TodaysBaby Quality Improvement: Safe Sleep Teaching and Role Modeling in 8 US Maternity Units
BACKGROUND AND OBJECTIVES: Nursing education and role modeling can increase adherence to safe sleep practices. Eight US hospital maternity units with variable baseline approaches to education participated in a national multicenter nursing quality improvement (QI) intervention to promote safe sleep practices. The goals at participating maternity units were to (1) increase the rate of mothers who reported receiving safe sleep information from nurses to ≥90% and (2) increase the rates of infants observed sleeping supine in a safe environment to ≥90%.
METHODS: A safe sleep QI toolkit, designed for and provided to all sites, included an educational curriculum and tools to use for staff and parent education. Local teams implemented safe sleep education using the tools as plan-do-study-act cycles. After each cycle, audits assessing maternal report of nursing education on safe sleep and inpatient infant sleep position and environment were performed.
RESULTS: The QI interventions lasted a median of 160 days (range, 101–273). Mothers reported receiving information on 4 primary safe sleep topics 72% to 95% of the time (a 24%–57% increase over the baseline). Additionally, 93% of infants were observed in a supine sleep position, and 88% of infants were observed in a safe sleep environment (a 24% and 33% increase over baseline, respectively). These rates were sustained up to 12 months later.
CONCLUSIONS: Implementation of a multisite QI intervention for safe sleep parenting education and role modeling led to increased knowledge of and compliance with safe sleep practices during postpartum hospitalization.
- AAP —
- American Academy of Pediatrics
- PDSA —
- QI —
- quality improvement
- SMART —
- Social Media and Risk Reduction Training
Annually, ∼3500 infants die suddenly and unexpectedly during sleep in the United States, despite the successful Back to Sleep campaign of the 1990s that halved the sudden infant death syndrome rate.1 Adherence to supine sleep recommendations has plateaued since 2001,2 and public health efforts have not resulted in significant decreases in soft bedding use and bed-sharing.3,4 Advice and role modeling to caregivers by health care providers during the postpartum hospital stay are associated with greater caregiver adherence to the American Academy of Pediatrics (AAP) safe sleep recommendations.5,6
Most US births occur in a hospital setting, which affords an ideal opportunity to model and provide education about safe sleep practice for caretakers. Although nurses interface most frequently with parents in the postpartum setting and have tremendous impact on infant care practices after discharge,5,7 there is inconsistent in-hospital adherence to safe sleep practices.8,9
We therefore developed a quality improvement (QI) intervention for safe sleep education as part of a multicenter trial for promoting AAP safe sleep recommendations. In this article, we describe the strategies used to improve safe sleep education and role modeling at 8 US maternity units and the extent to which participating maternity units achieved the goals of ≥90% maternal-reported, in-hospital safe sleep education on sleep position: an environment without objects, room-sharing (but not bed-sharing), pacifier use after established breastfeeding, and ≥90% of infants with observed safe sleep practices (supine in a separate sleep environment [ie, crib or bassinette] free of other objects).
The Social Media and Risk Reduction Training (SMART) study is a multicenter, randomized controlled trial of 2 interventions aimed at promoting safe sleep practices. In 1 intervention, hospital staff provided QI education in maternity units on either safe sleep (n = 8) or breastfeeding (n = 8) practices. The hospitals in the safe sleep QI program were evaluated in this analysis. At baseline, these hospitals had variable approaches for the delivery of safe sleep education and modeling practices to parents. Members of the SMART study team visited and provided initial training and tools on enrollment. However, the 8 hospitals implemented the QI independently, with minimal interaction among hospitals. Therefore, the participating hospitals were not part of a QI collaborative but rather completed nearly simultaneous QI projects using a common set of tools.
