FIRST STEPS TO THE 10 STEPS

1. FIRST STEPS TO THE 10 STEPS Cambridge Health Alliance May 23, 2013

2. Where we were 2004 - Cambridge Health Alliance (CHA) submits Letter of Intent to the Baby Friendly Hospital Initiative (BFHI). 2009 - The Cambridge Birth Center receives BFHI designation. 2010 - CHA submits extension request to BFHI 2012 – CHA “falls off ” original BFHI pathway

3. Our fresh start January 2013 – • Anita Gupta MD, IBCLC, newborn hospitalist, reconvenes the Breastfeeding Task Force after a seven month hiatus. A multidisciplinary group of 30 people including ambulatory and inpatient clinicians as well as representatives of community groups attend the meeting. • Jessica Buinicki BSN, RN joins CHA as the new permanent nurse manager for inpatient maternity services. • Lactation consultant hours were increased from 30 hours to 48 hours.

4. A full time lactation consultant and a part time lactation consultant took permanent positions. February 2013- • MA Department of Public Health provides CHA with a technical assistance grant. March 2013- • CHA staff begins working with technical support team from DPH • First practice change “Delay the Bath” is introduced to staff

5. Delay the Bath • The first bath will be delayed until at least 12 hours of life. • The bath will be done in the mother’s room. • The mother and other family members will be encouraged to participate in bath. • A tub bath is recommended for the first bath. .

6. April 1st is designated as the official roll out date Prior to April 1st: • Journal articles about importance of uninterrupted skin to skin between mother and infant immediately after birth, thermoregulation in the newborn, AAP guidelines for administration of routine neonate procedures and medications are distributed to all nursing staff • Discussions are held about project at staff meetings in March • All ambulatory and inpatient staff caring for pregnant women receive information about “Delay the Bath” to provide patient education about importance of initiative for newborn health

7. Crib cards were printed to cue clinical staff to infant’s medication administration “eyes and thighs” and bath. • Flyers with brief summary of benefits of delay the bath were posted on the unit. • The flyers translated into the patient population’s main languages, Spanish, Portuguese, Haitian as well as English were developed for patient education on admission to unit. • Bath kits using basins stocked with towels, face cloths, soap, comb, diaper, t-shirt, and hat were assembled by CNAs and decorated with pink and blue ribbons

8. Guidelines and procedures • Guidelines and procedures for timing of routine procedures and bathing infant are developed and distributed to all inpatient staff. • The bath guidelines reinforce policy requiring uninterrupted skin to skin contact for at least 60 minutes in healthy term newborns. Vital signs are done with infant on mother’s abdomen. • Guidelines state that mother and infant are to be transported from labor and delivery to mother-baby unit together and brought directly to mother’s room. • Weighing and measuring of infant and administration of routine medications are done at mother’s bedside, preferably before transfer of couplet from labor and delivery.

9. Promising early results March 2013 • Breastfeeding initiation : 93% • Exclusive breastfeeding at discharge: 58% April 2013 • Breastfeeding initiation: 93% • Exclusive breastfeeding at discharge: 75% May 1 -19, 2013 • Breastfeeding initiation: 92% • Exclusive breastfeeding at discharge: 73%

10. Quality improvement plan Bath crib cards collected from May 7-21 to track: • Hours of life of infant when bath was given • If infant was bathed in mother’s room or nursery • Type of bath- sponge bath or tub bath • Approximately 50% return of crib cards during QI period • Cards collected indicated 20 of 22 infants were at least 12 hours of life • Information incomplete on many cards about location and type of bath

11. Feedback from patients and RNs During staff meetings in April and May, the project was discussed. In April, the biggest concern was workflow. The nurse manager was able to provide role clarity. In May, RNs voiced feeling more confident with sponge bathing than tub baths. The goal is tub baths for all infants. An in service/competency on tub baths is being planned. All of the patient feedback has been positive.

12. Next steps • Continue to fully implement practice of first bath as a tub bath in mother’s room for all healthy term infants • Conduct periodic chart audits of infant’s hour of life at time of first bath (equal to or >12 hours of life) • Collect data about duration of skin to skin after birth (currently documenting time of initiation) • Continue with efforts to implement skin to skin in OR • Track monthly breastfeeding initiation and exclusivity rates