Preterm infants placed in the Neonatal Intensive Care Unit are the most vulnerable population compared to all other populations. In the first few hours of life, these preterm infants can suffer from typical problems, such as hypothermia and/or hypoglycemia due to prematurity. By using the Golden Hour Protocol, preterm infants can show improved outcomes in their quality of life. In this paper, I present a discussion of various key concepts on the quality of care and safety of preterm infants in NICU, which is a topic of interest that I have observed; I also give some examples of improvements that can be made to improve the quality of life of infants in the NICU.
Keywords: Quality and Safety, NICU, preterm babies, Golden Hour protocol, CINAHL
Quality and Safety Assignment
Quality improvement consists of systematic and continuous actions that lead to measurable enhancement of health care services and the health outcomes of targeted patient groups. The Neonatal Intensive Care Unit (NICU) provides a good platform for the implementation of a various quality improvement practices as a highly complex adaptive system (Harriman et al., 2018). Complex adaptive systems such as the NICU are departments and entities that are part of the interlinked whole. Teams have to manage working within emerging ecosystems, by understanding the factors that facilitate team effectiveness while managing and supporting teams and team conflicts, and by understanding the development of conflict resolution models. As such, the quality improvement process requires those working in NICU to be trained in various aspects, such as patient safety and the principles of quality improvement.
Hypothermia and hypoglycemia in newborns are a universal problem associated with increased morbidity and mortality. Various outcomes have been associated with hypothermia and hypoglycemia in newborns, including delayed adjustment to newborn circulation (Lunze et al., 2014), metabolic acidosis, coagulopathy, oxygen dependency, intraventricular hemorrhage, late-onset sepsis, neurodevelopmental disturbances, and death. The World Health Organization has recommended that the temperatures of newborns be maintained between 36.5 and 37.5°C. Preterm infants, especially the very low birth weight infants, are particularly at risk for hypothermia because of their greater evaporative, convective, and conductive heat losses, as well as their diminished physiological responses to cold stress. Preterm infants are at increased risk of hypoglycemia due to decreased glycogen stores, leading to a decreased ability to produce glucose (Lunze et al., 2014). They are also likely to have increased metabolic demands and subsequent increase in glucose utilization due to stress, respiratory distress syndrome, hypoxia, and other factors. While term infants usually feed within an hour of birth, preterm infants must rely on glucose-containing intravenous fluids to maintain adequate blood glucose levels after birth. A quality improvement initiative was planned to reduce the incidence of hypothermia and hypoglycemia. The effectiveness of the new interventions was studied during the implementation period, as well as following implementation to evaluate for sustained effectiveness.
There is a need to identify and promote workable practices and simultaneously eliminate risks to patient safety through evidence-based practices in order to improve the quality of care in NICU. However, there exists a considerable gap between research and the actual clinical practice. In this case, quality improvement initiatives provide the necessary framework that is required to do the right things in the right way. The quality improvement initiatives enable clinicians to realize better care outcomes with patients. For instance, there have been various medical improvements in neonatal care that focus on reducing mortality and morbidity. For example, during my clinical hours in the NICU, I have seen premature infants in incubators at set temperatures to decrease the complications of hypothermia. Having an incubator with a set temperature helped to keep the premature infants warm while head to toe assessments were conducted on them.
The key underlying factor is the experience of the neonates as well as the parents in the time spent in the NICU. Through my clinical practice, I have noticed that many parents experience good outcomes with their babies graduating from NICU without the need for longer or more extensive medical care. However, some parents have horrible experiences as their babies experience complications in NICU, increasing their duration of stay. The rate of survival of neonates is one of the measures of real outcomes in health care. Lifetime outcomes in NICU help to improve patient care, hence providing important measures for consideration. The practice of monitoring the outcomes of different neonatal units helps in discovering the real issues in those units (Harriman et al., 2018). From the findings of such monitoring practices, strategies can be established for addressing the identified real issues.
The practice of quality improvement requires the combination of efforts from various quarters, including health care professionals, patients, family members, educators, as well as researchers, towards ensuring the adoption of various changes required to enhance healthcare outcomes in the system. Through my experience at the NICU, I have noticed that the excellent collaboration among the interdisciplinary team members in various aspects, including daily rounds on patients and the education of parents on various topics. The ultimate purpose of quality improvement is to ensure that a methodology is developed for improving care and enhancing the reliability of care for the neonates in NICU. The value of healthcare is accurately defined from the perspective of the patient as well as based on the individual-centered care model that considers health quality indicators. This conceptualization of the value of healthcare is based on the fact that parents’ expectations go beyond ensuring infant survival from NICU. Parents are also concerned about the safety of their infants and the reliability of care processes. Additionally, they expect high levels of pain management, careful handling, and necessary attention towards the development of their babies’ needs (Harriman et al., 2018). Addressing these needs improves the levels of parental satisfaction with NICU services and the likelihood of strong positive health outcomes for preterm infants in NICU.
