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Chester County Hospital Maximizes Safety for Infants

Infant Safety

How do you maximize safety for infants? That was the question confronting the Mother Baby Unit at Chester County Hospital after a briefing on the rising number of infant falls across Pennsylvania and the United States.

Their answer was the Infant Safety Bundle, a multidisciplinary program that united new moms, family members, and care providers in common cause: protecting babies.

Falls are the leading cause of Emergency Room visits in young children. Infants 12 months or younger have the highest risk of falling or being dropped. The Patient Safety Authority reports that the most common cause of an infant fall was a family member dropping a newborn after falling asleep (55.1 percent). More than nine percent of the falls caused serious harm, according to the Authority.

“Maternal exhaustion is part of it,” said Liz Waterhouse, RNC-OB, who led the Mother Baby Unit when the Bundle began. “And I think moms don’t realize that there is this risk of dropping their newborns.”

The Infant Safety Bundle raises awareness of those risks in three ways:

First is a one-page safety agreement between new parents and the hospital. It outlines the institution’s infant security procedures – for example, bracelet identification numbers that match infants with moms and reminding parents to ensure that any staff handling their newborn is wearing an official employee badge. It also details parental responsibilities, including: never let the baby out of your sight, don’t let the baby sleep in bed with you, and if you’re feeling tired, transfer the baby to the crib – or ask staff to do this for you.

“It’s a team effort,” Waterhouse said. “We’ll help you and you help us and together we’ll make the hospital a safer environment.”

Second, the cribs in patient rooms now come with brightly colored tags, with lettering in English and Spanish, on the ABCs of infant safety: “I sleep ALONE on my BACK in my CRIB.” The tags are attached to the crib at eye level for the mom in the bed.

The third piece is a four-minute video (also bilingual) that outlines risk factors such as caregiver sleep deprivation and the side effects of maternal medication, and encourages safety measures like placing the infant in the crib immediately after feeding. It demonstrates how babies should be moved from room to room via cribs – never carried by staff or family members. It emphasizes safe breastfeeding positions for the child, and what to do in the event of a fall.

The bundle was awarded an I Am Patient Safety Award from the Pennsylvania Patient Safety Authority in 2018 for its use of Authority resources. It was one of 10 overall winners and was chosen from over 200 state-wide applicants.

New parents are clearly paying attention. Jodi Levine, MD, FAAP, who narrates parts of the video, is sometimes recognized by patients. “Their reactions surprised me,” Levine said. “I thought they might see the Bundle as just another thing they have to do: ‘Sign this paper. Watch this video.’ But I’ve had some positive reaction. People thank us for the reminders.”

She notes that the program has been equally important for staff. “The Safety Bundle also included nursing education, reminding them to be on the lookout if a mom looks a little tired,” she said. “They can be proactive and say, ‘Let me put your baby in a safe place in the crib for you.’ They are noticing more, and trying to troubleshoot for each individual patient as they come in.”

Chester County Hospital’s Bundle is just one way that Penn Medicine is ensuring infant safety. In May 2017, Pennsylvania Hospital and the Hospital of the University of Pennsylvania (HUP) received a three-year, $1.35 million grant from the state Department of Health to design a program for promoting and evaluating safe sleep practices for newborns. The program – the Philadelphia Safe Sleep Awareness for Every Well Newborn (SAFE) – will be rolled out to hospitals, ambulatory care settings, communities and homes. That effort follows on the work of nurses in the Intensive Care Nursery at HUP who, in 2015, developed safe-sleep practices adapted from the American Academy of Pediatrics. Chester County Hospital also began to implement this important initiative in early 2018.

“This can be an uncomfortable subject,” Waterhouse said. “People wince a little bit at the thought of a baby slipping and falling to the floor. I think the administration was at first surprised that it’s as much of a problem nationally as we’re seeing in the reports, but they were very supportive of what we wanted to do because it would benefit patients.”

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