Stasis in the absence of explicit direction
Although the intervention’s strategic flexibility was widely endorsed, it was also discussed as inadvertently working against optimal intervention delivery. Three main issues were identified. First, the flexibility inherent in the COMFORT assessment, which was categorised into a range of scores indicating sedation ‘status’ for weaning. The categorisation could be problematic due to an overlap in ranges (10–12 consider weaning sedation; 12–17 comfortable and can be safely extubated). A child who scored in the range 12, or just above, could fail a SBT screen and remain longer on the ventilator. Second, the option of running a SBT for up to two hours. This period of time could allow attention to move away from a patient’s weaning progress as other priorities of patient care took precedence. It could also diminish the perceived importance of the need to extubate, as staff were aware a patient could remain on SBT settings for two hours. On the occasions when a patient remained on a SBT for longer than two hours, the end goal of extubation could be undermined in that the patient could tire and need to be returned to higher levels of support. Third, the intervention did not stipulate that extubation should follow within a set time after a successful SBT, in recognition that this might not be practically possible. However, the lack of such a requirement was linked to an indefinite postponement of extubation in some cases as other unit pressures took priority and/or relevant staff were unavailable.