Improving Safe Sleep Practices for Hospitalized InfantsKristin A. Shadman, MD, a Ellen R. Wald, MD, a Windy Smith, RN, b Ryan J. Coller, MD, MPHa

aDepartment of Pediatrics, University of Wisconsin School

of Medicine and Public Health, Madison, Wisconsin; and bAmerican Family Children’s Hospital, Madison, Wisconsin

Dr Shadman conceptualized and designed the

study, designed the data collection instruments,

participated in the analysis and interpretation of

the data, and drafted the initial manuscript; Dr Wald

conceptualized and designed the study and critically

reviewed the manuscript; Ms Smith coordinated

and supervised data collection and critically

reviewed the manuscript; Dr Coller performed the

analysis, participated in the interpretation of the

data, and reviewed and revised the manuscript;

and all authors approved the fi nal manuscript as

submitted.

DOI: 10.1542/peds.2015-4441

Accepted for publication Apr 29, 2016

Address correspondence to Kristin A. Shadman, MD,

Department of Pediatrics, University of Wisconsin,

H4/468 CSC, 600 Highland Ave, Madison, WI 53972.

E-mail: kshadman@pediatrics.wisc.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,

1098-4275).

Copyright © 2016 by the American Academy of

Pediatrics

FINANCIAL DISCLOSURE: The authors have

indicated they have no fi nancial relationships

relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors

have indicated they have no potential confl icts of

interest to disclose.

Despite declines in sudden infant

death syndrome (SIDS) during the

Back to Sleep Campaign through

2001, additional reductions have

not occurred, and SIDS remains the

leading cause of death in infants

beyond the neonatal period in the

United States. 1 In response to this

plateau, the American Academy

of Pediatrics (AAP) has expanded

recommendations for SIDS prevention

and addressed safe sleep practice

(SSP) in newborn nurseries and

NICUs. 2 Although >20% of all pediatric

discharges are among children <1

year of age, 3 SSP recommendations

in general inpatient settings have

not been established, and adherence

for hospitalized infants is not well

studied.

Hospitalizations offer unique

opportunities to provide education

abstractBACKGROUND AND OBJECTIVES: Adherence to the American Academy of Pediatrics

safe sleep practice (SSP) recommendations among hospitalized infants is

unknown, but is assumed to be low. This quality improvement study aimed

to increase adherence to SSPs for infants admitted to a children’s hospital

general care unit between October 2013 and December 2014.

METHODS: After development of a hospital policy and redesign of room setup

processes, a multidisciplinary team developed intervention strategies

based on root cause analysis and implemented changes using iterative

Plan–Do–Study–Act cycles. Nurse knowledge was assessed before and after

education. SSPs were measured continuously with room audits during

sleeping episodes. Statistical process control and run charts identified

improvements and sustainability in hospital SSPs. Caregiver home practices

after discharge were assessed via structured questionnaires before and

after intervention.

RESULTS: Nursing knowledge of SSPs increased significantly for each item (P ≤

.001) except avoidance of bed sharing. Audits were completed for 316 sleep

episodes. Simultaneous adherence to all SSP recommendations improved

significantly from 0% to 26.9% after intervention. Significant improvements

were noted in individual practices, including maintaining a flat, empty

crib, with an appropriately bundled infant. The largest gains were noted in

the proportion of empty cribs (from 3.4% to 60.3% after intervention, P <

.001). Improvements in caregiver home practices after discharge were not

statistically significant.

CONCLUSIONS: Sustained improvements in hospital SSPs were achieved

through this quality improvement initiative, with opportunity for continued

improvement. Nurse knowledge increased during the intervention. It is

uncertain whether these findings translate to changes in caregiver home

practices after discharge.

QUALITY REPORTPEDIATRICS Volume 138 , number 3 , September 2016 :e 20154441

To cite: Shadman KA, Wald ER, Smith W, et al.

