Improving Safe Sleep Practices for Hospitalized Infants

Children’s National Medical Center (CNMC) is located in the northwest quadrant of Washington, D.C; it was established in 1870 and remains the only standalone pediatric academic hospital in the region serving patients primarily aged between 0 to 21 years old (“At a Glance,” 2017). Hospital admissions have an average length of stay of 6 days and total approximately 15,700 annually (“At a Glance,” 2017). CNMC is ranked fifth nationally by U.S. News & World Report on the 2018-2019 U.S. News Best Children's Hospitals Honor Roll and is ranked first in neonatology nationally. Children’s National Medical Center serves primary children, but also adults with congenital illness. There is a high attention to family- and patient-centered care, so caregivers are very involved in all aspects of caring and advocating for their children, even in the sickest of states. Children’s provides acute and intensive inpatient care as well as primary, emergency and specialty ambulatory care on the main hospital campus; there are primary and specialty care services located throughout the Washington, D.C. region as well.

Description of the Problem

SIDS is the sudden and unexpected death of a child less than one year old in which the cause of death cannot be identified following investigation (Centers for Disease Control and Prevention, 2018); according to a 2016 report by the American Academy of Pediatrics, about 3,500 infants die from Sudden Infant Death Syndrome in the United States each year. Of these, about 900 are preventable and are potentially due to preventable accidents such as strangulation or suffocation in a bed or crib (Centers for Disease Control and Prevention, 2018). Although causes of infant death may be unknown, many may be attributed to unsafe sleeping environments. In 1994, the American Academy of Pediatrics (AAP) launched the “Back to Sleep Campaign;” after initiation of this campaign, the national rate of SIDS has decreased by 50 percent (American Academy of Pediatrics, 2016).

The current safe sleep recommendations from the American Academy of Pediatrics are identified as the “ABC’s” of safe sleep (2016). The ‘A’ stands for “alone” - in an empty crib, and involves avoiding blankets, pillows, soft toys, and any crib bumpers (American Academy of Pediatrics, 2016). The ‘B’, “back,” instructs caregivers to place infants on their backs to sleep on a flat surface; though if the baby is able to roll over on their own and does so after placement on their back, it is safe and acceptable to leave them in a non-supine sleeping position (American Academy of Pediatrics, 2016). Lastly, the ‘C’, “crib,” encourages parents to place their child in a crib to sleep, not in bed with parents or another otherwise unsafe sleeping environment (American Academy of Pediatrics, 2016). Other recommendations include that the infant share a bedroom with the parents for the first 6 months of life, and to avoid infant exposure to smoke, and drugs (American Academy of Pediatrics, 2016). Unfortunately, 22 percent of parents are not placing their babies on their backs to sleep, 61 percent of parents report bed sharing, and 39 percent use soft bedding (Centers for Disease Control and Prevention, 2018). There is a higher incidence of sleep-related infant deaths among American Indian, Alaskan Native, and African-American populations (Centers for Disease Control and Prevention, 2018).

Often, health care providers are role models for safe sleep practices as they frequently see the infants, and educate parents. In hospital inpatient settings, members of the health care team have a special opportunity to promote safe habits, including safe sleep. A study performed in 2002 by Colson and Joslin found that parents who witnessed health care providers lay babies supine to sleep were twice as likely to do the same at home; however, about half of the healthcare providers failed to model safe sleep practices in the inpatient setting. Several barriers for lack of staff adherence to safe sleep guidelines might include concerns about reflux, attempts to improve the patient’s respiratory status, and not having access to resources such as sleep sacks or swaddle devices available as determined by the Ohio Education and Safe Sleep Environment (EASE) Project researchers Macklin, Gittelman, Denny, Southworth, and Arnold (2016). Despite any perceived or actual barriers, members of the healthcare team have a responsibility to model safe sleep practice to help caregivers foster positive outcomes for infants at home, especially as many of these in-hospital barriers are resolved in pediatric patients prior to hospital discharge.

