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The Golden Hour

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The Golden Hour ANC200120.qxp 8/18/10 7:06 PM Page 221 DAVID J. ANNIBALE, MD; ROBIN L. BISSINGER, PHD, APRN, NNP-BC The Golden Hour he first hour of life for a premature infant rep- surfactant were associated with similar improved out- resents a time period during which the infant comes for very premature infants. In both of these T faces challenges that carry risks of short- and interventions, reduced oxygen delivery and alveolar long-term injury, lifelong developmental delay, and recruitment with surfactant immediately after estab- even death. Delivery room personnel have the lishment of ventilation, delivery of oxygen and opportunity to impact the transitional process, posi- mechanical ventilation must be adjusted in accord tively or negatively. During this time period, the cli- with ongoing assessment of the infant’s response to nician is faced with complex decisions based on mul- resuscitation. In addition, there are other systems that tiple systems that require attention knowing that care must be considered simultaneously. Thermal stresses, in these first minutes of life can translate into lifelong states that might predispose to central nervous system medical problems. In this way, the first hour of injury, rapid responses to the possibility of infection or neonatal life parallels concepts upon which the blood losses, and the rapid delivery of fluids and nutri- Golden Hour of Trauma is based. Is there reason to ents are simultaneously demanding attention during develop a golden hour in neonatal-perinatal medicine? the first minutes to hours of extrauterine life. Is the analogy between this and the Golden Hour of As one can infer from the description given earlier, Trauma strong enough to adopt in our field? In the time period beginning at birth and extending trauma, the golden hour is a concept of time—it is through stabilization is associated with multiple con- important to get the patient to a facility where defini- siderations occurring both simultaneously and in tive care can be provided within 60 minutes. In neona- sequence, sometimes dependent on each other (ie, tology and within the articles presented in this month’s the delivery of intravenous antibiotics requires vas- journal, there is a focus that begins with birth but cular access, the timing of which in turn is dependent extends beyond the first 60 minutes. We hope to chal- on respiratory interventions). Coupled with person- lenge the reader to move beyond simple timing of nel management (often involving personnel of vary- interventions into the “why” and “how” of what we do. ing or limited experience), the opportunity for Indeed, the process of respiratory adaptation exem- “ordered chaos” to become simply chaos is signifi- plifies the opportunity to impact care in the first cant. Approaches to minimize that risk include the moments of extrauterine life. As described in this issue neonatal resuscitation program developed by the by Snyder et al, the management of oxygen exposure American Academy of Pediatrics and the American and alveolar recruitment presents challenges that are Heart Association.3 As a result, we are faced with a associated with the potential for both benefit and multitude of tasks (cognitive, procedural, commu- harm. There are now data emerging that demonstrate nicative, and managerial) that must be completed in successful resuscitation with reduced delivery of oxy- a relatively short time. Yet we must recognize that, as gen that can be achieved without increased mortality,1 humans, our ability to multitask is poorly developed. thereby avoiding unnecessary free radical generation The activities that occur in the stabilization of a crit- and injury. In the 1990s, the timing of surfactant deliv- ically ill infant parallel those of the stabilization of a ery was investigated resulting in evidence that pro- trauma victim. As in neonatology, the stabilization of phylactic therapy2 and postventilatory therapy2 with trauma victims involves prompt stabilization of the air- way and cardiopulmonary support to establish or maintain vital signs, attention to multiple aspects of the Author Affiliation: Medical University of South Carolina, Charleston. patient’s condition (vital signs, saturation, and response Correspondence: David J. Annibale, MD, MUSC Children’s Hospital, to resuscitation), attention to the prevention of injury Neonatology, 165 Ashley Ave, MSC 917, Charleston SC 29425-9170 (oxygen toxicity vs shock), rapid initiation of vascular ([email protected]). access, rapid initiation of therapeutic interventions (sur- Copyright © 2010 by the National Association of Neonatal factant vs volume resuscitation), and the prevention of Nurses. injury progression (alveolar recruitment vs stabilization DOI:10.1097/ANC.0b013e3181e9e244 of the spine). We propose that the development of a Advances in Neonatal Care • Vol. 10, No. 5 • pp. 221-223 221 Copyright © 2010 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited. ANC200120.qxp 8/18/10 7:06 PM Page 222 222 Annibale and Bissinger neonatal-perinatal medicine version of the golden hour problems are associated with difficulties in estab- involves systems, personnel, knowledge, communica- lishing leadership shifts in critical events, allocating tion, and practice to ameliorate the demands of multi- workload, managing conflict resolution, monitoring tasking on those providers caring for the most critically each other’s performance….”