Franklin County Infant Safe Sleep and SIDS Risk Reduction Initiative

1. 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

2. 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 Our strategies were strongly linked to recommendations provided through the Child Fatality Review (CFR) processOur strategies were strongly linked to recommendations provided through the Child Fatality Review (CFR) process

3. 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)

4. 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). Why? Don�t know for certain, but could be related to LBW & VLBW babies (higher incidence among African Americans); moms who smoke during pregnancy, moms with medical conditions; or can it be attributed to environmental factors and risky behaviors� (unsafe sleep environment, unsafe sleep position)�are these conditions higher among African Americans; I don�t have evidence to confirm or denyWhy? Don�t know for certain, but could be related to LBW & VLBW babies (higher incidence among African Americans); moms who smoke during pregnancy, moms with medical conditions; or can it be attributed to environmental factors and risky behaviors� (unsafe sleep environment, unsafe sleep position)�are these conditions higher among African Americans; I don�t have evidence to confirm or deny

5. Environmental Conditions Franklin County Child Fatality Review statistics about SIDS deaths in 2000-2003 indicate*: 46% had moms who smoked during pregnancy 88% had been exposed to ETS 38% were not sleeping alone at the time of death 47% were not on a firm sleeping surface 41% were found in areas with heavy bedding/ pillows For instances where this information is known, but often it is not known; through CFR process, we�ve identified that we need to do a better job with collecting this information (too many unknowns and blanks); a huge �gray area� exists when it comes to SIDS and SUID; back in the early 2000s, there wasn�t consensus on how to classify deaths, medical community wasn�t in tune with how to distinguish between SIDS, positional asphyxia, parental overlay, accidents; our task force tries not to get bogged down with the clinical diagnosis, but rather we work to reduce risk factors proven to be associated with infant sleep related deaths Firm sleeping surface- of 57 deaths, 19 yes firm surface; 17 were not, 21 were unknown or blankFor instances where this information is known, but often it is not known; through CFR process, we�ve identified that we need to do a better job with collecting this information (too many unknowns and blanks); a huge �gray area� exists when it comes to SIDS and SUID; back in the early 2000s, there wasn�t consensus on how to classify deaths, medical community wasn�t in tune with how to distinguish between SIDS, positional asphyxia, parental overlay, accidents; our task force tries not to get bogged down with the clinical diagnosis, but rather we work to reduce risk factors proven to be associated with infant sleep related deaths Firm sleeping surface- of 57 deaths, 19 yes firm surface; 17 were not, 21 were unknown or blank

6. 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

7. 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) Conditions of the cribs/bassinets were not known in most casesConditions of the cribs/bassinets were not known in most cases

8. Conclusions from Child Fatality Review Process Data highlight unsafe sleep practices Back 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

9. 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 Also, Columbus� Healthy Start Project, called Caring For 2, also provides significant funding to the COHMAB to address system and capacity issues relating to our local health system action plan, one component of which is to decrease risk factors for and deaths caused by SIDS Also, Columbus� Healthy Start Project, called Caring For 2, also provides significant funding to the COHMAB to address system and capacity issues relating to our local health system action plan, one component of which is to decrease risk factors for and deaths caused by SIDS

10. 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 We�re proud that all Franklin County birthing hospitals are represented; hospitals joined at different timesWe�re proud that all Franklin County birthing hospitals are represented; hospitals joined at different times

11. 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 FC averages over 18,000 births/yr, so hospitals provide logical venue to reach parents TC conducted workshop for task force and hospital staff sharing info about their hospital based initiative and programs components: audits, policy development, adherence to policy; back to sleep isn�t enough; hospital policies and education need to include safe sleep environment; TC had grant, we didn�t FC averages over 18,000 births/yr, so hospitals provide logical venue to reach parents TC conducted workshop for task force and hospital staff sharing info about their hospital based initiative and programs components: audits, policy development, adherence to policy; back to sleep isn�t enough; hospital policies and education need to include safe sleep environment; TC had grant, we didn�t

12. 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) Pre/post surveys developed by staff in Office of Assessment & Surveillance with expertise in survey development; tool enables us to assess knowledge, attitudes, beliefs and behaviors of health professionals; Findings revealed from the observational audits and hospital staff surveys confirmed the critical need for an infant safe sleep educational intervention targeting healthcare professionals in the hospital setting. Hospital staff surveys also indicated that current education regarding infant safe sleep is often lacking information on ways to reduce critical risk factors, namely exposure to tobacco smoke.Pre/post surveys developed by staff in Office of Assessment & Surveillance with expertise in survey development; tool enables us to assess knowledge, attitudes, beliefs and behaviors of health professionals; Findings revealed from the observational audits and hospital staff surveys confirmed the critical need for an infant safe sleep educational intervention targeting healthcare professionals in the hospital setting. Hospital staff surveys also indicated that current education regarding infant safe sleep is often lacking information on ways to reduce critical risk factors, namely exposure to tobacco smoke.

13. 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

14. 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

15. Curriculum Content Definition of SIDS 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

16. 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 Educational intervention was standardized tool that ALL birthing hospitals agreed to useEducational intervention was standardized tool that ALL birthing hospitals agreed to use

17. Beginning Steps � Hospital A Met with management �Back to sleep� already in newborn policy How to enforce compliance Need to change policy to include 2005 AAP recommendations Task force involvement Identified safe sleep champions for each shift Acquired photographic evidence

18. Pre-Audit Photographic Evidence

19. Safe Sleep Champion Recommendations Interview staff #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

20. 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

21. 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

22. Position of Baby

23. Non-Essential Items in Crib

24. Outcomes

25. Ongoing Plans Continue with safe sleep audits Continue with safe sleep champions Safe sleep education incorporated into new staff orientation

26. Hospital B Guidelines reviewed at Staff Meetings In-services offered Online Education with post-test Poor attendance at in-services. Excellent (100%) compliance with online education, as it is offered 24/7 and staff can complete during down time at work. This education is MANDATORY for all RNs and UAP. Poor attendance at in-services. Excellent (100%) compliance with online education, as it is offered 24/7 and staff can complete during down time at work. This education is MANDATORY for all RNs and UAP.

27. Crib Cards � placed on all infant cribs, designed as a reminder for staff and parents & families. Parents can take them home. Crib Cards � placed on all infant cribs, designed as a reminder for staff and parents & families. Parents can take them home.

28. 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 Annual audit due May 2008Annual audit due May 2008

29. 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 Interesting note: despite 97% of staff indicating they recommend back sleeping position, the audits revealed that only 50% of babies in nurseries were being placed to sleep on their backs; this suggests a disconnect between knowledge and behavior; reminder - the overwhelming belief is that parents will mirror behaviors they witness in the hospital setting; therefore, if a nurse places an infant to sleep on its side, parents will do the same Interesting note: despite 97% of staff indicating they recommend back sleeping position, the audits revealed that only 50% of babies in nurseries were being placed to sleep on their backs; this suggests a disconnect between knowledge and behavior; reminder - the overwhelming belief is that parents will mirror behaviors they witness in the hospital setting; therefore, if a nurse places an infant to sleep on its side, parents will do the same

30. Position of Baby

31. Non-Essential Items in Crib

32. 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 Honorable STAR award at 2007 CityMatCH conference and 2008 NACCHO model practice award recipientHonorable STAR award at 2007 CityMatCH conference and 2008 NACCHO model practice award recipient

33. 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

34. 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

35. Contact Information Karen Gray, MS, CHES Columbus Public Health Public Health Program Manager 614-645-2134 kareng@columbus.gov