The Journal of Maternal-Fetal & Neonatal Medicine
ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmf20
Implementing safe sleep practices in a neonatal intensive care unit Kristin C. Voos, Amy Terreros, Phyllis Larimore, Mary Kay Leick-Rude & Nesha Park To cite this article: Kristin C. Voos, Amy Terreros, Phyllis Larimore, Mary Kay LeickRude & Nesha Park (2015) Implementing safe sleep practices in a neonatal intensive care unit, The Journal of Maternal-Fetal & Neonatal Medicine, 28:14, 1637-1640, DOI: 10.3109/14767058.2014.964679 To link to this article: http://dx.doi.org/10.3109/14767058.2014.964679
Accepted online: 12 Sep 2014.Published online: 29 Sep 2014.
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Article views: 100
View related articles
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijmf20 Download by: [University of Otago]
Date: 05 October 2015, At: 06:08
http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, 2015; 28(14): 1637–1640 ! 2014 Informa UK Ltd. DOI: 10.3109/14767058.2014.964679
ORIGINAL ARTICLE
Implementing safe sleep practices in a neonatal intensive care unit Kristin C. Voos1, Amy Terreros2, Phyllis Larimore3, Mary Kay Leick-Rude1, and Nesha Park1 Division of Neonatology, Department of Pediatrics, 2Division of Child Abuse and Neglect, Department of Pediatrics, and 3Department of Pediatrics, Children’s Mercy Hospitals and Clinics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
Downloaded by [University of Otago] at 06:08 05 October 2015
1
Abstract
Keywords
Objective: Sudden infant death syndrome (SIDS) remains the leading cause of death in the postnatal period. Accidental suffocation and strangulation in bed deaths have quadrupled. The American Academy of Pediatrics (AAP) expanded its back to sleep recommendations to include a safe sleep environment. The AAP makes recommendations to healthcare professionals to model safe sleep practices and educate families on SIDS reduction strategies. The dual aims of this project were to develop a safe sleep educational model for our neonatal intensive care unit (NICU), and to increase the percentage of eligible infants in a safe sleep environment. Method: The NICU Safe Sleep policy was revised to include AAP updated recommendations. Educational updates were provided to staff. A safe sleep packet with a video was created for and shared with families. Wearable blankets were implemented. A safe sleep observation checklist was created. Baseline data and post-education random observations data were collected and shared with staff. Results: At baseline, 21% of eligible infants were in a safe sleep environment. After education and reported observation, safe sleep compliance increased to 88%. Conclusions: With formal staff and family education, optional wearable blanket, and data sharing, safe sleep compliance increased and patient safety improved.
Injury prevention, safe to sleep, sudden infant death
Introduction Sudden infant death syndrome (SIDS) and other sleep-related deaths, including suffocation and entrapment, continue to be a major public health concern. Premature and low birth weight infants have a higher risk of SIDS than term infants [1,2]. Although SIDS rates declined from 120 deaths per 100 000 live births in 1992 to 56 deaths per 100 000 live births in 2001, rates from 2001 to 2006 have remained constant [3]. Even with the dramatic decline, SIDS remains the leading cause of death in the post-neonatal period [4]. In addition, accidental suffocation and strangulation in bed deaths have quadrupled from 1984 to 2004 [3,5]. In response to these preventable deaths, the American Academy of Pediatrics (AAP) expanded its previous back to sleep recommendations in 2011 to include a safe sleep environment. The most recent recommendations include supine positioning, using a firm sleep surface, breastfeeding, room-sharing without bed-sharing, administering routine immunizations, and considering the use of a pacifier [3]. Address for correspondence: Kristin C. Voos, MD, Division of Neonatology, Department of Pediatrics, Children’s Mercy Hospitals and Clinics, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, USA. Tel: 9136387210. E-mail: [email protected]
History Received 20 June 2014 Accepted 9 September 2014 Published online 29 September 2014
The AAP also recommends avoiding soft bedding, loose blankets, overheating, and exposure to tobacco smoke, alcohol, and illicit drugs [3]. The AAP makes specific recommendations for healthcare professionals to model safe sleep in the hospital setting and educate the families of infants on SIDS risk-reduction strategies [3]. Parental knowledge and acceptance of safe sleep practices are keys in decreasing the risk of unexpected infant deaths [6]. Studies have shown that nurses and other medical team members play crucial roles in parent education. Infant positioning in the hospital strongly influences parents’ practices at home [7–9]. Creating a safe to sleep environment in the NICU setting can be challenging. Prone sleeping positions and elevation of the head of the bed are encouraged early in the hospital course to optimize respiratory mechanics [10]. Nurses often use infant positioning devices or blanket rolls for developmentally-appropriate care early in the infant’s stay. Extra blankets may be applied for thermoregulation concerns when weaning to a crib. Though these practices may be appropriate early in the hospital course, AAP stresses that NICUs should model safe sleep practices well before discharge and clearly educate parents on the importance and timing of placing an infant in a safe sleep environment [3]. Even with the AAP recommendations, there is a knowledge gap in SIDS prevention and implementation among NICU nursing and