The neonates are at high risk of hypothermia owing to their limited abilities to respond to various body mechanisms effectively, such as limited ability to initiate non-shivering thermogenesis. They are always at a risk of hypoglycemia due to their low glycogen storage and the inability to produce sufficient glucose. The neonates also have a high vulnerability to increased metabolic needs due to stress, respiratory distress syndrome, alongside other factors that increase glucose utilization. Unlike term infants, preterm infants usually rely on glucose-containing intravenous (IV) fluids to maintain adequate blood glucose levels immediately after birth. The preterm infants are known to have immature innate as well as adaptive immunity that places them at increased risks of infection.
The establishment of an evidence-based Golden Hour protocol with accurately defined roles for each participant could help in increasing the efficiency of the NICU staff, therefore, improving the patient outcomes. This calls for necessary strategies that could help minimize the effects of various problems, such as hearing loss, oxygen requirement, and seizures; thus, ultimately improving outcomes amongst the population. The Golden Hour Protocol provides the necessary guide that facilitates quality caring for preterm infants systematically, especially at birth. The Golden Hour Protocol can as well be established depending on the variations that cater to the specific needs of the unit (Harriman et al., 2018). Such protocol entails interventions that are focused on improving quality care activities in the delivery room, which may include respiratory stabilization, early initiation of IV fluids and nutrition, and thermoregulation, among others.
Identifying the Problem
At birth, premature infants have very limited energy stores. In utero, the placenta provides the energy needs of the fetus through the transport of glucose, amino acids, free fatty acids, and ketones, and the majority of glycogen accretion takes place during the third trimester. Following birth and the clamping of the umbilical cord, the neonatal glucose concentration decreases quickly. Glucose is the main energy substrate in the neonate, and the major source of glucose utilization is the neonatal brain. Extremely premature infants have a primary failure in the production and storage of glycogen and may lack the cerebral defenses against hypoglycemia that exist in term infants. Moreover, early protein administration is required to prevent catabolism and help stimulate endogenous insulin secretion and thus buffer the infants against the occurrence of hyperglycemia.
The ultimate objective of the Golden Hour protocol is to prevent hypothermia amongst the neonates. The Golden Hour protocol ensures that preterm infants are exposed to delivery room temperatures of between 23˚C and 25˚C, placed on a thermal mattress, and wrapped using polyethylene plastic bags. One of the randomized controlled trials on the Golden Hour protocol confirms the fact that the utilization of occlusive plastic wrappers on neonates at birth improves the NICU admission temperature as compared to not wrapping the infants. The result of the study revealed that the infants subjected to a plastic wrap at the point of delivery showed significantly higher temperatures as compared to those in the control group and those not placed under the plastic wrap (P< .003) (Lambeth et al., 2016). It is thus concluded that the plastic wrap was effective as a measure of preventing hypothermia in preterm infants immediately after birth.
The implementation of the Golden Hour protocol has shown significant improvement, according to studies by Lambeth et al. (2016). The authors also revealed significant improvement in the time of initiation of the administration of dextrose IV fluids. At the same time, a significant increase in the number of infants with glucose concentrations above 50 mg/dL during admission to NICU was observed after implementing the protocol (Lambeth et al., 2016). Further, the Golden Hour protocol aims at improving the time taken to initiate the administration of empiric antibiotics at the point of indication. Such results show clinical significance in the improvement in the time taken to complete the admission process. The awareness of the pharmacy staff of the Golden Hour protocol led to a decrease in the time of drug administration (Croop et al., 2020). This outcome justifies the recommendation for staff education as an intervention strategy for enhancing the implementation of the Golden Hour protocol.
Creating an Action plan
Implementation of the Action Plan
Expected results. In preterm infants, the challenges to hypothermia prevention begin in the operating room, where a series of morbidities can begin if effective prevention procedures are not followed. Past trials have shown that a series of interventions can successfully result in continuous improvement outcomes, particularly if all team members are effectively trained on the rationale behind the implementation of different intervention measures. Through the application of interdisciplinary collaboration, continuous education of healthcare providers, well-designed initiatives for quality improvement, it is possible to prevent hypothermia in high-risk preterm neonates. It is also possible to avoid moderate hypothermia and all care providers should focus on this for newborns (Fanaroff & Fanaroff, 2016). I confidently believe that positive impacts will be realized on the health outcomes of the high-risk preterm infant population by conducting reinforcement education among team members who have been in the organization for longer periods of time, and introducing the concept to new staff members who join the team. This positive outcome will, in turn, contribute to the overall health of the organization and its staff.
