Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Training/Education, Educational Material (provider), Audit/Attestation (provider), PROFESSIONAL_CAREGIVER, Education/Training (caregiver), HOSPITAL, Quality Improvement, Crib Card

Intervention Description: This quality improvement project used an interprofessional, multimodal approach to improve sleep safety for hospitalized infants. The working group for this project included the Director of Quality Improvement for the Department of Pediatrics, a Pediatric Hospitalist, a Senior Advanced Practice Nurse in Pediatrics, Senior Associate Counsel for the Office of Counsel, and a medical student with a background in social work. The interdisciplinary group met to review and discuss improvements to communication and facilitated the development of five family interventions: a designated safe sleep web page, a clear bedside guide to safe sleep, additional training for nursing staff in motivational interviewing, a card audit system, and electronic health record smart phrases. A short survey was conducted to assess how the safe sleep toolkit has been useful to care providers in the Children’s Hospital. 

Intervention Results: With the initial pilot implementation of the K-cards, staff reported increased ease of audits. Adherence to recommended safer sleep measures was a major barrier in previous attempts to improve institutional sleep safety (1). By making adherence easier, providers may be more likely to both participate in quality improvement tracking measures and follow-up with families directly.

Conclusion: These coordinated interventions reflect advantages of an interprofessional and family-centered approach: building rapport and achieving improvements to infant sleep safety.

Setting: Golisano Children’s Hospital

Population of Focus: Hospital healthcare providers

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Home Visits, Motivational Interviewing, PROVIDER/PRACTICE, Nurse/Nurse Practitioner, Telephone Support, CAREGIVER, Home Visit (caregiver), Assessment (caregiver), Attestation (caregiver), Motivational Interviewing/Counseling

Intervention Description: This pilot study evaluated the effectiveness of a nurse-delivered home-visiting program during the postpartum period that included a low-intensity smoking relapse-prevention intervention.

Intervention Results: Although both groups showed significant relapse from being smoke free, the intervention group was twice as likely to be smoke free at 3 and 6 months, and three times as likely to be smoke free at both times. The cotinine verification revealed a misclassification rate of 37% at the 6-month follow-up (i.e., participants self-reported as abstinent but shown by cotinine not to be abstinent).

Conclusion: The effectiveness of this brief, low-cost, and potentially replicable intervention in improving the rate of persistent postpartum smoke-free status for women who quit smoking during pregnancy is encouraging. A randomized trial of the approach is warranted.

Study Design: Pilot study; Prospective two-group design

Setting: Birthing hospital plus home visit

Population of Focus: English-speaking women who delivered healthy babies, resided in Franklin County, Ohio, and reported quitting smoking during pregnancy and at least 7 days before delivery

Data Source: Questionnaire that included smoking history and attitudes and intent to stay smoke free administered at baseline. Saliva sample for maternal cotinine analysis collected at baseline and 3 and 6 months for all participants who self-reported abstinence (defined as no smoking for the previous 7 days)

Sample Size: 97 in the baseline group and 122 in the intervention group

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, Provision of Safe Sleep Item, HOSPITAL, Policy/Guideline (Hospital), Sleep Environment Modification, CAREGIVER, Education/Training (caregiver), Educational Material (caregiver), HEALTH_CARE_PROVIDER_PRACTICE, Audit/Attestation

Intervention Description: The purpose of this study was to improve safe sleep practices for infants in nonneonatal pediatric units with implementation of specific interventions.

Intervention Results: Safe sleep was observed for 4.9% of 264 infants at baseline and 31.2% of 234 infants postintervention (P<.001). Extra blankets, the most common of unsafe items, were present in 77% of cribs at baseline and 44% postintervention. However, the mean number of unsafe items observed in each sleeping environment was reduced by >50% (P=.001).

Conclusion: Implementation of site-specific interventions seems to improve overall safe sleep in inpatient pediatric units, although continued improvement is needed. Specifically, extra items are persistently left in the sleeping environment.

Study Design: QE: pretest-posttest

Setting: Eight children’s hospitals

Population of Focus: Infants aged 0 to 6 months admitted to the general pediatric unit (excluding infants in the NICUs, PICUs, and maternal fetal units)

Data Source: Crib audit/infant observation

Sample Size: Baseline (n=234) Follow-up (n=210)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PROFESSIONAL_CAREGIVER, Education/Training (caregiver), Educational Material (caregiver), HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Home Visit (caregiver), Audit/Attestation

Intervention Description: The Maternal Infant Health Outreach Worker (MIHOW) program is an early-childhood home visiting program that uses community health workers (CHWs) to improve health outcomes in underserved communities. To be a MIHOW home visitor, women must be from the target community, be of the same culture and/or language group of families served, have completed all MIHOW training, and use the MIHOW curriculum. This randomized clinical trial evaluated the impact of MIHOW’s use of CHWs on selected maternal/infant outcomes up to 15 months postpartum. All study participants received the minimal education intervention (MEI), which consisted of printed educational materials about health and child development, compared to the intervention group that also received MIHOW home visitation services. Data was collected during interviews conducted by trained data collectors who were fluent in Spanish, also spoke English, and were from the same community.

