Table of ContentsProblem DescriptionLiterature ReviewStakeholder Assessment and Communications PlanPlan Description Commentary MEGAN by Meredith Ferfolia:a. Discuss the change strategies to use and the variables to measure (process, outcome, balance). Description of Evaluation Plan Conclusions References Children's National Medical Center (CNMC) is located in the northwest quadrant of Washington, DC; was founded in 1870 and remains the only free-standing academic pediatric hospital in the region primarily serving patients ages 0 to 21 (“At a Glance,” 2017). Hospital admissions have an average length of stay of 6 days and amount to approximately 15,700 per year (“At a Glance”, 2017). CNMC is ranked fifth nationally by U.S. News & World Report on U.S. News' 2018-2019 Best Children's Hospitals list and is ranked first nationally in Neonatology. Children's National Medical Center serves primary school children, as well as adults with congenital conditions. There is a great focus on family- and patient-centered care, so caregivers are very involved in all aspects of caring for and advocating for their children, even in the sickest states. Children's provides acute and intensive inpatient care, as well as primary, emergency and specialty outpatient care on the main hospital campus; There are primary and specialty care services located throughout the Washington, DC region. Say no to plagiarism. Get a tailor-made essay on "Why Violent Video Games Shouldn't Be Banned"? Get an Original Essay Description of the Problem SIDS is the sudden, unexpected death of an infant less than one year old in which the cause of death cannot be identified following investigation (Centers for Disease Control and Prevention, 2018) ; According to a 2016 report from the American Academy of Pediatrics, approximately 3,500 children die from sudden infant death syndrome in the United States each year. Of these, approximately 900 are preventable and are potentially due to preventable incidents such as strangulation or suffocation in a bed or crib (Centers for Disease Control and Prevention, 2018). While the causes of infant death may be unknown, many may be attributed to unsafe sleep environments. In 1994, the American Academy of Pediatrics (AAP) launched the “Back to Sleep Campaign”; after starting this campaign, the national SIDS rate decreased by 50% (American Academy of Pediatrics, 2016). The current safe sleep recommendations from the American Academy of Pediatrics are identified as the “ABC” of safe sleep (2016). The “A” stands for “only” – in an empty crib, and involves avoiding blankets, pillows, stuffed animals, and any crib bumpers (American Academy of Pediatrics, 2016). The “B,” “back,” tells caregivers to place babies on their backs to sleep on a flat surface; however, if the baby is able to roll over on his or her back and does so after being placed on his or her back, it is safe and acceptable to leave him or her in a non-supine sleeping position (American Academy of Pediatrics, 2016). Finally, the “C,” “crib,” encourages parents to place the baby in a crib to sleep, not in the parents' bed or other otherwise unsafe sleep environment (American Academy of Pediatrics, 2016). Other recommendations include having the child share a bedroom with the parents for the first 6 months of life and avoiding the child's exposure to smoking and medications (American Academy of Pediatrics, 2016). Unfortunately, 22% of parents do not put babies on their backs to sleep, 61% of parents report bed-sharing, and 39%use soft beds (Centers for Disease Control and Prevention, 2018). There is a higher incidence of sleep-related infant deaths among American Indian, Alaska Native, and African-American populations (Centers for Disease Control and Prevention, 2018). Often, caregivers are role models for safe sleep practices, as they often see infants, and educate parents. In inpatient hospital settings, healthcare team members have a special opportunity to promote safe habits, including safe sleep. A 2002 study by Colson and Joslin found that parents who witnessed caregivers placing babies on their backs to sleep were twice as likely to do the same at home; however, approximately half of healthcare workers failed to model safe sleep practices in hospital settings. Several barriers to staff failure to adhere to safe sleep guidelines could include concerns about reflux, attempts to improve the patient's respiratory status, and lack of access to resources such as sleeping bags or available swaddling devices, as determined by Ohio Education and Safe Sleep Environment (EASE) Project researchers Macklin, Gittelman, Denny, Southworth, and Arnold (2016). Despite any perceived or real barriers, health care team members have a responsibility to model safe sleep practice to help health care providers promote positive outcomes for children at home, especially as many of these hospital barriers are resolved in pediatric patients first. of discharge from hospital. At Children's National Medical Center, a safe sleep policy was established in 2008 and last revised in 2017; This policy reflects AAP recommendations