Improving Safe Sleep Practices for Hospitalized

Infants. Pediatrics. 2016;138(3):e20154441

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SHADMAN et al

and role modeling to families

and providers. Studies have

demonstrated that supine position

and bed sharing at home are both

positively and negatively influenced

by SSP modeled in the newborn

nursery 4, 5 and sleep advice provided

by health care professionals. 6 –8

Given this influence of SSP modeling

from the newborn nursery, we

were concerned about potentially

negative influence of unsafe sleep

practices modeled in inpatient

settings. Parents of hospitalized

infants encounter unsafe practices,

such as leaving personal care items

in the crib, elevating the head of

the bed (HOB), or using towel rolls

to position the child. Despite the

risk of SIDS associated with such

practices 9 –13 our experience suggests

they commonly occur in inpatient

settings. This practice counters a

professional responsibility to follow

established guidelines intended to

reduce preventable sleep-related

deaths regardless of the setting. 4, 14, 15

Previous quality improvement work

in other settings demonstrated

the value of various approaches to

improving SSP: providing nursing

education, using visual cues for

families and providers, auditing

cribs, and surveying parent-reported

practices. 14, 16 Such strategies were

therefore anticipated to provide

a framework on which additional

improvement activities might be

added.

To address concerns about

nonadherence and poor modeling

of SSP at our children’s hospital,

we used quality improvement

methods to enhance knowledge,

attitudes, and practices related to

the SSP recommendations issued

by the AAP. Our specific aim was

to increase the number of infants

sleeping in complete adherence

to the AAP SSP guidelines to 90%

within 12 months. We hypothesized

that workflow redesign, nurse

education, and reinforcement

through infant room audits during

sleep episodes with just-in-time

feedback would result in improved

adherence to recommended SSP. We

also hypothesized that caregivers

would report increased knowledge

and adherence to the AAP sleep

recommendations at home after

discharge.

METHODS

Context

The American Family Children’s

Hospital is a medium-sized, urban,

academic children’s hospital where

the majority of infants are admitted

to 1 of 3 mixed medical and surgical

units. There is no birthing service

at the hospital. Hospital medicine,

subspecialty, and surgical attending

physicians staff these units, supervise

pediatric and surgical residents, and

collaborate with nursing colleagues.

Planning the Intervention

We chose SSP as an area for

improvement after the release of the

2011 AAP infant sleep environment

recommendations. 2 This work

paralleled our community hospital

advocacy task force initiative to

improve the safety of home sleep

practices. Figure 1 provides an

overview of the hospital quality

improvement project.

A multidisciplinary stakeholder team

of nurses, attending and resident

physicians, a surgical advanced

practitioner, and a hospital quality

and patient safety officer gathered

before the intervention. This group

defined the ideal hospital SSP based

on AAP guidelines for the home

sleeping environment adapted to the

inpatient setting by using local expert

opinion and best practice sleep

policies from 3 other institutions.

A baseline assessment of hospital

SSP was conducted via a Web-

based audit tool on the intervention

unit and included rooms of all

hospitalized infants <12 months of

age, regardless of underlying medical

condition, length of stay, or acuity of

illness. Rooms were excluded if they

were located outside the primary

intervention unit.

Improvement Activities

After the baseline assessment, a

fishbone diagram (Supplemental

Figure 3) was constructed to

identify important candidate causes

of nonadherence with SSP in the

hospital; improvement activities

were then designed to address these

causes. We developed a hospital

policy statement for SSP, a process

map of standard infant room setup

on admission, followed by a redesign

to eliminate both placement of

extraneous items in the crib and

provision of excessive linens for

bundling. Our final activity at the

start of the project was development

of a computer-based education

module outlining SSP. Hospital staff

nurses and nursing assistants from

all units completed this education

module during their annual

education review in 2014.

Data from Web-based room audits

were reviewed by a smaller unit-

based workgroup every 2 weeks.

Additional improvement activities

targeted adherence to SSP by using

iterative Plan–Do–Study–Act cycles.

A summary of activities included the

following:

1. Recruitment of nurse and nursing

assistant safe sleep champions

2. Auditing of infant rooms

weekly by champions with

the development of scripts for

champions to provide feedback to

colleagues after room audits

3. Distribution of commercial sleep

sacks to intervention unit and

families

4. Incorporation of a visual cue in

infant rooms based on the US

Department of Health and Human

Services Safe to Sleep educational

campaign material 1

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PEDIATRICS Volume 138 , number 3 , September 2016

5. Designation of space for the

infant’s personal care items

6. Delivery of grand rounds to

physician and nursing providers

by a national expert

Results of key measurements and

targets for improvement were added

to the unit’s publicly posted quality

scorecard.

Study of the Improvement

Nurse Knowledge

Nurses’ knowledge of AAP SSP

was assessed immediately before

and after the module via a Web-

based questionnaire designed for

this project. Key hospital SSPs

queried included maintaining a flat

HOB, absence of items in the crib,

appropriate bundling (sleeper alone,

single blanket or sleep sack), and

supine sleep position in the crib. Self-

reported comprehension of the AAP

sleep recommendations was also

assessed.

