P2.H147: Transition to Safe Sleep Practices for Infants Born Before 32 Weeks Gestation in a Level IV NICU

Purpose/Objectives: Preterm infants are at significantly higher risk of sleep-related deaths than term-born infants. It is important to model safe sleep (SS) practices for families while their babies are cared for in the hospital to increase the likelihood that these practices will be carried out at home.
The American Academy of Pediatrics’ 2022 SS recommendations include supine sleeping on non-inclined surfaces and avoidance of head coverings or loose soft items in the bed.
Our NICU lacked standardized criteria for “readiness” to transition to SS, creating missed opportunities to model SS practices for families.
The focus of our initiative was to standardize the process of transitioning infants born before 32 weeks gestation to SS practices as soon as developmentally appropriate.
We sought to increase our unit’s compliance with SS practices from a baseline of 12% to >50% within 12 months of the start of the initiative.

Design/Methods: This initiative took place in a 73-bed, level IV single family room NICU.
A multidisciplinary team of nurses, neonatologists, nurse practitioners, physical (PT) and occupational therapists (OT) and quality improvement scientists reviewed current literature, SS recommendations and published reports of other centers’ SS initiatives.
An algorithm published by another center was modified and implemented to screen infants for readiness to transition to SS (Figure 1). The modified algorithm included a developmental assessment performed by PT/OT which determined infants’ readiness to remove positioning supports.
The integration of the developmental assessment underwent several PDSA cycles, resulting in worklist modifications which prompt PT/OT evaluations when criteria are met. The assessment results are then added into the providers’ daily progress notes for easy access. When the assessment results indicate appropriate, providers place the order to begin SS, prompting the care team to maintain a sleep environment in accordance with AAP recommendations.
Statistical process control P-charts were used to evaluate the results of bedside SS audits.

Results: We have achieved and sustained our goal of >50% infants cared for in SS environments from our baseline of 12%.
The use of burp cloths has been the most difficult practice to change, with 67% of infants found with one in their crib. Inconsistent availability of full-sized mattress sheets was found to be a barrier to compliance.
Developmental positioner use and head of bed elevation were found in less than 30% of infants with SS orders.

Conclusion/Discussion: Through this initiative, we have significantly increased the number of infants cared for in a SS environment while in our unit, and thus been able to model this practice for families well before NICU discharge. This increases the likelihood that families will implement safe sleep practices for their babies at home, which will ultimately reduce the risk of sleep related deaths in these infants.