Abstract
Sudden infant death syndrome (SIDS) is a leading cause of infant mortality in the US. The American Academy of Pediatrics has provided recommendations for infant sleeping position and environment to decrease SIDS rates. These recommendations reinforce the importance of modeling safe sleep practices in the newborn nursery. Although many quality improvement initiatives have been undertaken to improve safe sleep in the nursery, such efforts are sparse in low-volume birth hospitals. This project aimed to improve infant sleep practices in a 10-bed level I nursery using visual cues (crib cards) and nursing education. We defined “safe sleep practice” if a newborn slept in a safe position in a flat bassinet and in a safe environment. We measured safe sleep practices before and after the intervention using an audit tool. As a result, safe sleep practices improved from 32% (30/95) preintervention to 75% (86/115) postintervention (P < 0.01). This study demonstrates that implementing a quality improvement initiative to improve infant sleep practices in a low-volume nursery is feasible and impactful.
Keywords: Quality improvement, safe sleep, sudden infant death syndrome, sudden unexpected infant deaths
Sudden unexpected infant death is defined as the sudden and unexpected death of any newborn <1 year of age and includes sudden infant death syndrome (SIDS), death from unknown cause, and accidental suffocation and strangulation in bed.1 SIDS is one of the leading causes of infant mortality in the US, contributing to 1250 deaths in 2019.2 In July 2022, the American Academy of Pediatrics (AAP) released updated guidelines with recommendations for a safe sleep environment to reduce the risk of all sleep-related infant deaths. These recommendations reinforced the importance of a supine sleeping position, use of a firm, flat, noninclined sleep surface, room sharing without bed-sharing, and avoidance of soft objects. The guidelines also provided specific recommendations for staff in the newborn nursery to endorse and model the SIDS risk-reduction recommendations from birth and well before anticipated discharge.3
The recommendation to model safe sleep in newborn nurseries is based on evidence that observed infant sleep position in the hospital, and physician and nurse advice on safe sleep practices, strongly influence the parental choice of infant sleep position.4–6 The immediate postpartum period in the hospital provides a unique opportunity to educate parents on infant sleep practices. However, many hospitals do not have an infant sleep policy or provide formal training to nursery staff on infant safe sleep practices.7 This lack of training has been especially apparent in low-volume hospitals.7 In addition, there is inconsistency in modeling safe sleep practices in the newborn nursery, with multiple studies showing high rates of nonsupine sleep position and unsafe sleep environment.8,9
Multiple institutions have successfully implemented quality improvement (QI) programs in newborn nurseries and inpatient pediatric units to improve infant safe sleep. For example, a large multi-institutional collaborative in Ohio successfully improved safe sleep practices in the hospital by multifactorial QI interventions, including staff education, parental support, and environmental modifications such as the acquisition of sleep sacks.10 Another large academic hospital in Kansas improved safe sleep compliance to >80% using similar methods.11 Most of these QI initiatives have been done in large academic tertiary care centers. However, information on the feasibility and impact of such QI initiatives on a smaller scale is unknown, especially in a low-volume birthing unit with limited resources.
In our 10-bed low-volume unit, we routinely noticed instances of unsafe sleep environment characterized by propping up cribs, plush toys, and fluffy blankets in the crib and bed-sharing with the mother. In addition, there was no formal staff education on infant safe sleep practices. Hence, we embarked on this QI initiative to increase compliance with the AAP recommendations for infant safe sleep practices in our newborn nursery.
METHODS
This pre- and postintervention QI study was designed to evaluate the effectiveness of interventions to improve infant safe sleep practices in a newborn nursery unit. Institutional review board exemption was obtained before the start of the study. The study setting was a 10-bed level 1 nursery within a suburban medical center with about 600 deliveries per year. The newborns room in with mothers to promote breastfeeding and bonding. At baseline, nurses had no standardized education on infant safe sleep practices. Parents of newborns were given written materials in the standardized labor and delivery packets as well as oral teaching at discharge with nursing staff and some providers. This included brief teaching about placing infants on their back to sleep without further emphasis on a safe sleep environment.
