Golden Hour Thermoregulation of Extremely Low Birth Weight Infants Amaris Keiser MD, Angela Montgomery MD, Matthew Bizzarro MD, Yeisid Gozzo MD and the Delivery Room Initiative Committee Yale University School of Medicine, New Haven, CT, USA Primary author: Amaris Keiser, MD amaris.keiser@yale.edu (203) 688-2320 KEYWORDS: Thermoregulation, hypothermia, ELBW Background: Effective stabilization and management of the extremely low birth weight (ELBW) infant during the hour immediately following delivery room (DR) resuscitation termed the Golden Hour is known to have an impact on short and long-term outcomes. Compared to VON published data, we noted elevated rates of hypothermia (temperature <36.5 C) on admission to the neonatal intensive care unit (NICU) at our institution. We felt this to be secondary to a lack of standardized thermoregulatory measures and lack of emphasis on preventing heat loss during the DR resuscitation and transition to the NICU. Aims: To decrease the incidence of ELBW hypothermia (skin temperature <36.5 C) on admission from 69% to no more than 47% to align with the 2013 VON annual incidence. We will achieve this within 1 year, and strive to maintain and improve upon this rate over time. Ultimately, our goal is for all ELBW infants to have an admission temperature between 36.5 C and 37.5 C, in the optimal physiologic range. Setting: A Level IV, 54 bed NICU (Type C) at an urban academic medical center with approximately 800 admissions per year (88% inborn). ELBWs account for approximately 9% of annual admissions. Mechanisms/Drivers of change: Traditionally, the initial management of ELBW infants at our institution was provider-dependent, without consensus or evidence-based guidelines to inform medical management or insure consistency. The multidisciplinary Delivery Room Initiative Committee identified the absence of clearly-defined and standardized thermoregulatory measures and lack of emphasis on maneuvers to establish normothermia and prevent hypothermia during the DR resuscitation and initial NICU stabilization as potential drivers of current undesirable outcomes (Figure 1). Methods: We created formal thermoregulation management guidelines, including setting the DR ambient temperature to 78 F, setting the radiant warmer to 10 heat, consistent and appropriate use of a chemical warming mattress for all deliveries at <30 weeks, placement of a warmed hat immediately after drying, placing sides of the radiant warmer up and nesting the infant with warm blankets promptly after resuscitation, and keeping the infant on the warming mattress during the transition to the NICU and umbilical line placement. Measures: Measures were collected via chart review, analyzed quarterly and presented at committee meetings biannually. Outcome measures: Average ELBW admission temperature Percent of ELBWs with admission body temperature <36.5 C Percent of ELBWs with admission body temperature > 37.5 C Percent of ELBWs with admission body temperature 36.5 C 37.5 C Data/Results: Our data demonstrate an overall decrease in the incidence of ELBWs with admission temperatures <36.5 C (57% vs 69%), an increase in the percent of admission temperatures within the goal range (37% vs 31%), and a trend towards overall higher admission temperatures (Figures 2-3). However, we were unable to decrease rates of hypothermia to below the 2013 VON incidence of 47.7%, and our data are highly variable (Figures 4-6). Discussion: Our data demonstrate initial success in decreasing the absolute rate of ELBW admission hypothermia by 12% following project implementation, though we did not reach our goal rate of 47.7%. We were unable to sustain this initial improvement in admission temperatures, which indicates the need to critically review our processes and chosen measures through additional PDSA cycles and determine how best to refine our intervention to yield lasting results.
Team Acknowledgement: Amaris Keiser, MD: prepared abstract, involved in identification of potential drivers, development of educational materials, development of implementation strategies, responsible for data collection, collation and analysis Angela Montgomery, MD: involved in identification of potential drivers, development of educational materials, development of implementation strategies, responsible for data collection and analysis Yeisid Gozzo, MD: senior leader, head of Delivery Room Initiative Committee (DRIC), provided structure and oversight for all aspects of this project, provided ongoing support for this project Matthew Bizzarro, MD: senior leader, identified need to address poorly performing outcome measures, created DRIC, provided ongoing support for this project Delivery Room Initiative Committee members: involved in the identification of potential drivers of change, creation of interventions, implementation of initiative, and ongoing education/training of staff members Angela Craft, APRN, NNP-BC Nancy Koval, APRN, NNP-BC Tracy Gambardella, PA-C Megan Luizzi, PA-C Timothy Mack, RT Steven Nivison, RT Louise Dunphy, RN Michele Faust, RN Erica Leighton, RN
Key Driver Diagram Figure 1: Key Driver Diagram demonstrating the mechanisms we believe account for the pre-intervention elevated rates of ELBW hypothermia. Distribution of ELBW Admission Temperatures, Pre- and Post-Intervention 7 6 5 Incidence 4 3 Pre- Interven6on Post- Interven6on 1 <36.5 36.5-37.5 >37.5 Admission Temperature (degrees Celcius) Figure 2: Bar graph demonstrating overall decrease in incidence of hypothermia before and after implementation (69% vs 57%).
