SAFE SLEEP AND FALLS PREVENTION: INPATIENTS

DOCUMENT TYPE: PROCEDURE

Site ApplicabilityBC Women’s Hospital (BCWH)

Practice Level/CompetenciesBasic Skill

PolicyBC Women’s Hospital has universal safe sleep and infant falls prevention policies that apply to all infants admitted to the Maternal-Newborn and Neonatal Intensive Care Programs. An enhanced safe sleep and falls prevention discussion and individual care planning is indicated for any mother/caregiver when the infant is identified to be at a higher risk for unsafe sleep or fall while in hospital. This applies to any unit where families are caring for their infant in hospital.The Perinatal Substance Use Program (Families in Recovery or FIR) cares for a population at a significantly higher risk for sleep related deaths and infant falls and therefore safe sleep and falls prevention care planning takes place routinely with all these families.

Equipment & Supplies Forms:

Safe Sleep and Falls Prevention Care Plan Infant Falls Risk Assessment Safe Infant Care Flow Sheet

Resources For Health Care Providers:Safer Infant Sleep – A practice support tool for healthcare professionals (PSBC)The Safer Infant Sleep: Practice Support Tool for healthcare professionals is intended to facilitate and encourage an open discussion around safer infant sleep starting in the prenatal period.

Honouring Our Babies Safe Sleep Cards and Facilitators Guide (First Nations Health)The Safe Sleep Cards and Facilitators Guide provides the health care provider with an interactive, evidence informed approach and the requisite knowledge and language to engage in a safe sleep discussion with indigenous families in a trauma informed and culturally sensitive manner.

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SAFE SLEEP AND FALLS PREVENTION: INPATIENTS

DOCUMENT TYPE: PROCEDUREResources for Patients and Families:Safer Sleep For My Baby - Helping Parents and Caregivers Create a Safer Sleep Plan (PSBC)

Honouring Our Babies Safe Sleep Toolkit: A Summary for Families (First Nations Health)

Procedure

A. Safe Sleep Care PlanningSTEPS RATIONALE/RESOURCE1. General Guidance Select the most appropriate teaching resources listed above to

support the safe sleep and infant falls prevention discussion. Initiate the discussion before delivery (for antepartum in-patients), or

as soon as possible after birth.

When having discussions, care providers must recognize the power differential that exists between them and the patient/family, especially if there is a history of child protection involvement.

2. Review the ‘Safe Sleep and Falls Prevention Care Plan’ with the patient/family

The discussion topics and suggested strategies are on p. 1-2 of the care plan and are highlighted below.

P. 3 is for the individualized strategies and a copy of that can be provided to the patient.

Safe Sleep and Falls Prevention Care Plan(Appendix A)

3. Key Messages to provide to families1. Our goal is to encourage rooming-in, mother & baby togetherness,

skin-to-skin contact, and breastfeeding if possible, while at the same time supporting you to keep your baby safe.

2. We will work with you to help to decrease the risk of your baby having a sleep related death or accidental fall.

3. We also want to help you to find a safe sleeping solution that will work for you once you leave the hospital.

45% of families in British Columbia report frequent bed-sharing with their infant (Gilmour, Ramage-Moring & Wong, 2019).Breastfeeding was the most commonly cited reason for infant bed-sharing.

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SAFE SLEEP AND FALLS PREVENTION: INPATIENTS

DOCUMENT TYPE: PROCEDURE4. Discuss how the family can minimize sleep related risks Avoid bed-sharing or falling asleep with your baby on a chair or

couch Minimize exposure to smoke - quit or decrease smoking; avoid 2nd

and 3rd hand smoke; if you do smoke, change clothes and wash hands before touching baby

Maximize breastfeeding – and/or expressed breastmilk If possible, decrease or stop any medications or other drugs that are

causing excessive drowsiness or are making you sleep heavier Postpartum fatigue/sleep deprivation – nap when baby naps; ask for

help from family or nurses

When other risk factors are present, such as: smoking in pregnancy and/or postpartum, drinking alcohol or taking medications or drugs that cause sedation, or having had a premature or low birth weight baby, bed-sharing is NOT advisable due to the increased risk of sleep related death (PSBC, 2017)Refer to ‘Safer Infant Sleep – A practice support tool for healthcare professionals’ for further details on these risks.

5. Discuss other ways the family can help their baby to sleep safely

Always place your baby on a firm flat surface and on its back to sleep Never have loose blankets, or soft toys in the cot – consider using a

sleep sac Avoid overheating your baby Never prop the bottle Discuss how to prevent accidental falls Supervise your baby at all times Never leave baby unattended on an adult bed or counter If you are drowsy, dizzy or in pain ask for help to hold your baby, or

place it in its bassinette Secure baby safely with a kangaroo wrap when skin-to-skin Keep room clutter free to avoid tripping When transporting baby outside of room place in bassinet or stroller

The majority of infant falls in hospital occur while and infant is being held by a parent.