At Children’s National Medical Center, a safe sleep policy was instituted in 2008, and last reviewed in 2017; this policy mirrors AAP recommendations and highlights the need for nurses to adhere to and model care behaviors at all times that influence infant sleep safety at home. Following policy amendment, education was provided to nurses via an emailed PowerPoint and unit audits have occurred monthly since that time with no further education, intervention or follow-up. Compliance with the policy has shown some improvement, though it is inconsistent and audit results vary considerably between months ranging between 46 and 81 percent compliance with an overall goal of 100 percent compliance across all units ([Children's National Clinical Audits on Safe Sleep Practices], 2018). The audit forms list reasons that specific patient environments and sleeping states were found to be inadequate, but do not specify the frequency with which each problem occurred or remedial actions that were taken. This proposed evidence-based practice project will be constructed to target not only consistency in compliance, but also in managing discrepancies thereof to achieve and model best practice behaviors. The specific aim of this evidence-based practice project is to increase safe sleep compliance in hospitalized infants to 90 percent by June 2019, following 3 full months of project implementation at Children’s National Medical Center.

Literature Review

A safe sleep program was instituted at the Hospital of the University of Pennsylvania following the death of two former Neonatal Intensive Care Unit patients who had been discharged from the hospital; this evidence-based practice project was described in the 2016 article entitled “An Evidence-Based Infant Safe Sleep Program to Reduce Sudden Unexplained Infant Deaths” by Zachritz, Fulmer, and Chaney and published in the American Journal of Nursing in 2016. Furthermore, the authors provide significant statistics demonstrating that of all infants experiencing sudden death in Philadelphia, Pennsylvania between 2009 and 2010, 89 percent were in unsafe sleep environments that may have contributed to their deaths (2016). Prior to program implementation at the hospital, the results of unit audits were found to be inconsistent and did not demonstrate adherence to the AAP guidelines. Additionally, parent teaching was lacking and self-reported data revealed that parents often placed their child in danger by “co sleeping with their baby,... plac[ing] objects in the infants’ crib, and… put[ting] infants to sleep on a non flat surface” (Zachritz, Fulmer, & Chaney, 2016).

According to the evidence-based practice article, Fulmer and Chaney created a multidisciplinary team, including nurses, physicians, and occupational and respiratory therapists, that met over a two year period of time prior to project implementation. Utilizing Institute for Healthcare Improvement recommendations on change projects, a safe sleep bundle was developed that included the purchase and use of sleep sacks for in-hospital sleep that parents were able to take at discharge for home use, a new clinical guideline, standardized parent and caregiver teaching, and prenatal community outreach (Zachritz, Fulmer, & Chaney, 2016). Infants were included in the practice change only if their medical needs did not outweigh the benefits of the guideline in reducing SIDS incidence. Education was provided to all direct patient caregivers as well as other unit-based support staff and assessed via audits on all infants in addition to staff compliance with caregiver education. The implementation of the safe sleep program demonstrated a 70 percent increase in compliance with sleep environment in the hospital; real-time education was provided when discrepancies were found to improve future staff and caregiver compliance and further model appropriate behaviors (Zachritz, Fulmer, & Chaney, 2016).

The overarching goal of the project was to not only become compliant with best practice standards, but to model healthy behaviors for sleep outside of the hospital. The importance of a program that models appropriate behaviors for caregivers is truly immeasurable and standardization of best practices is important so caregivers receive the same message from all health care providers. This project furthermore embodies the core bioethical principles of beneficence and nonmaleficence; when these principles allow caregivers to act in the best interest of the vulnerable child, they allow the infant to develop and grow safely while minimizing the known controllable risks of SIDS.

A quality improvement project to improve safe sleep practices, as described in the article “Integrating Safe Sleep Practices into a Pediatric Hospital: Outcomes of a Quality Improvement Project,” was implemented at a large U.S. children’s hospital in Arkansas where the 2010 infant mortality rate was 133 percent above the national average (Rowe, et al., 2016). This study sought to discover if education and policy change would affect safe sleep practice (SSP) adherence in the 370 bed inpatient children’s hospital. A group known as the Safe Sleep Task Force was developed to study the current SSP occuring at the hospital with a goal of increasing the percentage of infants in American Academy of Pediatric recommended safe sleep environments, and to sustain these practices (Rowe, et al., 2016).

