Improving Safe Sleep Practices for Hospitalized Infants

Sleeping Safe and Sound: A Multidisciplinary Hospital-wide Infant Safe Sleep Quality Improvement Initiative

INTRODUCTION

Promoting safe sleep to decrease sudden unexpected infant death is challenging in the hospital setting.

LOCAL PROBLEM

Concern for adherence to safe sleep practice across inpatient units at a large pediatric hospital.

METHODS

Used quality improvement methodologies to promote safe sleep across all units.

INTERVENTIONS

Development of a multidisciplinary expert group, hospital-wide guidelines, targeted interventions, and bedside audits to track progress.

RESULTS

Adherence to safe sleep practices improved from 9% to 53%. Objects in the crib were a major barrier to maintaining a safe sleep environment. Safe sleep practices were less likely to be observed in infants with increased medical complexity (p = .027).

CONCLUSIONS

Quality improvement methodology improved adherence to infant safe sleep guidelines across multiple units. Medically complex infants continue to be a challenge to safe sleep. Therefore, ongoing education for staff and further research into best practices for the most complex infant populations are necessary.

Early and consistent safe sleep practices in the neonatal intensive care unit: a sustained regional quality improvement initiative

OBJECTIVE

To increase compliance with standardized safe sleep recommendations for patients in a cohort of regional level III/IV neonatal intensive care units (NICUs) in accordance with recently revised guidelines issued by the American Academy of Pediatrics (AAP).

STUDY DESIGN

A regional quality improvement (QI) initiative led by a multidisciplinary task force standardized safe sleep criteria across participating NICU sites. Universal and unit-specific interventions were implemented via Plan-Do-Study-Act (PDSA) cycles with evaluation of compliance through routine crib audits, run chart completion, and Pareto chart analysis.

RESULTS

Following QI implementation, compliance with safe sleep guidelines for eligible NICU infants improved from 34% to 90% from October 2019 through September 2022.

CONCLUSION

Compliance with early, consistent modeling of safe sleep practices nearly tripled in this cohort of regional NICUs. A standardized, timely approach to safe sleep transition demonstrated dramatic and sustained improvement in the practice and modeling of safe sleep behaviors in the NICU.

Steering the Titanic: One tertiary care children's hospital's experience navigating safe sleep for hospitalized infants

BACKGROUND

Sudden Unexpected Infant Death (SUID) is the leading cause of death in infants 1 month to 1 year of age in the United States. Despite extensive efforts in research and public education, rates of sleep-related infant death have plateaued since the late-1990s, largely due to unsafe sleep practices and environments.

LOCAL PROBLEM

A multidisciplinary team assessed our institution's compliance with its own infant safe sleep policy. Data was collected on infant sleep practices, nurses' knowledge and training on the hospital policy, and teaching practices for parents and caregivers of hospitalized infants. Zero crib environments from our baseline observation met all the American Academy of Pediatrics recommendations for infant safe sleep.

METHODS

A comprehensive safe sleep program was implemented in a large pediatric hospital system. The purpose of this quality improvement project was to improve compliance with safe sleep practice from 0% to 80%, documentation of infant sleep position and environment every shift from 0% to 90%, and documentation of caregiver education from 12% to 90% within 24 months.

INTERVENTIONS

Interventions included revision of hospital policy, staff education, family education, environmental modifications, creation of a safe sleep taskforce, and electronic health record modifications.

RESULTS

Documented compliance with infant safe sleep interventions at the bedside improved from 0% to 88%, while documentation of family safe sleep education improved from 12% to 97% during the study period.

CONCLUSIONS

A multifaceted, multidisciplinary approach can lead to significant improvements in infant safe sleep practices and education in a large tertiary care children's hospital system.

What are the barriers to sustaining a safe sleep program for infants within hospital settings: An integrative review of the literature

PROBLEM

Safe sleep programs have been existing since the concept was first defined in 1969. The need for health care providers to model safe sleep practices is essential for successful adherence; however, barriers to promoting safe sleep practices hinder healthcare providers' ability to implement safe sleep in hospital settings.

