The first 60 minutes of a premature infant’s life is considered the “Golden Hour”. Care and treatment provided during the first hour of life can mean the difference between life and death or long-term health problems. In recognition that some of its processes were not meeting best practices (e.g. administering antibiotics within one hour), BC Women’s Hospital Newborn Intensive Care Unit used lean methodologies and process improvement techniques to standardize practice for all premature infants admitted to the Neonatal Program.

This initiative resulted in the Golden Hour Protocol, which includes: – clarified and standardized roles of staff during the admission process – reporting tool to standardize handover and a process to give advance notice before arrival – reduced rework by combining two documents into one “Admission Checklist” document that is now official chart documentation – golden hour check at one hour to review patient status – 5S (sort, straighten, shine, standardize, sustain) on admission documentation – admission status board to provide updated information on pending admissions – new physician practice for line placement to ensure timely antibiotics administration – process with Radiology to provide advance notice for X-rays.

 The Golden Hour Protocol reviews a baby’s health status at one hour after admission in five critical areas: respiration, cardiovascular function, neurological response, fluid and glucose levels, and body temperature. The results from each of these five areas determine the infant’s health status: red (acute) zone requiring immediate interventions, yellow zone requiring close monitoring, or green zone where the infant is responding well to stabilization.

At BC Women’s Hospital, the Golden Hour Protocol practice change has been in place since June 2011 and is now part of the standard work on all Neonatal Intensive Care Unit admissions. This project was done using Lean methodology in order to create the standard for roles of the multidisciplinary team. This work designed how the multidisciplinary team can function to stabilize new admissions. A laminated Golden Hour Check is at each bedside and once the five vital areas are assessed, approximately at one hour after admission, the nurse documents this on the Admission Checklist. The administration of antibiotics and completed x-rays are also documented on the checklist to note that these activities are completed in order to address any health concerns of the infant in a timely manner.

Contact Information:

Title: Quality Leader, NICU, BC Women's Hospital

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