The University of Alabama at Birmingham Regional Neonatal Intensive Care Unit created the Golden Week program to improve outcomes for infants born prematurely at 28 weeks’ gestation or earlier. The program has resulted in a 30 percent relative risk reduction in infant mortality or severe intraventricular hemorrhage within the first week of life.
Through the Golden Week program, we have standardized care that infants receive during their first week of life, ultimately improving their survival rates. The program provides guidance for physicians and nurses on clinical and nonclinical aspects of caring for an extremely preterm newborn.
Golden Week
Featured Speaker:
Colm Travers, MD
Colm Travers, MD Interests include Reducing major morbidities and mortality among preterm infants, long term outcomes in survivors of prematurity, implementation of evidence based practice, disparities in neonatal-perinatal care, and global neonatal health. Transcription:
Golden Week
Dr Andrew Wilner (Host): Welcome to the Children's of Alabama Peds Cast. I'm your host, Dr. Andrew Wilner. Today's segment will feature Dr. Colm Travers to discuss the Golden Week Program at UAB and Children's of Alabama. Welcome, Dr. Travers.
Dr Colm Travers: Hi, thanks very much for having me on.
Dr Andrew Wilner (Host): Dr. Travers, you are an Assistant Professor at the University of Alabama at Birmingham and a neonatologist. Could you tell me a little bit about what a neonatologist does?
Dr Colm Travers: We take care of sick babies and infants. Many of the babies that we take care of were born prematurely or with a lower birthweight or they had some illness in the first few weeks after they were born.
Dr Andrew Wilner (Host): So, what does that mean in terms of medical problems?
Dr Colm Travers: So babies who are born prematurely can have a wide variety of medical issues, such as respiratory distress syndrome, which causes them to have difficulty breathing. They can suffer from conditions such as intracranial hemorrhage, which are bleeds in the brain. They can also have issues with their intestines, such as necrotizing enterocolitis, and infection of the intestines, and they can have a higher risk of getting late-onset sepsis, of developing chronic lung disease from being born preterm. And they're also at higher risk of mortality.
Dr Andrew Wilner (Host): Well, I understand that at UAB, there's a special program called the Golden Week Program. How does that address these problems?
Dr Colm Travers: So the Golden Week Program was a quality improvement initiative that we started at UAB back in 2015 to improve the outcomes for our extremely preterm infants. Extremely preterm infants are babies who are born from 22 to 27 weeks of gestational age. A full-term pregnancy would usually be 39 to 40 weeks.
Dr Andrew Wilner (Host): Wow. So just a little over half of what's expected sometimes.
Dr Colm Travers: That's right.
Dr Andrew Wilner (Host): And what does the Golden Week Program do?
Dr Colm Travers: So we were hoping to reduce the rate of severe brain bleeds or intracranial hemorrhage or death in these extremely preterm infants in the first seven days after birth. And we reduced the rate of severe brain bleed death in the first week after birth from about 27% down to about 15%.
Dr Andrew Wilner (Host): Well, I'm a neurologist, so I'm interested in intracranial hemorrhage, of course. And those brain bleeds occur postnatally, not prenatally?
Dr Colm Travers: We believe the majority of the brain bleeds occur postnatally. But there could be some of the brain bleeds that might happen before birth or during birth. But many of them will happen after the babies are born, typically in the first three days. About 95% of them occur in the first week.
Dr Andrew Wilner (Host): So hypothetically, if they're postnatal, there's a window where you can intervene in those first 24 or 72 hours. So what can you do to prevent these bleeds?
Dr Colm Travers: So there are multiple evidence-based potentially better practices that may reduce the risk of severe brain bleeds or death in our preterm infants. So we hope that, by standardizing our use of evidence-based potentially better practices, we could reduce variability in care management and improve the outcomes for these extremely preterm babies.
Dr Andrew Wilner (Host): Can you give me an example of one of these interventions?
Dr Colm Travers: So there's some interventions that happened before even the babies are born, such as antenatal corticosteroids, which are injections given to the mother to help with the fetal maturation. And they can help to stabilize the blood vessels in the brain so that they are less likely to have a bleed. Then, things like delayed cord clamping when the baby's born can also help to reduce the risk of the baby having a brain bleed. Then, after the baby's born, how we take care of the baby's lungs with the ventilator, preventing big swings in their carbon dioxide level. Avoiding giving boluses or starting blood pressure medicines if the baby doesn't need it. Again, all these different ways to reduce swings in blood pressure going to the brain because, in our little babies, they don't have a lot of autoregulation in their cerebral circulation. So anything that we do that causes a swing in the blood pressure going to the brain could increase their risk of having a brain bleed.