AIM

To determine the barriers to promoting safe sleep practices amongst healthcare workers in the hospital setting.

METHODS

Whittemore & Knafl's framework (2005) guided this integrative review. CINAHL, PubMed, and Academic Search Complete databases were used as a search strategy. Inclusion criteria was limited to studies between 2010 and 2021, were peer-reviewed, in English, and quality improvement projects consisting of barriers to implementing safe sleep practices within hospitals. To assess quality of the included studies, the Mixed Methods Appraisal Tool and Standards for Quality Improvement Reporting Excellence were used. The studies were analyzed by two of the authors with data further categorized using the Social Ecological Model (SEM) to develop themes.

RESULTS

Findings of the 10 included studies were presented in the form of a data display matrix. The authors used the SEM to categorize the findings under three main categories at the organizational, individual, and cultural levels.

CONCLUSIONS

Barriers need to be addressed in hospital settings to reduce the risk of sudden infant death syndrome. Therefore, it is vital to consider those barriers while providing teaching programs in hospital settings.

IMPLICATIONS

Findings from this review provide the core elements to consider for the development of safe sleep programs in the hospital setting.

Ensuring Safe Sleep in the Pediatric Intensive Care Unit: A Systematic Review of Informed Development of Clinical Guidelines for Implementation in Practice

INTRODUCTION

Although general safe sleep guidelines have been established, their utility and implementation have yet to be examined systematically for inpatient populations for application to infants in the pediatric intensive care unit (PICU) setting. This study aimed to complete a systematic review of inpatient safe sleep practices studies to develop then safe sleep clinical guidelines for implementation in the care of medically complex infants in the PICU.

METHOD

This review was registered with PROSPERO and adheres to Preferred Reporting Items for Systematic reviews and Meta-Analyses systematic review guidelines.

RESULTS

Nineteen articles met the inclusion criteria. A safe sleep guideline algorithm for medically complex infants in the PICU was created for implementation.

DISCUSSION

Consistent and comprehensive safe sleep education and modeling by health care professionals in the inpatient setting is an effective technique to reduce the risk of harm and promote safe sleep behaviors in the home setting.

Quality improvement initiative to improve infant safe sleep practices in the newborn nursery

The American Academy of Pediatrics recommends that healthcare professionals model their safe infant sleeping environment recommendations, yet adherence to safe sleep practices within our community hospital mother–baby unit was low. We used quality improvement (QI) methodology to increase adherence to infant safe sleep practices, with a goal to improve the proportion of infants sleeping in an environment that would be considered ‘perfect sleep’ to 70% within a 1-year period. The project occurred while the hospital was preparing for Baby Friendly certification, with increased emphasis on rooming in and skin to skin at the same time.

Multiple Plan–Do–Study–Act cycles were performed. Initial cycles targeted nurse and parental education, while later cycles focused on providing sleep sacks/wearable blankets for the infants.

While we did not meet our goal, the percentage of infants with ‘perfect sleep’ increased from a baseline of 41.9% to 67.3%, and we also saw improvement in each of the individual components that contribute to this composite measure. Improvements were sustained over 12 months later, suggesting that QI interventions targeting infant safe sleep in this inpatient setting can have long-lasting results. This project also suggests that infant safe sleep QI initiatives and preparation towards Baby Friendly Hospital Certification can be complementary.

Evidence Base for 2022 Updated Recommendations for a Safe Infant Sleeping Environment to Reduce the Risk of Sleep-Related Infant Deaths