1638
K. C. Voos et al.
medical staff. The dual aims of this project were to develop a safe sleep educational model for our NICU, and to increase the percentage of eligible infants in a safe sleep environment.
Methods Setting The Children’s Mercy Hospital NICU is large tertiary care unit in Kansas City, MO, with an average census of 70 infants. The NICU has approximately 900 admissions a year and most are out-born.
Downloaded by [University of Otago] at 06:08 05 October 2015
Planning The Institutional Review Board approved our project as quality improvement. A multidisciplinary committee used multiple Plan, Do, Study, Act cycles to achieve improvement goals. The committee consisted of a parent advisor, staff nurses, neonatologists, discharge coordinators, social workers, unit educators, and other ancillary staff. Representatives from administration, NICU, injury prevention, and child abuse and neglect teams collaborated to form the Safe to Sleep Team. The goal was to implement a safe sleep NICU program that included a revised policy outlining practice changes, staff training, and updated parent education materials. The revised NICU Safe Sleep policy included AAP updated recommendations. Safe sleep was defined as an infant sleeping on its back, with the head of bed flat, one fitted sheet with no other objects in the crib. Our unit decided an infant was eligible for safe sleep practices when transitioned to an open crib and medically stable. For example, an infant older than 32 weeks’ gestation not requiring positive pressure ventilation in an open crib would be eligible for safe sleep. Safe sleep was set as the standard of care. Any other medically necessary positioning such as elevating the head of the bed required a medical order. Education Educational presentations were prepared to include evidencebased best practices for safe sleep. These presentations were given at discipline-specific educational updates. Unit-based safe sleep nursing competencies, which included case studies and peer reviews of compliance to policies, were developed by unit educators. A family education plan consisted of education by the bedside nurse, reinforced by a safe sleep packet with written and video materials. Staff shared the packet and video with families when the infant moved to an open crib. The safe sleep video was made available for inpatient families to view either on a DVD player or on the hospital closed-circuit television system. Wearable blankets were made available to swaddle the infants and discourage the use of loose blankets in the crib. Data collection A checklist was created to identify the following risk factors: Head of bed elevated without a medical order Infant not positioned on back Infant asleep in seat or swing
J Matern Fetal Neonatal Med, 2015; 28(14): 1637–1640
Toys in bed Pillow in bed Gel pillow or position device in bed Loose blanket in bed A check mark for any of the above factors indicated an unsafe sleep environment. The Safe Sleep Team performed safe sleep observation rounds, initially every 3 months then monthly to encourage improved compliance. The checklist was used when rounding through the unit to obtain compliance data with safe sleep recommendations. Safe sleep observation rounding was an additional educational opportunity to provide one-on-one staff education and encouragement as needed. Compliance using the safe sleep checklist was shared with staff via e-mail and flat screen monitor displays to show unit progress.
