In-hospital newborn falls are arguably one of the most under-researched and under-reported issues for organizations that care for newborn patients. Many of these falls can result in injury, death, financial loss, and emotional stress to the caregiver(s). Therefore, in order to reduce the incidence of newborn falls, searching the literature to ascertain causation and associated risks associated with in-hospital newborn falls must occur in order to employ the necessary prevention strategies and measures. Looking upon the issue of preventing in-hospital newborn falls with great sensitivity is essential. This is the case because not only can the newborn be harmed due to a fall, but the actual newborn fall can also elicit strong feelings of guilt and culpability in the caregiver(s). This article reviewed the literature to examine the factors associated with in-hospital newborn falls, explore prevention measures, and presents best practices of how the adoption of an in-hospital safe-sleep policy can prevent newborn falls.
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Preventing In-Hospital Newborn Falls: A Review of Literature
Prevention of in-hospital falls among patients is a vital issue for all healthcare organizations. In order to best protect patients, both the Institute of Medicine and the Joint Commission recognize patient safety problems, mandate the need for improvement, and encourage development of safety systems (Institute of Medicine of the National Academies, 2012; The Joint Commission, 2012). By ensuring the safety of the newborn during hospitalization, medical professionals can promote an overall culture of safety for patients and caregivers. Newborn falls within the inpatient setting is a multifaceted issue due to the physical, emotional, and psychological complexities of all who are involved. Newborns are at risk for falls as soon as they enter this world. Newborns are a vulnerable population and rely solely on their caregivers to protect them from injuries. Newborn falls concern all stakeholders because of resultant physical trauma to the newborn, legal issues, increased financial costs, and subsequent emotional distress to the family (Monson, Henry, Lambert, Schmutz, & Christensen, 2008).
Background and Significance
Following World War II, the emergence of rooming-in became a trend across the United States (Crenshaw, 2007). Rooming-in occurs when a mother and newborn remain continuously together 24 hours a day (Crenshaw, 2007). Research has shown that rooming-in is extremely beneficial to promote early maternal-child attachment and meet the emotional and physical needs of mothers and newborns (Crenshaw, 2007). Although there are many benefits to rooming-in, overlooking important basic safety considerations can pose serious risks to the safety of newborns.
The risk of newborn falls begins at delivery and continues throughout the duration of the hospital stay until both mother and newborn are discharged. According to Phalen and Smolenski (2010), in-hospital newborn falls are defined as a newborn falling onto the hospital floor accidentally. This can be caused by judgment errors from the hospital staff, caregiver(s) or environmental factors (Paul, Goodman, Remorino, & Bolger, 2011; Phalen & Smolenski, 2010).
Children are susceptible to many preventable injuries. The leading cause of non-fatal injuries in children ages 0 to 19 are falls (Centers for Disease Control and Prevention [CDC], 2012). Initial data have shown that in-hospital newborns falls occur at a rate of 1.6-4.14/10,000 live births, which accumulates to approximately 600 to 1,600 newborn falls annually (Helsley, McDonald, & Stewart, 2010). The majority of documented falls occurred when the mother fell asleep while holding the newborn in a bed or reclining chair; additional falls have occurred during delivery or transportation (Helsley et al., 2010; Abike et al., 2010).
The safety and well-being of hospitalized newborns are of utmost importance, and they are the responsibility of all staff members caring for this population. The development and implementation of a safe-sleep protocol or policy in order to prevent in-hospital newborn falls is of paramount importance. Thompson (2005) noted that, although parents may desire to sleep with their newborn, the need for continuous monitoring and assessment, paired with the risk of injury from falling or entrapment, is a priority consideration in the delivery of optimal patient care within the hospital setting. Therefore, policy guidelines that discuss and promote separate, but close, sleep spaces between mothers and newborns should be followed to reduce the risk of injury to newborns during sleep. Thompson (2005) also reports that parental education on the risks of bed-sharing should be conducted by hospital staff. Some of the risks of bed-sharing include entrapment, suffocation, and sudden infant death syndrome (SIDS) (Thompson, 2005). The purpose of this publication is to examine best practices related to preventing in-hospital newborn falls.