Every year in the United States, approximately 3500 infants die of sleep-related infant deaths, including sudden infant death syndrome (SIDS) (International Statistical Classification of Diseases and Related Health Problems 10th Revision [ICD-10] R95), ill-defined deaths (ICD-10 R99), and accidental suffocation and strangulation in bed (ICD-10 W75). After a substantial decline in sleep-related deaths in the 1990s, the overall death rate attributable to sleep-related infant deaths have remained stagnant since 2000, and disparities persist. The triple risk model proposes that SIDS occurs when an infant with intrinsic vulnerability (often manifested by impaired arousal, cardiorespiratory, and/or autonomic responses) undergoes an exogenous trigger event (eg, exposure to an unsafe sleeping environment) during a critical developmental period. The American Academy of Pediatrics recommends a safe sleep environment to reduce the risk of all sleep-related deaths. This includes supine positioning; use of a firm, noninclined sleep surface; room sharing without bed sharing; and avoidance of soft bedding and overheating. Additional recommendations for SIDS risk reduction include human milk feeding; avoidance of exposure to nicotine, alcohol, marijuana, opioids, and illicit drugs; routine immunization; and use of a pacifier. New recommendations are presented regarding noninclined sleep surfaces, short-term emergency sleep locations, use of cardboard boxes as a sleep location, bed sharing, substance use, home cardiorespiratory monitors, and tummy time. In addition, additional information to assist parents, physicians, and nonphysician clinicians in assessing the risk of specific bed-sharing situations is included. The recommendations and strength of evidence for each recommendation are published in the accompanying policy statement, which is included in this issue.

Practicing What We Preach: An Effort to Improve Safe Sleep of Hospitalized Infants

Introduction:

To prevent sudden unexpected infant death, pediatric providers recommend the ABCs of infant sleep: Alone, on the Back, and in an empty Crib. This study’s objective was to document sleep practices of infants admitted to a large children’s hospital, examine adherence to American Academy of Pediatrics safe sleep guidelines, and develop interventions to improve guideline adherence.

Methods:

We conducted a pre/post quality improvement study at a single quaternary care medical center from 2015 to 2019. Infants 0 to younger than 12 months were observed in their sleeping environment pre- and post-implementation of multiple hospital-wide interventions to improve the sleep safety of hospitalized infants.

Results:

Only 1.3% of 221 infants observed preintervention met all ABCs of safe sleep; 10.6% of 237 infants met the ABCs of safe sleep postintervention. Significant improvements in the post-intervention cohort included sleeping in a crib (94% versus 80% preintervention; P < 0.001), avoidance of co-sleeping (3% versus 15% preintervention; P < 0.001), absence of supplies in the crib (58% versus 15% preintervention; P < 0.001), and presence of an empty crib (13% versus 2% preintervention; P < 0.001).

Conclusions:

Most infants hospitalized at our institution do not sleep in a safe environment. However, the implementation of a care bundle led to improvements in the sleep environment in the hospital. Further research is necessary to continue improving in-hospital safe sleep and to assess whether these practices impact the home sleep environment.

Improving Adherence to Safe Sleep Guidelines for Hospitalized Infants at a Children’s Hospital

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Introduction:

Sudden unexpected infant deaths are a major problem nationally. We had poor adherence to safe sleep recommendations locally at our institution. Given the significance of this problem, hospital administration at a tertiary children’s hospital tasked a multidisciplinary group of faculty and staff with improving sleep environments for hospitalized infants.

Methods:

Our safe sleep task force implemented targeted interventions using the American Academy of Pediatrics policy statement as the gold standard and based on hospital data to address areas of greatest nonadherence to recommendations. We aimed to improve weekly average adherence to 95% over 12 months. A proportions process control chart (p-chart) tracked average weekly adherence over a 52-week time frame. In addition, we performed Student’s t-testing to evaluate differences in adherence over time.

Results:

There was a significant improvement in overall adherence to safe sleep recommendations from baseline (M = 70.8%, SD 21.6) to end of study period (M = 94.7%, SD 10.0) [t(427) = −15.1, P ≤ 0.001]. Crib audits with 100% adherence increased from a baseline (M = 0%, SD 0) to the end of the study period M = 70.4%, SD = 46) [t(381)= −21.4, P ≤ 0.001]. This resulted in two trend shifts on the p-chart using Institute for Healthcare Improvement control chart rules.

Conclusions:

Targeted interventions using QI methodology led to significant increases in adherence to safe sleep guidelines. Notable improvements in behavior indicated significant changes in safe sleep culture. We also noted continued adherence in follow-up audits reflecting sustainability.