(p52) Obstacles to suc- ill of patients at their most vulnerable time. cess, therefore, include poor individual communica- The much-cited Golden Hour in Trauma arose tion skills, poor individual listening skills, an unwill- from the idea that prompt delivery of definitive care ingness to challenge traditional hierarchical barriers, results in better outcomes in trauma patients. and a narrow focus on one’s individual task without Acceptance of this paradigm resulted in our current regard to the overall team goal.10 Well-functioning system of trauma centers, trauma teams, aeromedical teams can perform to a level that maximizes or even transport systems, and efforts to get trauma victims to exceeds the skills of its individual team members. a trauma center within 1 hour.4 However, in a sys- Interdisciplinary training and team development is tematic attempt to determine the strength of evidence an effective approach to improve outcomes and the in support of that supposition, Lerner and Moscati4 reduction of medical errors but requires training at conclude that the concept of a Golden Hour in both the individual level and the team level.11 In this Trauma is “not scientifically supported,” an opinion regard, the golden hour concept in neonatal-perinatal supported by a recent cohort study of more than medicine offers the opportunity to develop better- 3600 patients.5 The debate impacts our entire trauma functioning teams where individuals are still skilled care system but focuses specifically on the time to get and the team structure functions to reduce the a patient to a medical center. Still, the term “golden chance of adverse outcomes. hour” has been applied to heat stroke,6 myocardial In this issue, we review the evidence in support of infarction,7 pulmonary embolism,8 and pediatric specific interventions designed to achieve the above transport,9 and now, neonatal medicine. goal. While we will divide the “hour” (or “hours”) Then, why devote an issue of the ANC to the golden into systems or treatments, the promise of the golden hour in neonatal-perinatal care? Our first response is hour in neonatal care lies not only in evidence-based that the golden hour we refer to is not the Golden treatment but also in team structure, communication, Hour of Trauma Care. Specifically, the Golden Hour and proficiency. The development of systems of care in Trauma refers to attempts to get patients rapidly in the delivery room and stabilization area is of para- from the scene to trauma centers appropriate for the mount importance for the success of evidence- injury involved and then encompasses care at the supported golden hour interventions. While the field scene, transport policies and equipment, and the avail- of trauma surgery grasps the implications of recent ability of centers meeting standards for designation as challenges to the evidence basis of the Golden Hour trauma centers. The degree of stabilization at the in Trauma, we should learn from the controversy and trauma scene is obviously a part of that process and the measure our effectiveness. What components of the debate. In the delivery of critically ill infants, in most golden hour are of importance? Which components cases, we have met that goal. Still, the delivery and should be made a priority temporally? Which com- resuscitation areas can be treated as part of the contin- ponents are unnecessary (thereby freeing time and uum of hospital care (ie, not analogous to a trauma hands for something else)? These questions lend scene) or as a location where newborns are rapidly themselves not only to clinical investigation but also resuscitated and moved to definitive care in the NICU to quality and safety monitoring. While we would (more analogous to a trauma scene). With the imple- like to be confident in the processes we put in place mentation of definitive care in the stabilization area, during the first hours of neonatal life, we must admit the situation better parallels that of reperfusion in that the evidence basis for some therapies is limited. myocardial infarction where the rapid initiation of Still, we must make decisions. And we must also treatment after presentation to a health care facility is assess the results of those decisions. the focus. When presenting the golden hour of care in critically ill neonates, we are specifically referring to References the initiation of treatments in a systematic, efficient 1. Escrig R, Arruza L, Izquierdo I, et al. Achievement of targeted saturation val- manner in an effort to rapidly stabilize the patient, ues in extremely low gestational age neonates resuscitated with low or high oxygen concentrations: a prospective, randomized trial.
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