The Intervention: Hospital QI Teams
Study investigators conducted a study enrollment visit lasting 2 to 3 hours at each participating hospital to introduce the TodaysBaby Safe Sleep Toolkit, instruction manual, and data collection tools and procedures. Each hospital identified a site “champion” (usually a nurse manager or nurse educator) who provided educational material about safe sleep to maternity nursing staff, emphasizing their role in role modeling and education for parents and visiting family members. Physician and nursing team members could receive part 4 Maintenance of Certification credits or continuing education units, respectively, if they met participation requirements. The study team provided technical assistance, but otherwise, the local teams operated independently. Study investigators held 1 conference call with representatives from each hospital, during which they could ask questions, troubleshoot common concerns, and share strategies to overcome barriers. To increase the feasibility of more widespread implementation in the future, we standardized implementation of the QI intervention as much as possible; therefore, no other study team support was provided to sites during the active QI phase.
The Intervention: Development of the Safe Sleep Toolkit
Guiding principles in the development of the toolkit were ease of implementation and cost-effective use across a variety of locations and settings. Study investigators developed the Safe Sleep Nursing Education Toolkit using (1) existing tools, including the National Institutes of Health Safe Infant Sleep Curriculum for Nurses10 and the 2011 AAP safe sleep recommendations11; (2) previous epidemiologic research about barriers to adherence to safe sleep practices (such as concerns about choking if supine)1,12–18; (3) qualitative data from nursing leadership at the participating maternity units identifying successful materials, venues, and strategies used in previous QI projects on their units; (4) qualitative data from focus groups with maternity staff at Yale University and the University of Virginia to identify facilitators and barriers to providing safe sleep education to parents; and (5) consultation with an advertising agency with expertise in branding and social marketing to provide insight into the designing and scripting of educational materials for nursing staff to deliver to families. The tools were designed to be a “campaign” rather than a traditional “educational initiative.” The campaign name, “TodaysBaby,” and logo were used on all materials (Supplemental Fig 6).
The toolkit materials emphasized that infant sleep practices be modeled and taught by nursing staff and provided strategies for addressing known barriers to adherence. Elements included sleep position, the absence of other objects in the sleep environment, room-sharing without bed-sharing, and the introduction of a pacifier for sleep once breastfeeding is established. The final toolkit included the following: (1) PowerPoint slides providing a brief review of the plan-do-study-act (PDSA) cycle methodology19 and key safe sleep messages for nursing staff; (2) posters calling attention to the QI campaign and the need to deliver key messages; (3) pocket-sized cards that nurses could use when counseling parents about safe sleep; (4) sample letters that could be sent to hospital leadership, QI officers, and pediatric and obstetrical providers to raise awareness about the QI campaign and highlight the AAP recommendations; (5) a sample hospital policy on safe sleep that could be adapted for each hospital; and (6) a secure SMART study Web site with safe sleep resources, answers to frequently asked questions about infant safe sleep, and the ability to track QI progress.
The Intervention: Site QI Activities
QI activities occurred between July 2014 and July 2015. Each hospital initiated its QI intervention on a rolling basis. The baseline data at each hospital were collected at a single point in time, ∼2 weeks before beginning the QI intervention, to allow time for planning the first cycle’s intervention. Hospitals used PDSA cycles19 as the cornerstone of their QI initiatives. On the basis of audit results after each cycle, each team decided on changes for their next cycle. Hospitals were encouraged to individualize their approaches on the basis of needs and previous successful strategies (eg, e-mail reminders, team huddle updates, and presentations at staff meetings). Maternal education was expected to be completed during the postpartum hospital stay.
Measures and Audits (Study of Interventions)
The main outcomes included (1) reports by mothers of receiving safe sleep information from nursing staff and (2) observations of infants sleeping in a supine position and in a safe sleep environment. By using identical measures for each hospital, outcomes were assessed by unannounced audits of postpartum mothers and sleeping infants on the maternity unit before discharge. Mothers were asked if nurses advised them on safe sleep practices, including (a) placing the infant on his or her back for sleep, (b) not placing anything in the bassinet or crib other than the infant, (c) sharing the room but not the bed with the infant, and (d) offering a pacifier at sleep time once breastfeeding is established. Sleeping infants were observed for sleep position (supine versus other) and safe sleep environment, standardly defined as the following: absence of objects (other than a thin swaddle blanket or light cotton blanket tucked snugly on 3 sides, below the level of the infant’s neck) and sleep location (alone in bassinet, not bed-sharing with sleeping adult).
