As someone whose research focuses on developing and implementing interventions to improve safe sleep practices, I am always looking for new ideas and approaches. In my opinion, the hardest place to change practices is on the pediatric inpatient service. The patients have been home and sleep practices, regardless of what they are, have become entrenched. Additionally, the patients, in addition to not feeling well, are in an unfamiliar setting, with strangers poking and prodding them, and it is often a natural inclination for parents, in an effort to comfort their children, to do things, such as requesting that the head of the bed be elevated, that they might not do at home.
I was therefore excited to see a Quality Report by Dr. Erich Batra and colleagues at Penn State University and Albany Medical Center that is being early released in Pediatrics this week, entitled “Improving Hospital Infant Safe Sleep Compliance Using Safety Prevention Bundle Methodology” (10.1542/peds.2020-033704).
The authors used a different approach to infant safe sleep in the hospital. They reasoned that sleep-related deaths, both in the hospital and after discharge, could be defined as a “hospital-acquired condition (HAC)”, defined as a condition that causes harm and that “a patient develops while in the healthcare setting while being treated for something else”, if unsafe sleep practices had been modeled during the hospital stay.
They then created a HAC safety prevention bundle for their entire hospital, including NICU, PICU, intermediate care units, all pediatric inpatient services (general pediatric, hematology/oncology), peri-anesthesia, and the newborn nursery. The advantage of a HAC safety prevention bundle is that it is reviewed regularly by hospital leadership and becomes part of the hospital’s safety culture.
The Safe Sleep Committee for the hospital decided on four metrics: supine position, head of bed flat, sleep area free of extra items, and caregiver receipt of safe sleep information. Over time, they demonstrated improvements in three of these metrics. The proportion of babies sleeping supine did not increase much, largely because the baseline proportion of babies sleeping supine was high, so there was not much room to improve.
When you read this article, pay attention to the details of the quality improvement interventions that were implemented, the challenges that this hospital faced in improving their practices, and some of the unanticipated consequences of strategies, which then required some tweaking.
I found it interesting that this safety prevention bundle focused on 4 specific metrics. There are of course additional safe sleep guidelines that they could have chosen. I think that this was a wise decision – prioritize a few metrics and then build from there.
Kudos to Dr. Batra and his colleagues – they are leading the way for other hospitals that have historically found universal safe sleep policies to be “too big” to tackle. I look forward to seeing how this safety prevention bundle continues to evolve – and learning from this and other similar hospital initiatives that are inspired by this one!