Hospital SSPs

SSP room audits were conducted

via a structured Web-based audit

tool designed for this study. The

tool included items that assessed

infant sleep location (crib or other),

infant sleep position (supine, side,

or prone), HOB position (elevated

or flat), number of items per crib,

and appropriate bundling (sleep

sack, single blanket, sleeper

alone). Complete adherence to

SSP was defined as presence of all

recommendations simultaneously

(sleeping in a crib, supine,

appropriately bundled with a flat

HOB and no items in the crib).

Nurses from the safe sleep

workgroup collected baseline data

by using the Web-based audit

tool between October 2013 and

November 2013, from a convenience

sample of rooms of sleeping

infants, with a goal of 10 room

observations per week. Safe sleep

champions collected ongoing data

during the intervention period,

typically overnight from infant sleep

episodes on the intervention unit

through December 2014. Champions

continuously reviewed the audit tool

with the supervising nurse manager.

Caregiver-Reported Practices at Home

The home sleep practices of

discharged infants <6 months of

age were assessed via a structured

data collection tool during the

preintervention phase, October 2013

through January 2014, and in the

postintervention period, February

through April 2014. Discharges from

the intervention unit in the previous

month were obtained weekly from

administrative data, and a research

e3

FIGURE 1Hospital-based SSP implementation timeline of data collection and interventions, July 2013 through December 2014.

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SHADMAN et al

nurse attempted phone contact ≤2

times. Caregivers were excluded if

they did not speak English, they were

inaccessible by phone, or the child

was in foster care.

As in the room audit tool, measures

of SSP included infant sleep location,

sleep position, HOB position, and

appropriate bundling. In addition,

we inquired about bed sharing,

and caregivers were queried for

recollection of sleep education by

hospital staff. We did not inquire

about the number of items in the

crib, because we thought this would

be an unreliable question to recall.

The definition of complete adherence

to SSP otherwise paralleled that for

inpatient SSP. Clinical characteristics

we hypothesized to influence SSP at

home were also assessed: history of

reflux, apnea or cardiorespiratory

monitor use, assisted respiration, and

tube feeding.

Analysis

Differences in nurse knowledge,

hospital practices, and caregiver

practices at home before and after

the improvement interventions

were assessed with χ2 tests for

categorical variables and t tests

for continuous variables. A P value

<.05 was considered significant.

Statistical process control (SPC)

p-charts and run charts were used

to monitor changes in hospital SSPs

using established rules for identifying

special cause variation. 17, 18 We

considered 8 consecutive points

above or below the centerline and

any points outside the control

limits to represent special cause

variation and prompt a change in the

centerline. 19, 20 Such observations

happen <0.4% of the time by chance

and are therefore conventionally

accepted as suggesting statistically

significant changes.21

Human Subjects Protection

This quality improvement initiative

was considered exempt by the

University of Wisconsin School

of Medicine and Public Health’s

Institutional Review Board.

RESULTS

Nurse Knowledge

Nursing staff completed 289

preeducation knowledge assessments

and 315 posteducation assessments.

Staff were primarily full-time

registered nurses with >5 years of

experience, nearly half of whom

had children of their own ( Table 1).

Preeducation and posteducation

results of SSP knowledge are

presented in Table 1. Staff

demonstrated increased knowledge

of appropriate sleep position, crib

items, HOB position and bundling,

and self-rated comprehension of

the AAP SSP recommendations

(P ≤ .001).