6. Recommended actions when bed-sharing, or falling asleep anywhere while holding the baby, is identified

1st occurrence: Place baby in bassinet, assess cause and reinforce safe sleep

education. Evaluate safety of rooming in. Reassess at morning rounds or care team huddle. Develop collaborative care plan if not already in place.

2nd occurrence: Place baby in bassinet, re-assess cause and reinforce safe sleep

education. Revaluate safety of rooming in. Reassess at morning rounds or care team huddle. Review and update care plan – escalate strategies

3rd occurrence: Care for baby in nursery for remainder of the night (if in day – for

6-8 hours) to allow mom to rest. Reassess at morning rounds or care team huddle. Review and update care plan - escalate strategies If ministry social worker assigned, share safe sleep planning for

support, emphasizing patient’s strengths and engagement in

If at any time an infant’s safety rooming-in is a concern despite added supports, it will be placed in the nursery in order to support the family to keep their baby safe while working on a solution.An important consideration for child protection services when working with high risk families who are struggling with bed-sharing is the active engagement of the mother/family in a problem solving process (MCFD).

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SAFE SLEEP AND FALLS PREVENTION: INPATIENTS

DOCUMENT TYPE: PROCEDUREproblem-solving process.

7. Different safety strategies to consider Routine: Bed at lowest level at night - Side rails up - Plan for naps

when baby sleeping - Engage support person or nursery to provide night time help

Review medications that may be adding to drowsiness – can they be adjusted?

Lights on when feeding - chew gum - play music - watch TV - cold cloth

If sitting up in bed or in chair to feed consider using a breastfeeding pillow

Secure baby safely with a kangaroo wrap when skin-to-skin (only use wraps when awake)

Bring baby to nursery for feeds Arrange for 1 or more feeds during night to be done by nurses

(encourage pumping EBM during day) Place baby in bassinet on bed with bed low and all side rails up,

remove all extra blankets and pillows Place mattress on floor with bassinet beside mattress (assess safety

– place on side where not in danger of being stepped on) Implement safety rounds during day and/or increase frequency at

night Baby in nursery at night, mom comes to nursery to do feeds,

consider rooming in with mom during day Care provided by family in nursery for support and supervision All care provided by nursing in nursery until safety concerns resolved

Work with patient/family to identify with what will work for them.These are suggestions; the mother/family may find other strategies that meet their needs.

8. Complete the ‘Safer Sleep for My Baby Care Plan’ with the patient/family

Either the mother/caregiver or nurse can document on the care plan the strategies that have been agreed upon to create a safer sleep for the baby.

Provide patient/caregiver with the original and place a photocopy in the care plan section of the health record.

Review plan daily, revise strategies and escalate interventions if necessary.

B. Infant Falls Risk AssessmentSTEPS RATIONALE/RESOURCE

1. Infant Falls Risk Assessment - Overview All postpartum women and newborns have a baseline falls risk that

BC Women’s Hospital’s universal falls prevention precautions address.

This assessment is intended for infants who have a significantly higher risk of a preventable fall over and above this baseline in order for individualized safety measures to be put into place.

Falls Prevention: Woman/PatientFalls Prevention: Newborn and InfantRooming-In Safety AssessmentAccreditation Canada Qmentum Standards Obstetric Services V 14 – Dec 2018

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SAFE SLEEP AND FALLS PREVENTION: INPATIENTS

DOCUMENT TYPE: PROCEDURE2. Complete the Infant Falls Risk Assessment WW.XXX

Complete whenever routine nursing assessment has identified on admission or transfer that an infant is at a higher risk of a fall; when there is a change in maternal/caregiver condition or behaviour that might increase risk; and following a safety event, fall or near miss.

The Infant Falls Risk Assessment is initiated and maintained by the point of care nurse who is caring for the infant.

The Infant Falls Risk Score is determined by the total points from the Maternal/Caregiver Falls Risk, Alertness Level, Sedation Risk, and Infant Care Concerns.Low Risk = 0 -1; Moderate Risk = 2-3; High Risk = 4 or more

Infant Falls Risk Assessment (Appendix B)Currently there is no validated tool for infant falls risk assessment. A validation of the BCWH Infant Falls Risk Tool is in progress.

3. Determine Actions and Strategies On p.2 of the form are the recommended actions and strategies for

communication and care planning in low, moderate and high falls risk situations.

4. Implement the Safe Infant Care Flow Sheet when an increased falls risk has been identified.

The Safe Infant Care Flow Sheet is used routinely within the Perinatal Substance Use program.

This includes an ongoing re-assessment of the infant falls risk. Complete once per shift or more frequently as indicated. Implement for newborns on other units when a moderate or high risk

of a fall has been identified.