Dr Andrew Wilner (Host): And you found by developing a program in standardizing the care that you actually did have some impact. Is that right?
Dr Colm Travers: Yeah, that's right. We, first of all, did a lot of education around our standardized evidence-based guidelines and we used lots of checklists and communication tools. But ultimately, we felt that using electronic medical record order sets would be a really nice way to standardize the treatment and reduce the variability and improve the adherence to those evidence-based potentially better practices that we thought would improve the outcomes. So we developed a set of special order sets for our golden weakers, our babies who were born extremely preterm at UAB.
Dr Andrew Wilner (Host): Sometimes physicians bristle a little bit when there's like standardized order sets and it's not the way they're used to doing that. Did you find any of that reaction? And if so, what did you do about it?
Dr Colm Travers: It's a great point. I think when you're setting out to do a quality improvement plan, it's so important to have buy-in from all the different stakeholders. And I think we're very lucky to work in a group that tries to practice evidence-based medicine. And we had a group of nurses and nurse managers and respiratory therapists who were really eager to improve the care, improve the outcomes, and also to understand the practices that we were doing and why we were doing them. And everybody wanted to help ultimately to improve the care for the babies. So we had a lot of meetings to agree on what was the best practices between us all. We met monthly and we actually continue to meet monthly to develop our guidelines to monitor data and to improve the outcomes ultimately.
Dr Andrew Wilner (Host): How many neonatologists are there in your program?
Dr Colm Travers: So we have about 90 pediatric residents, about nine neonatal fellows and about 22 neonatal faculty members.
Dr Andrew Wilner (Host): Wow. That sounds like a lot to me. That's great. You got a lot, because it's a 24/7 kind of care that these infants need, right? It's basically an ICU setting.
Dr Colm Travers: Yeah, this is an intensive care unit for these tiny babies. We also have about over 200 staff of nurses and respiratory therapists who we also needed to make sure we're up-to-date with our evidence-based guidelines and we're practicing evidence-based medicine to improve the outcomes for these babies.
Dr Andrew Wilner (Host): Now, prevention is always the key. Is there anything that a pregnant woman can do to try and avoid being in that ICU with their child?
Dr Colm Travers: It's difficult sometimes to know in advance who's going to be at highest risk of delivering preterm. We know that mothers who had had a previous preterm birth will be at higher risk. We know there are certain risk factors for preterm birth, such as smoking cigarettes, not having good prenatal care. So I think it's very important for mothers to make sure that they start prenatal care early, so that the obstetricians can identify those at risk. And then, if a mother does have signs that she could potentially be going into preterm labor or have other signs that maybe she's becoming unwell, it's very important to seek care early so that the obstetricians, they do such a good job sometimes at delaying or preventing preterm birth.
Dr Andrew Wilner (Host): Right. Well, it sounds like this Golden Week Program has been a success and you plan to continue and enhance it. Is that correct?
Dr Colm Travers: Yeah, that's correct. We actually, last year, launched a training program for all of the nurses who practice in the neonatal intensive care unit at the University of Alabama Birmingham. And so now, we have a team of highly trained neonatal nurses who are our Golden Week Program nurses and they take care of the babies predominantly for the entire first week after they're born. And last year in 2021, we had our best year ever for reducing intracranial hemorrhage or death in our babies.
Dr Andrew Wilner (Host): Well, that's fantastic. Dr. Travers, this has been a great discussion. Is there anything else you'd like to add?
Dr Colm Travers: I think it just shows the importance of communication and working together as a team in a complex environment, like the neonatal intensive care unit. And that when everybody works together and uses evidence-based medicine, that it's possible to improve outcomes for the sickest babies.
Dr Andrew Wilner (Host): Well, that concludes our program for today. I'd like to thank our guest, Dr. Colm Travers, for a very informative discussion.
Dr Colm Travers: Well, thanks very much for having me on.
