Perinatal Quality Collaboratives are Partners in Safe Sleep Message Spread

Safe sleep messages are often contradicted in advertising. Magazines have images of babies sleeping on their stomachs and surrounded by stuffed animals and loose blankets. Furniture sections of baby stores are filled with cribs with matching bumper sets and newborn quilts. This culture of mixed messages not only confuses parents, according to a recent study from the American Academy of Pediatrics, but it also makes clinician’s work on safe sleep practices more challenging.

Recently, several perinatal quality collaboratives (PQCs)—networks of perinatal care providers and public health professionals working to improve pregnancy outcomes for women and newborns—have begun to focus their attention on improving safe sleep practices in neonatal intensive care units (NICUs) as a step toward reducing infant mortality rates. Peggy Settle, RN, PhD, a member of the Massachusetts Neonatal Quality Improvement Collaborative, says that PQCs are the ideal place to work on the safe sleep message because pre-term infants are at a distinct risk for sleep-related infant mortality and lower rates of safe sleep positioning after discharge. Working with NICU clinicians also supports an important prevention technique—modeling behavior.

“Research shows that parents will model the behavior of nurses caring for their babies in the hospital,” says Settle. “And while surveys of nurses show that they are aware of safe sleep practices, they are not necessarily practicing those methods in the clinical setting. If you watch a nurse engage in unsafe practices, of course parents will think they will be appropriate when they get home.”

The Massachusetts collaborative includes nurses and physicians from the nine NICUs across the state. Together they identify core groups of clinicians at each institution and provide teams with information and education about quality improvement and implementing safe sleep practices in each organization. In addition to benchmarking tools and data, the collaborative also shares anecdotal experiences around safe sleep practices.

“Hats are a big issue in NICU—everyone wants to donate knit hats and blankets, but because of safe sleep practices, we can’t use either,” Settle says. Instead, the hospital asked its volunteer knitters to create hammocks to hang outside of the crib. This approach continues to engage volunteers while at the same time providing a safe place to store stuffed animals.

The work of the PQC aligns with the improve safe sleep practices strategy of the Collaborative Improvement and Innovation Network to Reduce Infant Mortality (Infant Mortality CoIIN), a national initiative to reduce infant mortality and improve birth outcomes in the U.S., which NICHQ is facilitating.

“IM CoIIN is helping to educate parents to do the right thing at home, and these efforts match well with PQC initiatives to improve hospital-based safe sleep practices,” says Munish Gupta, MD, MMSc, a leader of the Massachusetts PQC. “A significant portion of infant deaths are related to safe sleep practices, and hospitals are and should be an important part of our broader safe sleep improvement work.”

The Massachusetts PQC makes key tools available to participants, including a uniform process for identifying the eligibility of newborns for safe sleep practices, which takes into account gestational age and any medical conditions. The PQC also encourages placing cards on each crib in the NICU. One describes infant therapeutic positioning (for babies who are not yet eligible for safe sleep practices) and a second card that emphasizes the “back to sleep” method, including the absence of toys, stuffed animals and loose bedding. A regular auditing process helps the participating hospitals measure their progress and raises the bar overall, Settle says. For example, collaborative member Worcester Memorial Hospital instituted a dashboard that shows how staff are performing on safe sleep practices month-to-month.

“By creating a visual, it helps people implement practices into their work,” says Settle. “Sometimes it’s hard to integrate basic changes into your practice but by creating redundancies, we start to see results,” Settle says.

Perhaps more than anything, the PQCs and IM CoIIN encourage members to learn from each other.

“We encourage our group to share widely and steal shamelessly; it’s the mantra of quality of improvement,” Settle says. “Healthcare has traditionally been very territorial, but we can’t be shy about doing that, particularly when you are focused on changing a culture.”

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To learn more about state PQCs, visit the CDC PQC website page.

Learn more about the Infant Mortality CoIIN initiative.