When Sleeping Isn’t Safe: Working to Create Correct Sleeping Environments for

Hospitalized Infants in Ohio

Jamie R. Macklin, MD, FAAPNationwide Children’s Hospital

April 4, 2014

History of “Safe Sleep”1992: AAP recommends that all infants sleep on backs or sides to reduce SIDS Statement revised in 1996

1994: NIH/NICHD launches the “Back to Sleep” campaign to spread the message

SIDS Death Rate and Sleep Position 1988 – 2003

(per 1,000 Live Births)

SIDS and Other Sleep-related Infant DeathsSince 1992, SIDS deaths have decreased.

However, other causes have increased as SIDS has declined. SuffocationAsphyxiaEntrapment (strangulation in bed)

Thus, recently, sleep-related infant deaths have plateaued.

Compliance with “Back to Sleep” campaign unchanged at 75% since 2001

In Ohio…

49th/50th highest African-American infant mortality rate

47th/50th highest overall infant mortality rate2010 CDC dataBehind Tennessee, Mississippi, and

Alabama

In Ohio…819 sleep-related deaths in 2007-2011

15% of infant deaths, more than any other cause besides prematurity

>3 sleep-related infant deaths/weekEnough to fill 7 kindergarten classrooms each year!

Sleep-related deaths account for more infant deaths than any cause except prematurity.

Black infants and male infants are disproportionately affected.

What to Do?In 2011, the AAP Task Force on SIDS

expanded its focus towards creating a safe sleep environment for infants.SIDS (Sudden Infant Death Syndrome)SUID (Sudden Unexpected Infant Death)

Eighteen recommendations directed at parents, healthcare providers, researchers, and health policy makers

Safe Sleep in Hospitals: The Problem

Despite AAP recommendations, health care providers and staff do not always model safe sleep practices in the inpatient setting.

We know that parents are more likely to model actions and behaviors demonstrated by health care providers rather than modeling from verbal instructions.

An Idea is Born…

May 2012: Columbus Public Health Dept. presented a conference on the new 2011 AAP Safe Sleep recommendations.Dr. Rachel Moon was the speaker.

Nationwide Children’s Hospital (NCH) staff at the conference realized that the hospital’s practices did not align with many of the new recommendations.

Formation of a Safe Sleep CommitteeFollowing the conference, an interest

meeting was held in June 2012.Over 50 employees of the hospital came.

The NCH Safe Sleep Committee was formed in July 2012.APRN’s, physical and occupational therapists,

inpatient (day/night shift)/outpatient nursing staff, and a physician (now two)

The group has stayed fairly constant since inception.

Monthly Monday afternoon meetings

The Pre-Intervention AuditsMembers audited inpatient infant sleep

environments (looking at location/ position of infant, items in crib, etc.) in September 2012.

Franklin County Dept. of Public Health form

ExclusionsNICUVentilator/NIPPVTracheostomiesRecent spinal surgeries

Audit Form QuestionsDemographics

AgeUnit LocationTime

Location of Baby (crib, couch, etc.)Position of Baby (back, side, etc.)Condition of Crib/Baby

Blankets, toys, diapers/wipes?Was the head of the bed elevated?

Developmental Tools Used Inappropriately?

The Audit FormTotal Possible Points: 7.0 points

The higher the score, the better the performance/audit

Average Hospital Score: 3.8/7.0 points

“Safe Sleep Bundle” Limited RolloutIntervention Planning September 2012-

June 2013Updating of Existing Hospital Policy

Changing language related to GER interventions, firm mattress use

Ultimately finalized July 2013Focused efforts on the General Pediatrics

unitRollout in June 2013Underlined interventions were first

To increase the quantities of safe sleep behaviors in infants <1 year of age by increasing Safe Sleep Audit

Scores from average 3.8/7.0 to 6.0/7.0 points by

xxx

Specific Aim

Nursing Education

PCA, PT/OT (Multi-Disciplinary) Education

Management of Environment

Key Drivers Interventions(Ideas)

Physician Education

Parent/Caregiver Education

CHEX ModuleQuality Board Tips (Marketing)Nurse Champions/RN Care PartnersScripting for/with ParentsSafe Sleep “Cheat Sheet”

Grand Rounds with Dr. Rachel MoonHospital Peds Web module

Safety Videos/Edutainment System (Franklin County/CPSC/NICHD)Take-Home Magnets (Marketing)Brochures (NICHD)Safe Sleep Posters (Clinics)

Sleep sacks (Halo)Assess hospital policy on clothingallowed for patientsMattresses on beds need evaluatedFitted Sheets

Nationwide Children’s Hospital Safe Sleep Key Driver Diagram (“Bundle” at Time of Rollout)

