Goal: To develop a standardized infant safe sleep and SIDS risk reduction educational model for use in the hospital setting in Franklin County, Ohio.
Objectives: To implement a hospital-based infant safe sleep initiative within all Franklin County birthing hospitals by December 2007.
To evaluate intervention effectiveness at 6 weeks, 6 months, and 12 months post-intervention.
To increase the percentage of babies in well-baby nurseries being placed to sleep on their backs by at least 20% by December 2007.
This initiative addresses infant safe sleep and SIDS risk reduction practices in the hospital setting. Process: Analyses conducted by Columbus Public Health using the Perinatal Periods of Risk (PPOR) methodology revealed that SIDS deaths occurred at a statistically significantly higher rate for African American babies. Further, data obtained from the Franklin County Child Fatality Review (FCCFR) confirm that there is great opportunity to reduce risk factors associated with SIDS occurrence–-safe sleep issues including appropriate bedding, position and co-sleeping; environmental tobacco smoke; and smoking during pregnancy.
In 2004-2006, SIDS was the third leading cause of infant death in Franklin County. According to data from the Ohio Department of Health, Vital Statistics, there was a total of 20 deaths classified as SIDS in Franklin County in 2006, accounting for 12.2% of infant deaths. The Healthy People 2010 goal is to reduce deaths from sudden infant death syndrome (SIDS) to 0.25 deaths per 1,000 live births. In Franklin County, rates are more than four times higher than the Healthy People 2010 goal, and African American infants suffer disproportionately high rates. In 2004 and 2006, the SIDS death rate for African American infants was nearly twice as high as the rates for Caucasian infants and the overall Franklin County rates; also notable for those years, the rates were more than eight times greater than the Healthy People 2010 goal.
FCCFR statistics about SIDS deaths in 2000-2003 indicate that, for deaths for which this information is known, 46% had moms who smoked during pregnancy; 88% had been exposed to environmental tobacco smoke; 38% were not sleeping alone at the time of death; 47% were not on a firm sleeping surface; and 41% were found in areas with heavy bedding/pillows. Among Franklin County SIDS deaths in 2004, 58% percent of the mothers smoked during pregnancy; 63% were exposed to secondhand smoke; 42% were found on their stomach or side at time of death; and 32% were found sleeping on same surface with an adult.
Further, of all SIDS deaths in 2004, 26% occurred in a crib or bassinet, while 69% of SIDS deaths occurred in locations considered unsafe, such as in other beds, on couches, and other locations. Based on recommendations from the FCCFR, the Infant Safe Sleep and SIDS Risk Reduction Task Force convened in November 2005 with a goal of promoting safe sleep techniques, educating about safe sleep environments, and reducing SIDS and sleep-related deaths in Franklin County. The Task Force decided to concentrate on educating healthcare professionals in the hospital setting first.
Agency Community RolesThe Columbus Public Health Department (CPH) dedicates a small portion of the Child and Family Health Services (CFHS) funding to conduct a community education campaign regarding infant safe sleep messages. The CFHS Project Director serves as the co-chairperson of the Franklin County Infant Safe Sleep and SIDS Risk Reduction Task Force, which developed this hospital-based initiative.
The Task Force consists of approximately 35 individuals from an array of maternal and child health organizations, including Columbus Public Health, Council on Healthy Mothers and Babies, Nationwide Children’s Hospital, The Ohio State University Medical Center, Doctor’s Hospital, Riverside Methodist Hospital, Mount Carmel Health System (including East, West, and St. Ann’s), Grant Hospital, Region IV Perinatal Center, March of Dimes, Ohio Department of Jobs and Family Services, Communities in Schools, and a SIDS parent.
The CPH convenes monthly meetings of the Task Force, records meeting minutes, and maintains electronic and one-on-one communication between meetings. Additionally, the CFHS project director conducts evaluation activities. This process is an example of how collaborative effort across governmental agencies, hospitals, and faith-based systems can be organized around a community health initiative. It further demonstrates that there’s an important role for health department leadership in group facilitation, coordination of intervention, and outcome evaluation.