Results Education Educational sessions were held for nursing staff, physicians, and neonatal nurse practitioners (NNP). Nursing administration made the nursing educational sessions mandatory, and all 250 nurses attended. A similar safe sleep presentation was given at an NNP quarterly meeting and was audiotaped and posted online for viewing. Physician education was provided at a regular scheduled noon conference and at a division meeting. Educational sessions were followed up by an e-mail reviewing the most frequently asked questions and concerns from the educational sessions. The response e-mail addressed specific concerns along with proposed solutions. Nursing administration made safe sleep one of the yearly competencies. Each nurse completed the competency, which included a module with questions, a case study, and peer review of bedside safe sleep practices. Parent safe sleep packets were distributed when an infant was moved to a crib and became safe sleep eligible. Safe sleep education was added to our unit’s discharge checklist. The safe sleep packet and video were reviewed with the family again prior to discharge. The discharge checklist was completed prior to discharge and documented in the chart under discharge teaching. Data At baseline, 21% (6/28) of eligible infants were in a safe sleep environment. Ten separate observation rounds using the safe sleep checklist resulted in a total of 260 patients observations. Average of 26 patients (range of 19–32) were eligible during each of the observation rounds. Adherence with safe sleep policies increased to 88% (23/26) over 1.5 years with education sessions, safe sleep observation rounds, and checklist data reported to staff (Figure 1). The three most common findings of an unsafe sleeping environment were head of bed elevated, 29% (8/28); infant not positioned on back, 21% (6/28); and toys in bed, 32% (9/28). After education and reported observations, compliance with safe sleep recommendations improved. Head of bed elevated without a medical order decreased to 0%; infant not positioned on back decreased to 12% (3/26), and reduced incidence of toys in cribs to 4% (1/26).
Safe sleep in a NICU
70% 60% 50% 40%
37%
30% 21%
20% 10%
1639
Children's Mercy Kansas City NICU Safe Sleep Compliance 88% 74%
74% 66% 60% 59%
54% 42%
Shared Data & Reminders 4/2013
80%
FAQs 4/2012 & 6/2012
90%
Nursing Competencies Assigned 6/2012
100%
Policy Revision & Staff Educaon 4/2012
Figure 1. Safe sleep compliance.
Posioning & Reflux with Safe Sleep SBAR 7/2012
DOI: 10.3109/14767058.2014.964679
0%
Downloaded by [University of Otago] at 06:08 05 October 2015
Percent Compliant
Discussion Creating a safe to sleep environment in the NICU setting is essential for protecting patients’ safety. A knowledge gap exists between SIDS prevention recommendations and implementation among NICU nursing and medical staff. Prior to education, only 21% of our eligible infants were in a safe sleep environment. Other studies have also shown a similar gap in knowledge versus actions and policies. In a survey of 430 nurses, only 42% to 64% of NICU nurses identified themselves as always following safe sleep recommendations when preparing infants for discharge [11]. Another survey showed that only half of NICU nurses advised parents to place their infants on their backs to sleep after discharge [12]. Although newborn sleep-related deaths are not expected in the NICU, the inpatient setting provides an opportunity to model risk reduction behavior [12]. Moon et al. found that parents who observed health care professionals placing infants in the side or prone position were likely to infer that supine positioning was not important [13]. Our approach to staff and parent education contributed to the increase of infants in a safe sleep environment in the NICU to over 88%. The most appropriate time to institute safe sleep practices remains a question in many NICUs. AAP policy says ‘‘as early as 32 weeks.’’ Some institutions use a cut-off before discharge. One survey in the United Kingdom began supine sleeping 1–2 weeks before discharge [14]. We have found that predicting discharge in the NICU is not always accurate. We also felt that using a discharge timeline would miss a window for modeling safe sleep when an infant is stable in a crib but still growing and working on tolerating feeds. We decided that, for our unit, safe sleep would be the standard of care when an infant transitioned to a crib. If there was a medical reason for other positioning, then an order was required. The transition to a crib seemed to be an optimal time to educate parents about safe sleep. The use of positioning devices and soft bedding is advocated for the developmental support of premature infants [15]. So, removing the soft