The study team consisted of pediatricians, family medicine residents, and nurses. The team utilized the plan, do, study approach to streamline their QI efforts. Prior to the start of the study, a key driver diagram was constructed by the team to identify factors influencing infant sleep practices (Figure 1). This illustrated multiple factors contributing to unsafe sleep practices in the newborn nursery, including limited teaching materials from staff to parents and lack of staff training. To determine baseline rates of infant sleep position and environment, we collected data through random audits between September and October 2020. Following this, QI interventions were implemented in November 2020.
Figure 1.
Fishbone analysis of drivers of infant sleep practices in the newborn nursery.
The study had two key interventions: (1) bassinet cards and (2) nursing education. Laminated cards placed in the bassinets in all 10 rooms served as a visual tool to remind caregivers and nurses of infant safe sleep practices (Figure 2). The card included a photo of a newborn sleeping in the ideal position and a simple ABC mnemonic of safe sleep: Alone, on the Back, in the Crib. We conducted interactive small group sessions (up to five nurses per session) using a short 12-slide PowerPoint. The 10-minute presentation reviewed the importance of a safe sleep environment, defined a safe sleep environment—including having an empty, flat crib free of items except for a pacifier or swaddling blanket—and stressed the importance of a supine sleeping position. The sessions also discussed use of the bassinet cards as a visual tool and presented baseline data on safe sleep environment. At the beginning of our study, the unit had 10 bassinets with a firm mattress in a removable acrylic tub on a stainless-steel base. The bassinets could be propped and were often propped by nurses when there was a concern for aspiration. In December 2020, half of the mother-baby suites were equipped with new bassinets with the mattress and tub attached to the base, not removable or capable of being propped.
Figure 2.
Bassinet cards as a visual reminder of infant safe sleep. Photography consent was obtained from the infant’s parents.
All newborns born between September 2020 and May 2021 who underwent routine newborn care in the nursery were eligible for the study. Pre- and postintervention data were collected via convenience sampling using a paper audit tool. Family medicine residents, as well as night charge nurses, completed data collection. We excluded newborns who were found to be awake during attempted data collection. We collected data without notifying the remainder of the nursing staff to minimize staff behavior changes, especially during baseline data collection. Preintervention data were collected from September to mid-November 2020. Auditing was paused in late November 2020 while the interventions of nursing education and bassinet card attachments were carried out. Postintervention data were collected from December 2020 to May 2021.
We created a questionnaire based on the AAP’s Ohio Chapter statewide QI project to improve safe sleep practices in infants.10 The audit tool consisted of the following items: infant awake (yes/no), mother awake (yes/no), other caregivers awake (yes/no), sleep location (bassinet, bed, other), items besides pacifier/swaddle in the crib, and position of bassinet (flat/propped). Attempts were made to complete audits during both the day and night shifts.
The primary outcome measures were the percentage of infants sleeping in a safe location, with bassinet flat, and a safe sleep environment. We defined the sleep position/location as “safe” when an infant was sleeping supine in a bassinet or in the arms of an awake caregiver. We defined a “safe” bassinet position when the bassinet was flat without any propping. We defined a “safe” sleep environment as an empty bassinet except for a hospital swaddling blanket or a plain pacifier free of attachments. Finally, we defined “overall safe sleep practice” as a newborn sleeping in a safe position in a flat bassinet and a safe environment. The goal of the QI project was to increase the proportion of infants in overall safe sleep practice by 30%.
Data collected on paper audits were entered into a Microsoft Excel database. We used frequencies and percentages to describe infant sleeping practices in the nursery. We used Fisher’s exact test to compare infant sleep practices in the pre- and postintervention groups. Finally, we used run charts to track changes in safe sleep practices over time. All analysis was done using STATA, and P < 0.05 was considered significant.
RESULTS
A total of 210 crib audits were performed, including 95 audits preintervention and 105 audits postintervention. Nighttime audits were conducted in 44% (42/95) and 37% (43/115) of the pre- and postintervention groups.