Hospital Safe Sleep Practices

Changes in SSP by audits (n =

316) are shown in Table 2 and

the Fig 2 SPC charts. Baseline data

demonstrated that >96% of cribs

contained ≥1 item (mean 4.4 items

per crib), 40% had an overbundled

infant, and almost 20% were not

flat. Significant implementation

improvements were observed

in the number of crib items and

the proportions of cribs with no

items, flat HOB, and appropriate

bundling (P < .001). Initially, no sleep

episodes were completely adherent

to recommendations, although this

number increased to 26.9% after

implementation (P < .001). Supine

e4

TABLE 1 Nurse Knowledge Before and After Safe Sleep Education Intervention

Preeducation, n = 289 Posteducation, n = 315 P

n % Correct n % Correct

Sleep position .001

Supine 275 95.8 310 99.7

HOB position <.001

Flat 220 76.1 299 95.5

Appropriate bundling 242 83.7 290 92.7 .001

Items in crib <.001

None 210 72.7 277 87.9

AAP bed-sharing policy 283 100 309 99.7 .34

Refl ux and sleep position knowledge 89 30.9 188 60.0 <.001

Self-rated comprehension (4-point Likert scale) <.001

Highest category 66 23.2 147 47.4

Years of nursing experience .97

0–2 79 27.4 85 27.7

3–5 53 18.4 54 17.6

6–10 59 20.5 60 19.5

>10 97 33.7 108 35.2

Have their own children 139 48.4 150 48.7 .95

Occupation .90

Registered nurse 252 87.5 274 88.7

Nursing assistant 24 8.3 23 7.4

Work effort < 50% 36 12.6 32 10.4 .38

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PEDIATRICS Volume 138 , number 3 , September 2016

sleep position of an infant in a

crib (location) had high baseline

performance (>75% adherent)

without significant increases after

implementation.

Similarly, under established run chart

rules 19, 20 SPC charts demonstrated

statistically significant improvement,

that is, special cause variation as

defined in the Methods section,

shortly after the implementation

began and was sustained for all

measures except supine sleep

position and crib sleep location

(Supplemental Figure 4). Special

cause improvement in crib sleep

location was briefly noted after the

educational intervention, although

this improvement was sustained for

only ~2 months before returning to

baseline levels.

Caregiver-Reported Practices at Home

Table 3 highlights the characteristics

of infants included in the caregiver

surveys. A total of 56 caregivers

before nurse SSP education and 48

caregivers after the education were

surveyed (46% response rate). There

were no differences in age or clinical

characteristics between infants of

caregivers surveyed before and

during implementation.

The reported increase in SSP

education received by caregivers

during implementation was not

statistically significant. None of the

measures we included demonstrated

an increase in the implementation

compared with preimplementation

periods. However, caregivers

did report a high rate of crib

sleeping both before and during

implementation (85.7% and 93.8%,

respectively) and absence of bed

sharing (>94% in both cases). They

simultaneously reported a high use

of alternative sleep locations at least

once per day in both before- and

during-implementation periods

(62.5% and 66.7%, respectively).

DISCUSSION

We conducted a multifaceted

quality improvement project

incorporating workflow redesign,

nurse education, and audit and

feedback, which increased nurse

knowledge of SSP and improved

adherence to individual components

of SSP, including maintaining a flat,

empty crib with an appropriately

bundled infant. Adherence to SSP by

caregivers at home was unchanged.

Although we did not reach our

aim of 90% adherence within 12

months, we did achieve significant

improvement in complete adherence

to SSP recommendations. Whereas

previous improvement studies have

focused on infant SSP in newborn

nurseries and NICUs, 14, 16, 22 this is

the first study to our knowledge in a

general inpatient setting.

Our work in this setting complements

and extends previous research

describing the influence of modeling

SSP in the newborn on home

sleep environments. 14, 23 Previous

quality improvement efforts have

demonstrated improvement

in adherence to individual SSP

components 14 or a more limited

assessment of complete adherence

to SSP guidelines (eg, sleeping alone,

supine, and in a crib). 16 We sought

to investigate a more comprehensive

assessment of adherence to all SSP

recommended by the AAP.

Similar to other studies, 24, 25 we

found high levels of nurse knowledge

about SSP, particularly regarding

supine position. The significant

improvement we observed in

knowledge of recommendations

for flat HOB, empty cribs, and

appropriate bundling after education

was also consistent with previous

work. 22 These gains in knowledge

were encouraging because our

baseline audits demonstrated poor

adherence to these specific practices.

Despite these gains, however,

half of the nurses did not rate

their own comprehension of SSP

recommendations at the highest

level. This might suggest a need to

expand the scope of educational

content or to build nurse confidence

in their knowledge. Although

the training module delivered

fundamental information, time

constraints, and its “just-in-time”

nature limited an in-depth discussion

of the rationale behind the SSP

recommendations.

Preimplementation measurement

confirmed our assumption that

adherence to SSP recommendations

was generally low. Most notably, no

cribs had complete adherence to SSP.

As in other studies, 14, 16 implementing

room audits demonstrated overall

improvements, with larger gains

in a subset of practices. Complete

adherence remains challenging,

probably because of the need for

unique solutions for different

components of a safe sleep

environment. Certain SSPs are

probably more responsive than

others to our intervention strategies.

