A new approach to weaning critically ill patients from mechanical ventilation across the UK
Critically ill patients having long periods of mechanical ventilation are at higher risk of morbidity. The research lead by Professor Bronagh Blackwood identified ways to optimise inter-disciplinary collaboration in weaning infants and children from mechanical ventilation and, by July 2020, nearly two-thirds (18/28) of UK paediatric intensive care units had adopted the protocolised weaning intervention that was designed based on this research. Without this research and the implementation activities, the approach to ventilator weaning practice in the UK would not be as collaborative or evidence based as it is currently.
Annually, in the UK, approximately 20,000 infants and children are treated in intensive care and, of these, around 12,000 receive mechanical ventilation. Mechanical ventilation is potentially lifesaving, but it can compromise the child’s comfort, feeding and mobility. Furthermore, it carries risks of vocal cord dysfunction, subglottic stenosis, ventilator-induced lung injury and nosocomial pneumonia, therefore the sooner children are appropriately weaned, the better their outcomes. Decisions about when they are well enough to come off ventilator support are complex. The SANDWICH intervention transformed the approach to this key aspect of the care of critically ill children.
Reducing the time that patients in intensive care units (ICUs) spend on mechanical ventilation by optimising their weaning from ventilator support is an important patient outcome and a top priority for critical care clinicians. Over recent years, weaning protocols were developed to guide clinicians in this process through encouraging more collaborative working and reducing variation in practice. In the early 2010s, 18% of UK paediatric ICUs had a weaning protocol, compared to 54% and 31% in UK and European adult ICUs, respectively.
Professor Blackwood synthesized research findings on weaning protocols worldwide, showing a clinically significant reduction of 6 hours (from 134 to 126 hours) (based on 260 children in 1 trial) in duration of mechanical ventilation when protocols were used in paediatric ICUs and of 25 hours (96 to 71 hours) in adult ICUs (2205 patients, 14 trials). This work also highlighted considerable differences in how trial outcomes were measured, impeding the interpretation of this body of research. However, despite the beneficial effects of weaning protocols, there were discordant results among the adult trials, and just the one eligible trial in children. Professor Blackwood explored reasons for the discordant results in a synthesis of 11 qualitative studies of staff views in adult and paediatric ICUs and identified facilitators and barriers to clinicians using weaning protocols. These included the extent of clinician experience; inter-professional hierarchies and collaboration; ICU workload; and user-friendliness of the protocol. These reasons are often ignored in designing and implementing strategies to improve weaning outcomes and the qualitative evidence synthesis provided evidence-based foundations for change.
By early 2018, the feasibility work and broad engagement with the UK paediatric ICU community, led to the SANDWICH quality improvement intervention being commissioned for funding by the NIHR. Nearly two-thirds (18/28) of UK paediatric ICUs agreed to come on board with the weaning strategy and implement the SANDWICH intervention with the inter-disciplinary, collaborative working practices that it entailed. In 2018, 71% (8129/11390) of ventilated children, some of the sickest children in the UK, were being cared for in one of the 18 ICUs that had adopted the SANDWICH intervention. From February 2018, each month the clinical staff of one ICU were trained, and they continued to wean from ventilation using the SANDWICH intervention. In total, 83% (1865/2247) of staff in 18 ICUs were trained, successfully passed the online course, and delivered the SANDWICH weaning strategy. The success of this quality improvement intervention in changing medical and nursing practice was particularly mentioned by a Consultant in Paediatric Intensive Care from an NHS Cambridge University Hospital. By August 2019, 64% (18/28) of all NHS PICUs had changed practice and all were weaning children using the SANDWICH intervention. By October 2019 when the trial ended, the number of children weaned using the SANDWICH intervention was 5,646. Results from this trial showed a small, but significant reduction of 5-9-hours in duration of mechanical ventilation until successful liberation. Furthermore, in an accompanying editorial presented following the presentation of results, the SANDWICH intervention was accredited as an intervention that made a significant impact on patient outcomes.
Since January 2020, the intervention and its materials became available to the remaining 10 PICUs in the UK and by December 2020, one of these have adopted it, with further adoption halted by COVID-19. The SANDWICH website has provided free access to the SANDWICH intervention and all training materials. Since this went live, 1,509 users from 10 countries have downloaded the materials: 35% from the United States and 28% from the UK. Furthermore, nearly one-year on, a follow-up survey indicated that all participating paediatric ICUs continue to use one or more of the SANDWICH intervention components.