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A literature review was conducted in order to identify the prevalence of in-hospital newborn falls. Initial searches yielded three articles that addressed in-hospital newborn falls. Due to the limited amount of articles published regarding in-hospital newborn falls, the search criteria were expanded to include other areas of concern that may increase the risk of falls for newborns. The search criteria included keywords such as newborn falls, infant falls, safe-sleep policies, preventing newborn falls, safe-sleep environments, co-sleeping, bed-sharing, and SIDS. These terms were entered into EBSCOhost databases: Academic Search Premier, Cumulative Index for Nursing and Allied Health Literature (CINAHL), MEDLINE, ProQuest, and PsycINFO. The quantitative and qualitative evidence published between 2002 and 2012 that addressed a multitude of issues surrounding newborn falls was examined. The final 12 studies were analyzed and selected based on strength of the research and clinical support, and applicability. These studies included quantitative studies, case control studies, cross-sectional survey-based studies, retrospective chart reviews, live query of event databases, qualitative studies, and systematic review.
The studying and reporting of in-hospital newborn falls is a relatively new topic of concern. Morse (2009) noted that 6% of patient falls result in serious injuries that can culminate into compromised health situations and, in more severe cases, death. The author classified falls into three groups: accidental, anticipated and unanticipated physiological falls (Morse, 2009). The majority of in-hospital newborn falls can be classified under anticipated physiological falls, which can be prevented by first identifying those who are at risk. Patients who are classified as medium or high fall risk should be assessed in order to correct or lower the possible cause of falling and includes identifying and implementing a nursing plan of care in order to reduce the risk of falling. Morse (2009) concluded that preventing in-hospital newborn falls require an approach that is coordinated, planned, and involves the hierarchy of all staff members. Â
Helsley et al. (2010) noted that in-hospital newborn falls occur at a rate of approximately 600 to 1,600 falls each year in the United States. The majority of these falls occur when the mother falls asleep with the newborn in her arms. During the postpartum hospitalization, the promotion and importance of close physical interaction is one reason for the high occurrence of newborn falls. Close physical interaction primarily occurs during infant feeding since skin-to-skin contact and breastfeeding are known to promote bonding. Hospitals are faced with the challenge of balancing the important aspects of bonding and safety for both the mother and newborn. A project involving the World Health Organization (WHO) and the United Nation Children's Fund (UNICEF) resulted in the Baby-Friendly Hospital Initiative (BFHI). The BFHI produced guidelines for assessing the level of risk for babies and mothers bed-sharing in a hospital and includes the delineation of a supervision level on the basis of risk assessment (Helsley et al., 2010). Interventions recommended to reduce in-hospital newborn falls are the creation and development of the patient safety contract, improving equipment safety, and educating mothers on information related to newborn falls (Helsley et al., 2010).
Galuska (2011) discussed the creation and implementation of a universal newborn fall prevention program. Core elements of this program included parent teaching, a pledge form signed by parent and nursing staff to support patient safety, infant safety signs, utilization of hourly rounds, and promotion of maternal rest (Galuska, 2011). Prior to this program, five newborn falls occurred in one year. Since the development of the newborn fall prevention program, St. Francis Hospital and Medical Center has not had a documented newborn fall in eleven months (Galuska, 2011). The evidence supports the notion that the implementation of a newborn fall prevention program is favorable for preventing in-hospital newborn falls.
Ruddick, Ward Platt, and Lazaro (2009) concluded that newborns are susceptible to skull fractures, even when falling from lower-level surfaces. The researchers' conducted a chart review that queried an event database to review newborn falls that occurred on a postnatal ward over a five year period. Eleven newborns were included in the review, but not all newborns were radiographed post-fall. The majority of newborns in the study fell from their mothers' arms or knees when in a bed or chair, one newborn fell from a mother's arms while being placed in a bassinette and one newborn fell from a delivery bed (Ruddick, Ward Platt, & Lazaro, 2010). Although the majority of newborns did not sustain significant known head trauma (no physical trauma signs seen to physical trauma that included swelling and bruising), three newborns had single linear parietal skull fractures, and one newborn exhibited signs of traumatic encephalopathy with left parietal and fronto-parietal fractures (Ruddick, Ward Platt, & Lazaro, 2009). This demonstrates that falls can cause significant damage even from lower-level surfaces, and attention needs to be given in order to prevent physical head trauma in the newborn.
