Best Practice:

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• Best Practice
• Infant Safe Sleep in the Hospital

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Infant Safe Sleep Hospital Project
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Objectives

• Discuss importance of implementing hospital based
  safe sleep program
• Identify possible obstacles in developing new
  policies and implementing safe sleep practices
• Identify techniques used to sustain changes in
  practice
• Discuss special considerations in promoting safe
  sleep in the NICU and Pediatric units

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• A non-profit organization dedicated to
• preserving the lives of newborns and
• healing families, one day at a time.

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• Lead organization for the Back to Sleep and
  Infant Safe Sleep campaigns.
• Michigans central referral site for grief
  services related to all infant deaths.
• In partnership with the Michigan Department of
  Community Health.

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Race Specific Infant Mortality Rate
Michigan Compared to US
Infant Mortality Rate
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Safe Sleep Project

• Develop hospital model for institutionalizing
  infant safe sleep
• Evidenced based
• Can be replicated

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Safe Sleep Project

• Initial project included 2 Detroit hospitals
• Project expanded to include 4 more hospitals
• Replicated in additional 8 hospitals

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Project Goal

• The project goal is to reduce preventable infant
  deaths by teaching anyone caring for infants
  about ALL
• aspects of an infant safe
• sleep environment.
• We must move beyond
• Back to Sleep.

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Project Objectives

• Assess current hospital practice and policies
  regarding infant safe sleep
• Develop hospital policy addressing infant safe
  sleep
• Educate hospital staff regarding policy
• Implement policy
• Evaluate compliance with policy

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Project Objective 1 Assessing
Hospitals Current Practice
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Assessing Hospitals Current Practice

• Conducted hospital audits to access nursing
  practices and parents knowledge level before
  beginning project
• Position of baby
• Location of baby
• Condition of crib
• Assessed parents knowledge of safe sleep and
  intended practices

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Assessing Your Hospital

• Hospital Re-enactment
• Pictures

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Hospital Re-Enactments
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Hospital Re-Enactments
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Hospital Re-Enactments
Hospital Re-Enactments
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Hospital Re-Enactments
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Hospital Re-Enactments
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Hospital Re-Enactments
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Hospital Re-Enactments
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Assessing Hospital

• Collect and review all hospital policies with
  references to infant sleep
• Admissions forms and information
• Discharge materials
• All policies including
• Thermoregulation Policy
• Newborn Care Policy
• Neonatal Abstinence Policy (Drug withdrawal)

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Project Objective 2 Nursing Policy
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Policy

• Based on AAP guidelines (2005)
• Be specific
• Expectations of nurses while infant in hospital
• Expectations regarding discharge
• teaching for parents and families
• Some hospitals included NICU and Pediatrics into
  general policy
• Some wrote separate policy for these areas

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Policy

• Most critical factor in initiating and
  maintaining change in behavior and practice
• Policy is now standard of practice
• Only with written policy can staff be held
  accountable for actions
• Policy is necessary for any setting

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Obstacles

• Approval from all hospitals and committees
• Must follow hospital guidelines
• Once policy committee approves must obtain
  signatures from all involved supervisors
• Time frame

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Project Objective 3 Educating Staff
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Death Scene Re-enactments
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Lessons from death scenes
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Lessons from death scenes

• prone position / head covered

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Lessons from death scenes
CPSC Investigation
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Lessons from death scenes
CPSC Investigation
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Lessons from death scenes
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Lessons from death scenes
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Lessons from death scenes
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Wedging / Entrapment
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Educating staff

• Include factors of unsafe sleep environment
• Prone position
• Soft bedding
• Using bumper pads or stuffed animals in crib
• Baby Sleeping in Adult in or Youth Bed
• Sleeping on a Sofa, Soft Mattress or Water Bed

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Educating staff

• Sleeping with an adult or another child
• Possibility of overlay
• Florence Nightingale 1861 Baby must have a cot
  to itself else it runs the risk of being
  over-laid or suffocated. Baby must not be
  covered up too much in bed, nor too little.

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Unsafe Sleep Environment

• Side position is unstable and infants can roll
  into prone position.
• Risk of suffocation for infants rolling prone may
  be even higher than being placed in prone
  position initially.

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Side Position

• Studies show that 70 90 of maternity hospitals
  still advocate the use of side sleeping position.
• Primary reason stated is fear of aspiration
  although there is no forensic, pathological or
  epidemiological evidence to substantiate these
  fears. (Fleming Blair 2002)

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Aspiration and Supine Positioning
Continuing Education Program on SIDS Risk
Reduction, U.S. Department of Health and Human
Services, December 2006.
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Aspiration and Supine Positioning

• When baby in supine position, trachea lies on top
  of the esophagus.
• Any regurgitation or reflux from the esophagus
  must work against gravity to be aspirated into
  the trachea
• In prone position the trachea lies below the
  esophagus
• In this position anything refluxed will pool at
  the opening of the esophagus

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Prone Position and GER

• GER may be more common in supine position
• Significant episodes of apnea are seldom a
  consequence of reflux
• Keeping the head of the crib elevated was shown
  to make little difference in reflux.
• The American Society of Gastroenterology no
  longer recommends prone position as a therapy for
  reflux in infants. Medical treatment of reflux is
  preferable to pone sleep position.

