762 - Decreasing Early Hypoglycemia in Preterm Infants

Publication Number: 1738.762

Devanshi S. Shah, Cohen Children's Medical Center, New York, NY, United States; Benjamin Winchel, Northwell, Staten Island, NY, United States; Kristina Scarfo, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Brooklyn, NY, United States; Marta Kurhan, Northwell, Wantagh, NY, United States; Zachary H. Ibrahim, Cohen Children's Medical Center, Merrick, NY, United States; Olena Predtechenska, Northwell Health, Bellmore, NY, United States; Barry Weinberger, Cohen Children's Medical Center, New Hyde Park, NY, United States

Background: Neonatal hypoglycemia can contribute to physiologic instability and long-term developmental impairment in preterm infants. Previous studies have suggested that lack of intravenous access in the delivery room is the biggest obstacle to the early identification and treatment of hypoglycemia. "Golden hour" protocols have been introduced in many units to standardize the stabilization of preterm infants within one hour of birth, including vascular access. Nevertheless, the reported incidence of neonatal hypoglycemia remains as high as 73%. The incidence of hypoglycemia for infants born at < 30 weeks' gestation was 38% in our level III and IV NICUs.

Objective: Our SMART aims were to: 1) decrease the time to start of dextrose-containing fluids to 45 mins after birth (process), and 2) reduce the incidence of hypoglycemia from 38% to 20% for infants born at < 30 weeks' gestation in our NICUs (outcome) by October 31, 2025.

Design/Methods: Infants born at < 30 weeks between Nov 2024 and Oct 2025 in our 57-bed level IV and 30-bed level III NICUs were included. A committee of neonatologists and nurses identified best practices, including: 1) umbilical access in the DR, 2) "PIV timeout" at 30 minutes to redirect to placement of a peripheral IV if an umbilical line is considered not likely before 45 mins, 3) dextrose-containing fluids by 45 mins, before radiologic confirmation of line position, and 4) point-of-care glucose at 1 hour of life. Several PDSA cycles were performed to disseminate and implement these practices.

Results: Time to dextrose fluid administration decreased from median 113 to 60 mins after initiation of education (PDSA 1), with further improvement to 39 mins after implementation of the Golden Hour protocol and introduction of logo buttons (PDSA 2,3,4) (Fig. 1). The percentage of patients with hypoglycemia decreased from median 38% to 15% after implementation of the Golden Hour protocol (Fig. 2).

Conclusion(s): A systematic educational program, comprehensive Golden Hour protocol and visual aids successfully decreased the incidence of hypoglycemia in preterm infants. We believe that targeted focus on the outcome of hypoglycemia facilitated the success of the overall Golden Hour program because hypoglycemia is both clinically important and immediately known. Visual aids (e.g., buttons) are a time-efficient way to maintain focus on hypoglycemia and sustain success during the Golden Hour.

Fig. 1: Run chart: Age at start of intravenous dextrose.
PDSA 1: Targeted e-mails about complications of hypoglycemia to all staff and announcements at nursing brief every shift.
PDSA 2: Educational program on Golden Hour with sessions for medical and nursing staff.
PDSA 3: Roll-out of comprehensive Golden Hour protocol, with posters in the delivery areas on the sequence and time course for stabilization and vascular access in the first hour.
PDSA 4: One-on-one nursing education and distribution of pins with a mascot and the catchy slogan "Dextrose to Thrive, Line by 45" (Fig. 3).

Fig. 2: Run chart: Hypoglycemia (%).


Fig. 3: Logo on buttons distributed to staff