Improving Hospital Infant Safe Sleep Compliance by Using Safety Prevention Bundle Methodology

BACKGROUND AND OBJECTIVES

Sudden unexpected infant death often results from unsafe sleep environments and is the leading cause of postneonatal mortality in the United States. Standardization of infant sleep environment education has been revealed to impact such deaths. This standardized approach is similar to safety prevention bundles typically used to monitor and improve health outcomes, such as those related to hospital-acquired conditions (HACs). We sought to use the HAC model to measure and improve adherence to safe sleep guidelines in an entire children's hospital.

METHODS

A hospital-wide safe sleep bundle was implemented on September 15, 2017. A safe sleep performance improvement team met monthly to review data and discuss ideas for improvement through the use of iterative plan-do-study-act cycles. Audits were performed monthly from March 2017 to October 2019 and monitored safe sleep parameters. Adherence was measured and reviewed through the use of statistical process control charts (p-charts).

RESULTS

Overall compliance improved from 9% to 72%. Head of bed flat increased from 62% to 93%, sleep space free of extra items increased from 52% to 81%, and caregiver education completed increased from 10% to 84%. The centerline for infant in supine position remained stable at 81%.

CONCLUSIONS

Using an HAC bundle safety prevention model to improve adherence to infant safe sleep guidelines is a feasible and effective method to improve the sleep environment for infants in all areas of a children's hospital.

Implementing a Hospital-Based Safe Sleep Program for Newborns and Infants

BACKGROUND

An unsafe sleep environment remains the leading contributor to unexpected infant death.

PURPOSE

To determine the effectiveness of a quality improvement initiative developed to create a hospital-based safe sleep environment for all newborns and infants.

METHODS

A multidisciplinary team from the well-baby nursery (WBN) and neonatal intensive care unit (NICU) of a 149-bed academic, quaternary care, regional referral center developed and implemented safe sleep environments within the hospital for all prior to discharge. To monitor compliance, the following were tracked monthly: documentation of parent education, caregiver surveys, and hospital crib check audits. On the inpatient general pediatric units, only hospital crib check audits were tracked. Investigators used Plan-Do-Study-Act (PDSA) cycles to evaluate the impact of the initiative from October 2015 through February 2018.

RESULTS

Safe sleep education was documented for all randomly checked records (n = 440). A survey (n = 348) revealed that almost all caregivers (95.4%) reported receiving information on safe infant sleep. Initial compliance with all criteria in WBN (n = 281), NICU (n = 285), and general pediatric inpatient units (n = 121) was 0%, 0%, and 8.3%, respectively. At 29 months, WBN and NICU compliance with all criteria was 90% and 100%, respectively. At 7 months, general pediatric inpatient units' compliance with all criteria was 20%.

IMPLICATIONS FOR PRACTICE

WBN, NICU and general pediatric inpatient unit collaboration with content experts led to unit-specific strategies that improved safe sleep practices.

IMPLICATIONS FOR RESEARCH

Future studies on the impact of such an initiative at other hospitals are needed.

Understanding how and why audits work in improving the quality of hospital care: A systematic realist review

BACKGROUND

Several types of audits have been used to promote quality improvement (QI) in hospital care. However, in-depth studies into the mechanisms responsible for the effectiveness of audits in a given context is scarce. We sought to understand the mechanisms and contextual factors that determine why audits might, or might not, lead to improved quality of hospital care.

METHODS

A realist review was conducted to systematically search and synthesise the literature on audits. Data from individual papers were synthesised by coding, iteratively testing and supplementing initial programme theories, and refining these theories into a set of context-mechanism-outcome configurations (CMOcs).

