The Golden Hour Focus on preplanning role definition

The Golden Hour Focus on pre-planning, role definition, improving communication and increasing efficiency of surfactant administration Revised 8. 5. 13

Pre-planning for Deliveries <27 weeks Transport RN • • 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) RT • • • Bring vent to DR Bring Neopuff to DR. Starting settings PIP=25, PEEP = 6 Have appropriate size face mask out and ready, have ETCO 2 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 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

Pre-planning for Deliveries ≥ 27 weeks Transport RN • • 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) RT NNP fellow/MD of • Bring Neopuff to • Notify impending delivery DR. Starting and discuss specifics of care settings PIP=25, plan PEEP = 6 • Determine estimated weight • Have appropriate and tell transport size face mask out RN and RT in order to know & pulse oximeter appropriate meds, ready ETT size, and IV fluid rate based on estimated weight

Surfactant administration in DR Goal: Safely improve efficiency in surfactant administration to neonates warranting intubation in the delivery room 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 60 bpm 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 Guideline for ETT Weight ETT size (mm) Cut length (cm) Insertion length at the lip (cm) 500 gm 2. 5 13 5. 5 - 6 750 gm 2. 5 13 6 1000 gm 2. 5 13 6 1500 gm 3. 0 14 7 2000 gm 3. 0 14 7 2500 gm 3. 5 14 8 3000 gm 3. 5 15 8 3500 gm 3. 5 15 9 4000 gm 4. 0 16 10

Quick Reference Guides Approx. ~50% for Gest. Age weight estimate Weight ETT size (mm) Cut length (cm) Insertion length at the lip (cm) 24 weeks 500 gm 2. 5 13 5. 5 - 6 26 weeks 750 gm 2. 5 13 6 28 weeks 1000 gm 2. 5 13 6 30 weeks 1500 gm 3. 0 14 7 33 weeks 2000 gm 3. 0 14 7 35 weeks 2500 gm 3. 5 14 8 40 weeks 3500 gm 3000 gm 3. 5 15 8 3500 gm 3. 5 15 9 4000 gm 4. 0 16 10

QUICK REFERENCE GUIDE

Delivery Room Quick-Check List