P0741 - Improving Early and Consistent Safe Sleep Practices in the NICU: a Regional NICU Quality Improvement Project

Background: Although there has been national progress in reducing sudden unexplained infant deaths (SUID) since the American Academy of Pediatrics (AAP) “Back-to-Sleep” campaign in 1994, the rates of accidental suffocation and strangulation in bed (ASSB) continue to rise. The risk of ASSB is inversely related to gestational age, with those most at risk being the extremely premature. As these infants spend so much of their early lives in the neonatal intensive care unit (NICU), it is important for units to model safe sleep behaviors when developmentally appropriate in accordance with the AAP recommendations of initiation after 32 weeks corrected gestational age.

Aims: We aimed to increase the percentage of eligible infants consistently in safe sleep environment (alone, back, crib, flat) prior to discharge in a cohort of regional Level III/IV NICUs from baseline by 20% in a 5 month period of Rapid Cycle Improvement Collaborative, through February 24, 2020.

Methods: A multidisciplinary team of key stakeholders in four regional Level III/IV NICUs assembled for this quality improvement (QI) project after obtaining parental feedback and leadership support. We enacted rigorous QI methodology to include co-creation of a single Process Map, a Simplified Failure Mode Effects Analysis, and a Key Driver Diagram. We refined our focus through Pareto chart analysis prior to employing a series of PDSA and PDSA ramps according to the institution-specific needs and culture.
Subjects: Medically stable NICU patients on 1L respiratory support or less, without medically indicated positioning restrictions, meeting developmental criteria (defined as 32 weeks corrected gestational age or greater, working on oral skills, and without other restrictions per the patient's multidisciplinary team).

Results: Prior to our intervention period, there was no regionally uniform safe sleep criteria for our area NICUs. Our work brought together four institutions to identify a common goal and a uniform process to work towards this goal. The team anticipated and worked through challenges faced universally at all sites as well as those that were site specific. Our baseline collection found only 37% of our newly defined qualifying population were in safe sleep. We were able to more than double that to 71% of qualifying babies being in safe sleep.

Conclusions: We surpassed our goal, increasing our regional Level III/IV NICUs safe sleep compliance from 37% to 71%, successfully improving early and consistent modeling of best practices for families in accordance with current AAP recommendations. Next steps include transitioning to sustain mode and preparing to spread to regional Level I/II nurseries and pediatric floors.