Extremely premature (EP) infants are fragile, susceptible to rapidly developing hypothermia and hypoglycemia, and face substantial risk of long-term morbidity and mortality. Golden Hour protocols (GHP) bundle and standardize evidence-based practices for care of these vulnerable infants during the first 60 minutes of life and are reported to decrease short-term and potentially decrease long-term morbidity and mortality. The purpose of the study was to examine short- and long-term outcomes in EP infants following implementation of a GHP in one neonatal intensive care unit.

Cyclical plan-do-study-act quality improvement (QI) methodology was utilized. Data were collected on inborn infants < 27 weeks' gestation (2012-2017) over 3 phases; pre-GHP (n = 80), Phase I (n = 42), and Phase II (n = 92). There were no statistically significant differences in infant characteristics.

A systematic approach to care of EP infants in the first hour of life resulted in improved short-term outcomes. Significant differences were observed in minutes to completion of GHP care [median (Q1,Q3) 110 (89,138) vs 111 (94,135) vs 92(74,129) respectively p = 0.0035], abnormal temperature (59% vs 26% vs 38%; p = 0.001) and hypoglycemia (18% vs 7% vs 4%; p = 0.012).

Evaluation of long-term morbidity and mortality did not reveal significant differences. However, there was an increase in the number of infants resuscitated and admitted at the cusp of viability (22 and 23 weeks gestation) over the three phases of the study (16%, 16%, 29%) similar to national trends of providing more aggressive care at earlier gestational ages. Although significant improvements in long-term outcomes were not observed, the lack of significant differences may represent a protective effect of GHP as the highest risks of morbidity and mortality are associated with the most premature infants.

Additional studies, larger sample sizes, and consistent analysis of long-term morbidities would provide greater insight into the impact of GHP. Ongoing QI should focus on sustaining achieved improvements, continuing to improve time to completion of care, and seeking additional, meaningful short-term outcome measures.