Transcript Using Nursing Pillows to Prevent Newborn Falls Poster

Preventing the Plunge
Using Nursing Pillows to Prevent Newborn Falls
Denver, Colorado
Cyndy Krening, MS, RNC-OB, C-EFM, Sarah Smith, MSN, RNC-MNN, Deb Lowery, MS, RN
Introduction/Background
Newborn falls continue to be a problem in hospitals due to
maternal fatigue after delivery, side effects of medications, being
awakened at night for newborn feedings, maternal sleepiness due
to hormones released during breastfeeding, co-sleeping
(intentional or unintentional), darkness, and unfamiliar
surroundings. Many studies indicate the majority of falls occur
when the mother falls asleep while holding her newborn
(Matteson, Henderson-Williams, & Nelson, 2013).
In 2012 we began to notice an increase in newborn falls. Initial steps
to reduce falls included:
• Revision of our Safety First Newborn Instructions for Parents form.
Initially this form was reviewed in L&D and the patient was asked to
sign and then the form was placed in the chart. This form was
revised to be a duplicate so that a copy is given to the patient after
signing. The safety instructions are also reviewed again upon
transfer to the postpartum unit.
• Implementation of frequent purposeful rounding to check on
patients and move babies to
their cribs if an unsafe situation
is noticed.
• Creation of Prevent Your Baby
from Falling cards with key tips
that are posted on the mirror
in each postpartum room.
After implementation of the above steps, our newborn fall rate
didn’t decline –it hit a record high in 2013!
Objectives
Data
• Identify 3 risk factors for newborn falls in the postpartum period.
• Discuss 2 education strategies employed in an effort to eliminate
newborn falls.
• Describe the use of a nursing pillow to prevent newborn falls, and the
incidence of falls since implementation.
Zero newborn falls
have occurred
in the 26
months since
implementation
of the
nursing pillows!
Methods
Our goal was to decrease or eliminate the incidence of newborn falls after
traditional patient education strategies had failed. In January 2014:
• Hospital grade nursing pillows with disposable covers were purchased
for each postpartum room.
• Staff were educated about the implementation of nursing pillows to
decreased risk of newborn falls.
• The Prevent Your Baby from Falling tip cards were updated to include
information about the nursing pillows.
• Patients are educated to use the pillow during feedings, especially at
night when tired. Nursing pillows provide physical support for the
baby.
• Use of the nursing pillow is reinforced during hourly rounds.
Conclusion
This innovative, cost-effective strategy has greatly minimized the risk of newborn
falls in the immediate postpartum period. Patients, staff and providers have
voiced satisfaction with the nursing pillows and enhanced newborn safety.
References
• Ainsworth RM, Maetzold L, Mog C, & Summerlin-Long S (2013). Protecting our littlest
patients: A newborn falls prevention strategy. JOGNN, 42(s1), s76-7.
• Galuska L (2011). Prevention of in-hospital newborn falls. Nursing for Women’s Health,
25(1), 59-61.
• Helsley L, McDonald JV & Stewart VT (2010). Addressing in-hospital “falls” of newborn
infants The Joint Commission Journal on Quality & Safety, 327-333.
• Matteson T, Henderson-Williams A, Nelson J (2013). Preventing in-hospital newborn falls:
A literature review. MCN, 38(6), 359-66.
• Pennsylvania Patient Safety Authority (2014). Keeping your newborn baby safe from falls
while in the hospital. Harrisburg, PA.