bedding and positioning devices when going to a crib provided a clear cut-off time for nursing staff and parents to know when to begin safe sleep practices. Nurses were also able to use this transition time to explain parents safe sleep and its importance in reducing accidental suffocation deaths at home. Our strategy included policy change, nursing education, development of parent education materials, and recorded observations. Multiple presentations across different media assisted with reinforcement of initial nursing education at our updates. Allowing time for staff to ask questions and giving feedback helped to identify barriers and concerns. We addressed the concerns expressed by staff on an ongoing basis by providing answers to the most common questions. Initial questions expressed by staff centered on swaddling and family-provided decorative loose blankets in the bed. A solution to this issue was provision of wearable blankets for swaddling and warmth. An infant could be wrapped without having a loose blanket in the bed. Wearble blankets were not required for a safe sleep environment but gave nurses and families the option of swaddling without loose blankets and subsequent suffocation risks. Following our education strategies, we saw a significant increase in a safe sleep environment for our eligible infants. When compliance plateaued around 40–60%, we started reporting the safe sleep checklist observations on a monthly basis with reminders of our goal to increase compliance. Reporting more frequently on our checklist observations and celebrating successes with staff contributed to us reaching our goal. Limitations to our project included that we observed only a single site and that observations were done during the day. As we implemented a multi-faceted program that included change in policy, staff education, parent education, and wearable blankets, we do not know which of the interventions contributed most to the change in practice. Next steps would be to evaluate staff and parent knowledge of safe sleep practices and family compliance with safe sleep practices after discharge. In conclusion, staff and
1640
K. C. Voos et al.
family education, optional wearable blanket, and data sharing with staff resulted in safe sleep practice and patient safety improvement.
Declaration of interest Authors report no financial disclosure or conflict of interest.
Downloaded by [University of Otago] at 06:08 05 October 2015
References 1. Malloy MH, Hoffman HJ. Prematurity, sudden infant death syndrome, and age of death. Pediatrics 1995;96:464–71. 2. Halloran DR, Alexander GR. Preterm delivery and age of SIDS death. Ann Epidemiol 2006;16:600–6. 3. SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Task Force on Sudden Infant Death Syndrome, Moon RY. Pediatrics 2011;128:1030–9. 4. Centers for Disease Control and Prevention. Atlanta, GA, USA; 2013 October 25. Available from: http://www.cdc.gov/features/ sidsawarenessmonth/ [last accessed 19 Jun 2014]. 5. Shapiro-Mendoza CK, Kimball M, Tomashek KM, et al. US infant mortality trends attributable to accidental suffocation and strangulation in bed from 1984 through 2004: are rates increasing? Pediatrics 2009;123:533–9. 6. Gelfer P, Cameron R, Masters K, Kennedy K. Integrating ‘‘Back to Sleep’’ recommendations into neonatal ICU practice. Pediarics 2013;131:e1264–70.
J Matern Fetal Neonatal Med, 2015; 28(14): 1637–1640
7. Vernacchio L, Corwin MJ, Lesko SM, et al. Sleep position of low birth weight infants. Pedatrics 2003;111:633–40. 8. Colson ER, Joslin SC. Changing nursery practice get inner-city infant in the supine position for sleep. Arch Peditr Adolesc Med 2002;156:717–20. 9. Shaefer SJ, Herman SE, Frank SJ, et al. Translating infant safe sleep evidence into nursing practice. J Obstet Gynecol Neonatal Nurs 2010;39:618–26. 10. Wolfson MR, Greenspan JS, Deroras KS, et al. Effect of position on the mechanical interaction between rib cage and abdomen in preterm infants. J Appl Physiol 1992;72:1032–8. 11. Grazel R, Phalen AG, Polomano RC. Implementation of the American Academy of Pediatrics recommendations to reduce sudden infant death syndrome risk in neonatal intensive care units: an evaluation of nursing knowledge and practice. Adv Neonatal Care 2010;10:332–42. 12. Mason B, Ahlers-Schmidt C, Schinn C. Improving safe sleep environments for well newborns in the hospital setting. Clin Pedistr 2013;52:969–75. 13. Moon RY, ODen RP, Joyner BL, et al. Qualitative analysis of beliefs and perceptions about sudden infant death syndrome in African-American mothers: implications for safe sleep recommendations. J Pediatr 2010;157:92–7. 14. Rao H, May C, Hannam S, et al. Survey of sleeping position recommendations for prematurely born infants on neonatal intensive care unit discharge. Eur J Pediatr 2007;166:809–11. 15. Hunter J. Therapeutic positioning: neuromotor, physiologic and sleep implications. In: Kenner C, McGrath JM, eds. Developmental care of newborns and infants, a guide for health professionals, 2nd ed. Glenview, IL: NAAN; 2010:285–312.
ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmf20
Implementing safe sleep practices in a neonatal intensive care unit Kristin C. Voos, Amy Terreros, Phyllis Larimore, Mary Kay Leick-Rude & Nesha Park To cite this article: Kristin C. Voos, Amy Terreros, Phyllis Larimore, Mary Kay LeickRude & Nesha Park (2015) Implementing safe sleep practices in a neonatal intensive care unit, The Journal of Maternal-Fetal & Neonatal Medicine, 28:14, 1637-1640, DOI: 10.3109/14767058.2014.964679 To link to this article: http://dx.doi.org/10.3109/14767058.2014.964679
Accepted online: 12 Sep 2014.Published online: 29 Sep 2014.
Submit your article to this journal
Article views: 100
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijmf20 Download by: [University of Otago]
Date: 05 October 2015, At: 06:08
http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, 2015; 28(14): 1637–1640 ! 2014 Informa UK Ltd. DOI: 10.3109/14767058.2014.964679
ORIGINAL ARTICLE
Implementing safe sleep practices in a neonatal intensive care unit Kristin C. Voos1, Amy Terreros2, Phyllis Larimore3, Mary Kay Leick-Rude1, and Nesha Park1 Division of Neonatology, Department of Pediatrics, 2Division of Child Abuse and Neglect, Department of Pediatrics, and 3Department of Pediatrics, Children’s Mercy Hospitals and Clinics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
Downloaded by [University of Otago] at 06:08 05 October 2015
1
Abstract
Keywords
Objective: Sudden infant death syndrome (SIDS) remains the leading cause of death in the postnatal period. Accidental suffocation and strangulation in bed deaths have quadrupled. The American Academy of Pediatrics (AAP) expanded its back to sleep recommendations to include a safe sleep environment. The AAP makes recommendations to healthcare professionals to model safe sleep practices and educate families on SIDS reduction strategies. The dual aims of this project were to develop a safe sleep educational model for our neonatal intensive care unit (NICU), and to increase the percentage of eligible infants in a safe sleep environment. Method: The NICU Safe Sleep policy was revised to include AAP updated recommendations. Educational updates were provided to staff. A safe sleep packet with a video was created for and shared with families. Wearable blankets were implemented. A safe sleep observation checklist was created. Baseline data and post-education random observations data were collected and shared with staff. Results: At baseline, 21% of eligible infants were in a safe sleep environment. After education and reported observation, safe sleep compliance increased to 88%. Conclusions: With formal staff and family education, optional wearable blanket, and data sharing, safe sleep compliance increased and patient safety improved.