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Paul et al. (2011) posit that newborn in-hospital falls remain under-recognized and possibly under-reported by health care professionals and caregivers. Many times after a newborn falls, caregivers' may experience feelings of guilt or fear, which may cause falsification, delay or under-reporting of such incidences. The researchers noted that the most common cause of newborn falls was the mother falling asleep while holding the newborn. Strategies suggested to reduce these incidences are parental education about the potential for newborn falls out of the maternal bed or from a chair, discouraging sleeping while holding the newborn, and parents informing staff members when taking their baby to bed. In order to make parents aware and realize the importance of reporting any incidences of falling, a non-judgmental approach is suggested (Paul et al., 2011).
Not only are awareness and education important factors in preventing in-hospital newborn falls, but also how to implement recommendations and suggestions to change practice. Hitchcock (2012) reviewed the American Academy of Pediatrics' (AAP) recommendations for safe sleep. Promoting safe sleep is of utmost importance for decreasing injury and increasing the survival of newborns. However, staff members who care for newborns are inconsistent in the message they portray and relay to new parents (Hitchcock, 2012). All staff members must be aware of the AAP's best practice guidelines and follow the given recommendations since this will provide a consistent message among all providers who take care of newborns. The incorporation of a safe-sleep policy that highlights safe-sleep guidelines and promotes a clear message of how to implement such practices ensures all staff caring for newborns will follow and support best practice guidelines (Hitchcock, 2012).
In 2011, the AAP reaffirmed best practice guidelines regarding SIDS prevention measures for infants. In order to help reduce infant deaths during sleep, the AAP expanded upon their previous guidelines to include safe-sleeping practices that focus on SIDS prevention measures along with safe-sleeping environments (American Academy of Pediatrics [AAP], 2011a). Although the majority of the guidelines are related to the home environment, the AAP has started focusing on hospital measures that can accompany the guidelines; incorporating safe-sleep practices immediately after birth will aid caregivers in adopting safe-sleep practices.
The AAP guidelines are split into three levels of recommendation: Level A, Level B, and Level C. Level A recommendations are ". . . based on good and consistent scientific evidence . . . . There is high certainty that the net benefit is substantial and the conclusion is unlikely to be strongly affected by the results of future studies" (AAP, 2011a, p. 1031). Level B recommendations are constructed on limited data: "The available evidence is sufficient to determine the effects of the recommendations on health outcomes, but confidence in the estimate is constrained . . . . As more information becomes available, the magnitude or direction of the observed effect could change. . . ." (AAP, 2011a, p. 1031). Level C recommendations are predominantly founded on ". . . consensus and expert opinion" (AAP, 2011a, p. 1031). Although all of the AAP recommendations are important to incorporate into practice, five recommendations will be discussed to support the prevention of in-hospital newborn falls. The five AAP recommendations are as follows: supine sleep position, firm sleep surface, recommendation of room-sharing without bed-sharing, ensuring the avoidance of alcohol and illicit drug prenatally and after delivery, and the use of SIDS risk-reduction recommendations by all health care providers starting at birth (AAP, 2011a). The first four recommendations stated are categorized as Level A and the fifth recommendation is Level C.
Back to sleep
The "Safe to Sleep" campaign, formerly known as the "Back to Sleep" campaign, aims to educate health professionals, parents, and caregivers regarding the importance of the supine sleeping position. Since 1994, this campaign has significantly reduced the number of infant deaths related to SIDS by 50% and increased the number of infants sleeping on their backs (National Institute of Child Health & Human Development [NICHD], 2012). However, over the past ten years, the number of infant deaths related to SIDS has plateaued (NICHD, 2012) which signifies a need for further education and intervention on this issue. Infants placed on their stomach or side before sleeping have an increased risk for SIDS, hypercapnia, and hypoxia resulting from re-breathing exhaled gases, overheating, and diminished sleep-wake cycles that allow the infant to respond to stressors during sleep (American Academy of Pediatrics [AAP], 2011b). Infants placed in the side sleep position are "â€¦inherently unstable, and the probability of an infant rolling to the prone position from the side sleep position is significantly greater than rolling prone from the back" (AAP, 2011b, p. e1347). Infants are more likely to be in the prone or side position when sleeping with a parent/caregiver (Baddock, Galland, Bolton, Williams, & Taylor, 2006). The infant is vulnerable to injury if placed on an unsafe sleeping surface due to rolling, falling, suffocation, or entrapment (AAP, 2011b).