“Safe Sleep Bundle”Rollout ResultsNew audits performed in September

2013General Pediatrics Unit score: 5.7/7.0

pointsStatistically significant improvement from

baseline score and from the rest of the units of the hospital

Hospital average score: 4.5/7.0 points

“Safe Sleep Bundle” Hospital-wide RolloutOctober 2013Education and interventions introduced

to all units in the hospitalNew audits performed in January 2014

General Pediatrics Unit score: 6.1/7.0 points (Specific Aim met)

Hospital average score: 5.1/7.0 pointsCurrently working with lower-scoring

units to improve compliance with recommendations

To increase the quantities of safe sleep behaviors in infants <1 year of age by increasing Safe Sleep Audit

Scores from average 3.8/7.0 to 6.0/7.0 points by

xxx

Specific Aim

Nursing Education

PCA, PT/OT (Multi-Disciplinary) Education

Management of Environment

Key Drivers Interventions(Ideas)

Physician Education

Parent/Caregiver Education

CHEX ModuleQuality Board Tips (Marketing)Nurse Champions***Scripting for/with ParentsSafe Sleep “Cheat Sheet”

Grand Rounds with Dr. Rachel MoonHospital Peds Web module

Safety Videos/Edutainment System (Franklin County/CPSC/NICHD)Take-Home Magnets (Marketing)***Brochures (NICHD)Safe Sleep Posters (Clinics)

Sleep sacks (Halo)Assess hospital policy on clothingallowed for patientsEvaluation of Mattresses***Fitted Sheets

Nationwide Children’s Hospital Safe Sleep Key Driver Diagram (Where We Are Now)

Lessons Learned…

Keys to SuccessSupportive hospital leadership

Nursing administrationPhysician staff

A passionate Safe Sleep CommitteeMultidisciplinary is best, if possible!

Reaching out to community resourcesCIAG grantOBBO

Challenges and Pitfalls“But that’s not the way we’ve done it before!!”“My baby’s pediatrician says that….”“The consult doctor that was just here told us

that….”“My baby is different; the rules don’t apply

because….”

Education of physicians, nursing and ancillary staff, and parents/caregivers is essential for successful change.

“Buy-in” from staff, while difficult in several instances, is also essential.

Working with other departments can be frustrating, at times.

Small Steps are Still Steps…PDSA cycles

Even one intervention is still great if it yields change.

Focus on one area of improvement if needed, instead of all at once.

Many free or inexpensive options exist.NICHD website/brochures (http://

www.nichd.nih.gov/sts/materials/Pages/default.aspx)

CPSC videos (http://www.cpsc.gov/en/Safety-Education/Safety-Education-Centers/cribs)

The Ohio AAP “EASE” Project

Education and Sleep EnvironmentCreated in Fall 2013 as a means to

improve infant safe sleep practices in ALL children’s hospitals in Ohio

Modeled after the NCH Safe Sleep project

12-month project, initiated in February 2014

EASE Project GoalsTo increase the quantities of safe sleep

behaviors in infants <12 months of ageTo show that greater than 90% of infants

will be in a safe sleep environment (Alone, on Back, in an empty Crib) during hospitalization Random weekly audits

To provide safe sleep information to parents/caregivers of greater than 90% of infants upon hospital discharge

To increase the quantities of safe sleep behaviors in infants <1 year of age by increasing Safe Sleep Audit

Scores from average xxx/7.0 points to xxx/7.0

points by xxx(hospital-wide)

Specific Aim

Nursing Education

PCA, PT/OT (Multi-Disciplinary) Education

Management of Environment

Key DriversInterventions

(Ideas)

Physician Education

Parent/Caregiver Education

CHEX Quality Board Tips (Marketing)Nurse Champions/RN Care PartnersScripting for/with ParentsSafe Sleep “Cheat Sheet”

Grand Rounds with Dr. Rachel MoonHospital Pediatrics Web module

Safety Videos/Edutainment System (County/CPSC/NICHD)Take-Home Magnets (Marketing)Brochures (NICHD)Safe Sleep Posters (Clinics/Off-Sites)

Sleep sacks (Halo)Assess hospital policy on clothingallowed for patientsMattresses on beds need evaluatedFitted Sheets?Ohio AAP EASE Project Key Driver Diagram

(Courtesy of Nationwide Children’s Hospital)

EASE Project RequirementsCompletion of random weekly audits

At least 10/weekCompletion of at least 3 PDSA cycles to

improve outcomesAttendance of at least 75% in monthly

Action Period Calls

Get Ready to Make a Difference!Overall, hospitals can help parents learn to

practice safe sleep by providing education and resources and by demonstrating desired behaviors.

More than half of children’s hospitals are not following guidelines for safe sleep.

Barriers to following safe sleep recommendations include parental and healthcare worker misunderstanding and lack of modeling and reinforcement in the healthcare setting.

We Can Change This!!!

Questions?