RESULTS

From our synthesis of 85 papers, seven CMOcs were identified that explain how audits work: (1) externally initiated audits create QI awareness although their impact on improvement diminishes over time; (2) a sense of urgency felt by healthcare professionals triggers engagement with an audit; (3) champions are vital for an audit to be perceived by healthcare professionals as worth the effort; (4) bottom-up initiated audits are more likely to bring about sustained change; (5) knowledge-sharing within externally mandated audits triggers participation by healthcare professionals; (6) audit data support healthcare professionals in raising issues in their dialogues with those in leadership positions; and (7) audits legitimise the provision of feedback to colleagues, which flattens the perceived hierarchy and encourages constructive collaboration.

CONCLUSIONS

This realist review has identified seven CMOcs that should be taken into account when seeking to optimise the design and usage of audits. These CMOcs can provide policy makers and practice leaders with an adequate conceptual grounding to design contextually sensitive audits in diverse settings and advance the audit research agenda for various contexts.

PROSPERO REGISTRATION

CRD42016039882.

Coming Together to Save Babies: Our Institution's Quality Improvement Collaborative to Improve Infant Safe Sleep Practices

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Many hospitalized infants are not observed in an American Academy of Pediatrics-recommended safe sleep environment, which can translate to unsafe sleep practices at home. We implemented this collaborative to reduce our county’s sleep-related death rate by improving infant safe sleep practices in the freestanding children’s hospital setting and increasing safe sleep screening and education in our clinics and emergency departments (EDs).

Expansion of a multi-pronged safe sleep quality improvement initiative to three children's hospital campuses

Background

The American Academy of Pediatrics (AAP) recommends infants should be Alone, on their Back, and in a clear Crib to combat relatively stagnant rates of sudden unexpected infant death (SUID). These are referred to as the ABCs of safe sleep. Studies have shown these recommendations are not consistently followed in the hospital setting, but further investigation would determine how to improve the rate of adherence. The objective of this study was to evaluate the impact of an expanded safe sleep initiative at three Georgia free-standing children’s hospital campuses before and after a multipronged safe sleep initiative.

Methods

A quality improvement program with a pre/post analysis was performed using a convenience method of sampling. Infants < 12 months old in three inpatient pediatric campuses were analyzed pre- and post- interventions. The intervention included: 1) nursing education, 2) identification of nurse “safe sleep” champions, 3) crib cards, 4) crib audits, and 5) weekly reporting of data showing nursing unit ABC compliance via tracking boards. The goal was ABC compliance of ≥25% for the post-intervention period. A standardized crib audit tool evaluated sleep position/location, sleep environment, and ABC compliance (both safe position/location and environment). Chi square analysis, Fisher’s exact test, and logistic regression were used to compare safe sleep behaviors before and after the interventions.

Results

There were 204 cribs included pre-intervention and 274 cribs post-intervention. Overall, there was not a significant change in sleep position/location (78.4 to 76.6%, p = 0.64). There was a significant increase in the percent of infants sleeping in a safe sleep environment following the intervention (5.9 to 39.8%, p < 0.01). Overall ABC compliance, including both sleep position/location and environment, improved from 4.4% pre-intervention to 32.5% post-intervention (p < 0.01). There was no significant variability between the hospitals (p = 0.71, p = 1.00).

Conclusions

The AAP’s safe sleep recommendations are currently not upheld in children’s hospitals, but safer sleep was achieved across three children’s campuses in this study. Significant improvements were made in sleep environment and overall safe sleep compliance with this multi-pronged initiative.

Modeling Safe Infant Sleep in the Hospital

PURPOSE

Despite reductions in the rate of sudden infant death syndrome (SIDS) over the last 25 years, over 3000 infant deaths annually in the US are attributable to sleep-related causes. We aimed to improve safe sleep practice (SSP) adherence by healthcare providers working with infants admitted to an inpatient pediatric unit in an urban academic center specifically increasing compliance on five core SSP (supine, alone in the crib, no objects in crib, appropriate bundling, and flat crib).

DESIGN AND METHODS

This Quality Improvement project evaluated a staff education intervention using a pre- and post-design. Surveys of providers determined baseline SSP knowledge. Adherence to SSP in the hospital was audited before and after education. One hundred pre-intervention infant sleep placement observations were recorded and 123 were collected post-intervention.