Costs and ExpendituresProgram planning and development costs estimated at less than $8,000 over an 18-month period. In-kind costs for each hospital participating in the initiative is estimated at approximately $10,000 over a two-year period.
ImplementationThe Task Force performed literature review and explored other national programs, which justified starting with nurses as educators and models of safe sleep practices. This Initiative addresses healthcare professionals in the hospital setting, specifically those who work in well-baby units. There are seven birthing hospitals in Franklin County, OH, and each is represented on the Task Force.
Activities included the following:
1. Assessing current hospital practice and policies regarding infant safe sleep (Summer 2006).
2. Developing hospital-based education component addressing infant safe sleep (Oct.-Dec. 2006).
3. Educating hospital staff regarding infant safe sleep through implementation of the educational component (Jan.-Dec. 2007).
4. Evaluating hospital practice and policies post intervention (Mar.-Dec. 2007).
The hospital observational audit measures included the following: Location (hospital) - Shift - Location of infant (nursery, mother’s room) - Position of infant (back, side, stomach) - Condition of crib (blankets, stuffed animals, toys, loose items, etc.) - General comments section.
Hospital staff surveys assessed knowledge, beliefs, and behaviors regarding infant safe sleep. Measures include the following: Occupation, Length of time in occupation, Whether staff is responsible for SIDS and safe sleep education, Education methods (video, brochure, face-to-face), Recommended sleep position (back, side, tummy), When education occurs (on admission, during hospitalization, on discharge), Components of education (crib safety, how to choose a mattress, what to put in crib, what not to put in crib, exposure to tobacco smoke, breastfeeding, bed sharing, room temperature, infant covering, sleep position, pacifier use), Whether staff has received formal education on safe sleep in past three years, If staff members feel they have received enough training, Whether the hospital has a safe sleep policy, Is the safe sleep message important?, Do you believe the risk of SIDS can be reduced?, Do you believe there are ways to prevent sleep-related infant deaths other than SIDS?, Do you believe your patients understand the need for infant safe sleep?, Do you believe your patients/patients' babies are at risk for SIDS and other sleep-related infant death?
Statistical analysis was completed using EPI Info.The Task Force conducted post-intervention audits at 6 weeks, 6 months, and 12 months in order to assess impact of the intervention. Staff surveys were conducted at 6 months and 12 months post-education-intervention in order to assess changes to knowledge, beliefs, and behaviors regarding infant safe sleep.
Addressing infant safe sleep in the hospital setting positively influenced staff behaviors, and the percentage of babies being placed to sleep on their backs in well-baby nurseries increased from 50% at pre-intervention to 90% at 6-months post-intervention. An effective hospital-based infant safe sleep and SIDS risk reduction intervention can potentially reduce infant sleep-related deaths. The Infant Safe Sleep and SIDS Risk Reduction Hospital-based Initiative also demonstrates how collaborative effort across governmental agencies, hospitals, and faith-based systems can be organized around a community health initiative.
Success of the hospital-based initiative on infant safe sleep and SIDS risk reduction highly depended on the dedication of hospital staff serving on the Task Force and their ability to "set the wheels in motion" in their individual settings. Hospital Task Force representatives met with management and encouraged updating safe sleep policies to include 2005 AAP recommendations.
Hospital representatives identified safe sleep champions for each shift. Hospitals have flexibility to determine the method of implementation within individual settings. Examples of methods selected include grand rounds, staff in-service trainings, and computer-based education with tests. The initiative is appealing due to minimal non-productive hours and ability to educate 100% of staff on duty. Ongoing reinforcement is continually necessary with support and encouragement from OB Management Teams.
Hospitals are committed to monitoring compliance with safe sleep policies. If necessary, hospitals can apply for grants to cover costs associated with implementing and maintaining an infant safe sleep and SIDS risk reduction education curriculum; however, within Franklin County, the costs to plan, develop, and implement the hospital-based initiative were minimal, and all hospital staff time was provided as in-kind services.