A Quality Improvement Initiative to Reduce Screen Time in a Children’s Hospital

An interdisciplinary team led by a pediatric hospitalist at a midwestern, academic children’s hospital designed a QI initiative for inpatient children age 2 and under. Our institutional review board determined this study to not be human subject’s research. Our children’s hospital is a tertiary-care academic children’s hospital with 190 beds housed in a building opened in 2017 with state-of-the-art technology designed to enhance the overall experience. In each inpatient room, children and caregivers have access to an interactive system consisting of a TV screen and a bedside tablet.

The focus of this project was on children age 2 and under admitted to an acute care pediatric floor of our children’s hospital. Children with coronavirus disease 2019 (COVID-19) infection or airborne illnesses, were not included in the audits. All other children, including those in other types of isolation, were included.

Team members included clinical nursing leaders, child life and music therapists, and a nursing QI leader. To begin, the group identified potential contributors to excessive screen time using a fishbone diagram (Supplemental Fig 6). Of the contributors, the group highlighted the lack of bedside alternatives and limited staff knowledge.

Baseline screen exposure was assessed by random audits performed by child life students. The audit was performed midday and documented utilization if screen media was on in the child’s room. The audits started in November 2019. The baseline period, before significant interventions, occurred from November 2019 through August 2020.

When possible, the audits were completed at least once per week, though dependent on the student’s schedule. The child life student went into all rooms that met inclusion criteria and used the opportunity to offer child life services if a caregiver was present. The audit recorded if a screen (TV or tablet) was on in the room and information on the room setting (Supplemental Fig 7). Some months in 2020 had lower census and audits were affected by COVID-19 isolation.

The primary outcome measure was percent of children who had screens turned on as measured by the audits. Although the audit did not assess how long the screen had been in use, this type of convenience and observational sample has been used successfully in other studies.^7,8 

The audits assessed process measures, including how often there was an adult present when the screen was on and if a screen alternative (ie, toy or mobile) was present in a child’s room.

Additional process measures included number of staff educated, the frequency that staff reported turning on screens for the target age group, and the frequency that staff reported offering screen alternatives to caregivers. To evaluate these measures, we surveyed direct care staff. The anonymous and voluntary survey was sent via e-mail and completed through a web-based survey tool. Survey responses were on a scale of 1 (never) to 5 (always). The survey respondents included nurses, nursing assistants, child life specialists, and music therapists. The survey assessed baseline behaviors and observations (Supplemental Fig 8).

The balancing measures evaluated potential reasons staff chose to use screens using survey questions about perceived workload when screens were used and if parents seemed upset when staff suggested turning off screens.

The project interventions were established after review of the fishbone diagram and creation of a key driver diagram (Fig 1). The baseline survey results helped frame the following interventions: addition of a music application, bedside card for caregiver education, staff education, and staff reminder e-mail. The survey questions were written purposely to raise awareness of behaviors related to screens and help shape future interventions. The same survey was sent post intervention to assess for changes in behaviors and attitudes.

Before this project, when staff wanted to play music for children, they used the bedside tablet, which required concurrent viewing of an animated video. Once staff left the room, there was no control over subsequent content when the initially selected music finished. Our music therapy staff worked with an information technology consultant to develop an application for the existing tablet platform. This application played music with an accompanying blank screen. Evidence-based playlists were designed specifically for the infant and toddler age groups.^8,9  The music application automatically turned off after a set length of time, allowing staff to play age-appropriate music without screen exposure for a prescribed length of time.

The next intervention was designed to provide caregiver education about the AAP recommendations and available alternatives at our hospital with a small card at the bedside (Fig 2). This served as a reminder for staff to turn off screens and offer available alternatives.

Live education was provided to 35 nurses and nursing assistants. Those who could not attend received written materials. The education included baseline project data and promoted staff awareness of screen time alternatives including the new music application. The physicians, pediatric residents, and hospitalists were provided a similar presentation by the hospitalist lead. All staff were encouraged to educate caregivers on this initiative.