RESULTS

Surveyed providers had appropriate knowledge of SSP; however, baseline audits indicated that no patients met all SSP practices in the hospital. Post-intervention adherence to SSP showed significant (p < .05) improvements in keeping the crib flat, removing objects from the crib, and avoiding over-bundling. Overall, SSP adherence increased by 12.5% post-intervention.

CONCLUSIONS

This quality improvement project suggests that the inpatient setting provides opportunities for providers to demonstrate SSP but that healthcare providers often do not follow SSP in practice. Continued education can lead to improvements in SSP adherence ensuring that hospitals are modeling SSP for the families of infants.

PRACTICE IMPLICATIONS

Limited improvements to SSP adherence illustrate the complexities of modifying provider behaviors in the absence of formal policy.

A Hospital-Based Initiative to Reduce Postdischarge Sudden Unexpected Infant Deaths

BACKGROUND AND OBJECTIVES

Sudden unexpected infant deaths (SUID) most often occur because infants are placed in unsafe sleep environments. Although authors of previous literature have demonstrated that parents who receive comprehensive safe sleep education increase knowledge and intention to place children in safe sleep environments, no studies have demonstrated improved outcomes. We describe the development of a hospital-based newborn SUID risk reduction quality improvement project and its effectiveness in reducing subsequent SUIDs in a community using linked outcome data from local Child Fatality Review Teams.

METHODS

Qualitative and quantitative evaluation of a long-term iterative performance improvement intervention for a nursery-based comprehensive safe sleep program in a community teaching hospital. Key themes and exemplary comments were noted. The rate of infant deaths per 1000 births was the primary quantitative outcome. The rate is calculated quarterly and monitored with control charts by using Child Fatality Review data about infant sleep deaths.

RESULTS

The average death rate fell from 1.08 infants per 1000 births preintervention to 0.48 infants per 1000 births after complete intervention, and the average number of deaths between deliveries increased from 1 in every 584 deliveries (upper control limit: 3371) to 1 in every 1420 deliveries (upper control limit: 8198). Qualitative observation of nursery providers revealed 3 themes, including routine inclusion of sleep safety information, dissemination of safety information by all staff, and personal commitment to success.

CONCLUSIONS

A comprehensive sleep safety culture change can be effectively integrated into a nursery setting over time by using feedback from Child Fatality Review and performance improvement methodology. Repeated messaging and education by the entire nursery staff has the potential to play a role in reducing sleep-related deaths in infants born at their hospital.

The EASE Project Revisited: Improving Safe Sleep Practices in Ohio Birthing and Children's Hospitals

Literature has shown hospitalized infants are not often observed in recommended safe sleep environments. Our objective was to implement a quality improvement program to improve compliance with appropriate safe sleep practices in both children's and birthing hospitals. Hospitalists from both settings were recruited to join an Ohio American Academy of Pediatrics collaborative to increase admitted infant safe sleep behaviors. Participants used a standardized tool to audit infants' sleep environments. Each site implemented 3 PDSA (Plan-Do-Study-Act) cycles to improve safe sleep behaviors. A total of 37.0% of infants in children's hospitals were observed to follow the current American Academy of Pediatrics recommendations at baseline; compliance improved to 59.6% at the project's end (P < .01). Compliance at birthing centers was 59.3% and increased to 72.5% (P < .01) at the collaborative's conclusion. This study demonstrates that a quality improvement program in different hospital settings can improve safe sleep practices. Infants in birthing centers were more commonly observed in appropriate sleep environments than infants in children's hospitals.

As easy as ABC: evaluation of safe sleep initiative on safe sleep compliance in a freestanding pediatric hospital

Background

The American Academy of Pediatrics (AAP) recommends the ABCs of safe infant sleep (alone, back, clear crib) to combat the increasing rates of Sudden Unexplained Infant Death (SUID). It is unclear if these recommendations are followed for infants hospitalized in pediatric facilities after the newborn period. The objectives of this study were to assess baseline infant sleep behaviors at a tertiary care freestanding pediatric hospital and to evaluate the effectiveness of a hospital-based infant safe sleep program in improving adherence to safe sleep recommendations.