Most infants in the pre and postintervention groups were sleeping in a safe environment (pre, 92/95, 96.8%; post, 108/115, 94%; P = 0.321) (Table 1). Of the three infants in the preintervention group sleeping in an unsafe position/location, one slept in the arms of a sleeping adult and two coslept with the caregiver. Of the eight infants in the postintervention group sleeping in an unsafe position/location, one slept on the side in the bassinet and seven coslept with the caregiver. In the preintervention group, 85% (81/95) of the bassinets were noted to be flat. However, this rate significantly increased in the postintervention group, with 94% (108/115) bassinets in a flat position (P = 0.038).
Table 1.
Safe sleep practices before and after the intervention
| Practice |
Preintervention
(n = 95) |
Postintervention
(n = 115) |
P value a |
|---|---|---|---|
| Safe sleep positionb | 92 (97%) | 108 (94%) | 0.321 |
| Flat bassinet | 81 (85%) | 108 (94%) | 0.038 |
| Safe sleep environmentc | 36 (38%) | 96 (83%) | <0.0001 |
| Overall safe sleep practiced | 30 (32%) | 86 (75%) | <0.0001 |
aChi-square test was used for bivariate analysis.
bInfant sleeping supine in the bassinet or held by an awake adult.
cEmpty bassinet except for hospital pacifier and swaddle blanket.
dInfant sleeping in a safe sleep position in a flat bassinet in a safe environment.
Only 35% (36/95) of infants were sleeping in a safe environment preintervention. This improved significantly to 83% (96/115) in the postintervention period (P < 0.01). In the preintervention period, 78 unsafe items were found in the bassinets; 42 bassinets had one unsafe item, 15 had two unsafe items, and two bassinets had three unsafe items. In the postintervention period, 26 unsafe items were found, with 13 bassinets with one unsafe item, five with two unsafe items, and one with three unsafe items. The most common unsafe items found in the bassinet were suction bulbs, loose blankets, and towels (Table 2). There was a significant decrease in the number of bassinets with these items in the postintervention period (Table 2). Overall safe sleep practices improved from 32% (30/95) preintervention to 75% (86/115) postintervention (P < 0.01) (Figure 3).
Table 2.
Unsafe items found in bassinet before and after the intervention
| Item |
Preintervention
(n = 95) |
Postintervention
(n = 115) |
P value * |
|---|---|---|---|
| None | 36 (38%) | 96 (83%) | <0.0001 |
| Suction bulb | 37 (39%) | 12 (10%) | <0.0001 |
| Loose blanket | 25 (26%) | 11 (10%) | 0.001 |
| Towel | 3 (3%) | 1(1%) | 0.227 |
| Extra clothing | 9 (9%) | 1 (1%) | 0.004 |
| Toy | 2 (2%) | 0 | 0.118 |
| Pacifier with attachment | 1 (1%) | 0 | 0.270 |
| Diaper/wipes | 1 (1%) | 1 (%) | 0.892 |
*Chi-square test was used for bivariate analysis.
Figure 3.
Percentage of infant safe sleep practice in the newborn nursery over the course of the study.
DISCUSSION
In a 10-bed nursery, the use of visual cues and nursing education resulted in a marked improvement in overall infant safe sleep practices from 32% to 75%. This study demonstrates that implementing a QI initiative to improve infant sleep practices in a low-volume nursery is feasible and impactful. We believe these simple and reproducible steps can be used at other birthing centers and nurseries to improve safe sleep environments.
Authors of previous studies have used similar strategies on a larger scale. For example, Kellems et al used a safe sleep nursing education toolkit consisting of PowerPoint slides, posters, pocket cards, and a secure website with safe sleep resources and successfully improved safe sleep positioning by 24% and safe sleep environment by 33%.12 Sleutel et al used a bundled intervention including nurse education, changing unit processes, crib cards, and room signs to improve nursing knowledge and practices related to safe sleep.13 Our study intervention was unique in using strategies scalable to a low-resource, small-volume unit. Most nursing education was done by two charge nurses and two residents on the QI team using PowerPoints and handouts with minimal training in QI methodology. Our visual reminders included small, laminated cards with simple messaging, which can be easily reproduced.