The AAP (2011b) recommends that infants be placed on a firm sleep surface with a fitted cover, and no loose bedding or soft objects in the sleeping area. This is recommended in order to reduce the risk of SIDS and other injuries resulting from suffocation and entrapment, which correlates with in-hospital fall prevention measures because positive role-modeling should begin immediately after delivery. If parents and caregivers see hospital personnel role-modeling safe-sleep behaviors and creating safe-sleep environments, then parents and caregivers have a higher incidence of following the same behaviors once discharged (AAP, 2011b).
Room-sharing compared to bed-sharing
Defining the terms room-sharing, co-sleeping, and bed-sharing are fundamental in order to properly discuss optimal infant sleeping environments. Room-sharing is described when an infant sleeps ". . . in the parents' room but on a separate sleep surface (crib or similar surface close to the parents' bed" (AAP, 2011b, p. e1350). Co-sleeping is a term used when the infant and parent ". . . sleep in close proximity (on the same surface or different surfaces) so as to be able to see, hear, and/or touch each other" (AAP, 2011b, p. e1350). Bed-sharing is defined as ". . . a specific type of cosleeping when the infant is sleeping on the same surface with another person" (AAP, 2011b, p. e1350). Since co-sleeping is a term easily confused with others, the AAP (2011b) recommends using room-sharing and bed-sharing to describe sleep practices; room-sharing is the recommended sleep practice by the AAP (2011b).
To ensure optimum safety, infants should be placed in their own sleep area which includes a crib, bassinette, or similar sleep space. The term bed-sharing does not specifically relate to only sleeping or sharing a bed. Infants should also not sleep on other surfaces such as couches or armchairs, with or without parents. The topic of bed-sharing is highly controversial since bed-sharing is associated with attachment, bonding, and improved breastfeeding rates (AAP, 2011b). However, having infants sleep in unsafe areas can prove detrimental due to risks associated with suffocation, entrapment, strangulation, falls, and death. Tappin, Ecob, & Brooke (2005) concluded that infants who bed-shared and were less than 11 weeks old were at an increased risk for SIDS. Regardless of the age of the infant, sleeping on a couch with parents is greatly discouraged (Tappin et al., 2005). A study completed by Helsley et al. (2010) discussed the importance of addressing in-hospital newborn falls. Over a two-year period, Helsley et al. (2010) completed a query of a live voluntary database of a seven-hospital system in Oregon. During that time, newborn falls were reported at a rate of 9/22,866 births, resulting in an overall fall rate of 3.94/10,000 births. Of the nine cases referenced, all infants were in bed with a caregiver (mother or father) during the time when falls occurred (Helsley et al., 2010). Immediately ensuring safe infant sleep post-birth, caregivers can help prevent in-hospital newborn falls, and also support the immediate development of safe-sleep environments.
Prenatal and postnatal exposure to alcohol and illicit drugs
Alcohol, tobacco, and illicit drug use pose significant health risks to women of childbearing age and their infants. When a mother is impaired by any substances and bed-shares, an infant is at an increased risk for injury and possible death. This is due to a decrease in parental arousal that allows them to properly care for their infant. Floyd et al. (2008) concluded that if an illicit substance is used during the preconception period it is likely to be used in the prenatal period. Blair et al. (2009), found that "[m]any of the deaths while cosleeping occurred in potentially hazardous environments, including a sofa or shared surface with an adult who had recently consumed alcohol or narcotics" (p. 920). There is also great concern for injury to an infant when a parent or caregiver is impaired by substances that decrease their arousal. A parent may become easily tired and fall asleep on any surface with an infant in their arms and subsequently drop the infant.