and highlights the need for nurses to adhere to and model care behaviors that affect infant sleep safety at home at all times. Following the policy change, training was provided to nurses via an emailed PowerPoint and unit audits have since taken place monthly without further training, intervention or follow-up. Policy compliance has shown some improvement, although it is inconsistent, and audit results vary considerably from month to month, ranging between 46 and 81 percent compliance with an overall goal of 100 percent compliance across all units ( [Children's National Clinical Audits on Safe Sleep Practices], 2018). The audit forms list the reasons why specific patient sleep environments and states were found to be inadequate, but do not specify how often each problem occurred or the corrective actions taken. This proposed evidence-based practice project will be built to target not only consistency in compliance, but also the management of related discrepancies to achieve and shape best practice behaviors. The specific aim of this evidence-based practice project is to increase safe sleep compliance in hospitalized infants by up to 90% by June 2019, after 3 full months of project implementation at Children's National Medical Center. Literature Review A safe sleep program was established at the Hospital of the University of Pennsylvania following the deaths of two former neonatal intensive care unit patients who had been discharged from the hospital; This evidence-based practice project was described in the 2016 article titled “An Evidence-Based Infant Safe Sleep Program to Reduce Sudden Unexplained Infant Deaths” by Zachritz, Fulmer, and Chaney and published in the American Journal of Nursing in 2016. Furthermore, the article authors provide statisticssignificant findings showing that of all infants who suffered sudden death in Philadelphia, Pennsylvania between 2009 and 2010, 89% were in unsafe sleep environments that may have contributed to their deaths (2016). Prior to implementing the program at the hospital, unit audit results were inconsistent and did not demonstrate adherence to AAP guidelines. Furthermore, parental teaching was lacking, and self-reported data revealed that parents often put their children in danger by “co-sleeping with their infant,… placing objects in the infant's crib, and… putting infants to bed.” . sleeping on an uneven surface” (Zachritz, Fulmer, & Chaney, 2016). According to the evidence-based practice article, Fulmer and Chaney created a multidisciplinary team, including nurses, physicians, and occupational and respiratory therapists, who met over a two-year period prior to implementation of the project. Using the Institute for Healthcare Improvement's recommendations on change projects, a safe sleep package was developed that included the purchase and use of hospital sleep bags that parents could take with them to discharge for home use, a new clinical guideline, standardized parent and parent caregiver teaching, and prenatal community outreach (Zachritz, Fulmer, & Chaney, 2016). Newborns were included in the practice change only if their medical needs did not outweigh the benefits of the guideline in reducing the incidence of SIDS. Training was provided to all patients' direct caregivers and support staff on the unit and assessed through audits of all newborns, as well as staff compliance with caregiver training. Implementation of the safe sleep program demonstrated a 70% increase in hospital sleep environment compliance; when discrepancies were detected, real-time training was provided to improve future compliance of staff and caregivers and further model appropriate behaviors (Zachritz, Fulmer, & Chaney, 2016). The overall goal of the project was to not only become compliant with best practice standards, but to model healthy sleep behaviors outside of the hospital. The importance of a program that models appropriate behaviors for healthcare providers is truly immeasurable, and standardizing best practices is important so that healthcare providers receive the same message from all healthcare providers. This project also embodies the fundamental bioethical principles of beneficence and non-maleficence; When these principles enable healthcare professionals to act in the best interests of the vulnerable child, they allow the child to develop and grow safely while minimizing the known controllable risks of SIDS. A quality improvement project to improve safe sleep practices, as described in the article “Integrating Safe Sleep Practices in a Children's Hospital: Results of a Quality Improvement Project,” was implemented in a large U.S. children's hospital. in Arkansas, where the infant mortality rate in 2010 was 133% higher than the national average (Rowe, et al., 2016). This study sought to find out whether changing education and policies would affect adherence to safe sleep practice (SSP) in the 370-bed inpatient children's hospital A group known as the Safe Sleep Task Force was created to study the current SSP occurring in the hospital with the goal of increasing the proportion of children in the settings. safe sleep patterns recommended by the American Academy of Pediatrics andto support these practices (Rowe, et al. , 2016). A review of the literature regarding the SSP helped the Safe Sleep Task Force develop a training and implementation plan for the hospital. Baseline data was collected from a variety of healthcare professionals to assess knowledge and beliefs focused on SSP, and the sleep environments of all infants up to 12 months were audited weekly using an audit tool developed by the task force ( Rowe, et al., 2016 ). 