Each hospital designated 1 to 2 QI team members (nurses, educators, or other staff members) to conduct unannounced audits; they were trained by study investigators and used standardized, structured, web-based data reporting forms. Audits of 10 mothers and 10 infants were conducted at baseline, at the end of each PDSA cycle (approximately every 2–3 weeks), and approximately monthly after completion of the site’s QI intervention. The number of observations and audits was selected to allow for rapid PDSA cycles20 without creating an undue burden on staff. The final audit at each site consisted of 20 maternal interviews and 20 infant observations. For each audit, staff approached 10 mothers, using a systematic sampling strategy (eg, first 10 sleeping infants, odd-numbered rooms) of their choosing that was consistently applied. The sampling strategy and time of day (day or night shift) for the audit was determined by each individual hospital QI team. The forms captured the local interventions used in each PDSA cycle and the audit results. Team progress tracked over time (and compared with the de-identified progress of other participating hospitals) was displayed and easily accessible on the study Web site. On completion of the QI intervention, the teams were asked to give their feedback regarding the impact and effectiveness of integrating project activities into nursing workflow via a written 2-page questionnaire and/or verbally by phone with a member of the study team. The questions were compiled by the study team and included items such as the unit’s experience of whether efficiency, patient care, or workflow were impacted negatively, which resources were most helpful and least helpful, and any changes they would suggest for other hospitals planning to implement the QI.
We estimated that it would take 3 to 4 months to complete the QI intervention but that the length of the campaign would vary for each hospital to achieve the goal of ≥90% compliance with all outcome measures. During the QI intervention, certain outcome measures (usually maternal report of nursing education on pacifier use) did not reach 90% compliance. In this case, the decision to end the local QI work was made jointly between the local hospital and the research team when it was mutually felt that further improvement was unlikely with the current resources. Once the QI intervention was considered completed, the hospitals entered “maintenance mode,” in which they were instructed to continue with the changes they had implemented to date but not to implement anything new; sites completed the standardized audit approximately monthly to monitor their results over time.
The interventions during each PDSA cycle were categorized as the following: staff awareness about the QI intervention and key messages, staff education on the evidence behind safe sleep, unit policy changes, and parent education (Table 1). The main outcomes among all participating hospitals were analyzed at baseline (“time 0”) and after PDSA cycles (2–3 week intervals) for 6 months by using run charts. We compared site-specific data regarding main outcomes at baseline and after the QI intervention. Average aggregate rates for each month were calculated on the basis of any data that were submitted by teams within a given month (Figs 1 and 2). During the maintenance mode, rates of outcomes were calculated at ∼4, 6, and 12 months postcompletion of the QI intervention to track sustainability (Figs 3 and 4).
The written and/or verbal feedback from the teams on completion of the QI intervention were reviewed by the study team, and dominant themes were identified and compiled to assist in informing the possibility of implementation at future sites.
Each site was instructed to provide their routine care and education for other aspects of maternal education and infant care in addition to the safe sleep education and role modeling targeted by the campaign. The institutional review board at each participating hospital approved the QI campaign as part of the larger SMART study.
Characteristics of the Sites
Characteristics of the 8 hospitals are shown in Table 2. One hospital (hospital 7) consisted of 2 campuses that completed separate QI interventions. These campuses are represented separately when the timing of active QI work versus the maintenance mode are presented (Fig 5) because the QI intervention started and stopped at different times at each site. However, the results from these 2 campuses are presented as 1 hospital (Tables 1 and 3, Figs 1–4). Hospitals were chosen from 4 different US regions. Six sites were urban, 2 were suburban, and 1 was rural. Six had >2000 deliveries (range, 1229–4376) in the QI period of July 2014 to July 2015. One hospital was designated “Baby-Friendly,” and 3 were in the initial designation process.
Intervention Over Time
In Fig 5, we show the timeline for each site’s enrollment and audits. Hospitals spent a median of 24.1 (range, 14.4–39.0) weeks completing the QI intervention. The maintenance mode for each site was a median of 51.6 (range, 29.3–61.4) weeks. Each team completed a median of 6 (range, 5–9) PDSA cycles. Each audit was completed over a median of 3 days (range, 0–60 days). Each hospital completed a median of 14 audits (range, 9–16).
