Improving Hospital Infant Safe Sleep Compliance by Using Safety Prevention Bundle Methodology

Abstract

BACKGROUND AND OBJECTIVES Sudden unexpected infant death often results from unsafe sleep environments and is the leading cause of postneonatal mortality in the United States. Standardization of infant sleep environment education has been revealed to impact such deaths. This standardized approach is similar to safety prevention bundles typically used to monitor and improve health outcomes, such as those related to hospital-acquired conditions (HACs). We sought to use the HAC model to measure and improve adherence to safe sleep guidelines in an entire children’s hospital. METHODS A hospital-wide safe sleep bundle was implemented on September 15, 2017. A safe sleep performance improvement team met monthly to review data and discuss ideas for improvement through the use of iterative plan-do-study-act cycles. Audits were performed monthly from March 2017 to October 2019 and monitored safe sleep parameters. Adherence was measured and reviewed through the use of statistical process control charts (p-charts). RESULTS Overall compliance improved from 9% to 72%. Head of bed flat increased from 62% to 93%, sleep space free of extra items increased from 52% to 81%, and caregiver education completed increased from 10% to 84%. The centerline for infant in supine position remained stable at 81%. CONCLUSIONS Using an HAC bundle safety prevention model to improve adherence to infant safe sleep guidelines is a feasible and effective method to improve the sleep environment for infants in all areas of a children’s hospital.

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.…”

“…For example, implementation of our care bundle was a more gradual process and included a longer postintervention time sample to monitor for a sustained change compared with the hospital-acquired conditions model used in a 2021 study from Batra et al In comparison with the Batra et al study and several others, our study is unique in that it describes variability in safe sleep practices among ages, diagnoses, and prematurity status. 5 , 19 , 21 Additionally, the inconsistent improvement suggests that there could be gaps in healthcare professional education about safe sleep, an unknown workflow barrier, or a parent/nursing practice belief that we do not yet understand. Scott et al demonstrated that a quality improvement collaborative improves screening, counseling, and documentation of anticipatory guidance during newborn nursery and primary care visits.…”