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 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 *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 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

Shifting The Focus to Infant 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 SIDS Infant 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 oIntroduce 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 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 oHow to enforce compliance oNeed to change policy to include 2005 AAP recommendations oTask force involvement Identified safe sleep champions for each shift Acquired photographic evidence

Pre-Audit Photographic Evidence

Safe Sleep Champion Recommendations Interview staff o#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 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

Non-Essential Items in Crib

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

Non-Essential Items in Crib

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, 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 (s ecured 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