Background and Aims

There is no international consensus on paediatric ventilator weaning practice. The Sedation AND Weaning In CHildren (SANDWICH) intervention provided a new weaning approach requiring whole-unit practice change.^[1] The aim of this study was to create successful practice change.

Methods

We used a four-phase Quality Implementation Framework (Fig 1).^[2] Methods included pre-trial visits to PICUs; collaboration meetings with clinical staff;⁽³⁾ on-site training and ongoing educational support during and following the change period; and evaluation of change.

Results

Phase 1: We visited 24 UK PICUs and conducted a collaboration meeting. ^[3] We achieved buy-in from 18 PICUs. We developed the SANDWICH training package including an innovative e-learning module, training manual and teaching resources.

Phase 2: During the trial, one site/month transitioned from delivering usual care to the SANDWICH approach. Site implementation plans included recruiting multidisciplinary champions (average 1:8 staff). The implementation manager (LMc) provided four champion training days/site and overall 431 were trained. Training was rolled out to 1955 multidisciplinary staff.

Phase 3: Support was provided locally by champions and overall by LMc. Multi-medium promotional materials were adapted for sites to aid information retention. Training was completed by 81% of staff within 8-weeks.

Phase 4: An online survey (August 2020) of sustainability conducted 10 months following trial closure indicated 17 (94.4%) PICUs continued to deliver components of the SANDWICH intervention.

Conclusions

Substantial preparation utilising a quality improvement change framework provided successful implementation of a complex critical care ventilation liberation intervention that was sustainable 10 months after implementation.

Background and Aims

The Sedation AND Weaning In CHildren (SANDWICH) trial tested an evidence-based intervention in ventilation liberation. [1] The intervention included wider engagement of bedside nurses in the process. The intervention created a change in multidisciplinary clinical practice. This presentation outlines the components of the intervention and adherence to each component.

Methods

The four components are shown in Fig. 1. Adherence was measured by the proportion (median, interquartile range) of the four intervention components performed and captured daily from accompanying checklists completed by ICU staff.

Figure 1: SANDWICH Intervention Bundle Core Components.[1]

Results

The intervention was implemented in 18 UK PICUs: 1955 multidisciplinary staff were fully trained after 12-weeks and 5646 children were weaned from ventilation with the new approach. Adherence was high for sedation assessment (median 83%, IQR 82%, 91%) and setting targets for sedation level (median 85%, IQR 63%, 89%) and ventilation parameters (median 90%, IQR 81%, 96%) on the ward round. Adherence was moderate for spontaneous breathing trial (SBT) screening (median 74%, IQR 66%, 83%) and lower for undertaking a SBT (median 40%, IQR 31%, 51%). Non-adherence accounted for 18% of explanations for not undertaking a SBT.

Conclusions

In critical care, to create a successful change on this scale requires sustained multidisciplinary team buy-in. Low adherence may be a sign of the difficulties clinicians experience in changing long-standing practices.

Reference

1. Blackwood, B., et al., Sedation AND Weaning In Children (SANDWICH): protocol for a cluster randomised stepped wedge trial. BMJ Open, 2019. 9(11): p. e031630.