Annibale, David J. MD; Bissinger, Robin L. PhD, APRN, NNP-BC
Medical University of South Carolina, Charleston.
Correspondence: David J. Annibale, MD, MUSC Children's Hospital, Neonatology, 165 Ashley Ave, MSC 917, Charleston SC 29425-9170 (firstname.lastname@example.org).
The first hour of life for a premature infant represents a time period during which the infant faces challenges that carry risks of short- and long-term injury, lifelong developmental delay, and even death. Delivery room personnel have the opportunity to impact the transitional process, positively or negatively. During this time period, the clinician is faced with complex decisions based on multiple systems that require attention knowing that care in these first minutes of life can translate into lifelong medical problems. In this way, the first hour of neonatal life parallels concepts upon which the Golden Hour of Trauma is based. Is there reason to develop a golden hour in neonatal-perinatal medicine? Is the analogy between this and the Golden Hour of Trauma strong enough to adopt in our field? In trauma, the golden hour is a concept of time—it is important to get the patient to a facility where definitive care can be provided within 60 minutes. In neonatology and within the articles presented in this month's journal, there is a focus that begins with birth but extends beyond the first 60 minutes. We hope to challenge the reader to move beyond simple timing of interventions into the “why” and “how” of what we do.
Indeed, the process of respiratory adaptation exemplifies the opportunity to impact care in the first moments of extrauterine life. As described in this issue by Snyder et al, the management of oxygen exposure and alveolar recruitment presents challenges that are associated with the potential for both benefit and harm. There are now data emerging that demonstrate successful resuscitation with reduced delivery of oxygen that can be achieved without increased mortality,1 thereby avoiding unnecessary free radical generation and injury. In the 1990s, the timing of surfactant delivery was investigated resulting in evidence that prophylactic therapy2 and postventilatory therapy2 with surfactant were associated with similar improved outcomes for very premature infants. In both of these interventions, reduced oxygen delivery and alveolar recruitment with surfactant immediately after establishment of ventilation, delivery of oxygen and mechanical ventilation must be adjusted in accord with ongoing assessment of the infant's response to resuscitation. In addition, there are other systems that must be considered simultaneously. Thermal stresses, states that might predispose to central nervous system injury, rapid responses to the possibility of infection or blood losses, and the rapid delivery of fluids and nutrients are simultaneously demanding attention during the first minutes to hours of extrauterine life.
As one can infer from the description given earlier, the time period beginning at birth and extending through stabilization is associated with multiple considerations occurring both simultaneously and in sequence, sometimes dependent on each other (ie, the delivery of intravenous antibiotics requires vascular access, the timing of which in turn is dependent on respiratory interventions). Coupled with personnel management (often involving personnel of varying or limited experience), the opportunity for “ordered chaos” to become simply chaos is significant. Approaches to minimize that risk include the neonatal resuscitation program developed by the American Academy of Pediatrics and the American Heart Association.3 As a result, we are faced with a multitude of tasks (cognitive, procedural, communicative, and managerial) that must be completed in a relatively short time. Yet we must recognize that, as humans, our ability to multitask is poorly developed.
The activities that occur in the stabilization of a critically ill infant parallel those of the stabilization of a trauma victim. As in neonatology, the stabilization of trauma victims involves prompt stabilization of the airway and cardiopulmonary support to establish or maintain vital signs, attention to multiple aspects of the patient's condition (vital signs, saturation, and response to resuscitation), attention to the prevention of injury (oxygen toxicity vs shock), rapid initiation of vascular access, rapid initiation of therapeutic interventions (surfactant vs volume resuscitation), and the prevention of injury progression (alveolar recruitment vs stabilization of the spine). We propose that the development of a neonatal-perinatal medicine version of the golden hour involves systems, personnel, knowledge, communication, and practice to ameliorate the demands of multitasking on those providers caring for the most critically ill of patients at their most vulnerable time.
