City of Columbus

Karen Gray, M.S., C.H.E.S.Columbus Public Health

Maternal and Child Health Division

Franklin County Infant Safe Sleep and SIDS Risk Reduction Initiative

Task Force Purpose

To reduce infant sleep-related deaths by promoting safe sleep and SIDS risk

reduction techniques, and by educating about safe sleep environments to all

individuals who are responsible for caring for infants

Objectives

• To educate healthcare professionals about infant safe sleep and the risks associated with SIDS through implementation of a standardized hospital-based infant safe sleep curriculum (Phase I);

• To provide educational materials to the community about infant safe sleep; and

• To conduct 3 trainings on infant safe sleep that will target childcare providers, home day care providers, home health care professionals, and staff of public OB and pediatric clinics (Phase II)

Significant Findings

• In Franklin County in 2003, the rate of SIDS for Black infants was 3 times higher than the rate for White infants

• In 2004, SIDS deaths among male infants (63%) and among Black infants (53%) were high relative to their representation in Franklin County’s population*

*According to the U.S. Census Bureau, 23% of children in Franklin County are Black and 51% are male (2000).

Source: Columbus Public Health, Franklin County Child Fatality Review,Annual Community Report, January 2007, Columbus, Ohio.

Environmental Conditions

Franklin County Child Fatality Review statistics about SIDS deaths in 2000-2003 indicate*:

46% had moms who smoked during pregnancy88% had been exposed to ETS38% were not sleeping alone at the time of death47% were not on a firm sleeping surface41% were found in areas with heavy bedding/

pillows

*Of those SIDS deaths for which this information is known

SIDS Risks

Among Franklin County SIDS deaths in 2004*:

• 42% were found on their stomach or side at time of death

• 32% were found sleeping on same surface with an adult

• 58% of the mothers smoked during pregnancy

• 63% were exposed to 2nd hand smoke*Sleep position not captured in previous FC CFR data reporting and analysis. Proportion of SIDS Deaths by Sleep Position, 2004 (N=19)

SIDS Risks – Sleep Location

• Of all SIDS deaths in 2004, 26% occurred in a crib or bassinette, while 69% of SIDS deaths occurred in locations considered unsafe, i.e., in other beds, on couches and other locations

Proportion of SIDS Fatality Reviews by Incident Sleep Place, 2004 (N=19)

Conclusions from Child Fatality Review Process

Data highlight unsafe sleep practicesBack sleep position, by itself, is not

protective when other unsafe factors are present

Too many babies are dying in unsafe sleep environments

These deaths are PREVENTABLE

Shifting The Focus toInfant Safe Sleep

Funding Provided By…

Columbus Public Health to the

Council on Healthy Mothers and Babies

Ohio Department of Health/Federal Government, Bureau of Child and Family Health Services, Child and Family Health Services Program

Member Organizations

• Columbus Public Health• Communities in Schools • Council on Healthy

Mothers and Babies• Doctor’s Hospital• Grant Medical Center• Help Me Grow• March of Dimes• Mount Carmel Health

System• Nationwide Children’s

Hospital

• Northwest Counseling Services

• Ohio Dept. of Health• Ohio Dept. of Jobs and

Family Services• OSU Medical Center• Region IV Perinatal

Center• Riverside Methodist

Hospital• St. Ann’s Hospital

Why Focus on Hospitals?

Findings from several studies indicate: most nurses aware of back sleep

recommendation most nurses afraid of aspiration preference for side position parent preference influenced by nurse

behavior

Information from Tomorrow’s Child: Michigan SIDSInfant Safe Sleep Hospital Project

Franklin County Program Components

• Hospital observational audits

• Pre/post surveys for hospitals, OB clinics and pediatric clinics assessing staff knowledge, beliefs and behaviors

• Education component – includes power point presentation for health professionals (i.e. nurses and patient educators)

Observational Audit Tool

• Location (hospital)

• Shift

• Location of infant (nursery, mom’s room)

• Position of infant (back, side, stomach)

• Condition of crib (blankets, stuffed animals, toys, loose items, etc.)

