1. Jamie R. Macklin, MD, FAAP Nationwide Children’s Hospital April 4, 2014

2. History of “Safe Sleep” 1992: AAP recommends that all infants sleep on backs or sides to reduce SIDS Statement revised in 1996 1994: NIH/NICHD launches the “Back to Sleep” campaign to spread the message

3. SIDS Death Rate and Sleep Position 1988 – 2003 (per 1,000 Live Births)

4. SIDS and Other Sleep-related Infant Deaths Since 1992, SIDS deaths have decreased. However, other causes have increased as SIDS has declined. Suffocation Asphyxia Entrapment (strangulation in bed) Thus, recently, sleep-related infant deaths have plateaued.

5. Compliance with “Back to Sleep” campaign unchanged at 75% since 2001

6. In Ohio… 49 th /50 th highest African-American infant mortality rate 47 th /50 th highest overall infant mortality rate 2010 CDC data Behind Tennessee, Mississippi, and Alabama

7. In Ohio… 819 sleep-related deaths in 2007-2011 15% of infant deaths, more than any other cause besides prematurity >3 sleep-related infant deaths/week Enough to fill 7 kindergarten classrooms each year! Sleep-related deaths account for more infant deaths than any cause except prematurity. Black infants and male infants are disproportionately affected.

8. What to Do? In 2011, the AAP Task Force on SIDS expanded its focus towards creating a safe sleep environment for infants. SIDS (Sudden Infant Death Syndrome) SUID (Sudden Unexpected Infant Death) Eighteen recommendations directed at parents, healthcare providers, researchers, and health policy makers

9. Safe Sleep in Hospitals: The Problem Despite AAP recommendations, health care providers and staff do not always model safe sleep practices in the inpatient setting. We know that parents are more likely to model actions and behaviors demonstrated by health care providers rather than modeling from verbal instructions.

10. An Idea is Born… May 2012: Columbus Public Health Dept. presented a conference on the new 2011 AAP Safe Sleep recommendations. Dr. Rachel Moon was the speaker. Nationwide Children’s Hospital (NCH) staff at the conference realized that the hospital’s practices did not align with many of the new recommendations.

11. Formation of a Safe Sleep Committee Following the conference, an interest meeting was held in June 2012. Over 50 employees of the hospital came. The NCH Safe Sleep Committee was formed in July 2012. APRN’s, physical and occupational therapists, inpatient (day/night shift)/outpatient nursing staff, and a physician (now two) The group has stayed fairly constant since inception. Monthly Monday afternoon meetings

12. The Pre-Intervention Audits Members audited inpatient infant sleep environments (looking at location/ position of infant, items in crib, etc.) in September 2012. Franklin County Dept. of Public Health form Exclusions NICU Ventilator/NIPPV Tracheostomies Recent spinal surgeries

13. Audit Form Questions Demographics Age Unit Location Time Location of Baby (crib, couch, etc.) Position of Baby (back, side, etc.) Condition of Crib/Baby Blankets, toys, diapers/wipes? Was the head of the bed elevated? Developmental Tools Used Inappropriately?

14. The Audit Form Total Possible Points: 7.0 points The higher the score, the better the performance/audit Average Hospital Score: 3.8/7.0 points

15. “Safe Sleep Bundle” Limited Rollout Intervention Planning September 2012-June 2013 Updating of Existing Hospital Policy Changing language related to GER interventions, firm mattress use Ultimately finalized July 2013 Focused efforts on the General Pediatrics unit Rollout in June 2013 Underlined interventions were first

16. To increase the quantities of safe sleep behaviors in infants <1 year of age by increasing Safe Sleep Audit Scores from average 3.8/7.0 to 6.0/7.0 points by xxx Specific Aim Nursing Education PCA, PT/OT (Multi- Disciplinary) Education Management of Environment Key Drivers Interventions (Ideas) Physician Education Parent/Caregiver Education CHEX Module Quality Board Tips (Marketing) Nurse Champions/RN Care Partners Scripting for/with Parents Safe Sleep “Cheat Sheet” Grand Rounds with Dr. Rachel Moon Hospital Peds Web module Safety Videos/Edutainment System (Franklin County/CPSC/NICHD) Take-Home Magnets (Marketing) Brochures (NICHD) Safe Sleep Posters (Clinics) Sleep sacks (Halo) Assess hospital policy on clothing allowed for patients Mattresses on beds need evaluated Fitted Sheets Nationwide Children’s Hospital Safe Sleep Key Driver Diagram (“Bundle” at Time of Rollout)

17. “Safe Sleep Bundle” Rollout Results New audits performed in September 2013 General Pediatrics Unit score: 5.7/7.0 points Statistically significant improvement from baseline score and from the rest of the units of the hospital Hospital average score: 4.5/7.0 points