The much-cited Golden Hour in Trauma arose from the idea that prompt delivery of definitive care results in better outcomes in trauma patients. Acceptance of this paradigm resulted in our current system of trauma centers, trauma teams, aeromedical transport systems, and efforts to get trauma victims to a trauma center within 1 hour.4 However, in a systematic attempt to determine the strength of evidence in support of that supposition, Lerner and Moscati4 conclude that the concept of a Golden Hour in Trauma is “not scientifically supported,” an opinion supported by a recent cohort study of more than 3600 patients.5 The debate impacts our entire trauma care system but focuses specifically on the time to get a patient to a medical center. Still, the term “golden hour” has been applied to heat stroke,6 myocardial infarction,7 pulmonary embolism,8 and pediatric transport,9 and now, neonatal medicine.
Then, why devote an issue of the ANC to the golden hour in neonatal-perinatal care? Our first response is that the golden hour we refer to is not the Golden Hour of Trauma Care. Specifically, the Golden Hour in Trauma refers to attempts to get patients rapidly from the scene to trauma centers appropriate for the injury involved and then encompasses care at the scene, transport policies and equipment, and the availability of centers meeting standards for designation as trauma centers. The degree of stabilization at the trauma scene is obviously a part of that process and the debate. In the delivery of critically ill infants, in most cases, we have met that goal. Still, the delivery and resuscitation areas can be treated as part of the continuum of hospital care (ie, not analogous to a trauma scene) or as a location where newborns are rapidly resuscitated and moved to definitive care in the NICU (more analogous to a trauma scene). With the implementation of definitive care in the stabilization area, the situation better parallels that of reperfusion in myocardial infarction where the rapid initiation of treatment after presentation to a health care facility is the focus. When presenting the golden hour of care in critically ill neonates, we are specifically referring to the initiation of treatments in a systematic, efficient manner in an effort to rapidly stabilize the patient, lessen the progression of illness, and prevent harm.
Our second response is that neonatal resuscitation is complex and takes place in an extremely dynamic and complex environment. In this type of environment, communication and team function can become important factors in success. In an analogous setting, the operating room, Schaefer et al link clinical outcomes to team performance and, specifically, communication stating, “basic communication problems are associated with difficulties in establishing leadership shifts in critical events, allocating workload, managing conflict resolution, monitoring each other's performance….”(p52) Obstacles to success, therefore, include poor individual communication skills, poor individual listening skills, an unwillingness to challenge traditional hierarchical barriers, and a narrow focus on one's individual task without regard to the overall team goal.10 Well-functioning teams can perform to a level that maximizes or even exceeds the skills of its individual team members. Interdisciplinary training and team development is an effective approach to improve outcomes and the reduction of medical errors but requires training at both the individual level and the team level.11 In this regard, the golden hour concept in neonatal-perinatal medicine offers the opportunity to develop better-functioning teams where individuals are still skilled and the team structure functions to reduce the chance of adverse outcomes.
In this issue, we review the evidence in support of specific interventions designed to achieve the above goal. While we will divide the “hour” (or “hours”) into systems or treatments, the promise of the golden hour in neonatal care lies not only in evidence-based treatment but also in team structure, communication, and proficiency. The development of systems of care in the delivery room and stabilization area is of paramount importance for the success of evidence- supported golden hour interventions. While the field of trauma surgery grasps the implications of recent challenges to the evidence basis of the Golden Hour in Trauma, we should learn from the controversy and measure our effectiveness. What components of the golden hour are of importance? Which components should be made a priority temporally? Which components are unnecessary (thereby freeing time and hands for something else)? These questions lend themselves not only to clinical investigation but also to quality and safety monitoring. While we would like to be confident in the processes we put in place during the first hours of neonatal life, we must admit that the evidence basis for some therapies is limited. Still, we must make decisions. And we must also assess the results of those decisions.
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3. American Academy of Pediatrics and American Heart Association. Textbook of Neonatal Resuscitation. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics and American Heart Association; 2006.
4. Lerner EB, Moscati RM. The golden hour: scientific fact or medical “urban legend”? Acad Emerg Med. 2001; 8:758–760.
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8. Wood KE. Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest. 2002; 121:877–905.
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