A review of literature regarding SSP helped the Safe Sleep Task Force develop an education and implementation plan for the hospital. Baseline data was collected from a variety of healthcare workers to assess the knowledge and beliefs centering around SSP and the sleep environments of all infants up to 12 months were audited weekly utilizing an audit tool developed by the task force (Rowe, et al., 2016). There were 1,656 staff members at the hospital who completed safe sleep video modules, and were provided information regarding the new policy and documentation changes; sleep sacks were also provided for use in-hospital to prevent the use of excess blankets in the sleep environment (Rowe, et al., 2016). The effectiveness of the interventions were measured through audits of the sleep environment and documentation, and compared to the pre-intervention audits; hospital staff were also surveyed regarding SSP knowledge and perceptions. Evaluation of sleep environments showed a 13 percent increase in adherence to SSP with an overall increase of knowledge and beliefs surrounding SSP, and a decrease in barriers (Rowe, et al., 2016).

All inpatient hospital facilities should make it a priority to increase safe sleep practice interventions and adherence to American Academy of Pediatrics recommendations. Caregivers of infants under one year old, unless medically excluded, should follow the AAP guidelines to reduce risk and incidence of sudden death related to preventable causes. Medical and hospital staff modeling safe sleep behaviors in the hospital would create a higher likelihood of parents and caregivers continuing these behaviors at home. As infant mortality is much higher in the United States when compared to other developed countries, it is important to identify and intervene upon preventable risks, especially in the hospital setting where caregivers have the opportunity to observe the behavior of experienced personnel who are perceived to be experts acting in the best interests of the infant (Rowe, et al., 2016).

Stakeholder Assessment and Communication Plan

As the current policy in place at Children’s National Medical Center was designed by the Neonatal Intensive Care Unit only, it is not currently reflective of attributes of care and practices central to each unit, therefore, the key stakeholders in this evidence-based practice change multi-disciplinary team should be representative of all hospital specialties and units. Unit nursing managers and leadership of the other previously listed disciplines will be asked to identify individuals to serve as members of this practice change team to ensure the team is comprehensive and representative and committee chairmen will be elected during the initial meeting. The key disciplines that play a significant role in implementing safe sleep in hospitalized infants and are stakeholders in this change project include nurses, nursing support staff, respiratory therapists, occupational and physical therapists, advanced practice registered nurses, doctors, nursing managers and directors, supply chain representatives, linen services and, last but not least, parents and caregivers. Nurses, nursing support staff, and respiratory therapists are integral in enacting and role modeling the components of the protocol as they spend a significant amount of time in direct care of the patient. Nurses, respiratory therapists, and occupational and physical therapists also share a large responsibility in educating parents and dispelling the myths of safe sleep such as infant sleep positioning and items that are allowed within the sleeping area. Advanced practice registered nurses and doctors should reinforce safe sleep behaviors during encounters with parents and caregivers and also correct discrepancies through real time education. Nursing managers and directors should work with the multi-disciplinary team including the supply chain representatives and linen services to ensure that sleep sacks are available to staff to support the safe sleep recommendations in a cost conscious manner. Following the initial meeting, other staff and potentially a parent or caregiver representative may be recommended for project inclusion at the discretion of the team to promote the most well-rounded intervention possible.