Safe Infant Care Flow Sheet (Appendix C)

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SAFE SLEEP AND FALLS PREVENTION: INPATIENTS

DOCUMENT TYPE: PROCEDURE1. Steps in Communication when a High Falls Risk has been

identified2. Alert the Charge Nurse (Fir or postpartum) or CNL (NICU)3. Activate the falls risk alert process:

In the Maternal-Newborn Program - Implement the Yellow Dot alert process for High Fall Risk A Yellow Dot sticker is applied to the spine of infant’s health

record and infant kardex if used

In NICU - Activate the Falls Risk Clinical Indicator on the door

Apply the Yellow Dot sticker to the Infant’s Bedside Information Tool under Mother’s History

4. Postpartum Report Sheet (if used)– document Infant Falls Risk under Safety Concerns

5. If not already in place, initiate the Safe Infant Care Flow Sheet6. Notify MRP during next rounds, review safety concerns with

family and team (there is a space for the MRP to sign when a plan has been initiated, reviewed or updated at the bottom of the Safe Infant Care Flow Sheet).

7. Initiate/update the Safe Sleep and Infant Falls Prevention Care Plan in collaboration with the family. If the infant is in NICU and the mother/caregiver is an in-patient on FIR or another postpartum unit, this is carried out together with the mother/caregiver’s point-of-care nurse.

Failure to communicate an identified falls risks is a patient safety event.

5. Communication on transferOn transfer of infant to/from FIR/Postpartum/NICU – send together with infant’s chart, and include review of documents in handover: Infant Falls Risk Assessment Infant Kardex with Yellow Dot sticker Safe Infant Care Flow Sheet Safe Sleep and Infant Falls Prevention Care Plan, or other safety

plan (if in place) On transfer to a new unit, documentation continues on the Safe

Infant Care Flow Sheet and Safe Sleep and Falls Prevention Care Plan.

As per policy: Falls Prevention: Woman/Patient

6. Ongoing communication when a mother and infant are being cared for on separate units

In principle, when a mother and infant are separated, daily

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SAFE SLEEP AND FALLS PREVENTION: INPATIENTS

DOCUMENT TYPE: PROCEDUREWhenever an inpatient mother and infant are being cared for on separate units: The perinatal point of care nurse for the mother will communicate on

a daily basis directly with the point of care nurse for the infant to provide an update on the mother’s status, including any falls risk or other safety concerns e.g. increased sedation; and in turn will receive an update on the infant’s status.

Document communication in the IP notes, and any changes to the safety assessment is updated on the Safe Infant Care Flow Sheet, Kardex and Care Plan.

communication between the maternal and infant point of care nurses should occur independent of safety concerns.

Documentation Place a photocopy of care plan in the care plan section of the health record. Place completed Infant Falls Risk Assessment form in infant’s chart. Document that a care plan has been developed or revised on the Safe Infant Care Flow Sheet,

Kardex, and Shift Report.

Related Policies Falls Prevention: Woman/Patient Falls Prevention: Newborn and Infant Rooming-In Safety Assessment Safe Sleep for Infants Safe Sleep and Falls Prevention Care Plan Infant Falls Risk Assessment Safe Infant Care Flow Sheet

References

Abike, F., Tiras, S. Dunder, I, Bahtiyar, A. Arturk, Uzan, O., & Demircan, O. (2010). A new scale for evaluating the risks for in-hospital falls of newborn infants: A failure modes and effects analysis study. International Journal of Pediatrics 1-9.

Accreditation Canada (2018. Qmentom Obstetric Standards Version 14.

Ainsworth, R. M., Summerlin-Long, S., Mog, C. (2016). A comprehensive initiative to prevent falls among newborns. Nursing for Women’s Health, June-July.

Blair, P., Ball H., McKenna J., Feldman-Winter L., Marinelli K., Bartick M., and the Academy of Breastfeeding Medicine (2020). Bedsharing and Breastfeeding: The Academy of Breastfeeding Medicine Protocol #6. Revision 2019. Breastfeeding Medicine, Volume 15, Number 1, 2020.

Children’s Hospital at Dartmouth (n.d.). Infant Fall Risk Assessment.

First Nations Health Authority (2017). Honouring Our Babies Safe Sleep Cards and Facilitators Guide.

First Nations Health Authority (2017). Honouring Our Babies Safe Sleep Toolkit: A Summary for Families.

Perinatal Services BC (nd). Safer Sleep For My Baby - Helping Parents and Caregivers Create a Safer Sleep Plan

Perinatal Services BC (nd). Safer Infant Sleep – A practice support tool for healthcare professionals.

The Joint Commission (March 2018) Quick Safety: Preventing newborn falls and drops. Issue 40.

Wentworth Douglas Hospital (2018). Infant Fall/Drop Prevention Assessment.

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SAFE SLEEP AND FALLS PREVENTION: INPATIENTS

DOCUMENT TYPE: PROCEDURE

Developed ByBCW Maternal Newborn Program – Senior Practice Leader

Version HistoryDATE DOCUMENT NUMBER and TITLE ACTION TAKEN22-Sept-2020

C-06-12-60848 Safe Sleep and Falls Prevention: Inpatients

Approved at: Perinatal Best Practice Committee

DisclaimerThis document is intended for use within BC Children's and BC Women's Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document. This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.

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