Bissinger, PhD, APRN, NNP-BC - Medscape - Sep 27, 2010.