1,656 hospital staff members completed safe sleep video modules and received information about the new policy and documentation changes; Sleeping bags were also provided for use in the hospital to avoid the use of excess blankets in the sleep environment (Rowe, et al., 2016). The effectiveness of the interventions was measured through audits of the sleep environment and documentation and compared to pre-intervention audits; A survey was also carried out among hospital staff regarding their knowledge and perceptions of SSP. Evaluation of sleep environments showed a 13% increase in SSP adherence with an overall increase in knowledge and beliefs related to SSP and a decrease in barriers (Rowe, et al., 2016). All inpatient hospital settings should make it a priority to increase interventions on safe sleep practices and adherence to the recommendations of the American Academy of Pediatrics. Those caring for infants younger than one year of age, unless medically excluded, should follow AAP guidelines to reduce the risk and incidence of sudden death related to preventable causes. Medical and hospital staff modeling safe sleep behaviors in the hospital would create a greater likelihood of parents and caregivers continuing these behaviors at home. Because infant mortality is much higher in the United States than in other developed countries, it is important to identify and intervene on preventable risks, especially in hospital settings where healthcare workers have the opportunity to observe the behavior of experienced staff who are perceived as experts who act in the best interests of the child (Rowe, et al., 2016). Stakeholder Evaluation and Communication Plan Because the current policy in place at Children's National Medical Center was designed by the Neonatal Intensive Care Unit only, it does not currently reflect attributes of care and practices central to each unit, therefore, the main Stakeholders in this multidisciplinary evidence-based practice change team should be representative of all hospital specialties and units. Unit nursing managers and leadership from other disciplines listed above will be asked to identify individuals who will serve as members of this practice change team to ensure the team is comprehensive and representative, and committee chairs will be elected at the meeting initial. Key disciplines that play a significant role in implementing safe sleep in hospitalized infants and are stakeholders in this change project include nurses, nursing support staff, respiratory therapists, occupational therapists and physical therapists, advanced practice nurses, physicians, nursing managers and directors, supplier representatives of the chain, linen services and, last but not least, parents and healthcare workers. Nurses, nursing support staff, and respiratory therapists play a critical role in implementing and modeling protocol components as they spend a significant amount oftime in direct patient care. Nurses, respiratory therapists, occupational therapists and physical therapists also share a great responsibility in educating parents and dispelling safe sleep myths, such as infant sleep positioning and objects allowed in the sleeping area. Advanced practice registered nurses and physicians should reinforce safe sleep behaviors during meetings with parents and caregivers and also correct discrepancies through real-time education. Nursing managers and directors should work with the multidisciplinary team, including representatives from the supply chain and linen services, to ensure that sleeping bags are available to staff to support safe sleep recommendations in a cost-conscious manner. After the initial meeting, other staff and potentially a parent or caregiver representative may be recommended for inclusion in the project at the discretion of the team to promote the most comprehensive intervention possible. The bi-weekly meetings will begin in January and February 2019 until the practice The change project will be launched on 1 March. Initial meetings will evaluate current safe sleep policies and procedures against current best practices published in peer-reviewed journals and from influential organizations, such as the American Academy of Pediatrics (AAP) and the National Association of Pediatric Nurse Practitioners (NAPNAP). In mid-February, stakeholders will complete an initial staff knowledge baseline survey that will be reviewed following implementation of the practice change. Stakeholders will also educate staff on best practices through internal services using PowerPoint slides and simulations. Between