Our nursery’s baseline rates of safe sleep position and location were high, and we did not see a significant change postintervention. The bulk of the improvement in safe sleep practices was characterized by decreased bassinet propping and ensuring a safe sleep environment, especially concerning the use of unsafe items in newborn bassinets. Bassinet propping was commonly seen in our nursery, with nurses citing fear of aspiration or acid reflux as common reasons. During our education session, the study team provided current literature on inclined sleep surfaces. We included information such as the infectiveness of inclined sleep position to decrease the risk of gastroesophageal reflux.14 In addition, we also discussed the likelihood of infants sliding down to a position that may compromise their respiration while sleeping on an inclined surface.3 The US Consumer Product Safety Commission has recalled several inclined sleepers and has identified approximately 73 infant deaths related to inclined sleep products between 2005 and 2019.15 We concluded that providing such evidence contrary to common beliefs convinced a few nurses to change practice. However, in December 2020, several bassinets in our unit were changed to a variation that could not be propped. We believe this, along with nursing education, helped achieve our reduction in bassinet propping.
The most common unsafe items found in the bassinet were suction bulbs and loose blankets. Although suction bulbs are not traditionally included in the list of “soft objects” to avoid in the infant sleep area, we aimed to model an “empty crib” for patients. However, upon interviewing nursing staff, there were significant concerns about infant choking, especially in the first 24 hours of life, with a need to have a bulb syringe close at hand when this happens. In a large (n = 3240 infants) prospective cohort study of full-term newborns observed for the first 24 hours of life, fewer than 4% spit up while sleeping, and none required serious interventions. However, suctioning with a bulb syringe was performed in 37% of the newborns who spit up.16 After multiple discussions with our nursing staff, we identified the need for a space to place the bulb syringes away from the bassinet but readily accessible when needed. Our newer bassinets could be fitted with a storage basket that fits to the outside of the bassinet. This change led to a modest but significant decrease in the rates of bulb syringes placed in the bassinets.
Our study had several limitations. First, given the size of our 10-bed nursery, our study sample size was limited. We included a convenient sample of infants for crib audits based on the availability of study personnel. Although this introduces selection bias, we attempted to minimize this by including all infants in the unit at each point of crib audits. This was a pre-post study with no control group. Factors other than the study intervention may have played a role in changing infant sleep practices. In fact, introducing new bassinets that cannot be propped and had a side storage basket for bulb syringes may have played a key role in decreasing bassinet propping. This emphasizes the need for environmental changes along with staff education to bring about meaningful practice change when designing a QI project. We are unaware of any other concurrent changes during our study period that could have accounted for a large change in practice. Lastly, our data relied on the observations made by the individual data collector, which innately creates room for bias. We attempted to minimize this by using a standardized audit tool, which was pilot tested and modified based on feedback.
This is one of the few studies aiming to improve infant sleep practices in a low-volume nursery unit. This QI initiative succeeded because of its simplicity and the collaborative effort of physicians and nurses. Future directions of this initiative include using the strategy of nursing education and visual reminders to improve safe sleep in newborns in other nurseries within the Baylor Scott & White Health care system. Pairing education and signage with environmental changes could also enhance this work in other settings. It is also essential to study the long-term effect of this strategy on postdischarge sleep practices at home through follow-up interviews.
In conclusion, there is a need to improve infant safe sleep education and modeling in newborn nurseries. Most prior QI initiatives to improve safe sleep in the nursery have been conducted in large academic hospitals with a high volume of births. Information on the feasibility and impact of such QI initiatives on a smaller scale is not known. By implementing a QI initiative using nursing education and visual reminders, we successfully increased the rates of safe sleep practices for newborns admitted to the nursery in a low-volume unit using minimal resources.
ACKNOWLEDGMENTS
The authors thank the staff of the women and children’s unit, without whom this initiative would not have been possible. We also thank Suzanne Schoplein, RN, and Tieryn Harris, RN, for being enthusiastic safe sleep champions in the unit and assisting with data collection. Finally, we thank Dr. Raju Muppala for aiding with data analysis.
Disclosure statement/Funding
The authors report no funding or conflicts of interest.
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