Saint Joseph Small Baby Committee pushes for the quickest “top-down” times

For extremely premature infants, those born between 22 and 30 weeks, optimizing their first minutes of life is essential for reducing mortality and risk of comorbidities. Saint Joseph care teams pursue three immediate goals: resuscitation, stabilization and minimal stimulation.

In neonatal care, the time it takes from birth to top down on the incubator, when babies can rest, is referred to as the “top-down” time. The top-down goal is 60 minutes, known as the “golden hour,” when a highly functioning team can efficiently and safely transition an infant from intrauterine to extrauterine life. Delays in this process can have significant adverse short- and long-term consequences. 

Once the top is down, the infant will remain under the minimal stimulation protocol for 72 hours.

Here’s the challenge: Infants born extremely premature require tremendous life-saving interventions to stabilize them for those three essential days of minimal stimulation time. Minutes are precious and pass quickly.

A baby in Saint Joseph’s NICU, 24 weeks

“Infants born at this gestational age require an incredible amount of teamwork from all involved,” said Corrie Alonzo, MD, Neonatal-Perinatal Medicine. “Respiratory stabilization, thermoregulation, transport to the NICU, placement of umbilical lines, initiation of fluids, it all adds up, and the clock is ticking.”

Alonzo is the physician lead of the Saint Joseph Small Baby Committee, so she would know; she’s the one holding the timer. The committee, which also includes Adrienne Isaacs, NNP, debriefs the care provided to infants during the golden hour, looking for new processes that can reduce the top-down time, while maintaining the highest standards of care.

And while the timing is tight, the variables are plenty. Meaning, that while it is not an easy task, there are always opportunities to shave minutes.

“The care we provide to small babies at Saint Joseph is exceptional, and the guidelines we follow during the golden hour deliver reliable, evidence-based care,” said Alonzo. “It’s our committee’s privilege and promise that we make every infant’s admission and time to top down as efficient and safe as possible.”

Alonzo describes the hectic first hour like this: These infants are born in the OR, where resuscitation begins. Most deliveries are planned, and all equipment is ready – but this might not be the case with emergent deliveries. Respiratory stabilization can take time and is unique to each infant. For example, an infant initially stable on CPAP might need intubation minutes later for surfactant administration. Thermoregulation is maintained using a thermal mattress and drape. The infant is then transported to the NICU using a transport shuttle. Umbilical lines are placed and their position is confirmed on x-ray. Initial labs are sent and intravenous fluids are prepared and initiated.

An intubated extreme preemie at Saint Joseph preparing for transport

“So even if these steps proceed without delay, you can see how the path from OR to incubator top-down can take 60 minutes.” According to Alonzo, the average year-to-date, top-down time for a small baby at Saint Joseph Hospital is 67 minutes. This is far below the recent literature Alonzo has reviewed of several centers that place their own top-down times at longer than 100 minutes.

That gap, and what it means for an infant’s long-term health and development, is remarkable.

“Our work in continuous quality improvement and the potential it can have on these infants’ lives inspires us to keep pushing for optimal care and team collaboration,” said Alonzo.

Recent developments: The Saint Joseph NICU advocated for and secured an investment to enhance nursing education, which now includes 45 hours of compensated small-baby lectures through the Engage Grow Thrive program.

The department also is trialing new positioning devices for small babies that mimic the in-utero environment. The positioners are soft and can be molded specifically to each infant, enabling better sleep and reducing stress. The brain of a premature infant develops rapidly and therapeutic positioning is critical, along with other interventions, such as skin-to-skin holding and infant massage.

Physicians who want to learn more about the Small Baby Committee or other recent or upcoming neonatal care enhancements can reach out to Alonzo at corrie.j.alonzo@kp.org.