Implementing a Maternal Rest Bundle to Prevent Newborn Falls

The specific aims of this quality improvement project were to (a) examine the demographics of newborns who fell and their mothers, (b) implement a maternal rest bundle, and (c) decrease the total number of newborn falls to zero events within 3 months.

We used a quality improvement project with a pre-/post-intervention design.

Nine newborn falls occurred over 3.5 years on a 40-bed mother-baby inpatient unit at an urban, safety-net, teaching hospital. One fall resulted in a major injury that required an escalation of care and extended length of stay.

A convenience sample of nine inpatient newborns who fell and their mothers.

We completed a retrospective review of medical records for the sample. We implemented a maternal rest bundle including staff and patient education, a safe sleep pledge contract signed by the woman, an official quiet time, and signage in the unit and each room. We tracked improvement with the outcome measure of the number of newborn falls, process measure of a staff evaluation survey, and balancing measure of a patient experience interview.

No newborn falls have occurred for 2 years (October 2018 to December 2020) since implementing the maternal rest bundle. Staff evaluated that the time of shift for quiet time should stay the same (53.33% [24/45]) and most frequently listed daily tasks as barriers to quiet time. Women reported they found quiet time beneficial (95% [912/960]).

The elimination of newborn falls in the hospital unit occurred after we implemented the maternal rest bundle. Sustainability can be attributed to staff support and engagement.