Integrating “Back to Sleep” Recommendations Into Neonatal ICU Practice

Setting

The CMHH NICU is a large tertiary care unit in Houston, Texas, with an average census of 100 infants. There are 900 to 1000 admissions to the NICU per year; approximately one-third are born outside CMHH. During random crib audits in May and June 2010 performed in the level II nursery at CMHH, only 39% of infants were sleeping in the supine position, 5% had a firm sleeping surface, and 45% had no soft objects in bed. Although these hospitalized infants were not at risk because they were being continuously monitored, predischarge sleep practices that conflict with the AAP recommendations for SIDS prevention are likely to be continued after discharge when the infants are no longer being monitored. Furthermore, a postdischarge telephone survey of parents, done at the same time along with crib audits, showed that only 23% of parents reported full compliance with SSPs at home.

Overall Framework

A quality improvement model was developed to translate the AAP guidelines on SSPs into nursing practice in our NICU. The project team worked closely with all key stakeholders, including representatives from administration, nursing, physical and occupational therapy, and physicians. Team members met regularly once or twice a month for the duration of the project. They were responsible for developing a unit guideline on SSPs, educational materials for nurses and parents, visual cues for staff, a tool for auditing cribs, and conducting a parental survey. Team members performed literature searches and group interviews with physicians, nurses, and parents to identify facilitators and barriers for developing and implementing safe sleep policies in premature infants. The project was divided into before-intervention (May–June), intervention (July–September), and after-intervention (October–November) phases. The before-intervention phase was defined as the time before any interventions or staff interviews were started. The intervention phase included the development of nursing guidelines and education of staff nurses on SSPs. The after-intervention phase was measured after the nursing guidelines and nursing education campaign on SSPs were completed.

Intervention and Implementation

All nurses in the NICU were required to complete the continuing education program on SIDS risk reduction developed by the National Institute of Child Health and Human Development.¹⁷ They were also tested on safe sleep role modeling during their annual skills evaluation. The National Institute of Child Health and Human Development computer module took about 1 hour to complete and provided 1 hour of continuing education credit for the nurses. The module covered theories of SIDS etiology, outlined modifiable and nonmodifiable risk factors, and provided strategies on risk reduction. Numerous question and answer sessions with the nursing staff were conducted to educate them on issues regarding specific implementation strategies for our NICU. The project was also discussed with the physicians in a division meeting to elicit their acceptance and incorporate their suggestions.

On the basis of the literature review, expert opinions, and numerous unit discussions, an algorithm was developed to determine when an infant was ready to start SSPs in our NICU (Fig 1). NICU therapeutic positioning was defined as positions (prone, side-lying, elevated head of bed, etc.) and positioning tools (positioning aids, blanket rolls) used in the NICU for medical reasons but not appropriate for the routine home environment. SSP included the following components: sleeping on the back on a firm, flat mattress covered by a fitted sheet; blanket positioned in such a manner that it stays below the shoulders, preventing possible airway obstruction; a crib free of loose material including pillow-like stuffed toys and bumper pads; and room temperature that is comfortable for a lightly clothed adult (21.13–23.35°C).^21-23

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FIGURE 1

Algorithm to determine when an infant is ready to begin SSPs. BPD, bronchopulmonary dysplasi.

A laminated “Back to Sleep” crib card based on the AAP’s recommendations was developed (Fig 2). The clinical staff was responsible for putting the card on all open cribs. The crib card was used to remind medical providers and parents that the infant had started SSPs. This form of implementation would also cue nurses to provide discharge teaching to the parents. The crib card had 2 sides: one with an explanation of SSPs and the other with NICU therapeutic positioning for infants who were not ready to start SSP; it was secured to the crib with the appropriate side up. At discharge, parents received a different Back to Sleep card with the SSP recommendations on one side and cardiopulmonary resuscitation tips on the other side for use on the baby’s crib at home.

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FIGURE 2

Each infant’s crib had a crib card that would either recommend therapeutic positioning or Back to Sleep practices depending on the readiness to begin SSPs.

SIDS education was offered to all parents. Parents were encouraged to watch the DVD on safe sleep education from the First Candle Foundation (www.firstcandle.org); the DVD explained how to implement SSPs in the home setting. The DVD method was used to provide consistent and accurate information. A written parent discharge instruction sheet containing language-appropriate information on SSPs was given to every family; neonatal nurses reviewed the instructions with parents before discharge. SSP strategies were also included in the agenda of the discharge educational class for parents.

Methods of Evaluation

A crib audit tool was developed to monitor in-hospital compliance with SSPs and limit the variability among observers. A single-page form was created to collect information on the sleep position of the infant (back, prone, side), presence of firm sleep surface, and absence of extra soft objects in the bed. Only cribs of the SSP-eligible infants were selected for auditing (Fig 1, Initiating SSP Algorithm). Multiple audits were conducted by different quality improvement team members in each phase of the project. There were 2 or 3 days on which audits were conducted in each phase. They were taken during weekdays on day shifts without previous warning to the staff nurses.

A questionnaire was developed to monitor parental compliance with SSPs at home after discharge (Table 1). This questionnaire was added to the routine postdischarge telephone courtesy calls. Parents of all discharged patients were routinely contacted by phone within several days of discharge. A maximum of 2 attempts was made to reach a parent. Parents were asked about SSPs and provided with counseling if incorrect practices were identified. A pilot survey was conducted to assess understanding of the questions. The surveys were provided before, during, and after the implementation of the changes. A parent was counted as fully compliant only if all requirements of SSPs were always in place (eg, if parent answered “sometimes” when the correct response was “always,” the compliance was counted as not fully compliant). The results of the crib audits and parental surveys were displayed in the nursing lounges for review and feedback to reinforce the educational measures.

Analysis

Comparisons between the before- and after-implementation phases were made by using Fisher's exact test (Stata 11.0; StataCorp, College Station, TX). The nurses’ participation with education was monitored by the NICU’s clinical nurse educators by collecting copies of continuing education certificates.