The Golden Hour

1. The Golden Hour Focus on pre-planning, role definition, improving communication and increasing efficiency of surfactant administration Revised 8.5.13

2. Pre-planning for Deliveries <27 weeks Transport RN RT NNP Notify fellow/MD of impending delivery and discuss specifics of care plan Determine estimated weight and tell transport RN and RT in order to have appropriate ETT size cut, surfactant drawn up & IV fluid ready based on estimated weight Have UAC/UVC out, flushed & ready • Tell team members of impending delivery: NNP, RT, bedside RN, charge RN • Bring surfactant and have it warmed and drawn up for babies <27 weeks • Have suction ready • Have PIV out & ready • Have IV fluids ready • Have DR and transporter ready • Review preplanning checklist in DR with team (verbal) • Bring vent to DR • Bring Neopuff to DR. Starting settings PIP=25, PEEP = 6 • Have appropriate size face mask out and ready, have ETCO2 detector & pulse oximetry ready • Have sterile blade, appropriate size ETT based on estimated weight cut & ready in sterile fashion on Mayo stand in DR • Have one ETT size bigger and one smaller than the ETT that is cut available in DR for use if needed (not cut prior to delivery) • Have neobars available

3. Pre-planning for Deliveries ≥27 weeks Transport RN RT NNP Notify fellow/MD of impending delivery and discuss specifics of care plan Determine estimated weight and tell transport RN and RT in order to know appropriate meds, ETT size, and IV fluid ratebased on estimated weight • Tell team members of impending delivery: NNP, RT, bedside RN, charge RN • Bring surfactant for infants 27-34 weeks but do not warm or draw up. • Do not routinely bring surfactant for infants >34 weeks unless stated by MD/NNP • Have suction ready • Have PIV out & ready • Have DR and transporter ready • Review preplanning checklist in DR with team (verbal) • Bring Neopuff to DR. Starting settings PIP=25, PEEP = 6 • Have appropriate size face mask out & pulse oximeter ready

4. Surfactant administration in DRGoal: Safely improve efficiency in surfactant administration to neonates warranting intubation in the delivery room Guideline for ETT New Process: (if warrants intubation in DR) • Suction mouth then nose per NRP • Intubate • NNP/MD to hold ETT at appropriate insertion length to roof of mouth • Confirm ETT placement by auscultation, condensation in tube, and + yellow pediacap color change • Reconfirm appropriate length at lips • Administer surfactant WITHOUT TURNING the infant’s position in 2 equally divided aliquots with PPV bagging for 1-2 minutes at approximate rate of 60bpm in between aliquots • RT to temporarily stabilize ETT using silk tape and 1 wrap around ETT • RT to stabilize ETT and vent tubing position so no torque on the baby/ETT/tubing • NNP to work on access • RT to measure for Neobar and warm it • Once access complete and baby ready for transfer back to NICU, Neobar to be applied by RT and RN under controlled environment to minimize extubation • Final preparation and return to NICU

5. Quick Reference Guides

6. QUICK REFERENCE GUIDE

7. Delivery Room Quick-Check List