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DAVID J. ANNIBALE, MD; ROBIN L. BISSINGER, PHD, APRN, NNP-BC
The Golden Hour
T
he first hour of life for a premature infant rep-
resents 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, posi-
tively or negatively. During this time period, the cli-
nician is faced with complex decisions based on mul-
tiple 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 defini-
tive care can be provided within 60 minutes. In neona-
tology 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 chal-
lenge the reader to move beyond simple timing of
interventions into the “why” and “how” of what we do.
Indeed, the process of respiratory adaptation exem-
plifies 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 oxy-
gen that can be achieved without increased mortality,1
thereby avoiding unnecessary free radical generation
and injury. In the 1990s, the timing of surfactant deliv-
ery was investigated resulting in evidence that pro-
phylactic therapy2 and postventilatory therapy2 with
Author Affiliation: 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
(annibald@musc.edu).
Copyright © 2010 by the National Association of Neonatal
Nurses.
DOI:10.1097/ANC.0b013e3181e9e244
Advances in Neonatal Care • Vol. 10, No. 5 • pp. 221-223
Copyright © 2010 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
surfactant were associated with similar improved out-
comes for very premature infants. In both of these
interventions, reduced oxygen delivery and alveolar
recruitment with surfactant immediately after estab-
lishment 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 nutri-
ents 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 con-
siderations occurring both simultaneously and in
sequence, sometimes dependent on each other (ie,
the delivery of intravenous antibiotics requires vas-
cular access, the timing of which in turn is dependent
on respiratory interventions). Coupled with person-
nel management (often involving personnel of vary-
ing or limited experience), the opportunity for
“ordered chaos” to become simply chaos is signifi-
cant. 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, commu-
nicative, 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 crit-
ically ill infant parallel those of the stabilization of a
trauma victim. As in neonatology, the stabilization of
trauma victims involves prompt stabilization of the air-
way 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 (sur-
factant vs volume resuscitation), and the prevention of
injury progression (alveolar recruitment vs stabilization
of the spine). We propose that the development of a
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222 Annibale and Bissinger
neonatal-perinatal medicine version of the golden hour
involves systems, personnel, knowledge, communica-
tion, and practice to ameliorate the demands of multi-
tasking 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 sys-
tematic 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 avail-
ability 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 contin-
uum 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 imple-
mentation 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 environ-
ment, communication and team function can
become important factors in success. In an analo-
gous setting, the operating room, Schaefer et al link
clinical outcomes to team performance and, specifi-
cally, communication stating, “basic communication
Copyright © 2010 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
problems are associated with difficulties in estab-
lishing leadership shifts in critical events, allocating
workload, managing conflict resolution, monitoring
each other’s performance….”(p52) Obstacles to suc-
cess, therefore, include poor individual communica-
tion skills, poor individual listening skills, an unwill-
ingness 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 para-
mount 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 com-
ponents 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.
References
1. Escrig R, Arruza L, Izquierdo I, et al. Achievement of targeted saturation val-
ues in extremely low gestational age neonates resuscitated with low or
high oxygen concentrations: a prospective, randomized trial. Pediatrics.
2008;121:875-881.
2. Kendig JW, Ryan RM, Sinkin RA, et al. Comparison of two strategies for sur-
factant prophylaxis in very premature infants: a multicenter randomized
trial. Pediatrics. 1998;101:1006-1012.
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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intervals and survival in trauma: assessment of the “golden hour” in a North
American prospective cohort. Ann Emerg Med. 2010;55:235-246. e4.
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The Golden Hour 223

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Advances in Neonatal Care • Vol. 10, No. 5

Copyright © 2010 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.