Injury prevention, safe to sleep, sudden infant death
Introduction Sudden infant death syndrome (SIDS) and other sleep-related deaths, including suffocation and entrapment, continue to be a major public health concern. Premature and low birth weight infants have a higher risk of SIDS than term infants [1,2]. Although SIDS rates declined from 120 deaths per 100 000 live births in 1992 to 56 deaths per 100 000 live births in 2001, rates from 2001 to 2006 have remained constant [3]. Even with the dramatic decline, SIDS remains the leading cause of death in the post-neonatal period [4]. In addition, accidental suffocation and strangulation in bed deaths have quadrupled from 1984 to 2004 [3,5]. In response to these preventable deaths, the American Academy of Pediatrics (AAP) expanded its previous back to sleep recommendations in 2011 to include a safe sleep environment. The most recent recommendations include supine positioning, using a firm sleep surface, breastfeeding, room-sharing without bed-sharing, administering routine immunizations, and considering the use of a pacifier [3]. Address for correspondence: Kristin C. Voos, MD, Division of Neonatology, Department of Pediatrics, Children’s Mercy Hospitals and Clinics, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, USA. Tel: 9136387210. E-mail: [email protected]
History Received 20 June 2014 Accepted 9 September 2014 Published online 29 September 2014
The AAP also recommends avoiding soft bedding, loose blankets, overheating, and exposure to tobacco smoke, alcohol, and illicit drugs [3]. The AAP makes specific recommendations for healthcare professionals to model safe sleep in the hospital setting and educate the families of infants on SIDS risk-reduction strategies [3]. Parental knowledge and acceptance of safe sleep practices are keys in decreasing the risk of unexpected infant deaths [6]. Studies have shown that nurses and other medical team members play crucial roles in parent education. Infant positioning in the hospital strongly influences parents’ practices at home [7–9]. Creating a safe to sleep environment in the NICU setting can be challenging. Prone sleeping positions and elevation of the head of the bed are encouraged early in the hospital course to optimize respiratory mechanics [10]. Nurses often use infant positioning devices or blanket rolls for developmentally-appropriate care early in the infant’s stay. Extra blankets may be applied for thermoregulation concerns when weaning to a crib. Though these practices may be appropriate early in the hospital course, AAP stresses that NICUs should model safe sleep practices well before discharge and clearly educate parents on the importance and timing of placing an infant in a safe sleep environment [3]. Even with the AAP recommendations, there is a knowledge gap in SIDS prevention and implementation among NICU nursing and
1638
K. C. Voos et al.
medical staff. The dual aims of this project were to develop a safe sleep educational model for our NICU, and to increase the percentage of eligible infants in a safe sleep environment.
Methods Setting The Children’s Mercy Hospital NICU is large tertiary care unit in Kansas City, MO, with an average census of 70 infants. The NICU has approximately 900 admissions a year and most are out-born.
Downloaded by [University of Otago] at 06:08 05 October 2015
Planning The Institutional Review Board approved our project as quality improvement. A multidisciplinary committee used multiple Plan, Do, Study, Act cycles to achieve improvement goals. The committee consisted of a parent advisor, staff nurses, neonatologists, discharge coordinators, social workers, unit educators, and other ancillary staff. Representatives from administration, NICU, injury prevention, and child abuse and neglect teams collaborated to form the Safe to Sleep Team. The goal was to implement a safe sleep NICU program that included a revised policy outlining practice changes, staff training, and updated parent education materials. The revised NICU Safe Sleep policy included AAP updated recommendations. Safe sleep was defined as an infant sleeping on its back, with the head of bed flat, one fitted sheet with no other objects in the crib. Our unit decided an infant was eligible for safe sleep practices when transitioned to an open crib and medically stable. For example, an infant older than 32 weeks’ gestation not requiring positive pressure ventilation in an open crib would be eligible for safe sleep. Safe sleep was set as the standard of care. Any other medically necessary positioning such as elevating the head of the bed required a medical order. Education Educational presentations were prepared to include evidencebased best practices for safe sleep. These presentations were given at discipline-specific educational updates. Unit-based safe sleep nursing competencies, which included case studies and peer reviews of compliance to policies, were developed by unit educators. A family education plan consisted of education by the bedside nurse, reinforced by a safe sleep packet with written and video materials. Staff shared the packet and video with families when the infant moved to an open crib. The safe sleep video was made available for inpatient families to view either on a DVD player or on the hospital closed-circuit television system. Wearable blankets were made available to swaddle the infants and discourage the use of loose blankets in the crib. Data collection A checklist was created to identify the following risk factors: Head of bed elevated without a medical order Infant not positioned on back Infant asleep in seat or swing
J Matern Fetal Neonatal Med, 2015; 28(14): 1637–1640
Toys in bed Pillow in bed Gel pillow or position device in bed Loose blanket in bed A check mark for any of the above factors indicated an unsafe sleep environment. The Safe Sleep Team performed safe sleep observation rounds, initially every 3 months then monthly to encourage improved compliance. The checklist was used when rounding through the unit to obtain compliance data with safe sleep recommendations. Safe sleep observation rounding was an additional educational opportunity to provide one-on-one staff education and encouragement as needed. Compliance using the safe sleep checklist was shared with staff via e-mail and flat screen monitor displays to show unit progress.