Dr Andrew Wilner (Host): Since 1911, Children's of Alabama has provided specialized medical care for ill and injured children, offering inpatient, outpatient, and primary care throughout central Alabama. Ranked among the best children's hospitals in the nation by US News and World Report, Children's serves patients from every county in Alabama and nearly every state. Children's is a private not-for-profit medical center that serves as the teaching hospital for the University of Alabama at Birmingham Pediatric Medicine, Surgery, Psychiatry, Research, and Residency programs. The medical staff consists of UAB faculty and Children's full-time physicians as well as private-practicing community physicians. I'm your host, Dr. Andrew Wilner. Thanks for listening. For more information, visit childrensal.org.
Golden Week
Dr Andrew Wilner (Host): Welcome to the Children's of Alabama Peds Cast. I'm your host, Dr. Andrew Wilner. Today's segment will feature Dr. Colm Travers to discuss the Golden Week Program at UAB and Children's of Alabama. Welcome, Dr. Travers.
Dr Colm Travers: Hi, thanks very much for having me on.
Dr Andrew Wilner (Host): Dr. Travers, you are an Assistant Professor at the University of Alabama at Birmingham and a neonatologist. Could you tell me a little bit about what a neonatologist does?
Dr Colm Travers: We take care of sick babies and infants. Many of the babies that we take care of were born prematurely or with a lower birthweight or they had some illness in the first few weeks after they were born.
Dr Andrew Wilner (Host): So, what does that mean in terms of medical problems?
Dr Colm Travers: So babies who are born prematurely can have a wide variety of medical issues, such as respiratory distress syndrome, which causes them to have difficulty breathing. They can suffer from conditions such as intracranial hemorrhage, which are bleeds in the brain. They can also have issues with their intestines, such as necrotizing enterocolitis, and infection of the intestines, and they can have a higher risk of getting late-onset sepsis, of developing chronic lung disease from being born preterm. And they're also at higher risk of mortality.
Dr Andrew Wilner (Host): Well, I understand that at UAB, there's a special program called the Golden Week Program. How does that address these problems?
Dr Colm Travers: So the Golden Week Program was a quality improvement initiative that we started at UAB back in 2015 to improve the outcomes for our extremely preterm infants. Extremely preterm infants are babies who are born from 22 to 27 weeks of gestational age. A full-term pregnancy would usually be 39 to 40 weeks.
Dr Andrew Wilner (Host): Wow. So just a little over half of what's expected sometimes.
Dr Colm Travers: That's right.
Dr Andrew Wilner (Host): And what does the Golden Week Program do?
Dr Colm Travers: So we were hoping to reduce the rate of severe brain bleeds or intracranial hemorrhage or death in these extremely preterm infants in the first seven days after birth. And we reduced the rate of severe brain bleed death in the first week after birth from about 27% down to about 15%.
Dr Andrew Wilner (Host): Well, I'm a neurologist, so I'm interested in intracranial hemorrhage, of course. And those brain bleeds occur postnatally, not prenatally?
Dr Colm Travers: We believe the majority of the brain bleeds occur postnatally. But there could be some of the brain bleeds that might happen before birth or during birth. But many of them will happen after the babies are born, typically in the first three days. About 95% of them occur in the first week.
Dr Andrew Wilner (Host): So hypothetically, if they're postnatal, there's a window where you can intervene in those first 24 or 72 hours. So what can you do to prevent these bleeds?
Dr Colm Travers: So there are multiple evidence-based potentially better practices that may reduce the risk of severe brain bleeds or death in our preterm infants. So we hope that, by standardizing our use of evidence-based potentially better practices, we could reduce variability in care management and improve the outcomes for these extremely preterm babies.
Dr Andrew Wilner (Host): Can you give me an example of one of these interventions?
Dr Colm Travers: So there's some interventions that happened before even the babies are born, such as antenatal corticosteroids, which are injections given to the mother to help with the fetal maturation. And they can help to stabilize the blood vessels in the brain so that they are less likely to have a bleed. Then, things like delayed cord clamping when the baby's born can also help to reduce the risk of the baby having a brain bleed. Then, after the baby's born, how we take care of the baby's lungs with the ventilator, preventing big swings in their carbon dioxide level. Avoiding giving boluses or starting blood pressure medicines if the baby doesn't need it. Again, all these different ways to reduce swings in blood pressure going to the brain because, in our little babies, they don't have a lot of autoregulation in their cerebral circulation. So anything that we do that causes a swing in the blood pressure going to the brain could increase their risk of having a brain bleed.
Dr Andrew Wilner (Host): And you found by developing a program in standardizing the care that you actually did have some impact. Is that right?