Bi-weekly meetings will commence in January and February 2019 until the practice change project is rolled out on March 1. The initial meetings will evaluate the current policies and procedures regarding safe sleep with respect to current best practices as published in peer reviewed journals and by influential organizations, such as the American Academy of Pediatrics (AAP) and the National Association of Pediatric Nurse Practitioners (NAPNAP). In mid-February, stakeholders will complete an initial baseline knowledge survey of staff that will be reviewed following the implementation of the practice change. Stakeholders will also educate staff of best practices through inservices utilizing PowerPoint slides and simulation. Between March 1 and May 30, stakeholder meetings will occur monthly, though unit representatives will complete weekly bedside rounding audits and completed tools will be sent to the committee chairmen for analysis and intervention as needed. Real-time education will be provided to staff when deficits are found, and audits will be evaluated for overall compliance and areas of weakness with regard to hospital unit. Stakeholders will also create signs to be posted on the unit and at the patient bedside to remind staff, parents, and other caregivers of safe sleep practices. Parents will also be provided stakeholder-created handouts at admission and discharge in addition to one-on-one discharge teaching that is provided by the discharging nurse. The entire stakeholder group will again meet in June to determine whether the practice change should be incorporated into a nursing practice guideline and further educational needs of staff will be determined using audit results.

Description of the Plan MEGAN Comment by Meredith Ferfolia:

a. Discuss change strategies to be used and the variable(s) to be measured (process, outcome, balancing).

Our quality improvement project goal is to improve the safe sleep protocol compliance in hospitalized infants; we will utilize the PDSA cycle, or Plan Do Study Act, to formulate our plan. After creation of the safe sleep team and initial planning meetings, as previously described, the audit and education process planning will begin to complete the “Do” portion of the model. The basis of our education and audit will be centered around the American Academy of Pediatric current safe sleep recommendations. The safe sleep environment audit tool will be a concise, eight question survey with questions centering around: keeping the head of bed flat with the baby supine, in crib on a firm surface with only a fitted sheet, in a sleep sack, with hat removed, and without excess materials or medical devices. The exact audit components will be decided upon and approved by the safe sleep stakeholders. A baseline practice audit will be performed to evaluate how many infants are following the safe sleep guidelines before interventions occur; infants that will be excluded from the audit include patients who are intubated, have central lines, or other equipment that requires device protection or who are unable to follow protocol in totality for health care reasons not otherwise specified. In the planning phase, there will also be a survey evaluating staff and parent knowledge and barriers to implementing safe sleep. The knowledge and belief staff survey will contain topics such as: knowledge of AAP recommendations, how often the recommendations are actually being followed, knowledge of the existing policy, barriers to practice implementation, and belief regarding relation of unsafe infant sleep to SIDS. The survey given to parents will ask if they are aware of the current recommendations, specifics about current infant sleep practices at home, and barriers encountered while attempting to practice safe sleep.

The education of the staff members will occur following initial environmental audits and knowledge surveys and will include a PowerPoint presentation discussing safe sleep with a clinical educator and a simulation session. The simulation will consist of staff assessing an infant-sized doll that has been placed in a crib with the goal of finding all the items that do not belong in the crib, addressing clothing and positioning issues, and well as other environmental problems. The hospital will post fliers at the bedside that are easy to read and include visual and written references to the safe sleep guidelines. Additionally, a hospital-wide television network education video will play automatically for all parents of children under 1 year of age upon admission to the hospital; furthermore, staff members will demonstrate safe sleep interventions to parents and caregivers. It is important that multidisciplinary healthcare providers consistently model and encourage SSP and that safe sleep behavior should also be reinforced by the provider during medical team rounds. Finally, upon discharge the healthcare workers should again reinforce safe sleep education and the importance of continuing this behavior at home.

After adequate staff education, the interventions will be studied to examine their effectiveness, with respect to the “Study” portion of the PDSA cycle; this should occur three months after the project is initiated. The safe sleep audits will be completed again, with a goal of 20 audits per week per unit to measure if the interventions were effective. During these audits by the safe sleep team, real-time education should occur by reviewing all discrepancies with health care members, parents and caregivers. This real-time education should furthermore include investigation of the barriers that are preventing the safe sleep practice as it is imperative that, once education is provided to staff, audits and follow-up education not only improve practice, but provide insight into areas of weakness and allow for practice improvement as necessary. The areas of weakness and need for further staff education should be formulated. The clinical practice guidelines should be further developed and modified based on the barriers and discrepancies found after intervention, thus completing the “Act” portion of the PDSA cycle.

