Implementation of a tummy time protocol: a quality improvement project in a level 3B NICU

Abstract

Background: Infants who spend prolonged periods in the supine position, particularly in the NICU, face an increased risk of plagiocephaly and developmental delays. Supine sleeping is recommended by the American Academy of Pediatrics, "Back to Sleep" campaign, which has successfully reduced sudden infant death syndrome by 40-60%. However, an increase in cranial abnormalities was observed following the widespread adoption. Daily tummy time supports motor development, reduces the risk of plagiocephaly, and promotes parental bonding. Methods: A six-week tummy time protocol was implemented in a level 3b NICU for infants who were 32 weeks corrected gestational age and medically stable. Brief 1-2-minute tummy time sessions were completed in the infant's bed or while holding with a parent. Tummy time sessions, education, and return demonstrations were documented on a bedside tracker. Pre- and post-implementation surveys were distributed to staff to gather perspectives. Parent surveys were distributed at discharge to evaluate readiness to complete tummy time at home. Results: Between January 15th and February 25th, only 23 out of 42 eligible infants had tracker sheets returned (55%). Out of 504 eligible days, tummy time sessions were recorded on 214 days, accounting for 42%. Post-implementation staff surveys showed positive results regarding their confidence in educating parents (M=4.7, sd=0.47) and the ease of implementation (M=4.38, sd=0.65). Comparing the results of the pre-and post-implementation surveys using a t-test yielded no significance. Obstacles to compliance included difficulty integrating new workflows, time constraints for education completion, tummy time, and documentation. Conclusion: Implementing the Tummy Time Protocol was crucial in changing practice patterns to align with best practices for infants admitted to the NICU. However, more work must be done to integrate tummy time sessions, early education, and documentation into a new workflow. Suggestions for improvement were provided, focusing on incorporating documentation into the electronic health record (EHR) system to improve compliance and reduce the risk of losing tracking sheets. In addition, future research is necessary to evaluate the long-term effects of tummy time implementation within the NICU. Specifically, research should focus on rates of plagiocephaly and outpatient therapy referrals following discharge from the NICU.