Expansion of a multi-pronged safe sleep quality improvement initiative to three children’s hospital campuses

Abstract

Background: The American Academy of Pediatrics (AAP) recommends infants should be Alone, on their Back, and in a clear Crib to combat relatively stagnant rates of sudden unexpected infant death (SUID). These are referred to as the ABCs of safe sleep. Studies have shown these recommendations are not consistently followed in the hospital setting, but further investigation would determine how to improve the rate of adherence. The objective of this study was to evaluate the impact of an expanded safe sleep initiative at three Georgia free-standing children's hospital campuses before and after a multipronged safe sleep initiative. Methods: A quality improvement program with a pre/post analysis was performed using a convenience method of sampling. Infants < 12 months old in three inpatient pediatric campuses were analyzed pre-and post-interventions. The intervention included: 1) nursing education, 2) identification of nurse "safe sleep" champions, 3) crib cards, 4) crib audits, and 5) weekly reporting of data showing nursing unit ABC compliance via tracking boards. The goal was ABC compliance of ≥25% for the post-intervention period. A standardized crib audit tool evaluated sleep position/location, sleep environment, and ABC compliance (both safe position/location and environment). Chi square analysis, Fisher's exact test, and logistic regression were used to compare safe sleep behaviors before and after the interventions. Results: There were 204 cribs included pre-intervention and 274 cribs post-intervention. Overall, there was not a significant change in sleep position/location (78.4 to 76.6%, p = 0.64). There was a significant increase in the percent of infants sleeping in a safe sleep environment following the intervention (5.9 to 39.8%, p < 0.01). Overall ABC compliance, including both sleep position/location and environment, improved from 4.4% pre-intervention to 32.5% postintervention (p < 0.01). There was no significant variability between the hospitals (p = 0.71, p = 1.00). Conclusions: The AAP's safe sleep recommendations are currently not upheld in children's hospitals, but safer sleep was achieved across three children's campuses in this study. Significant improvements were made in sleep environment and overall safe sleep compliance with this multi-pronged initiative.

Practicing What We Preach: An Effort to Improve Safe Sleep of Hospitalized Infants

“…Several prior studies have examined outcomes associated with implementing safe sleep initiatives in children’s hospitals. 5 , 18 – 21 A consistent area of statistically significant change among these studies, as with ours, is the reduction of nonmedical items in the crib, which is an essential behavior to model for families. 5 , 15 , 18 – 21 Although infants in our study were frequently asleep in the appropriate supine position in the preintervention group (86.5%), much like other studies, we failed to show improvement in this metric.…”

“… 5 , 18 – 21 A consistent area of statistically significant change among these studies, as with ours, is the reduction of nonmedical items in the crib, which is an essential behavior to model for families. 5 , 15 , 18 – 21 Although infants in our study were frequently asleep in the appropriate supine position in the preintervention group (86.5%), much like other studies, we failed to show improvement in this metric. 5 , 18 , 19 , 21 Although prior quality improvement work demonstrated that hospital staff could remove medical supplies from hospital cribs, 5 we did not demonstrate improvement in that aspect of the sleep environment.…”

“…5,15,18–21 Although infants in our study were frequently asleep in the appropriate supine position in the preintervention group (86.5%), much like other studies, we failed to show improvement in this metric. 5,18,19,21 Although prior quality improvement work demonstrated that hospital staff could remove medical supplies from hospital cribs, 5 we did not demonstrate improvement in that aspect of the sleep environment. This factor remains a large area for improvement for our institution even though our inpatient rooms include ample counter and storage space for supplies.…”

“…However, this quality improvement study confirmed that targeted interventions and education could improve many aspects of safe sleep in the hospital environment, consistent with findings from other institutions. 5 , 15 , 18 – 21 The main areas of improvement at our institution included more infants sleeping in the crib, reduction in co-sleeping, head-of-bed position more often not elevated, reduction in the presence of home supplies in the crib (specifically blankets, pillows, and bottles), and an empty crib. We did not find significant improvements in infant sleep position (supine versus prone) or the presence of medical supplies in the crib.…”

“…Finally, our study noted a statistically significant association with the change in location of the sleeping infant, whereas other studies did not demonstrate this improvement. 18 , 19 …”