Intervention Results: Enrolled women (N = 132) were randomly assigned, with 110 women completing the study (MEI = 53; MIHOW = 57). Positive and statistically significant (p < .01) effects of MIHOW were observed on breastfeeding duration, safe sleep practices, stress levels, depressive symptoms, emotional support, referral follow through, parental confidence, and infant stimulation in the home.

Conclusion: Findings provided strong evidence of the effectiveness of MIHOW for improving health outcomes in this sample. Using trained CHWs makes programs such as MIHOW a viable option for providing services to immigrant and underserved families.

Population of Focus: Pregnant Hispanic women living in middle Tennessee

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Training/Education, PROFESSIONAL_CAREGIVER, Education/Training (caregiver), HOSPITAL, Quality Improvement, Promotional Event, Audit/Attestation (Provider)

Intervention Description: Physicians from various units within the hospital system created and led multidisciplinary safe sleep teams. After attending a kickoff event to learn more about infant mortality and sleep related deaths, safe sleep champions from four teams were encouraged to work with their teams to tailor interventions, both specific to the needs of their areas and to address the global aim of county-wide sleep-related death reduction. The teams collaborated and produced a hospital-wide key driver diagram, highlighting the importance of screening, family education, staff education, and hospital reporting interventions. They were encouraged to complete as many Plan-Do-Study-Act (PDSA) cycles as necessary to improve safe sleep practices in both hospital and home settings.

Intervention Results: Our teams have significantly increased compliance with safe sleep practices in the inpatient and neonatal intensive care unit settings (P < 0.01). We have also increased screening and education on appropriate safe sleep behaviors by ED and primary care providers (P < 0.01). Our county's sleep-related death rate has not significantly decreased during the collaborative.

Conclusion: Our collaborative has increased American Academy of Pediatrics-recommended safe sleep practices in our institution, and we decreased sleep-related deaths in our primary care network. We have created stronger ties to our community partners working to decrease infant mortality rates. More efforts will be needed, both within and outside of our institution, to lower our community's sleep-related death rate.

Setting: Nationwide Children’s Hospital and delivery hospitals throughout Columbus Ohio

Population of Focus: Hospital healthcare providers

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Audit/Attestation (provider), PROFESSIONAL_CAREGIVER, Education/Training (caregiver), HOSPITAL, Quality Improvement

Intervention Description: This study evaluates a quality improvement program to improve compliance with appropriate safe sleep practices in both children’s and birthing hospitals. Hospitalists from both settings were recruited to join the Ohio American Academy of Pediatrics’ EASE (Education and Sleep Environment) injury prevention collaborative to increase admitted infant safe sleep behaviors. The collaborative leadership team required hospitalist physician champions at each institution to form and lead multidisciplinary groups composed of other physicians and trainees, nursing leadership, hospital administrators, child life specialists, and other health care providers as deemed necessary. The leadership team educated participating hospital teams about safe sleep evidence-based guidelines, local statistics, quality improvement principles, and the use of Plan Do-Study-Act cycles within their institutions via interactive exercises. Multidisciplinary interventions in the areas of physician and/or nursing staff education, environmental management strategies, policy creation/revisions, and parental support and education were among the interventioned encourages. The Ohio AAP chapter instructed teams to collect data by conducting random audits, using a standardized tool (available by request).

Intervention Results: A total of 37.0% of infants in children's hospitals were observed to follow the current American Academy of Pediatrics recommendations at baseline; compliance improved to 59.6% at the project's end (P < .01). Compliance at birthing centers was 59.3% and increased to 72.5% (P < .01) at the collaborative's conclusion.

Conclusion: This study demonstrates that a quality improvement program in different hospital settings can improve safe sleep practices. Infants in birthing centers were more commonly observed in appropriate sleep environments than infants in children's hospitals.

Setting: 3 Children's hospitals and 6 birthing hospitals in Ohio

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, Provision of Safe Sleep Item, HOSPITAL, Quality Improvement, Policy/Guideline (Hospital), Crib Card, Visual Display (Hospital), Sleep Environment Modification, Promotional Event, CAREGIVER, Education/Training (caregiver), Educational Material (caregiver), Attestation (caregiver), HEALTH_CARE_PROVIDER_PRACTICE, Audit/Attestation

Intervention Description: The purpose of this quality improvement project was to promote the AAP safe sleep recommendations and provide appropriate role modeling of these recommendations for hemodynamically stable infants throughout their hospital stay.

