Background Despite existing guidelines in the initial management of preterm infants, KK Women’s and Children’s Hospital Neonatal Unit’s ‘golden’ first hour stabilization rate was only twenty-eight percent (28%) in November 2018. Variations in practices post-resuscitation were observed and this had resulted in non-attainment of stabilization of our infants within the golden hour.

Objectives To increase the number of infants born preterm less than thirty-three (33) weeks gestation stabilized within the golden hour by thirty percent (30%) in six (6) months.

Methods Baseline stabilization time data was collected from eighteen (18) preterm infants less than thirty-three (33) weeks gestation over a one-month period. A questionnaire-based survey was conducted among one hundred six (106) staff to assess their concept of golden hour stabilization, and to recognize the challenges encountered on the ground. We found that only fifty-eight percent (58%) were convinced that one hour is the ideal stabilization time and that the lack of manpower was a major challenge to the achievement of golden hour stabilization. We performed a root cause analysis and mapped out the golden hour stabilization process. The key areas of concern leading to non-attainment of the golden hour goals were not achieving normothermia on admission, placement of intravenous glucose or parenteral nutrition and blood gas sampling. Interventions to address the key areas of concern in the golden hour stabilization process were put in place. These included: (1) Standardizing work processes with time-specific, well-defined roles for all healthcare staff involved in golden hour stabilization. (2) Use of a countdown timer to improve situational awareness during the first hour of stabilization. (3) Improving multi-disciplinary teamwork by encouraging communication and recognizing good team dynamics. (4) Roadshows and educational sessions among neonatal doctors and nurses to promote engagement. (5) Revision of admission criteria to the Neonatal Intensive care Unit (NICU). (6) Continual update of the department’s ‘Prevention of Hypothermia Workflow’. All interventions were subjected to multiple Plan-Do-Study-Act (PDSA) cycles for further refinement. The stabilization time was then tracked over time and compared with baseline.

Results The rates of infants stabilized within the golden hour improved from 28% to 97% after the interventions. Likewise, the mean and standard deviation stabilization time improved from 88 to 45 minutes and 43 to 13 minutes respectively.

Conclusions Streamlining practices and embarking on initiatives addressing hypothermia resulted in more infants stabilized within the golden hour. This had reduced variability in stabilization time, indicating a reduction in varied clinical practices in the unit.