The QI teams at each site (which included bedside nurses, nurse managers, and physicians) chose interventions for PDSA cycles based on perceived needs and the effectiveness of previous cycles. The interventions used in PDSA cycles and the percent of sites using each intervention are listed in Table 1. The most common strategy was the posting of TodaysBaby posters for nursing staff (used at all 8 hospitals), followed by nursing use of TodaysBaby pocket-size resource cards, huddle announcements, and staff meetings (each used by 7 hospitals). Five hospitals used staff e-mail blasts, removed contradictory messages from policies and education materials, and displayed posters and bulletin boards visible to families. We are unable to formally assess whether particular interventions had greater or lesser impact with only 8 hospitals completing their QI interventions in varied combinations.
Aggregated data of the main outcomes are shown in Figs 1 and 2. Mothers’ reports of receipt of nursing education on safe sleep practices (Fig 1) and observations of infants in a safe sleep position and environment (Fig 2) increased by >20 percentage points during the QI intervention. In general, hospital units that had low baseline percentages of adherence with the outcome measures attained similarly high percentages after the QI intervention as those with higher baseline percentages (Table 3). Overall, each individual hospital had a median increase of 30% (range, 10%–50%) across the 6 measures. Maintenance mode data demonstrated that improvements were maintained, with the exception of maternal report of nursing education regarding pacifier use (Figs 3 and 4).
Communication was minimal among the sites during the QI campaign, with the exception of the aforementioned conference call. This collaborative discussion was well received and helpful, especially for hospitals that were earlier in their QI intervention. The barriers discussed on the call included physician engagement, reviewing with physicians the evidence base for the recommendations, the need for scripting for nursing staff to answer common questions from families, and carving out staff time for the audits.
Because each unit implemented different interventions and different combinations of interventions, it is not possible to discern if any particular intervention was more effective than the others. However, in both qualitative interviews and the concluding survey, teams reported that reminders at huddles and staff meetings, the TodaysBaby pocket-sized cards used to teach parents, and individual crib cards (1 site created these for their own use) were the most useful strategies. In general, there was enthusiasm for the PDSA cycle methodology. Many sites endorsed the importance of having a champion. The hospitals reported that the toolkits were easy to use, they liked the branding and the scripting, and all of the tools were helpful to some degree. It was important for each hospital to be able to creatively tailor the approach for their site. In addition, hospitals commented that it was helpful to view their progress in comparison with the other participating hospitals on the study Web site. Although there were some initial concerns regarding the amount of time it would take and whether they could free up staff to perform the audits, all sites indicated that the audits were not time consuming (<30 minutes per cycle). Teams were surprised to discover that often some of the “other” items in the cribs (eg, thermometers, bulb syringes) were related to infant care. Most said that they would not change anything, but 2 sites mentioned that they would have liked more help with data collection, and 1 site said that they would have liked their PDSA cycles to be a little longer than the suggested 2 weeks.
Implementation of a nursing-focused safe sleep toolkit using QI methodology was feasible among 8 US maternity units and led to rapid improvement of adherence to AAP-recommended safe sleep practices during postpartum hospitalization, with over 90% of infants observed to be sleeping in the supine position and almost 90% of infants observed to be in a safe sleep environment. These improvements were sustained for 12 months after the QI intervention. This intervention was successful with minimal training in QI methodology and safe sleep practices provided by the study team among a diverse set of maternity units.
These results are consistent with results from studies in other hospital settings where QI methodology has been an effective strategy to increase adherence to infant safe sleep practices.21–23 As in the current study, the use of safe sleep toolkits that include education tools for nurses to deliver to families have also been successfully used in the NICU.24,25 In recent studies conducted in maternity units, researchers have demonstrated that bundled interventions using nurse modeling, parents viewing a DVD, and either nurses or parents signing a commitment or acknowledgment of the fact that education improved adherence to safe sleep practices at the time of discharge and at 4 months.26,27
This project was unique in that it was designed to be a comprehensive campaign, and each site could select resources and strategies from the toolkit to tailor their PDSA cycles on the basis of specific needs. The introduction and overview could be viewed online or presented in a webinar format, and the toolkit and materials could be downloaded as needed by each facility. Hospitals could identify champions and form teams on their own. Frequently asked questions and helpful resources were readily available online.