Quality of Research from the Synthesis of Recommendations
Support of clinical changes in my setting. The process measures applicable in this study directly contributed to the improvement and stabilization of the NICU. The measures led to significant improvements in the proportion of time taken by physicians to effect the required changes in neonatal care. This shows that the implementation of the evidence-based Golden Hour protocol was very effective and ensured significant improvements in euglycemia, euthermia, as well as the time required for stabilizing the admission of infants into the NICU. Sharma (2017) reports that with the implementation of the Golden Hour protocol, better health outcomes are realized with enhanced transport and reduced mortality. The identified improvements are consistent with the previous results recorded in other studies. In this case, the area of interest involves an increase in cases of resuscitation alongside the survival of infants following the intervention mechanisms. The implementation of these interventions offers a form of protective effect that has proven to be beneficial at some lower gestational age. The protocol provides efficient evidence-based care within the first hour of the life of an infant. It, therefore, has the potential to improve the results amongst the infant population. This finding qualifies the implementation of various quality improvement initiatives around the NICU setting to provide the best start for improving the quality of care for vulnerable preterm patients (Croop et al., 2020). Negligible improvements such as those recorded in the study are capable of contributing positive outcomes for the neonates; hence any degree of improvement is recommended.
Criticism of the recommendations. This study reveals the fact that preterm infants are one of the most vulnerable patient populations, especially in the early hours of life after delivery. These preterm infants are vulnerable to hypothermia, hypoglycemia, as well as early-onset of sepsis, which are common problems related to premature birth. However, there is a need to investigate the timings of the outcomes of the implementation of the Golden Hour protocol. At the same time, the degree of effectiveness of the implementation of the Golden Hour protocol within different NICU environments is still questionable. However, there is room for implementing practices that improve the level of effectiveness as well as the efficiency of stabilization of preterm infants during the admission process. The idea of emphasizing the concept of teamwork amongst multidisciplinary team members around the NICU is very crucial. This is because the objective of NICU is to provide an environment that replaces the womb to help optimize health recovery as well as growth (Croop et al., 2020). The earlier this is achieved after birth, the better the health outcomes for the infants are achieved.
Increasing parents’ confidence and satisfaction levels around NICU operations requires the implementation of various practices as outlined in the protocol. However, the sustenance of the NICU process requires health professionals to be capable of addressing the needs of all the affected during different phases of their stay in hospitals. Parents with very preterm infants and those with long NICU admissions require adequate attention, information, and follow-up. The nature of the relationship that exists between health professionals and patients provides a basis for a high level of parental satisfaction with the care provided in the NICU. However, most previous studies have not included the socio-demographic variables that usually affect patient satisfaction and the factors that relate to patient-reported experiences. In this case, improvement of quality of services at NICU requires the inclusion of data gathered from parents’ experiences and their levels of satisfaction with other factors already considered.
Croop, S. E., Thoyre, S. M., Aliaga, S., McCaffrey, M. J., & Peter-Wohl, S. (2020). The Golden Hour: A quality improvement initiative for extremely premature infants in the neonatal intensive care unit. Journal of Perinatology, 40(3), 530-539.
Harriman, T. L., Carter, B., Dail, R. B., Stowell, K. E., & Zukowsky, K. (2018). Golden Hour Protocol for Preterm Infants: A Quality Improvement Project. Advances in Neonatal Care, 18(6), 462-470.
Lambeth, T., M., Rojas, M., A., Holmes, A., P., & Dail, R., B. (2016). First golden hour of life: A quality improvement initiative. Adv Neonatal Care 16(4):264-272.
Lunze, K., Yeboah-Antwi, K., Marsh, D. R., Kafwanda, S. N., Musso, A., Semrau, K., Waltensperger, D. H., (2014). Prevention and management of neonatal hypothermia in Rural Zambia. PLoS One, 9(4). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3979664/
Sharma, D. (2017). Golden hour of neonatal life: Need of the hour. Mental Health, Neonatology, and Perinatology, 3(16). https://mhnpjournal.biomedcentral.com/articles/10.1186/s40748-017-0057-x