Description of the Evaluation Plan

The main outcome indicator of this project will be the percentage of overall compliance. Initially, 90 percent compliance will be targeted as the internal benchmark as there were several months that demonstrated compliance close to this value. Though there is currently a frequent and significant gap that exists between monthly average and this goal, this appears to be a goal that is achievable, but requires consistency in attainment.

This evidence based practice project would best be demonstrated on a run chart to adequately assess over compliance with the practice guidelines and determine how subsequent interventions have impacted that compliance. Data would be displayed on the run chart with time plotted in monthly intervals and the measurement figure as overall compliance with all aspects of the bundle. Run charts will be completed for each unit as well as one compiled for the hospital as a whole.

A bar chart will also be utilized to assess the other various data points obtained both pre- and post-intervention including overall compliance, discrepancies found, staff knowledge of the guidelines, parents knowledge of the guidelines, incidence of cited barriers to guideline implementation of staff, incidence of cited barriers to guidelines implementation of parents, and documentation of bundle compliance. An example of this chart is shown in the Appendix.

Conclusion

We hope that our change project will be enacted at Children’s National Medical Center in the hopes of encouraging parents to continue safe sleep practices in their home environment. We recognize that the hospital is a controlled environment, and that with close staff attention and electronic monitoring, sudden events in infants are often identified and intervened upon; we, therefore, hope that caregivers utilize the modeled behaviors as best practices for home where infants might be left alone for a period of time during sleep. Furthermore, project implementation should not occur during one period of time, but rather along a continuum and should be continually evaluated and altered when necessary to circumvent potential barriers or when new research provides evidence that practices should be changed; this multidisciplinary safe sleep project will fill a void in this project implementation process in assessing and addressing weaknesses in current practices and promoting safe sleep at home.

References

1. At a Glance [PDF]. (2017). Washington: Children's National Medical Center.
2. American Academy of Pediatrics. (2016, October 24). American Academy of Pediatrics Announces New Safe Sleep Recommendations to Protect Against SIDS, Sleep-Related Infant Deaths. Retrieved January 5, 2019, from https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/American-Academy-of-Pediatrics-Announces-New-Safe-Sleep-Recommendations-to-Protect-Against-SIDS.aspx
3. Centers for Disease Control and Prevention. (2018, December 31). Data and Statistics - SIDS and SUID. Retrieved January 5, 2019, from https://www.cdc.gov/sids/data.htm
4. [Children's National Clinical Audits on Safe Sleep Practices]. (2018, December). Unpublished raw data.
5. Children's National Medical Center Nursing Practice Guideline on Safe Sleep. (2017, January).
6. Colson, E. R., & Joslin, S. C. (2002). Changing Nursery Practice Gets Inner-city Infants in the Supine Position for Sleep. Archives of Pediatrics & Adolescent Medicine, 156(7), 717. doi:10.1001/archpedi.156.7.717
7. Macklin, J. R., Gittelman, M. A., Denny, S. A., Southworth, H., & Arnold, M. W. (2016). The EASE Quality Improvement Project: Improving Safe Sleep Practices in Ohio Children's Hospitals. Pediatrics, 138(4), 1-8. doi:10.1542/peds.2015-4267
8. Rowe, A. D., Sisterhen, L. L., Mallard, E., Borecky, B., Schmid, B., Rettiganti, M., & Luo, C. (2016). Integrating Safe Sleep Practices into a Pediatric Hospital: Outcomes of a Quality Improvement Project. Journal of Pediatric Nursing, 31(2), 141-147. Retrieved January 5, 2019, from https://www.sciencedirect.com
9. U.S. News & World Report. (2018). Children’s National Medical Center. Retrieved from https://health.usnews.com/best-hospitals/area/dc/childrens-national-medical-center-6330030
10. Zachritz, W., Fulmer, M., & Chaney, N. (2016). An Evidence-Based Infant Safe Sleep Program to Reduce Sudden Unexplained Infant Deaths. AJN, American Journal of Nursing,116(11), 48-55. doi:10.1097/01.naj.0000505590.78202.a2