In particular, we observed no

improvements in rates of appropriate

e5

TABLE 2 Audits of Hospital Practices Among Sleeping Infants

Preimplementation (n =

59), n (%)

Implementation (n = 257),

n (%)

P

Sleep location (crib) 46 (78.0) 215 (83.7) .30

Sleep position (supine) 47 (81.0) 215 (84.3) .54

HOB (fl at) 26 (44.1) 187 (73.3) <.001

Appropriate bundling 24 (40.7) 141 (56.0) .03

Items in crib, mean (SD) 4.4 (3.3) 0.9 (1.5) <.001

Cribs with 0 items 2 (3.4) 155 (60.3) <.001

Complete adherencea 0 (0) 69 (26.9) <.001

Age in months, mean (SD) 4.7 (2.9) 5.1 (3.5) .48

a Complete adherence indicates following all recommendations simultaneously (sleeping in a crib, supine, appropriately

bundled, with a fl at HOB and no items in the crib).

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SHADMAN et al

sleep location or supine position,

potentially explained by a lack of

emphasis in the training module

because initial rates were higher than

most measures.

Inconsistencies between

improvements in nurse knowledge

of a recommendation and changes

in practice for that recommendation

were observed. Improvement in

knowledge of SSPs through Web-

based education has been shown to

be achievable; however, increased

knowledge does not necessarily

translate into practice. 24 Some of

this apparent discrepancy may

be explained by a gap between

knowledge and firmly established

beliefs. For example, despite

knowing correct sleep position,

nurses may maintain the view that

supine position increases the risk

for aspiration. 24 – 26 Nurses may

believe that cardiorespiratory

monitors or frequent vital sign

checks reduce the need to worry

e6

FIGURE 2SSP adherence. Rooms with infant (A) sleeping fl at, (B) appropriately bundled, (C) with no items in crib, (D) with average number of items per crib, and (E) completely adherent.

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PEDIATRICS Volume 138 , number 3 , September 2016

about safe sleep. Families may hold

similar beliefs about SSP, 7, 24 creating

a secondary barrier to adherence

in the hospital. Parental preference

has also been demonstrated to

be a barrier to perfect practice

of sleep recommendations 23 and

may contribute to the lack of

improvement in some measures.

For example, our observed rates

of supine sleep positioning mirror

national rates of supine sleep

positioning in the home, 8 suggesting

to us that future Plan–Do–Study–

Act cycles will need to incorporate

consideration of current caregiver

practices into the development of

improvement activities.

Clinical situations may also influence

practices, even in the presence of

correct information. For example,

despite the lack of evidence, elevating

the HOB is often used as a strategy

for improving respiratory function

in infants admitted with respiratory

illness. Even if nurses know flat HOB

is the “correct answer, ” they may be

inclined to elevate the HOB of infants

admitted with respiratory problems.

Similarly, although evidence for

elevating the HOB in infants needing

nasogastric feeds or continuous

gastrostomy tube feeds is lacking,

there is confusion or disagreement

about positioning the HOB in these

infants.

Lastly, a lack of nurse empowerment

may explain gaps between

knowledge and practice. The

education module did not train

nurses to have skills to address

parent beliefs or practices that

conflicted with recommendations. At

times, nurses may not have known

how to mediate a nonadherent

environment when pressured by

parents. Furthermore, because staff

were not continually present in the

room, families may intentionally or

unintentionally have deviated from

desired SSP.