Improving the education of parents, caregivers, and healthcare professionals regarding safe-sleep practices is vital to the safety of newborns. Healthcare providers can model SIDS risk reduction techniques in order to ensure that families know how to reduce the risk of SIDS. The most critical opportunity for healthcare providers to influence parents' behavior is during 24 to 48 hours after delivery (First Candle, 2012). "Despite the fact that more than two thirds of nursery staff correctly identified supine placement as the preferred position for SIDS risk reduction, exclusive use and recommendation of the supine position was surprisingly low among nursery staff. . ." (Stastny, Ichinose, Thayer, Olson, & Keens, 2004, p. 125). Hitchcock (2012) discusses the fact that "[i]nfant sleep policies need to be written or revised to reflect the latest guidelines and staff expectations" (p. 394). In order to present a unified message to all parents, nursing staff and healthcare providers must be aware of best practice guidelines and incorporate them into their practice (Hitchcock, 2012). If healthcare providers are permitting parents to bed-share with their newborns in the hospital, then this message and practice can easily be adopted in the home setting. The two studies that looked at in-hospital newborn falls by Monson, Henry, Lambert, Schmutz, and Christensen (2008) and Helsley et al. (2010) found the majority of newborns who had fallen in-hospital, fell out of the arms of their parent/caregiver while in bed.
Limitations and Recommendations
Due to the minimal amount of information that has been found on this topic, further research is recommended. Little empirical evidence that covers a representative sample of in-hospital newborn falls across the United States exists. Other limitations include lack of financial information needed for implementation, unknown number of staff needed to construct and implement a policy, and how a safe-sleep policy will impact the different cultural and ethnic populations. The creation of a post-fall algorithm would be beneficial in order to standardize care for newborns. Due to the under-reported nature and under-documented accounts of in-hospital newborn falls, the true incidence is not widely known. Therefore, an accurate assessment and evaluation cannot be constructed in order to fix the issue.
In order to help prevent newborn falls, facilities should implement a tracking system that will monitor the occurrence of newborn falls. The statistics that would become available will help uncover the true prevalence of this issue. Further evidence-based practice (EBP) is crucial in order to improve practice and make enhancements in the prevention of in-hospital newborn falls.
The AAP continues to provide best practice guidelines and policy statements for many issues and topics that arise in pediatrics. The creation of safe-sleep policies that utilize the AAP guidelines for SIDS prevention and safe-sleep environments will provide organizations with the foundational measures for ensuring proper safe-sleep environments to prevent newborn falls and promote newborn safety. Incorporating these measures in safe-sleep policies will help with standardizing practitioner care and consistent messages to all families with newborns.
Clinical Nursing Implications
The implementation of best practice guidelines requires support from administration, leadership, and staff who care for mothers and newborns. In order to implement a safe-sleep policy within an organization, all staff involved must be committed to promoting and protecting a vulnerable population that cannot protect itself. Thompson (2005) discusses the strategies that must be included in order to incorporate these changes: (1) educating staff by utilizing staff meetings, in-services, and bulletin boards; (2) educating medical providers about the policy through written and verbal discussion; (3) informing all parties about policy intention and included content to the hospital's patient advocacy department to assist with concerns and complaints, and, (4) verbal and written communication with the hospital's translation services department to address cultural practices and assist with patient materials that require translation. By providing parents with written materials prenatally, and scheduling meetings with child birth educators in order to help disseminate information, healthcare professionals can help to provide a consistent, clear, and standardized message that will help reinforce best practice guidelines that will improve infant safety and injury prevention. The costs associated with such practices include monies for written materials for staff, medical providers, and translation services, and staff salaries that support policy development, educational in-services, and possible remediation (Thompson, 2005). Although the frequency rate of newborn falls is relatively small, researchers have shown that newborn falls do occur. The incorporation of best practice guidelines in safe-sleep policies in order to enhance fall prevention is crucial to help improve the safety of newborns.
The promotion of newborn safety is pivotal to the organization and all who care for this population. Newborn falls are preventable injuries. The confounding variables involved in newborn falls are multifaceted. In order for newborns to remain safe and thrive, healthcare professionals must find a balance that supports nurturing, attachment, and bonding among caregivers and newborns and the prevention of newborn falls. By utilizing existing evidence and expanding upon the current academic literature, researchers can begin to address this preventable injury. A hospital safe-sleep policy that encompasses the AAP safe-sleep guidelines will help promote safety for newborns. Addressing all aspects of this issue will provide healthcare workers with the needed information to prevent falls in newborns and emotional distress for caregivers.