• General comments section

Hospital Staff Survey Assessment• Discipline

• Length of employment

• Responsibility for safe sleep education

• When education occurs

• Components of safe sleep education

• Hospital policy

• 5 questions about beliefs/attitudes regarding infant safe sleep

Curriculum Content• Definition of SIDS

o Introduce concept of sleep-related death• Franklin County and national statistics• Reducing SIDS risks• Obstacles to complying with AAP guidelines• Role of the RN• Hospital safe sleep recommendations

- Hospital staff- Parents

• What to teach new parents- 2005 AAP guidelines

• Resources

Educational Intervention

Success was dependent on…Hospitals having flexibility to determine

method of implementation

Examples of methods selected include:

- grand rounds

- staff in-service trainings

- computer-based education with test

Beginning Steps – Hospital A• Met with management

o “Back to sleep” already in newborn policy

o How to enforce compliance

o Need to change policy to include 2005 AAP recommendations

o Task force involvement

• Identified safe sleep champions for each shift

• Acquired photographic evidence

Pre-Audit Photographic Evidence

Safe Sleep Champion Recommendations

• Interview staffo #1 reason for continuing to place infants on their

side was fear of aspiration

• Revise newborn policy

• Change verbage on clinical pathway and discharge summary to reflect safe sleep practices

• Re-educate staff

Revision of Newborn Policy• Infant is to be placed on back while in the

crib

• Instruct parents not to position infant on stomach or side

• Toys, stuffed animals, and extra blankets are not allowed in the crib

• Parents will receive education on SIDS/safe sleep practices

Staff Education

• Open house with free food from Thurs 0600 - Sat 0800• Invited all women’s health staff• Continuous PowerPoint presentation• Placed resource manuals on each unit• Education posters on every women’s health unit

Benefits of Education Process• Minimal non-productive hours • 100% of staff on duty educated• Parent tours, parents, and visitors asked to be educated

Position of Baby

4654

3

879797

3130

20

40

60

80

100

Pre-ed 6-wk. post ed 6-mos. post ed 12-mos. post ed

Perc

ent

Back Sleep Side Sleep

Non-Essential Items in Crib

27

2

15

02

7

120

5

10

15

20

25

30

Pre-ed 6-wk. post ed 6-mos. post ed 12-mos. post ed

Perc

ent

Blankets Toys

Outcomes

Ongoing Plans

• Continue with safe sleep audits

• Continue with safe sleep champions

• Safe sleep education incorporated into new staff orientation

Hospital B

• Guidelines reviewed at Staff Meetings

• In-services offered

• Online Education with post-test

Future Education Plans

• Infant safe sleep online education will continue to be a requirement for all Perinatal staff to complete at initial hire and annually

• An Infant Safe Sleep Station was part of Mandatory OB Education Days last fall

• Audits will be conducted as requested by the Franklin County Infant Safe Sleep and SIDS Risk Reduction Task Force to confirm that AAP Guidelines are being followed

Hospital Staff Survey

Within Franklin County Birthing Hospitals 97% of staff recommend back sleeping position Education typically occurs during hospitalization 65% of staff haven’t received formal training on

safe sleep in past 3 years 42% of staff don’t feel they’ve received enough

training Less than half (49%) of staff indicated their

hospital has a safe sleep policy; 6% said no; 45% didn’t know

N = 209

Position of Baby

Franklin County - All reporting hospitals

50

96

50

4

8091

209

0

20

40

60

80

100

Pre-ed 6-wk. post ed 6-mos. post ed 12-mos. post ed

Perc

ent

Back sleep Side sleep

Non-Essential Items in Crib

Franklin County - All reporting hospitals

23

12

1

13

1 143

0

5

10

15

20

25

Pre-ed 6-wk. post ed 6-mos. post ed 12-mos. post ed

Perc

ent

Blankets Toys

Summary Points

• Addressing infant safe sleep in the hospital setting positively influenced staff behaviors

• Positive behavior change has been maintained 12-months post-intervention

• The Initiative demonstrates that there’s an important role for health department leadership in group facilitation, coordination of intervention, and outcome evaluation

• The Initiative has been recognized nationally

Safe Sleep Symposium

• April 12, 2008

• 94 nurses, social workers, and childcare providers attended

• Grant through CJ Foundation for SIDS

• Highlighted infant sleep-related death data and safe sleep recommendations

Next Steps…Phase II

• Development of childcare provider educational PowerPoint

• Conduct 3 county-wide trainings (secured March of Dimes funding)

• Continue monitoring hospital-based safe sleep initiative

• Strengthen public information on infant safe sleep group

Contact Information

Karen Gray, MS, CHES

Columbus Public Health

Public Health Program Manager

614-645-2134

kareng@columbus.gov