To address these potential gaps

in knowledge and practice, future

efforts to improve SSP may

need to include training staff to

collaboratively resolve differences

with parents. Although informal

caregiver education occurred

at the bedside, future efforts

should be enhanced. Examples

of potentially effective strategies

include structured programs that

combine modeling with caregiver

education videos and SSP-specific

discharge instructions mirroring

efforts from newborn nurseries and

ICUs. 14, 16, 23

Despite significant improvements in

nurse knowledge and many hospital

practices, reported adherence of

caregivers to SSP recommendations

at home did not demonstrate

significant changes after our

implementation of SSP. Several

potential explanations exist for this

finding. First, posteducation surveys

were conducted shortly after the

nursing education intervention,

corresponding to a time in which

our hospital-based adherence to

e7

TABLE 3 Caregiver-Reported Sleep Practices at Home After Hospital Discharge

Preimplementation, n = 56 Implementation, n = 48

n (%) n (%) P

Hospital care team discussed safe sleep

Yes 15 26.8 17 35.4 .34

Sleep location

Crib 48 85.7 45 93.8 .18

Sleep position

Supine 50 89.3 45 93.8 .42

HOB position

Flat 38 79.2 29 65.9 .15

Appropriate bundling

Yes 42 76.4 42 87.5 .15

Items in crib

None 45 80.4 38 79.2 .36

Complete adherencea

Yes 23 41.1 22 45.8 .63

Bed sharing

No 53 94.6 46 95.8 .78

Alternative sleep locationb >1 per wk

Yes 43 76.8 41 85.4 .27

Alternative sleep locationb >1 per d

Yes 35 62.5 32 66.7 .66

Age in mo, mean (SD) — 3.0 (1.7) — 3.2 (1.8) .54

History of refl ux 5 8.9 8 16.7 .23

Apnea or cardiorespiratory monitor 2 3.6 2 4.2 .88

Assisted respiration 3 5.4 1 2.1 .39

Tube feeding 7 12.5 4 8.3 .49

a Complete adherence indicates following all recommendations simultaneously (sleeping in a crib, supine, appropriately bundled, with a fl at HOB and no items in the crib).b Alternative sleep location indicates location other than crib.

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SHADMAN et al

SSP was at its lowest. Repeated

evaluation of caregiver practices

during a period of more robust

adherence might provide better

assessment of their influence on

caregiver practice. Second, small

sample sizes limited our power to

detect changes in parent-reported

behaviors. Finally, most education

was done informally at the bedside,

which may have been less influential

in changing home sleep practice

and resulted in fewer caregivers

who recalled SSP education. Nurses

were instructed to provide SSP

education when they found the crib

to be in a state of nonadherence,

although this was at the discretion

of the nurse, and our intervention

did not allow us to systematically

evaluate these interactions. Nurses

may have provided inconsistent

education or failed to fully take

advantage of educational tools.

Improved implementation of

nurse–caregiver education may be

necessary to create changes in SSP

after discharge.

This work has several limitations.

First, we allowed infants to

be resampled because our

measurement unit of interest was

the sleeping episode rather than

patient. Though not completely

independent, each sleep occurrence

represented a new opportunity to

adhere to SSP recommendations.

We never resampled infants during

the same day or same sleep episode.

Second, the cross-sectional nature

of our nursing assessment makes

it unclear how long the increase in

knowledge was sustained. Future

efforts will retest nurse knowledge

at an interval farther from training.

In addition, we did not attempt to

link education of particular nurses

with their practice. Furthermore,

recall and response biases may

have influenced caregiver answers.

Third, our project included

assessment of supine sleep

position in some infants who

were developmentally able to

roll, although the findings did not

change when we excluded infants >6

months of age from analyses.

Lastly, we did not have complete

infant and staff demographic

data; therefore, the influences of

sociodemographics or education

could not be evaluated.

CONCLUSIONS

This project illustrates

our institution’s approach

to implementing the AAP

recommendations for infant SSP

in the hospital setting. Although

previous improvement interventions

have been successful in the NICU

and nursery setting, our findings

show that interventions may

also be successful in a general

inpatient setting, where providers

may have less expertise and focus

on safe sleep practices. Several

improvement strategies translated

well to this more heterogeneous

population, including nurse

education and audit and feedback.

This work identified elements of

SSP that are more challenging to

achieve in the hospital setting,

particularly eliminating items in the

crib, flattening the HOB, avoiding

overbundling, and completely

adhering to recommendations for

SSP. Future research should explore

root causes of nonadherence in

these areas and continue to examine

the potential influence of education

regarding SSP from the nonbirth

hospital on caregiver practices at

home.

ACKNOWLEDGMENTS

We thank Jody Belling, RN, and

Andrea Blom, RN, for their assistance

with caregiver interviews. We also

acknowledge the American Family

Children’s Hospital Safe Sleep

workgroup for their support in

designing the intervention. We thank

the safe sleep nurse champions for

their enthusiastic involvement in this

initiative.

ABBREVIATIONS

AAP:  American Academy of

Pediatrics

HOB:  head of bed

SIDS:  sudden infant death

syndrome

SPC:  statistical process control

SSP:  safe sleep practice

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DOI: 10.1542/peds.2015-4441 originally published online August 1, 2016; 2016;138;Pediatrics 

Kristin A. Shadman, Ellen R. Wald, Windy Smith and Ryan J. CollerImproving Safe Sleep Practices for Hospitalized Infants

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Kristin A. Shadman, Ellen R. Wald, Windy Smith and Ryan J. CollerImproving Safe Sleep Practices for Hospitalized Infants

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