18. “Safe Sleep Bundle” Hospital-wide Rollout October 2013 Education and interventions introduced to all units in the hospital New audits performed in January 2014 General Pediatrics Unit score: 6.1/7.0 points (Specific Aim met) Hospital average score: 5.1/7.0 points Currently working with lower-scoring units to improve compliance with recommendations

19. To increase the quantities of safe sleep behaviors in infants <1 year of age by increasing Safe Sleep Audit Scores from average 3.8/7.0 to 6.0/7.0 points by xxx Specific Aim Nursing Education PCA, PT/OT (Multi- Disciplinary) Education Management of Environment Key Drivers Interventions (Ideas) Physician Education Parent/Caregiver Education CHEX Module Quality Board Tips (Marketing) Nurse Champions*** Scripting for/with Parents Safe Sleep “Cheat Sheet” Grand Rounds with Dr. Rachel Moon Hospital Peds Web module Safety Videos/Edutainment System (Franklin County/CPSC/NICHD) Take-Home Magnets (Marketing)*** Brochures (NICHD) Safe Sleep Posters (Clinics) Sleep sacks (Halo) Assess hospital policy on clothing allowed for patients Evaluation of Mattresses*** Fitted Sheets Nationwide Children’s Hospital Safe Sleep Key Driver Diagram (Where We Are Now)

20. Lessons Learned…

21. Keys to Success Supportive hospital leadership Nursing administration Physician staff A passionate Safe Sleep Committee Multidisciplinary is best, if possible! Reaching out to community resources CIAG grant OBBO

22. Challenges and Pitfalls “But that’s not the way we’ve done it before!!” “My baby’s pediatrician says that….” “The consult doctor that was just here told us that….” “My baby is different; the rules don’t apply because….” Education of physicians, nursing and ancillary staff, and parents/caregivers is essential for successful change. “Buy-in” from staff, while difficult in several instances, is also essential. Working with other departments can be frustrating, at times.

23. Small Steps are Still Steps… PDSA cycles Even one intervention is still great if it yields change. Focus on one area of improvement if needed, instead of all at once. Many free or inexpensive options exist. NICHD website/brochures (http://www.nichd.nih.gov/sts/materials/Pages/def ault.aspx)http://www.nichd.nih.gov/sts/materials/Pages/def ault.aspx CPSC videos (http://www.cpsc.gov/en/Safety- Education/Safety-Education-Centers/cribs)http://www.cpsc.gov/en/Safety- Education/Safety-Education-Centers/cribs

25. The Ohio AAP “EASE” Project Education and Sleep Environment Created in Fall 2013 as a means to improve infant safe sleep practices in ALL children’s hospitals in Ohio Modeled after the NCH Safe Sleep project 12-month project, initiated in February 2014

26. EASE Project Goals To increase the quantities of safe sleep behaviors in infants <12 months of age To show that greater than 90% of infants will be in a safe sleep environment (Alone, on Back, in an empty Crib) during hospitalization Random weekly audits To provide safe sleep information to parents/caregivers of greater than 90% of infants upon hospital discharge

27. To increase the quantities of safe sleep behaviors in infants <1 year of age by increasing Safe Sleep Audit Scores from average xxx/7.0 points to xxx/7.0 points by xxx (hospital-wide) Specific Aim Nursing Education PCA, PT/OT (Multi- Disciplinary) Education Management of Environment Key Drivers Interventions (Ideas) Physician Education Parent/Caregiver Education CHEX Quality Board Tips (Marketing) Nurse Champions/RN Care Partners Scripting for/with Parents Safe Sleep “Cheat Sheet” Grand Rounds with Dr. Rachel Moon Hospital Pediatrics Web module Safety Videos/Edutainment System (County/CPSC/NICHD) Take-Home Magnets (Marketing) Brochures (NICHD) Safe Sleep Posters (Clinics/Off-Sites) Sleep sacks (Halo) Assess hospital policy on clothing allowed for patients Mattresses on beds need evaluated Fitted Sheets? Ohio AAP EASE Project Key Driver Diagram (Courtesy of Nationwide Children’s Hospital)

28. EASE Project Requirements Completion of random weekly audits At least 10/week Completion of at least 3 PDSA cycles to improve outcomes Attendance of at least 75% in monthly Action Period Calls

29. Get Ready to Make a Difference! Overall, hospitals can help parents learn to practice safe sleep by providing education and resources and by demonstrating desired behaviors. More than half of children’s hospitals are not following guidelines for safe sleep. Barriers to following safe sleep recommendations include parental and healthcare worker misunderstanding and lack of modeling and reinforcement in the healthcare setting. We Can Change This!!!

30. Questions?