Results Education Educational sessions were held for nursing staff, physicians, and neonatal nurse practitioners (NNP). Nursing administration made the nursing educational sessions mandatory, and all 250 nurses attended. A similar safe sleep presentation was given at an NNP quarterly meeting and was audiotaped and posted online for viewing. Physician education was provided at a regular scheduled noon conference and at a division meeting. Educational sessions were followed up by an e-mail reviewing the most frequently asked questions and concerns from the educational sessions. The response e-mail addressed specific concerns along with proposed solutions. Nursing administration made safe sleep one of the yearly competencies. Each nurse completed the competency, which included a module with questions, a case study, and peer review of bedside safe sleep practices. Parent safe sleep packets were distributed when an infant was moved to a crib and became safe sleep eligible. Safe sleep education was added to our unit’s discharge checklist. The safe sleep packet and video were reviewed with the family again prior to discharge. The discharge checklist was completed prior to discharge and documented in the chart under discharge teaching. Data At baseline, 21% (6/28) of eligible infants were in a safe sleep environment. Ten separate observation rounds using the safe sleep checklist resulted in a total of 260 patients observations. Average of 26 patients (range of 19–32) were eligible during each of the observation rounds. Adherence with safe sleep policies increased to 88% (23/26) over 1.5 years with education sessions, safe sleep observation rounds, and checklist data reported to staff (Figure 1). The three most common findings of an unsafe sleeping environment were head of bed elevated, 29% (8/28); infant not positioned on back, 21% (6/28); and toys in bed, 32% (9/28). After education and reported observations, compliance with safe sleep recommendations improved. Head of bed elevated without a medical order decreased to 0%; infant not positioned on back decreased to 12% (3/26), and reduced incidence of toys in cribs to 4% (1/26).
Safe sleep in a NICU
70% 60% 50% 40%
37%
30% 21%
20% 10%
1639
Children's Mercy Kansas City NICU Safe Sleep Compliance 88% 74%
74% 66% 60% 59%
54% 42%
Shared Data & Reminders 4/2013
80%
FAQs 4/2012 & 6/2012
90%
Nursing Competencies Assigned 6/2012
100%
Policy Revision & Staff Educaon 4/2012
Figure 1. Safe sleep compliance.