Intervention Results: Observations noted an improvement from 70% to 90% (p< 0.01) of infants in a safe sleep position when comparing pre- and postintervention results. There were some improvements in knowledge of and agreement with the AAP guidelines after the educational intervention, but not as much as expected.

Conclusion: There was inconsistency between nursing knowledge and practice about safe infant sleep. Nurses were aware of the AAP recommendations, but it took time to achieve close to full compliance in changing clinical practice. Observation was an important part of this initiative to reinforce knowledge and role model best practice for parents.

Study Design: QE: pretest-posttest

Setting: Golisano Children’s Hospital at the University of Rochester in NY

Population of Focus: Hemodynamically stable infants less than 1 year of age in the mother-baby unit and nine pediatric units

Data Source: Crib audit/infant observation

Sample Size: Baseline (n=65) Follow-up (n=60)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, PROFESSIONAL_CAREGIVER, Education/Training (caregiver), Provision of Safe Sleep Item, HOSPITAL, Quality Improvement, Sleep Environment Modification, Policy/Guideline (Hospital), Audit/Attestation

Intervention Description: The hospital’s safe sleep task force (SSTF) implemented targeted interventions using the American Academy of Pediatrics (AAP) policy statement as the gold standard and based on hospital data/crib audits to address areas of greatest nonadherence to recommendations. The SSTF created a standalone Infant Safe Sleep Policy for all infants admitted to the hospital; provided education on safe sleep to health care providers; created a patient education video for parents of all hospitalized infants; increased its Halo sleep sack allotment; and revised the room set-up to encourage adherence to AAP’s safe sleep guidelines. A safe sleep audit tool was used by clinical assistant or nurse (per hospitalized sleeping session) to assess adherence to safe sleep guidelines. The overall aim of the initiative was to increase the average weekly adherence to the AAP-recommended safe sleep practices for hospitalized infants to ≥95% over 12 months.

Intervention Results: There was a significant improvement in overall adherence to safe sleep recommendations from baseline (M = 70.8%, SD 21.6) to end of study period (M = 94.7%, SD 10.0) [t(427) = -15.1, P ≤ 0.001]. Crib audits with 100% adherence increased from a baseline (M = 0%, SD 0) to the end of the study period M = 70.4%, SD = 46) [t(381)= -21.4, P ≤ 0.001]. This resulted in two trend shifts on the p-chart using Institute for Healthcare Improvement control chart rules.

Conclusion: Targeted interventions using QI methodology led to significant increases in adherence to safe sleep guidelines. Notable improvements in behavior indicated significant changes in safe sleep culture. We also noted continued adherence in follow-up audits reflecting sustainability.

Setting: Tertiary children's hospital

Population of Focus: Hospital healthcare providers

Intervention Components (click on component to see a list of all articles that use that intervention): PARENT/FAMILY, Counseling (Parent/Family), CAREGIVER, Motivational Interviewing/Counseling, Attestation (caregiver)

Intervention Description: The current study examined home and full (i.e., home plus car) smoking ban adoption as secondary outcomes to a randomized controlled trial targeting reduced secondhand smoke exposure (SHSe) for children under treatment for cancer.

Intervention Results: Regardless of group assignment, there was an increase in home (odds ration [OR] = 1.16, p = .074) and full (OR = 1.37, p = .001) smoking ban adoption across time. Families in the intervention group were more likely to adopt a full ban by 3 months, but this difference was nonsignificant by 12 months.

Conclusion: Smoking bans are in-line with Healthy People 2020’s tobacco objectives and may be more feasible for parents with medically compromised children for immediate SHSe reduction. Furthermore, interventions targeting full smoking bans may be a more effective for comprehensive elimination of SHSe.

Study Design: RCT

Setting: Pediatric oncology hospital setting

Population of Focus: Parents (at least 1 adult smoker in home) of children under treatment for cancer

Data Source: Parent self-report on household and car smoking behavior, demographic, psychosocial, and medical/treatmentrelated information.

Sample Size: 119 families randomized

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Nurse/Nurse Practitioner, PROFESSIONAL_CAREGIVER, Education/Training (caregiver), HOSPITAL, Quality Improvement, Crib card, Audit/Attestation

Intervention Description: A multidisciplinary team developed a quality improvement initiative to create a hospital-based safe sleep environment for all newborns and infants prior to discharge. The safe sleep initiative included two key elements: (1) parent education about safe infant sleep that included verifying their understanding of safe sleep, and (2) modeling of safe infant sleep environment by hospital staff. To monitor compliance, documentation of parent education, caregiver surveys, and hospital crib check audits were tracked monthly. A visual safe sleep “crib ticket”—a checklist of safe sleep guidelines-- was placed at the bedside of newborns who were ready for supine positioning. Investigators used Plan-Do-Study-Act (PDSA) cycles to evaluate the impact of the initiative from October 2015 through February 2018.