The only measure that did not reach the ≥90% target was the report of receipt of nursing advice to use a pacifier during sleep once breastfeeding has been established. Lower reporting of receiving advice about pacifiers may be due to residual confusion regarding the AAP recommendations to introduce pacifiers as a part of safe sleep and sudden infant death syndrome risk reduction11 and the recent push to implement the Baby-Friendly Ten Steps, which discourage the introduction of pacifiers until breastfeeding is well established.28,29 For future implementation, greater emphasis on this recommendation with careful explanation may be needed to encourage appropriate pacifier use as a risk reduction strategy.
It is important to ascertain whether gains attained during the birth hospitalization are sustained postdischarge. The role modeling of safe sleep practices by hospital personnel is associated with greater caregiver adherence at home5,6 because it establishes or reinforces the importance of the safe sleep practices.15 There are few studies in which researchers evaluated longer-term effects of QI initiatives such as this, and discussing these effects are beyond the scope of this article. However, incremental benefits may be hard to demonstrate given that many hospitals have high baseline levels of adherence. Additional studies will be needed to determine the optimal timing and content needed for sustained increases in adherence.
The QI intervention was designed before the updated AAP policy statement in 2016,11 and therefore it is possible that the updated safe sleep recommendations could have required a change in the toolkit. However, the 4 safe sleep recommendations included in the QI campaign were unchanged in the 2016 AAP policy statement, making the QI campaign consistent with current AAP guidelines.
We did not formally assess each hospital’s baseline educational practices, although most did report having safe sleep brochures available. However, units with low baseline percentages of adherence with the outcome measures attained similarly high percentages after the QI intervention as those with higher baseline percentages.
Participating teams were engaged in the larger SMART study, suggesting that they were committed to the success of the safe sleep intervention. They also received basic training and support from the study team. However, individual hospital-level data on unit-specific barriers were not collected. Future maternity hospitals aiming to adopt the intervention may differ in level of engagement and resources, and there may be different barriers.
Teams collected their data at different times, depending on the rate of their PDSA cycles, so data were grouped by monthly intervals for 6 months. This provided only 7 data points (including the baseline), which was insufficient to create statistical process control charts, which would enable the creation of confidence limits around the outcomes. Individual hospitals wishing to implement this intervention would be able to decide for themselves an appropriate end point.
Adherence to infant safe sleep practices (including supine position and proper sleep location) in the first months of life remains suboptimal. Safe sleep education and role modeling for parents in the postpartum hospital setting are variable but represent an opportunity for intervention. The implementation of a simple, nursing-based safe sleep education toolkit using basic QI methodology among a diverse group of maternity units led to rapid and sustained improvements in safe sleep education and practices. This intervention has the potential for widespread adoption that may contribute to reduction in sleep-related infant deaths.
The authors thank the participating hospitals, without whom this study would not have been possible, and the local site QI champions for coordinating the intervention and reviewing and approving this manuscript: Carol Chavez, BSN, RNC-OB, C-EFM; Alexandra Clark, MD; Kimberly Congden, RN, BSN, IBCLC; Sharon Dey-Layne, RNC-HROB, MSN, CNS; Andrea Grzyb; Shirley Hamill, MSN, RN, IBCLC, LCCE; Mary Shilkaitis; Myron Sokal, MD; and Andrea Warren, MS, RNC-MN.
- Accepted August 16, 2017.
- Address correspondence to Ann Kellams, MD, Well Newborn and Breastfeeding Medicine Services, Newborn Observation and Procedure Unit, Box 801429, University of Virginia, Charlottesville, VA 22908. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (1R01HD072815) and the CJ Foundation for SIDS. Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: Dr Moon has given paid expert testimony in the case of an infant who died suddenly and unexpectedly in a child care center; the other authors have indicated they have no potential conflicts of interest to disclose.
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- Copyright © 2017 by the American Academy of Pediatrics