Posioning & Reflux with Safe Sleep SBAR 7/2012
DOI: 10.3109/14767058.2014.964679
0%
Downloaded by [University of Otago] at 06:08 05 October 2015
Percent Compliant
Discussion Creating a safe to sleep environment in the NICU setting is essential for protecting patients’ safety. A knowledge gap exists between SIDS prevention recommendations and implementation among NICU nursing and medical staff. Prior to education, only 21% of our eligible infants were in a safe sleep environment. Other studies have also shown a similar gap in knowledge versus actions and policies. In a survey of 430 nurses, only 42% to 64% of NICU nurses identified themselves as always following safe sleep recommendations when preparing infants for discharge [11]. Another survey showed that only half of NICU nurses advised parents to place their infants on their backs to sleep after discharge [12]. Although newborn sleep-related deaths are not expected in the NICU, the inpatient setting provides an opportunity to model risk reduction behavior [12]. Moon et al. found that parents who observed health care professionals placing infants in the side or prone position were likely to infer that supine positioning was not important [13]. Our approach to staff and parent education contributed to the increase of infants in a safe sleep environment in the NICU to over 88%. The most appropriate time to institute safe sleep practices remains a question in many NICUs. AAP policy says ‘‘as early as 32 weeks.’’ Some institutions use a cut-off before discharge. One survey in the United Kingdom began supine sleeping 1–2 weeks before discharge [14]. We have found that predicting discharge in the NICU is not always accurate. We also felt that using a discharge timeline would miss a window for modeling safe sleep when an infant is stable in a crib but still growing and working on tolerating feeds. We decided that, for our unit, safe sleep would be the standard of care when an infant transitioned to a crib. If there was a medical reason for other positioning, then an order was required. The transition to a crib seemed to be an optimal time to educate parents about safe sleep. The use of positioning devices and soft bedding is advocated for the developmental support of premature infants [15]. So, removing the soft
bedding and positioning devices when going to a crib provided a clear cut-off time for nursing staff and parents to know when to begin safe sleep practices. Nurses were also able to use this transition time to explain parents safe sleep and its importance in reducing accidental suffocation deaths at home. Our strategy included policy change, nursing education, development of parent education materials, and recorded observations. Multiple presentations across different media assisted with reinforcement of initial nursing education at our updates. Allowing time for staff to ask questions and giving feedback helped to identify barriers and concerns. We addressed the concerns expressed by staff on an ongoing basis by providing answers to the most common questions. Initial questions expressed by staff centered on swaddling and family-provided decorative loose blankets in the bed. A solution to this issue was provision of wearable blankets for swaddling and warmth. An infant could be wrapped without having a loose blanket in the bed. Wearble blankets were not required for a safe sleep environment but gave nurses and families the option of swaddling without loose blankets and subsequent suffocation risks. Following our education strategies, we saw a significant increase in a safe sleep environment for our eligible infants. When compliance plateaued around 40–60%, we started reporting the safe sleep checklist observations on a monthly basis with reminders of our goal to increase compliance. Reporting more frequently on our checklist observations and celebrating successes with staff contributed to us reaching our goal. Limitations to our project included that we observed only a single site and that observations were done during the day. As we implemented a multi-faceted program that included change in policy, staff education, parent education, and wearable blankets, we do not know which of the interventions contributed most to the change in practice. Next steps would be to evaluate staff and parent knowledge of safe sleep practices and family compliance with safe sleep practices after discharge. In conclusion, staff and
1640
K. C. Voos et al.
family education, optional wearable blanket, and data sharing with staff resulted in safe sleep practice and patient safety improvement.
Declaration of interest Authors report no financial disclosure or conflict of interest.
Downloaded by [University of Otago] at 06:08 05 October 2015
References 1. Malloy MH, Hoffman HJ. Prematurity, sudden infant death syndrome, and age of death. Pediatrics 1995;96:464–71. 2. Halloran DR, Alexander GR. Preterm delivery and age of SIDS death. Ann Epidemiol 2006;16:600–6. 3. SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Task Force on Sudden Infant Death Syndrome, Moon RY. Pediatrics 2011;128:1030–9. 4. Centers for Disease Control and Prevention. Atlanta, GA, USA; 2013 October 25. Available from: http://www.cdc.gov/features/ sidsawarenessmonth/ [last accessed 19 Jun 2014]. 5. Shapiro-Mendoza CK, Kimball M, Tomashek KM, et al. US infant mortality trends attributable to accidental suffocation and strangulation in bed from 1984 through 2004: are rates increasing? Pediatrics 2009;123:533–9. 6. Gelfer P, Cameron R, Masters K, Kennedy K. Integrating ‘‘Back to Sleep’’ recommendations into neonatal ICU practice. Pediarics 2013;131:e1264–70.
J Matern Fetal Neonatal Med, 2015; 28(14): 1637–1640
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