Dr Colm Travers: Yeah, that's right. We, first of all, did a lot of education around our standardized evidence-based guidelines and we used lots of checklists and communication tools. But ultimately, we felt that using electronic medical record order sets would be a really nice way to standardize the treatment and reduce the variability and improve the adherence to those evidence-based potentially better practices that we thought would improve the outcomes. So we developed a set of special order sets for our golden weakers, our babies who were born extremely preterm at UAB.
Dr Andrew Wilner (Host): Sometimes physicians bristle a little bit when there's like standardized order sets and it's not the way they're used to doing that. Did you find any of that reaction? And if so, what did you do about it?
Dr Colm Travers: It's a great point. I think when you're setting out to do a quality improvement plan, it's so important to have buy-in from all the different stakeholders. And I think we're very lucky to work in a group that tries to practice evidence-based medicine. And we had a group of nurses and nurse managers and respiratory therapists who were really eager to improve the care, improve the outcomes, and also to understand the practices that we were doing and why we were doing them. And everybody wanted to help ultimately to improve the care for the babies. So we had a lot of meetings to agree on what was the best practices between us all. We met monthly and we actually continue to meet monthly to develop our guidelines to monitor data and to improve the outcomes ultimately.
Dr Andrew Wilner (Host): How many neonatologists are there in your program?
Dr Colm Travers: So we have about 90 pediatric residents, about nine neonatal fellows and about 22 neonatal faculty members.
Dr Andrew Wilner (Host): Wow. That sounds like a lot to me. That's great. You got a lot, because it's a 24/7 kind of care that these infants need, right? It's basically an ICU setting.
Dr Colm Travers: Yeah, this is an intensive care unit for these tiny babies. We also have about over 200 staff of nurses and respiratory therapists who we also needed to make sure we're up-to-date with our evidence-based guidelines and we're practicing evidence-based medicine to improve the outcomes for these babies.
Dr Andrew Wilner (Host): Now, prevention is always the key. Is there anything that a pregnant woman can do to try and avoid being in that ICU with their child?
Dr Colm Travers: It's difficult sometimes to know in advance who's going to be at highest risk of delivering preterm. We know that mothers who had had a previous preterm birth will be at higher risk. We know there are certain risk factors for preterm birth, such as smoking cigarettes, not having good prenatal care. So I think it's very important for mothers to make sure that they start prenatal care early, so that the obstetricians can identify those at risk. And then, if a mother does have signs that she could potentially be going into preterm labor or have other signs that maybe she's becoming unwell, it's very important to seek care early so that the obstetricians, they do such a good job sometimes at delaying or preventing preterm birth.
Dr Andrew Wilner (Host): Right. Well, it sounds like this Golden Week Program has been a success and you plan to continue and enhance it. Is that correct?
Dr Colm Travers: Yeah, that's correct. We actually, last year, launched a training program for all of the nurses who practice in the neonatal intensive care unit at the University of Alabama Birmingham. And so now, we have a team of highly trained neonatal nurses who are our Golden Week Program nurses and they take care of the babies predominantly for the entire first week after they're born. And last year in 2021, we had our best year ever for reducing intracranial hemorrhage or death in our babies.
Dr Andrew Wilner (Host): Well, that's fantastic. Dr. Travers, this has been a great discussion. Is there anything else you'd like to add?
Dr Colm Travers: I think it just shows the importance of communication and working together as a team in a complex environment, like the neonatal intensive care unit. And that when everybody works together and uses evidence-based medicine, that it's possible to improve outcomes for the sickest babies.
Dr Andrew Wilner (Host): Well, that concludes our program for today. I'd like to thank our guest, Dr. Colm Travers, for a very informative discussion.
Dr Colm Travers: Well, thanks very much for having me on.
Dr Andrew Wilner (Host): Since 1911, Children's of Alabama has provided specialized medical care for ill and injured children, offering inpatient, outpatient, and primary care throughout central Alabama. Ranked among the best children's hospitals in the nation by US News and World Report, Children's serves patients from every county in Alabama and nearly every state. Children's is a private not-for-profit medical center that serves as the teaching hospital for the University of Alabama at Birmingham Pediatric Medicine, Surgery, Psychiatry, Research, and Residency programs. The medical staff consists of UAB faculty and Children's full-time physicians as well as private-practicing community physicians. I'm your host, Dr. Andrew Wilner. Thanks for listening. For more information, visit childrensal.org.