Intervention Results: Safe sleep education was documented for all randomly checked records (n = 440). A survey (n = 348) revealed that almost all caregivers (95.4%) reported receiving information on safe infant sleep. Initial compliance with all criteria in WBN (n = 281), NICU (n = 285), and general pediatric inpatient units (n = 121) was 0%, 0%, and 8.3%, respectively. At 29 months, WBN and NICU compliance with all criteria was 90% and 100%, respectively. At 7 months, general pediatric inpatient units' compliance with all criteria was 20%.

Conclusion: WBN, NICU and general pediatric inpatient unit collaboration with content experts led to unit-specific strategies that improved safe sleep practices.

Setting: Well-baby nursery (WBN) and NICU in an academic, quaternary care, regional referral center

Population of Focus: Hospital staff

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, HOSPITAL, Quality Improvement, Policy/Guideline (Hospital), Sleep Environment Modification, CAREGIVER, Educational Material (caregiver), HEALTH_CARE_PROVIDER_PRACTICE, Audit/Attestation

Intervention Description: A quality improvement project for implementing safe sleep practices (SSP) was conducted at a large, U.S children's hospital.

Intervention Results: Audit data showed that 72% and 77% of infants were asleep supine at baseline and follow-up respectively (p=0.07).

Conclusion: Infant safe sleep practices have the potential to reduce infant mortality.

Study Design: QE: pretest-posttest

Setting: A tertiary care children’s hospital in AR

Population of Focus: Infants 0-12 months in intensive care and medical-surgical units caring asleep at the time of the audit

Data Source: Crib audit/infant observation

Sample Size: Baseline (n=398) Follow-up (n=498)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, PROFESSIONAL_CAREGIVER, Training/Education (caregiver) , Audit/Attestation, Audit/Attestation (Provider)

Intervention Description: Pediatricians were recruited to participate in a a virtual quality improvement learning collaborative (QILC) that promoted screening for safe sleep practices in the home and counseling families on the ABCs of safe sleep during visits. Monthly hour-long learning collaborative webinars allowed practices to view their progress, share current plan-do-study-act cycles, review safe sleep best practices, and learn about quality improvement topics. Participants collected data on safe sleep documentation in a newborn discharge or well-child visit note, which was submitted at baseline and in subsequent phases.

Intervention Results: Thirty-four pediatricians from 4 inpatient and 9 outpatient practices participated in the QILC. At baseline, documentation of safe sleep practices varied greatly (0%-98%). However, by the end of the QILC, all participating practices were documenting safe sleep guidance in over 75% of patient encounters. Aggregate practice data show a significant, sustained improvement. The 12-month follow-up data were submitted from 62% of practices, with sustainment of improvement in 75% of practices.

Conclusion: A facilitated, virtual QILC is an effective methodology to improve safe sleep counseling among a diverse group of pediatric practices. It is one step in improving consistent messaging around safe sleep by healthcare providers as pediatricians work to decrease sleep-related infant deaths.

Setting: Online community of practice

Population of Focus: Inpatient and outpatient pediatricians

Intervention Components (click on component to see a list of all articles that use that intervention): PROFESSIONAL_CAREGIVER, Educational Material (caregiver), Provision of Safe Sleep Item, HOSPITAL, Quality Improvement, Crib Card, Policy/Guideline (Hospital), HEALTH_CARE_PROVIDER_PRACTICE, Educational Material (Provider), Nurse/Nurse Practitioner, Audit/Attestation, Audit/Attestation (Provider)

Intervention Description: This hospital quality improvement initiative performed a series of Plan-Do-Study-Act cycles designed to increase the proportion of infants placed in a “perfect sleep” environment that met all of the American Academy of Pediatrics’ infant safe sleep guidelines. The initiative took place while the hospital was preparing for Baby Friendly certification, with increased emphasis on rooming in and skin to skin at the same time. Initial cycles targeted nurse and parental education, while later cycles focused on providing sleep sacks/wearable blankets for the infants. The goal was to achieve 70% “perfect sleep” compliance among infants cared for in the hospital.

Intervention Results: While we did not meet our goal, the percentage of infants with 'perfect sleep' increased from a baseline of 41.9% to 67.3%, and we also saw improvement in each of the individual components that contribute to this composite measure. Improvements were sustained over 12 months later, suggesting that QI interventions targeting infant safe sleep in this inpatient setting can have long-lasting results.

Conclusion: This project also suggests that infant safe sleep QI initiatives and preparation towards Baby Friendly Hospital Certification can be complementary.

Population of Focus: Hospital healthcare providers