Average ELBW Admission Temperatures 37 VON 2013 Average "Roles & Responsibilities" chart updated Golden Hour Initiative presented to medical staff Initiative "Go Live" 36.5 Temperature (Celcius) 36 35.5 Yale Pre-intervention Average 35 Ongoing staff education Quarterly newsletter updates 34.5 Q2 2015 Q1 2015 Q4 2014 Q3 2014 Q2 2014 Q1 2014 Q4 2013 Q3 2013 Q2 2013 Q1 2013 Q4 2012 Q3 2012 Q2 2012 Q1 2012 Q4 2011 Q3 2011 Q2 2011 Q1 2011 Q4 2010 Q3 2010 Q2 2010 Q1 2010 Figure 3: Run chart demonstrating average ELBW admission temperatures over time. While not yet achieving the goal of all admission temperatures between 36.5 C and 37.5 C, the trend over time has been an overall increase in average admission temperatures.
Incidence of ELBW Hypothermia on Admission (<36.5 C) Incidence (%) 10 9 8 7 6 5 4 3 1 Jan- 13 Feb- 13 Mar- 13 Apr- 13 May- 13 Jun- 13 Jul- 13 Hypothermia data reviewed, goals and aims developed "Golden Hour Initiative" presented to medical staff Aug- 13 Sep- 13 Oct- 13 Nov- 13 Dec- 13 Jan- 14 Feb- 14 Mar- 14 "Roles & Responsibilities" chart updated Apr- 14 May- 14 Jun- 14 Jul- 14 Aug- 14 Initiative "Go Live" Sep- 14 Oct- 14 Nov- 14 Dec- 14 Jan- 15 JustBreathe newsletter with "Golden Hour" updates Feb- 15 Mar- 15 Apr- 15 May- 15 Jun- 15 Jul- 15 VON 2013 incidence hypothermia Yale 2013 incidence <36.5C <36.5C (%) Figure 4: Run chart demonstrating initial decrease in incidence of admission hypothermia, though the decreased rate was not sustained over time.
Incidence of ELBW Normothermia on Admission (36.5 C - 37.5 C) 10 8 Roles & Responsibilities chart updated "Golden Hour Initiaive" presented to medical staff JustBreathe newsletter with "Golden Hour" updates Incidence (%) 6 4 Hypothermia data reviewed, goals and aims developed Jan- 13 Feb- 13 Mar- 13 Apr- 13 May- 13 Jun- 13 Jul- 13 Aug- 13 Sep- 13 Oct- 13 Nov- 13 Dec- 13 Jan- 14 Feb- 14 Mar- 14 Apr- 14 May- 14 Jun- 14 Jul- 14 Aug- 14 Initiative "Go Live" VON 2013 incidence normothermia Yale 2013 incidence 36.5-37.5C 36.5C - 37.5C (%) Sep- 14 Oct- 14 Nov- 14 Dec- 14 Jan- 15 Feb- 15 Mar- 15 Apr- 15 May- 15 Jun- 15 Jul- 15 Figure 5: Run chart demonstrating initial increase in incidence of admission temperatures to within goal range; however, this trend was not sustained. Incidence of ELBW Hyperthermia on Admission (>37.5 C) Incidence (%) 10 9 8 7 6 5 4 3 1 Initiative Go Live Golden Hour Initiative presented to medical staff JustBreathe newsletter with Golden Hour updates Ongoing staff education VON 2013 incidence hyperthermia Yale 2013 incidence >37.5C >37.5C (%) Figure 6: Run chart demonstrating the infrequent, but measurable, occurrence of infant hyperthermia following implementation of this QI project. Of note, none of the infants had admission temperatures >38 C (febrile).
Golden Hour Thermoregula2on of ELBW Infants AIMS Primary Drivers Secondary Drivers Poten2al Change Concept Overall Project Goal To improve the delivery room management of ELBW infants to opnmize infant outcomes Primary Aim: ase the incidence of hypothermia on n (skin temperature <36.5 C) to at or e VON 50 th percen2le within 1 year of nta2on Secondary Aim: se the incidence of normothermia on n (skin temperature 36.5 C 37.5 C) to ve the VON 50 th percen2le within 1 year enta2on Outcome Measures: of inborn ELBW infants with admission ture <36.5 C, >37.5 C, and 36.5-37.5 C Balancing Measures erthermia on admission (skin perature >37.5 C) ence of IVH ence of DR chest compressions or ephrine administra2on ence of Apgar score <4 at 5 minutes ence of Pneumothorax Lack of standardized interven2ons to prevent heat loss and maintain normothermia in the DR Lack of standardized interven2ons to prevent heat loss and maintain normothermia upon admission to the NICU Lack of awareness of prevalence and implica2ons of hypothermia Lack of standardized approach to the resuscita2on of ELBW infants Failure to perform rou2ne maneuvers to conserve and preserve heat in the DR No standardized provider educa2on addressing how to establish and maintain normothermia/prevent heat loss in ELBWs Failure to perform rou2ne maneuvers to conserve and preserve heat in the NICU No specific focus on thermoregulatory measures during the DR resuscita2on and transi2on to NICU Inconsistent use of the chemical warming mabress Incorrect use of the chemical warming mabress Inconsistent/delayed placement of hat, removal of infant from wet blankets 1) Modifica2on of Roles and Responsibili2es chart 2) Review of the NRP algorithm with all NICU providers with a specific focus on preven2ng infant heat loss 3) Targeted provider educa2ona sessions addressing temperature management in the ELBW 1) Universal staff educa2on regarding prevalence and poten2al consequences of hypothermia 2) Reinforcement of effec2ve chemical warming mabress u during biannual skills valida2o sessions for ALL medical providers 3) Quarterly newsleber updates repor2ng progress/complianc 1) Modifica2on of preexis2ng Prepara2on Checklist 2) Dedicated space for warmed hats and blankets in the L&D warmer