In Tennessee, sleep-related infant deaths were the fourth leading cause of infant death from 2014-2018. Every 3 days, an infant dies from a sleep-related death in our state. Those statistics are staggering, unnecessary and heartbreaking. These deaths are preventable. A new study published in Pediatrics in May echoes our own state data; these babies are dying from an unsafe sleep environment. As the State TIPQC project leader, we are working to improve how our hospitals model and teach safe sleep, in order to improve how our families learn to keep their babies safe at home.  UTMCK's nurse practioners, nurses, managers, educators are working hard to grow our own safe sleep education and compliance.

In addition to updating our safe sleep policy based on the 2016 AAP recommendations, we have rolled out numerous PDSA cycles in both the NICU and our Mother-Baby Units (MBU). Highlights from our project include a nursing simulation sign-off for safe sleep positioning, development of crib cards for safe sleep in the NICU, picture guides for safe sleep posted on walls and in our discharge binders, as well as fundamental education to providers via email. The MBU has excelled in developing a feedback loop for safe sleep assessment and reinforcement that includes families for a twice daily safe sleep check during nursing bedside hand-off, and once daily by the rounding newborn practitioner. We meet virtually and via email monthly to assess our data and make revisions based on our progress. Through June, we have seen an overall improvement in our safe sleep compliance from a baseline of 61% to 83% in the NICU. Our MBU has had some variability in audit results, with our last compliance at 70%. Consistent with the state data, we have the most difficulty with loose blankets, objects in the crib and unnecessary head of bed elevation. As we look forward to sustainment, we would love to see our compliance reach and stay at 100%.