In summary, using a series of Plan Do Study Act cycles, our interventions started with the staff survey followed by the development of a music application as an alternative. We then supplied a bedside reminder for the staff in the form of a caregiver education card. Next, we used targeted staff education and reminded staff of the first 2 interventions, followed by a post intervention survey. After seeing an increase in screens being used in March 2021, we sent an e-mail to staff in April 2021 informing them of the audit data and reminding them to turn off screens.

The frequency of screen media turned on in the audited child’s room was tracked by month using a p-chart with control limits set at 3 standard deviations. Standard statistical quality control chart criteria were used for determining if observed changes were due to common cause variation or special-cause variation.⁹  We generated the statistical process charts with QI-Charts from PIP Scoville Associates as an add-on for Microsoft Excel. The average values from the pre and post intervention process measures were compared with independent samples t test using Microsoft Excel, significance testing with P < .05.

A total of 700 audits were collected with an average of 41 audits per month. There were only 3 audits during November 2019 as the project was just starting, so these were combined with December 2019.

Month to month variation for screens turned on during audit is demonstrated with a statistical process control chart in Fig 3. The baseline period showed screens on for an average of 63% of audited children. Special cause was met after the intervention, demonstrated by a shift of 8 consecutive points below the center line.

The percent of audits with the screens on when an adult was present increased postintervention (67% vs 83% P = .08), special cause met with 2 out of 3 consecutive points at the upper confidence limit (Fig 4). Having a toy or mobile in place remained unchanged after interventions (43% vs 44%).

Surveys were sent to staff members who provided direct patient care for the target population (n = 60). The survey respondents were mostly nurses (60%) and a combination of nursing assistants, occupational therapists, physical therapists, and child life specialists. The presurvey was completed by 25 staff members (42% response rate). The postsurvey was sent to the same staff group and 24 responded (40% response rate).

Comparison of the results of the pre and post survey are shown in Fig 5. In the pre survey, 84% of staff acknowledged that they turn on the TV at least sometimes, including 20% of staff that reported turning on the TV most of the time. In addition, 72% of staff reported parents always or most of the time turned on the TV. When parents have the TV on, 52% of staff reported that they never recommend turning it off. In the postintervention survey, most staff still reported turning on the TV at least sometimes, average responses in pre versus post of 2.4 vs 2.2 (P = .31). Notably, 0% reported this behavior most or all the time compared with 20% of staff preintervention. Fewer staff reported never recommending parents turn off the TV postintervention (52% vs 33%, P = .16). More staff reported offering parents screen alternatives postintervention (2.8 vs 3.4, P = .10).

Staff preintervention data revealed that 20% of staff felt that having the TV on made their job easier most or all the time compared with 13% after the intervention with average scores remaining largely unchanged (2.4 vs 2.3, P = .72). The perception of parents being upset stayed the same (2.3 vs 2.4, P = .71).

To our knowledge, this is the first QI initiative in the United States which aimed to reduce screen time exposure to young children in the hospital setting. The audits showed an overall reduction in screens used, though we did not achieve 50% reduction. It was encouraging to see the number of staff who reported turning on the TV “most of the time” was successfully reduced to zero. Despite the number of toy alternatives in the room remaining the same, staff reported offering more nonscreen alternatives to parents. Additionally, fewer staff reported that turning on the TV lessened their workload, though not statistically significant. The staff survey was intended to prompt staff to reflect on screen time behaviors as well as obtain data. Following the survey, we saw a decline in audits with screens on as our staff shifted their practice and modeled this to caregivers. The subsequent interventions helped keep this percentage lower than the baseline period. It does not appear that any 1 specific intervention resulted in improvement, rather a bundle of interventions implemented over time helped remind staff of the goal. TVs have long been a staple in hospital rooms, and now even more in-room tablets are making their way into children’s hospitals around the country. It is unclear how many of these hospitals have provided staff and caregivers guidance on the optimal utilization of these devices for different age groups. The project prompted staff to reconsider screen utilization in young children by increasing their knowledge about the deleterious effects of screen time, as well as providing better screen alternatives. Playing certain recorded music for a set length of time has proven benefits in hospitalized pediatric patients.^10,11  Development of the music application was an important part of the project.

