Post on 13-Dec-2015
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 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.
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)
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!!!