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Education Challenges

• In a hospital setting, there are many challenges
  to getting staff together for mandatory
  education. Completing the education without
  accruing overtime can be a real challenge.
• Ideas to help defeat the Time Issues may
  include
• Offering impromptu trainings by project staff on
  unit when census is low
• Offer on-line program
• Placing binder with written material on unit with
  written test

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• Project Objective 4
• Implement Policy

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Leading Change

• Be sure to have a passionate champion who will
  lead the change on the unit

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Expect Resistors

• Identify them
• Challenge them
• Work with them
• Empower them
• Champion their progress

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Project Objective 5

• Evaluate compliance
• with policy

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Quality Improvement

• Use safe sleep project as a quality initiative
  project for your unit
• Set goals
• Audit 10 infant sleep conditions per month
• Discuss progress toward goals at each staff
  meeting

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Celebrate Accomplishments

• Achieving short term goals gives staff a sense of
  movement and progress

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Sustaining the Change

• Leaders must communicate their vision for the
  promotion of safe sleep through words and
  behaviors

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Sustaining Change

• Be sure staff have the tools they need to be
  successful in promoting safe sleep
• Fitted sheets for cribs
• Adequate supply of brochures in several languages
• Educational videos for in-house patient education
  channels
• Sleep sacks for newborns

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Keep the Idea Fresh

• Make safe sleep a unit-based or annual
  competency
• Include education to every new employee
• Dont forget students, residents and physicians

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Tell Your Stories

• Post newspaper articles
• Partner with local Infant Mortality Review boards
• Communicate near-miss stories
• Take advantage of teachable moments

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Outreach

• Share your message with anyone who will listen
• Present at administrative or collaborative
  meetings
• Articles in hospital or community newspapers
• Communicate message to OB offices, pediatric
  offices and ERs

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Encourage staff outreach

• Provide staff with materials to take the message
  on the road
• Can present to child-care providers, church
  groups, neighborhood
• Staff then becomes the champions

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• SPECIAL BABIES
• SPECIAL SITUATIONS
• NICU and PEDIATRICS

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NICU Considerations
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Premature Infants at Higher Risk of Sudden Infant
Death

• The risk of sudden death is 3-6 times greater in
  preterm infants than in term infants.
• The association between prone sleeping and Sudden
  Infant Death is even greater among low birth
  weight infants.
• Recent studies show that preterm infants are more
  likely to sleep in prone position than term
  infants.

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Preterm Infants More Likely to be Placed in Prone
Position Post Discharge

• The lower the birth weight the more likely infant
  was to be placed prone to sleep.
• VLBW (lt 1500 grams) infants were placed to sleep
  in prone position almost twice as often as
  infants with birth weight 1500 2499 grams.
  (Vernacchio, 2003)

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Why Parents Place Infants Prone?

• Repeat what was seen in (NICU)
• Baby appears more comfortable
• Fear of aspiration
• Baby has reflux, or fear of reflux
• Influence of medical professionals

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MESSAGES WE GIVE TO PARENTS

• Studies show parents do model nursing practices
• Nurses are role models for parents
• Need to promote safe sleep environment during
  infants entire hospital stay.

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Practices in NICU Messages we are
giving to parents

• Prone position
• Soft bedding
• Nesting
• Swaddling

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Incorporate Safe Sleep Practices with Daily
Nursing Care

• Re-enforce to parents the possible need for prone
  position, positioning aides, soft bedding and
  swaddling while infant extremely premature,
  and/or sick.
• Remind parents NICU patients are safe
• Always on C/R monitors
• Always under direct supervision
• and observation of medical staff

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These practices are not recommended for home use.
Even if infant is discharged on home apnea
monitor infant should still sleep supine, on firm
mattress and in own crib with no soft bedding in
crib.
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Initiate Safe Sleep practices Long Before
Anticipated Discharge

• Infants will become use to sleeping position most
  often placed
• Dont wait until just prior to discharge to begin
  supine positioning

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SET UNIT GUEDELINES WHEN TO BEGIN SAFE SLEEP
PRACTICES

• Post conceptual age or chronologic age
• Specified weight
• When infant transferred to open crib

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ONCE INFANT IN CRIB

• Always place supine
• Remove positioning aides
• Remove any soft bedding sheepskin, blanket
  rolls
• Keep blankets away from face
• Attempt to minimize number of extra blankets
  used.
• Dont allow toys or stuffed animals in crib (or
  isolette)

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Role Model Safe Sleep Practices
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Pediatric Considerations
Pediatric Hospital Re-enactment Pictures
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Pediatric Hospital Re-enactment
Pictures
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Pediatric Hospital Re-enactment
Pictures
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Pediatric Hospital Re-enactment
Pictures
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Pediatric Hospital Re-enactment
Pictures
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Pediatric Hospital Re-enactment
Pictures
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Pediatric Hospital Re-enactment
Pictures
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Pediatrics Unique Situation

• Parents have already established sleeping
  patterns
• Infant is sick
• Little opportunity to role model
• Emphasize teaching

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Teaching Opportunities

• Re-enforce safe sleep practices
• Provide Safe sleep brochures, DVDs, information
  on blanket sleepers
• May need to develop Release of Responsibility
  form

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Behavioral Change

• Very slow process
• Keep re-enforcing message
• Continue to model safe sleep practices
• Dont forget to include grandparents in education

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By educating parents, grandparents and all
caregivers about the importance of safe sleep
environment WE CAN MAKE A DIFFERNCE AND
HELP SAVE BABIES LIFES
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OUR GOAL Healthy Babies.
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. And Healthy Families
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THANK YOU!
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materials Contact Tomorrows Child 1-800-331-7437
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