March 1 and May 30, stakeholder meetings will occur monthly, although unit representatives will complete weekly bedside audits and completed tools will be sent to committee chairs for review and intervention as needed. Staff will be provided with real-time training when deficiencies are detected and audits will be evaluated for overall compliance and areas of weakness regarding the hospital unit. Stakeholders will also create signs to be posted on the unit and at the patient's bedside to remind staff, parents and other caregivers about safe sleep practices. Parents will also be provided with handouts created by stakeholders at admission and discharge, as well as one-on-one discharge teaching provided by the discharging nurse. The full stakeholder group will meet again in June to determine whether the practice change should be incorporated into a nursing practice guideline, and additional staff education needs will be determined using the audit findings. Description of the MEGAN Plan Comment by Meredith Ferfolia:a. Discuss the change strategies to use and the variables to measure (process, outcome, balance). The goal of our quality improvement project is to improve compliance with the safe sleep protocol in hospitalized infants; we will use the PDSA cycle, or Plan Do Study Act, to formulate our plan. After the creation of the safe sleep team and initial planning meetings, as described above, the planning of the audit and training process will begin to complete the “Doing” part of the model. The basis of our training and testing will focus on the current safe sleep recommendations of the American Academy of Pediatrics. The safe sleep environment assessment tool will be a concise eight-question surveyfocus on: keeping the head of the bed flat with the baby on his back, in the crib on a solid surface with only a fitted sheet, in a sleeping bag, with the hat off and without excess materials or medical devices. The exact components of the audit will be decided and approved by safe sleep stakeholders. A baseline practice audit will be carried out to assess how many children are following safe sleep guidelines before interventions occur; Neonates who will be excluded from the audit include patients who are intubated, have central lines or other equipment requiring device protection, or are unable to follow the protocol in its entirety for health reasons not otherwise specified. In the planning phase, a survey will also be conducted to assess staff and parent knowledge and barriers to implementing safe sleep. The staff knowledge and belief survey will contain topics such as: knowledge of AAP recommendations, how often the recommendations are actually followed, knowledge of existing policy, barriers to implementing the practice, and belief regarding the relationship between unsafe infant sleep and SIDS . The survey for parents will ask if they are aware of current recommendations, specifics on current infant sleep practices at home, and obstacles encountered when trying to practice safe sleep. Training of staff members will occur following initial environmental audits and knowledge surveys. and will include a PowerPoint presentation discussing safe sleep with a clinical educator and a simulation session. The simulation will consist of staff evaluating a newborn-sized doll that has been placed in a crib with the goal of finding all objects that do not belong in the crib, addressing clothing and positioning issues, as well as other environmental issues . The hospital will post bedside flyers that are easy to read and include visual and written references to safe sleep guidelines. Additionally, an educational video on the hospital television network will automatically play for all parents of children under 1 year of age upon admission to the hospital; Additionally, staff members will demonstrate safe sleep interventions to parents and caregivers. It is important that multidisciplinary healthcare providers consistently model and encourage SSP and that safe sleep behavior is also reinforced by the provider during medical team visits. Finally, upon discharge, healthcare providers should again reiterate safe sleep education and the importance of continuing this behavior at home. After adequate staff training, the interventions will be studied to examine their effectiveness, compared to the "Study" part of the PDSA cycle; this should happen three months after the project starts. Safe sleep audits will be completed again, aiming for 20 audits per week per unit to measure whether interventions have been effective. During these checks by the safe sleep team, real-time education should occur by reviewing all discrepancies with caregivers, parents, and caregivers. This real-time training should also include an investigation into the barriers that impede safe sleep practice as it is imperative that once training is provided to staff, follow-up audits and training not only improve the practice but provide information on areas of weakness. and allow for improvement of practice if necessary. Areas of weakness and the need for further training should be formulated2