762 - Optimizing the Golden Hour for Infants at 22–24 Weeks: A Quality Improvement Initiative

Publication Number: 2743.762

Amy Kelly-Vega, Orlando Health Winnie Palmer Hospital, Orlando, FL, United States; Thais O. Queliz, Arnold Palmer Hospital for Children, Winter Park, FL, United States; Allison Ramey, Orlando Health, Orlando, FL, United States; Michael JOSEPH. McMahan, Arnold Palmer Hospital for Children, Windermere, FL, United States; Samantha Enstad, Arnold Palmer Hospital for Children, Orlando, FL, United States; Kathryn A. Winn, Arnold Palmer Hospital for Children, Windermere, FL, United States; Karla Diaz Ayllon, Pediatrix, Windermere, FL, United States; Catherine Love, Arnold Palmer Hospital for Children, Orlando, FL, United States

Background: Winnie Palmer Hospital for Women and Babies is a high-volume, high-acuity hospital dedicated to women's and neonatal care. Infants born at 22-24 weeks' gestation remain at high risk for mortality and early complications. As part of our internal Tiny Baby Collaborative (TBC) launched in Q3-2017, structured Golden Hour (GH) protocols were implemented to improve physiologic stability and early care processes. These included delivery room and NICU interventions such as airway management, early surfactant, umbilical line placement, dextrose infusion, and antibiotics (added in 2023). Prior to 2020, implementation was informal with variable adherence.

Objective: To evaluate the impact of structured GH protocols on admission temperature, glucose stability, and care timeliness in infants born at 22-24 weeks' gestation. Our initial goal was to increase GH completion to 75% by December 2022.

Design/Methods: This retrospective QI study included inborn NICU admissions at 22-24 weeks' gestation between Q3-2017 and Q4-2024. The pre-intervention period was Q3-2017 to Q4-2019; post-intervention began Q1-2020. GH completion was defined as all GH tasks completed within 60 minutes. Outcomes included GH completion rate, median GH duration, normothermia at admission, normothermia with euglycemia, and moderate to severe hypothermia. Chi-square tests were used for categorical comparisons, t-tests for continuous variables, and relative risk (RR) with 95% confidence intervals (CI) where applicable.

Results: A total of 324 infants were analyzed (pre n=75, post n=249):
GH completion increased from 8.0% (6/75) to 75.1% (187/249), p < 0.001, RR 9.4 [4.3-20.4]
Median GH time decreased from 110 to 54 minutes, p < 0.001
Normothermia increased from 47.9% (35/73) to 60.6% (149/246), p = 0.055, RR 1.27 [0.99-1.63]
Normothermia with euglycemia improved from 38.4% (28/73) to 50.0% (122/244), p = 0.080, RR 1.30 [0.96-1.76]
Moderate/severe hypothermia decreased from 16.1% (10/62) to 7.5% (17/228), p = 0.063, RR 0.46 [0.22-1.01]

Conclusion(s): Implementation of structured Golden Hour protocols led to a marked reduction in time to complete tasks and substantial improvement in adherence, achieving the target of 75% GH completion by December 2022. Although some outcomes did not reach statistical significance, positive clinical trends, specially in thermoregulation, have remained sustained. This multidisciplinary initiative remains active and continues to unite obstetrics, MFM, neonatology, nursing, RRTs, radiology, and fellows, fostering collaboration and continuous quality improvement in periviable care.

Control Chart: Golden Hour Completion Rates for Infants
Percentage of infants at 22-24 weeks' gestation who completed all Golden Hour interventions each quarter. Following implementation of standardized protocols and education (starting Q1-2020), there was a marked and sustained improvement in GH completion, rising from < 10% to consistently above 75%. Key interventions included scripting, symposiums, and monthly feedback.

Reduction in Golden Hour Admission Time Following Process Standardization
This X-bar control chart tracks median admission time in minutes for 22-24 week infants across quarterly periods. A significant and sustained reduction is observed after Q4-2019, following implementation of structured protocols, including scripted workflows and regular education. Median time dropped from 110 minutes to 54 minutes post-intervention, meeting the 60-minute target with minimal variability.

Improvement in Normothermia Rates in 22-24 Week Neonatal Admissions
This control chart shows quarterly trends in the percentage of neonatal admissions maintaining normothermia (36.5-37.5°C). A sustained increase occurred following structured Golden Hour interventions, peaking above 80% in some quarters. A temporary drop was observed after a systems issue limited OR thermostat control, highlighting operational impact. Despite variability, the centerline shifted from 50% to 75%, reflecting ongoing clinical progress.