Methods

A quality improvement program with pre- and post- analyses was performed on a convenience sample of infants < 12-months old utilizing a crib audit tool on two general pediatric inpatient units. The crib audit tool was used before and after the safe sleep program intervention. It recorded the infant's sleep position, location during sleep, and sleep environment. Interventions included: 1) nursing education, 2) crib cards with a checklist of the ABC's of safe sleep provided for the cribs of hospitalized infants, and 3) tracking boards to report weekly measured compliance with the ABCs. Chi square analysis was used to compare adherence to recommendations before and after program implementation.

Results

There were 62 cribs included pre-intervention and 90 cribs post-intervention. Overall, there was no significant change in safe sleep positioning (81% to 82%, p = 0.97). There was a significant increase in adherence to the safe sleep environment recommendation (3% to 38%, p < 0.01). Overall safe sleep, including both position and environment, referred to as ABC compliance, improved from 3% pre-intervention to 34% post-intervention (p < 0.01). Only 18% of cribs audited displayed a crib card, demonstrating poor compliance on placement of the cards. There was no significant difference in compliance with safe sleep recommendations between infants with a crib card compared to those without (25% vs. 37%, p = 0.51).

Conclusions

Significant improvements were made in sleep environments and overall safe sleep compliance after introduction of crib cards and tracking boards. Most likely the crib auditing process itself and the tracking boards had a larger impact than the crib cards.

A Statewide Hospital-Based Safe Infant Sleep Initiative: Measurement of Parental Knowledge and Behavior

Sleep-related infant deaths are a leading cause of infant mortality in Georgia, and these deaths are largely associated with unsafe sleep practices among caregivers. In early 2016, the Georgia Department of Public Health launched the Georgia Safe to Sleep Hospital Initiative, providing hospitals with safe infant sleep information and educational materials to be distributed to families and newborns. This study examined the knowledge and behaviors of a sample of Georgia parents after the implementation of the Hospital Initiative and identified the family characteristics and intervention components most closely associated with the knowledge and practice of safe infant sleep. The primary caretakers of all infants born in Georgia from August to October 2016 were invited to complete a web-based survey 1 month after hospital discharge. The final sample size included 420 parents of newborns, and the primary outcomes assessed included two measures of knowledge and four measures of infant sleep behaviors regarding infant sleep position and location. Most respondents demonstrated knowledge of the correct recommended sleep position (90%) and location (85%). Logistic regression revealed that receipt of information in the hospital was significantly correlated with safe sleep behaviors, and infant sleep habits tended to influence safe sleep practices. Additionally, Medicaid parents receiving bassinets from the hospital were 74% less likely to bed share (OR 0.26; 95% CI 0.007). Implementation of a statewide hospital initiative was associated with high levels of parental knowledge and behavior and may have been successful in reducing the practice of bed sharing among Medicaid parents.

The Impact of Quality Assurance Initiatives and Workplace Policies and Procedures on HIV/AIDS-Related Stigma Experienced by Patients and Nurses in Regions with High Prevalence of HIV/AIDS

Stigma is commonly experienced by people living with HIV/AIDS and by those providing care to HIV/AIDS patients. Few intervention studies have explored the impact of workplace policies and/or quality improvement on stigma. We examine the contribution of health care workplace policies, procedures and quality assurance initiatives, and self- and peer-assessed individual nurse practices, to nurse-reported HIV/AIDS-stigma practices toward patients living with HIV/AIDS and nurses in health care settings. Our sample of survey respondents (n = 1157) included managers (n = 392) and registered/enrolled nurses (n = 765) from 29 facilities in 4 countries (South Africa, Uganda, Jamaica, Kenya). This is one of the first studies in LMIC countries to use hierarchical linear modeling to examine the contributions of organizational and individual factors to HIV/AIDS stigma. Based on our results, we argue that organizational interventions explicitly targeting HIV/AIDS stigma are required to reduce the incidence, prevalence and morbidity of HIV/AIDS.