Massachusetts Hospital Shares Strategies for Eliminating Sleep-Related Infant Deaths

baby sleepingWith an infant mortality rate that is now the lowest of any state in the country, Massachusetts is leading the nation in improving health outcomes for newborn babies. Yet even with the state’s successes, Tufts Floating Hospital for Children in Boston, located in the heart of the state’s capital, knows there is always room for improvement, starting with eliminating sleep-related infant deaths.

In the U.S., sleep-related infant deaths, including accidental suffocation or strangulation in bed, sudden infant death syndrome (SIDS), and sleep related deaths from unknown causes, account for approximately 3,500 infant deaths annually. Sleep-related infant deaths are also the leading cause of death among Massachusetts infants aged 1 to 11 months, making it a critical lever for driving both state and national change.

Over the course of two years, Tufts Floating Hospital for Children partnered with NICHQ on the National Action Partnership to Promote Safe Sleep (NAPPSS-IIN), an initiative funded by the Health Resources and Services Administration Maternal and Child Health Bureau to make infant safe sleep and breastfeeding the national norm. Working together with four other hospital teams across the country, the Tufts team tested strategies to empower families to follow safe sleep guidelines so that more babies reach year one. As a hospital system that provides services for families throughout Eastern Massachusetts, the Floating Hospital for Children has the potential to not only markedly reduce infant deaths in the state, but also to identify best practices and insights that can be spread and scaled to hospitals across the nation.

“Tufts’ team has done a tremendous job of testing strategies and change ideas that support NAPPSS-IIN’s three primary drivers—active endorsement of the American Academy of Pediatrics safe sleep guidelines, empowering infant caregivers to practice safe sleep, and activating community champions,” says Pat Heinrich, RN, MSN, CLE. “Each driver stems from significant research on programs and strategies that can move the needle on reducing sleep-related infant deaths. By testing ways to support each driver, NAPPSS-IIN teams are discovering how hospitals can help more babies sleep safely. “

After two years of testing strategies and change ideas, Lisa Capra, MD, who leads the Tufts team’s improvement work, shared what’s helped her team drive improvement in their hospital system. Hospitals seeking to help more families adopt safe sleep practices can learn from and replicate the strategies she shares, which we’ve organized under NAPPSS-IIN’s three primary drivers.  

Support active endorsement of American Academy of Pediatrics (AAP) guidelines for infant safe sleep, including promoting breastfeeding in a safe sleep environment.

“We already had a safe sleep policy in place, but it was mainly geared toward the Neonatal Intensive Care Unit,” says Capra. “Now, we’ve refreshed it to make it more comprehensive, and worked to ensure health professionals throughout the hospital understand and promote it.”

Developing a safe sleep policy that is consistent with the updated AAP 2016 SIDS Task Force Recommendations is a priority (it’s also one of the first things NAPPSS-IIN teams recommend hospitals do). Yet while a formal policy is a critical driver of change (it helps standardize practices and promotes compliance across the health system), issuing a policy doesn’t guarantee successful implementation. For that, hospitals need to activate health care professionals as champions of the policy.

For Tufts, who was looking to spread their safe sleep policy across their hospital system, this meant finding ways to educate all relevant staff about the importance of safe sleep and energizing them about promoting change. They formalized education requirements for pediatric residents and nurses, requiring that both complete online safe sleep curriculum as part of their core competency, and provided a conference for pediatric and obstetrician residents on safe sleep. A ‘Safe Sleep Olympics’ complemented formal training by encouraging hands-on learning—during 'the Olympics,' pediatric and obstetric staff teams identified and corrected dangers in a sample unsafe crib, such as by removing loose blankets or pillows.

Aligning their safe sleep efforts with existing initiatives and empowering nurse champions facilitated Tufts’ successes, says Capra. “So many of our most effective interventions were nurse-driven; they’re critical partners for moving this work forward. We also capitalized on existing interest, partnering with pediatric units already targeting safe infant sleep, so folks were primed to jump on board.”

Give infant caregivers the knowledge, skills and self-efficacy to practice safe sleep for every sleep

Following safe sleep guidelines requires understanding them—that is, knowing how to follow them and why they can save babies’ lives. To help deepen families understanding of safe sleep guidelines, Tufts team member, Anne Marie Curry, RN, developed an interactive safe sleep flip book that health professionals can use when talking to families about safe sleep. The flip book shows an image on one page, which the family looks at, and a script with questions for families on the other page, which the health professional reads. By encouraging health professionals across the hospital system to use this book, and providing it in multiple different languages, Tufts has standardized how families learn about safe sleep, and developed an engaging tool to promote interactive conversations rather than didactic instruction.

“One of the most important messages we’re trying to deliver is how to breastfeed safely at night so we can address the risk of accidental bed-sharing” says Capra. “The flip book includes a page about this specifically, which really enforces that talking about safe sleep and breastfeeding with families is an important part of the teaching process.”

Looking for more ways to engage families in conversations about safe sleep and breastfeeding? Check out NICHQ’s video quiz, How Safe Sleep Savvy Are You? It asks families to identify different scenes as either safe or unsafe, and provides an explanation for each scene. Health professionals can sit side-by-side with families, review the quiz, and stop along the way to discuss questions and concerns.

Discharge interviews, where health professionals ask families what they’ve learned and what they still need to know, have also been a critical teaching intervention. Families give hospital staff feedback on how well they’re teaching methods are working, and hospital staff can fill in any gaps in knowledge prior to discharge.

“We’ve seen that things like the ‘ABCs’ of safe sleep get through to families, but we often see gaps in knowledge around the use of pacifiers or the dangers of overheating,” says Capra. “Discharge interviews give us an opportunity to reinforce messages that might have been missed.”

Activate community champions

Talking to families about safe sleep and breastfeeding in hospital settings is critical, but it is just one touch point. Community organizations and agencies give families multiple opportunities to learn and engage in conversations about recommended practices.

Located in Boston’s Chinatown, the Floating Hospital for Children partnered with their local Women Infant and Children’s (WIC) agency to improve exclusive breastfeeding rates in their Asian community. While Asian mothers and birthing people have strong breastfeeding and chestfeeding initiation rates, they also experience lower rates of continued exclusive breastfeeding/chestdeeding. Given that exclusive breastfeeding/chestfeeding correlates with lower rates of SIDS and is recommended for the optimal health of mothers, birthing people, and infants, Tufts’ team was eager to address this disparity. Working together with the South Cove WIC agency, the team launched a baby café where mothers and birthing people can drop in without an appointment and receive individual support on breastfeeding/chestfeeding and converse with their peers.

“Partnering with our local WIC has been a wonderful experience,” says Capra. “Their feedback helps us better understand parents’ expectations and experiences, and they’ve worked with us to coordinate our efforts so that families receive consistent messaging on safe sleep and breastfeeding, whether during WIC visits or while at the hospital.”

NAPPSS-IIN teams will continue to test safety bundles across multiple settings, sharing their successes and lessons-learned as they go. Interested in leveraging what they’ve learned so far? Find their top-recommended strategies to support safe sleep and breastfeeding here.