6545 Implementing research in PICU: integrating a sedation and ventilator liberation (SANDWICH) care bundle to promote early readiness for extubation

Objectives The SANDWICH trial in paediatric critical care was a cluster randomised trial of the cluster implementation of a sedation and ventilator liberation protocol. The trial demonstrated a reduction in the duration of invasive mechanical ventilation with the intervention.¹ Despite this positive result, implementation of this protocol within UK Paediatric Intensive Care Units (PICUs) has been variable. The objective of this project was to use implementation science to study the implementation of the SANDWICH care bundle within 1 of the participating PICU, using quality improvement methodology to increase compliance. Methods We conducted baseline data collection examining the electronic patient record of all patients receiving invasive mechanical ventilation within the participating PICU during a 1 month period in March 2023. Records were examined to assess compliance with all aspects of the SANDWICH bundle. We formed a multi-disciplinary team with key senior nursing leadership. This team utilised quality improvement methodology in implementing a staged approach. Implementations included a multidisciplinary bundle highlighting the SANDWICH protocol criteria and its importance. This was followed by educational interventions such as journal club discussions, formalised bedside nursing teaching, presentation at the monthly research meeting, and visual aids. Results The initial audit conducted in March 2023 (n=26 patients) indicated poor compliance with the spontaneous breathing trial (SBT) element of the bundle (3% of patients). It also highlighted that only 50% of eligible patients had an SBT within 24 hours of fulfilling the bundle's ventilator criteria. There was more consistent documentation of regular assessments of sedation levels using the COMFORT scale scoring and patient-specific oxygen saturation targets (100% daily documentation of both parameters). Subsequent staff survey analysis highlighted a reluctance to start breathing trials until ventilation parameters were lower than recommended and there was a general reduced confidence in independent bedside nurse decision making. The post-intervention data showed an improved compliance with the bundle. There was generalised improved confidence amongst the bedside nurses. Conclusion Improved compliance with the SANDWICH intervention was demonstrated following a multidisciplinary intervention. Reference Blackwood B, Tume LN, Morris KP, et al. Effect of a sedation and ventilator liberation protocol vs usual care on duration of invasive mechanical ventilation in pediatric intensive care units: a randomized clinical trial. JAMA. 2021;326(5):401–410. doi:10.1001/jama.2021.10296.