The Community Impact of Safe Sleep Practices in NICU Lisa Owens, D.O., Karen Thomas, MSN, RNC-NIC

OBJECTIVES Be able to understand the different classifications of infant death Be able to discuss the recommendations of the new AAP policy statement Recognize the prevalence of sleep related deaths in our community Gain a basic understanding of the TCH Woodlands NICU quality project Recognize the pervasiveness and urgency of this crisis

SUDI, SIDS, and SRD Sudden Unexpected Death in Infancy (SUDI) whether explained or unexplained CASE INVESTIGATION: cause is assigned Sudden Infant Death Syndrome (SIDS) – Sub-category of SUDI sudden and unexpected death, unexplained CASE INVESTIGATION: no cause assigned Sleep Related Death (SRD) – Sub-category of SUDI classifications such as suffocation, strangulation, entrapment, etc.

Brief History Sudden Infant Death Syndrome (SIDS) Loosely defined term until the mid 1980’s 1992 - AAP recommends supine positioning, 1994 “Back to Sleep” campaign Reduction of SIDS cases by 53% over 10 years after “Back to Sleep” Recent plateau; upward trend ASSB (accidental strangulation and suffocation in bed and other SRD’s) Recent decrease in SIDS maybe due to increase in new classification structure 2016 New Policy Statement

Policy Statement 2016 Recommendations from AAP Back to sleep, every sleep, by every caregiver until 1 year old Firm Sleep Surface Breastfeeding recommended Room sharing on separate surface recommended No soft objects or loose bedding Pacifier every sleep (*once exclusive breastfeeding is established)

Policy Statement 2016 Recommendations from AAP (cont.) Avoid smoke exposure during pregnancy and after birth Avoid alcohol and illicit drug use during pregnancy and after birth Avoid overheating Pregnant women should obtain prenatal care Infants should be immunized Avoid commercial devices

Policy Statement 2016 Recommendations from AAP (cont.) No CPR monitors Supervised tummy time Swaddling does not reduce risk, leave legs loose Health care providers and staff should endorse and model safe sleep Media and manufacturers should follow safe sleep guidelines Pediatricians and other primary caregivers should participate in campaigns Continue research to eliminate these deaths

New Recommendations Why the change? National Need for Change 3,500 deaths nationally – declining, but still a problem Upward trend in ASSB and other SRD’s is concerning 5 years old; new evidence (devices, monitoring systems, etc.) “the message has changed, because science has told us something new” Community Problem Montgomery County CFRT has identified the need for change

Community: CFRT Child Fatality Review Task Force Interdisciplinary team of community members MD, ME, Social Work, CPS, RN, EMS, CPD/TX Rangers, DA Review all child fatalities for the previous calendar year Discuss omission/commission Aggregate data – (for community and state) Make recommendations for community entities Secure funds for campaigns

Community: CFRT What does our county look like? Leading causes of child fatality in Montgomery County Sleep related deaths Suicide Vehicle restraints (lack of) Total fatalities generally between 30-40 Sleep related fatality info* 2014 – 38% 2015 – 32% 2016 – 34% *Source Montgomery County DA presiding officer Tyler Dunman

So why a quality project in NICU? NICU Quality Project So why a quality project in NICU? AAP says there’s a national problem, CFRT says there’s a local problem Recognize that LBW and VLBW infants (most of our population) = increased risk Recognized a need to educate staff (and families) about AAP recommendations Desire to be agents of change

SMART Aim Statement NICU Quality Project We will increase compliance with firm sleep surface, supine positioning, and no loose blankets, toys, or stuffed animals by 30% in 6 months.

Fishbone Diagram People Equipment Developmental Unsafe Sleep Practices No buy-in from RNs Swings, gliders, Boppy pillows Head shapes Belief in unsafe complications: reflux, aspiration, bradycardia Recliners, car seats Not developmentally friendly Ease of care Unsafe Sleep Practices Skin to Skin Thermoregulation Policy Cultural beliefs RNs wanting to personalize bed space Experience at other facilities NGT/OGT Feeding Policy Nesting Conventional Wisdom Environment Policy Family

Bed space free of loose blankets, position aids, toys? Auditing Tool Collection Dates: 2/25/2018 – 3/10/2018 Data collected on Dayshift and Nightshift Room ≥34 weeks Off CPAP? Firm Sleep Surface Infant Supine? Bed space free of loose blankets, position aids, toys? HOB Flat? Comments 401 Y N   402 403 404 405 406 407 408 409 410 411 412 413 414

Exclusion Criteria Infants less than 34 weeks Infants requiring CPAP or ETT

Dayshift Overall compliance 50.4%

Nightshift Overall compliance 52.5%

PDSA Cycle -1A: Education ACT PLAN Reminder Email Safe Sleep Algorithm Resend survey and encourage completion Address concerns Standardization of safe sleep practices Provide education for nurses Standardize discharge STUDY DO Re-evaluate safe sleep compliance during intervention Review and aggregate survey data Education PowerPoint for nurses developed, assigned, and completed Video/posters Survey nurse attitudes

PDSA Cycle -1B: Surveys ACT PLAN STUDY DO Re-educate parents where gaps exist Attempt to determine percentage of parents that follow-up Assess parental compliance with safe sleep discharge teaching Attain baseline data STUDY DO Review and aggregate survey data *see graph Survey developed Administered by SOAR staff during check-in

Education 1A PowerPoint for staff Posters for staff and families Nursing survey - recollecting Re-education as needed

Survey Questions 1B Is your baby exposed to cigarette smoke? Does your baby sleep in his or her own crib/bassinette? Does your baby sleep on a firm mattress? Do you keep toys or extra blankets in your baby’s crib? Do you put your baby on his/her back to sleep? Likert scale Always, Almost Always, Sometimes, Never

Survey Results

What’s Next? PDSA Cycle 2 – community data, anecdote, media Provide Montgomery County stats to staff Provide opportunity for victim’s families to provide their testimony of impact PDSA Cycle 3 – Sleep Sacks More global application (system-wide) Policy change Culture shift/change the world

RESOURCES to consider AAP Press Conference and Panel Discussion https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/american-academy-of-pediatrics-announces-new-safe-sleep-recommendations-to-protect-against-sids.aspx NIH Video on Safe Sleep https://www1.nichd.nih.gov/sts/news/videos/Pages/default.aspx Dr. Hanke’s Foundation http://www.charlieskids.org/

Testimony VIDEO (5 min) Produced by Cinncinati Cradle in Ohio in collaboration with Dr. Hanke https://www.youtube.com/watch?v=qJwP4GFv-Ck

Thank You Kindly! ? Questions Evaluations