In the hospital, it is reasonable that caregivers may want to use screens while in the presence of their child. This project was not intended to eliminate this type of screen use. We wanted to educate caregivers and empower staff to turn off the screen when no adult was present to regulate the content and length of utilization. We saw an increase in the percent of time an adult was present when the screen was in use, which may indicate fewer screens were turned on or more turned off when no adult was present. This metric was important as these children cannot control the digital media. We thought it possible that perceived parental dissatisfaction may increase with more staff recommending turning off screens or decrease after the education interventions. However, this balancing measure remained unchanged.

Caregivers of children in the hospital are a captive audience to receive health maintenance counseling or generalized child safety messages. Hospitalizations may be an effective time to educate caregivers on topics not directly related to their child’s diagnosis.¹²  This is an opportunity to explain recommended guidelines for screen exposure and educate caregivers on the impact of excessive screen time on their child’s development.¹³  Additionally, as demonstrated repeatedly in safe sleep research, role modeling best practices for children while hospitalized is an essential element to influence caregiving practices in the home.14 Caregiving practices modeled by healthcare providers in the hospital are more likely to be adopted and continued in the home setting.¹⁵ 

This project’s success was contingent on engaging front-line staff with effective education and providing alternatives to screen time. The project required engagement from child life specialists, music therapists, physicians, nurses, nursing assistants, and volunteers. Age-appropriate toys, puzzles, books, music, and interactions with caregivers or volunteers are all viable screen alternatives in the hospital. In our hospital, child life, music therapists, volunteers, and caregivers can be used to provide screen alternatives for young children. The COVID-19 pandemic limited volunteers in the hospital, however this project was conducted on a unit with very little volunteer support, so there was minimal impact on patients. Therapy services, toys, and books were still available. Not all hospitals have these resources and may need to find creative ways to engage caregivers in this initiative. In an Indian study, Singh et al were also able to demonstrate successful reduction in screen time for hospitalized children after implementation of a play protocol.¹⁶ 

We recognize that our project had limitations. This QI project took place in a single unit at a tertiary care hospital with specific digital media, which may limit generalizability. Not all hospitals have child life specialists, music therapists, and other staff dedicated to engaging children in their rooms. The audits were not consistent and were not representative of length of screen time exposure throughout the day, especially nights and weekends. Only the tablet and child’s TV screen were assessed. The auditors did not collect data on phones or other screens. The audits did not capture children in airborne isolation, a population who may rely on screens more as they cannot leave the room. The bedside education card was only available in English. The staff survey sample size was relatively small and unmatched pre and post interventions. The survey results were subject to response bias and the postsurvey results may have been influenced by knowing the study aims.

Using QI methodology, we reduced screen time exposure in a vulnerable age group. We educated staff and caregivers about AAP recommendations and created an alternative music application. We hope modeling the use of screen alternatives will ultimately decrease screen exposure when the child goes home. The establishment of a consistent approach to screen media in the hospital setting could be a guide for other institutions to begin analyzing their own approach to technology utilization.

The impact of excessive screen time on children may lead to slower learning, decreased physical health and mobility, as well as shape a child’s mental health. Using strategies to reduce screen exposure in the hospital, including modeling and education provided by hospital staff, could impact the public health of this generation of children for many years to come. Compliance has drifted slightly from 40% to 44% of screens on during random audits, which is still below the preproject baseline, despite the challenges of the ongoing pandemic. High levels of staff turnover, absence and use of traveling nurses coupled with increased staffing ratios have started to impact this process improvement effort.

To facilitate more compliance with the screen exposure guidelines, we will explore expansion of our volunteers and assure that all new and traveling staff are made aware of our standard. Future plans include implementation of this initiative on another acute care pediatric unit. Expanded implementation of a reliable standard throughout the children’s hospital will facilitate consistent messaging from all hospital staff on the AAP recommendations.

We thank Micah Scott, IT consultant, for his help developing the music application; Lisa Miguel, Child Life Specialist, for her help with project interventions and audit gathering; and Kristen Nelson, Music Therapist, for her help in compiling the music playlists.