103 - Obtaining Birth Weight in the Delivery Room: A Golden Hour Quality Improvement Initiative

Publication Number: 4101.103

Nisha Dalvie, Boston Children's Hospital, Somerville, MA, United States; Helen Healy, Beth Israel Deaconess Medical Center, Brookline, MA, United States; Rachel J. Copertino, Beth Israel Deaconess Medical Center, Boston, MA, United States; Gina Story, BIDMC, Melrose, MA, United States; Joyce Chan, Beth Israel Deaconess Medical Center, Boston, MA, United States; Emily Whitesel, Beth Israel Deaconess Medical Center, Boston, MA, United States

Background: Golden Hour efforts in neonatology aim to achieve efficient, effective initial stabilization. One component of the GH is to obtain intravenous (IV) access and stabilize blood glucose. In a level III NICU, nearly half of infants < 32 weeks' gestational age (GA) were found to be hypoglycemic (glucose < 45mg/dL) when first measured, and the average time to begin infusing IV fluids was 116 minutes from birth. Obtaining birth weight (BW) in the delivery room (DR) as part of a golden hour protocol may reduce time to start IV fluid infusions and promote euglycemia for high-risk infants.

Objective: To reduce the time to start of IV fluid administration among infants born < 32 weeks' GA (with the goal of starting IV fluids by 60 minutes of life), over 6 months, with implementation of a DR weighing protocol.

Design/Methods: A Golden Hour initiative, part of the Vermont Oxford Network Quality Improvement Collaborative All Care Is Brain Care focus, identified baseline data. A Driver Diagram was developed with the aim of reducing time to euglycemia (Figure 1). A subsequent PDSA of this initiative sought to focus on time to start IV fluid. Data was obtained from chart review. A multidisciplinary group reviewed current practice, developed a protocol for weighing infants in the DR, created a training video, and conducted education of all staff members. The pre-delivery huddle was updated for this practice change. Time to euglycemia was used as a process measure during this PDSA. Balancing measures included admission hypothermia and weighing errors (defined as a change in the average difference between initial BW and second weight).

Results: To date, time from birth to IV fluid administration has decreased from a baseline of 116 minutes to 89 minutes which has nearly met criteria for special cause variation (Figure 2). Time to euglycemia in this population decreased non-significantly from a baseline of 122 minutes to 108 minutes. Though without special cause seen yet, this may reflect both the faster administration of dextrose-containing fluids and the decreased time to first glucose measurement (80 minutes vs 64 minutes). Hypothermia at admission has not significantly changed and change from birth weight on DOL 1 has remained close to -3%.

Conclusion(s): Obtaining BW in the DR can help streamline the process to begin IV fluids for high-risk infants without negatively impacting other golden hour goals. By integrating DR weighing with streamlined central line preparation in the future, we hope to achieve a meaningful reduction in the incidence of hypoglycemia in this vulnerable population.

Figure 1. Driver Diagram for Time to Euglycemia in Infants <32 Weeks' Gestation
A drive diagram demonstrating the primary and secondary drivers of time to euglycemia in high-risk infants with proposed change ideas mapped to each driver.

Figure 2. X Chart of Time to IV Fluid Administration in Minutes from Birth
An X chart demonstrating average time to IV fluid start (in minutes from birth). Each point represents the average value for a group of 5 infants born starting from the date listed. The date of this PDSA cycle is indicated on the graph along with the change in center line.