The Daily Dose • Saturday, May 15, 2021
Care Beyond Cannulas: The Systems, Hospital and Individual Approach to ECMO Care
Various aspects of extracorporeal membrane oxygenation (ECMO) care provision including the system-level organization of ECMO referrals, unit and hospital-level staffing models and the importance of the individual and team-level impact of caring for the complex patients were examined during the Education Session III: ECMO: Beyond Cannulas, Flow or Patient Selection at the SOCCA 2021 Annual Meeting.
Angela Johnson, MD, University Hospital Cleveland Medical Center, and Peter Von Homeyer, MD, FASE, University of Washington, led the excellent panel. Presenters included Vadim Gudzenko, MD, Joseph Meltzer, MD, and Anahat Dhillon, MD.
The first panelist Dr. Gudzenko focused on various models of ECMO care at the systems-level and the use of mobile ECMO. He is an Associate Clinical Professor, David Geffen School of Medicine at UCLA and Director of the Anesthesiology Critical Care Fellowship and Medical Director of the adult ECMO/ECLS program at UCLA Health. He first explained that mobile ECMO includes secondary ECMO (transporting a patient on ECMO from one hospital to another), primary ECMO transport (deployment of specialized teams to cannulate a patient in the referring hospital with subsequent transfer to an ECMO center), as well as initiation of ECMO or ECPR outside of medical facilities, such as a train station or sidewalk. ECMO use has increased, the indications expanded and survival rates after ECMO use have improved as well, prompting the need for further inspection of the structure of allocation and provision of ECMO care.
Particularly in the context of the COVID-19 pandemic, the use of ECMO support has been associated with improved mortality rates and disability for patients with severe acute respiratory distress syndrome (ARDS). The results for ECMO use for ARDS secondary to COVID-19 are impressive with survival exceeding 50%. The cornerstone for successful referral and care of ECMO patients is the tertiary referral ECMO center which has the resources and multidisciplinary expertise in management of patients with respiratory and cardiac failure and the advanced skill sets to best care for these patients, as well as high volume (considered to be 20-30 cases/year).
It “takes a village” to appropriately provide ECMO care; it’s not just the circuit, it’s the team that is important, Dr. Gudzenko explained. That team must be available 24/7, be equipped to provide specialized transport and be composed of experienced personnel trained in transporting critically ill patients, insertion of ECMO cannulas, and management of the ECMO circuit. The hub-and-spoke-model is the primary model used in the United States in which tertiary ECMO centers (hub) receive and evaluate requests and assess availability of their own resources when referring hospitals (spokes) request an ECMO evaluation or transfer.
Another model is a regional ECMO system where all requests are received by the ECMO-hub transfer center, which screens all requests, screens and accepts patients, and helps coordinate transfer to ECMO centers which have availability at that moment. Dr. Gudzenko advocated for utilizing the network or regional coordination model to help allocate scarce resources and assist in coordination as this has been shown in France and Chile to allow for efficient use of critical care and ECMO resources at a high level with excellent survival rates. There are 11 centers in Southern California which form the Southern California ECMO Consortium. This consortium was formed during the pandemic to help coordination and help share experiences with management of COVID-19 patients. Although there was not a formal centralized hub for this example, it was a move towards ECMO coordination networks to assist in care for these complex and high-risk patients. He concluded that as the demand for ECMO is only going to increase, it is important to restructure our referral model to allow for centralized coordination of care to expand from our current hub-and-spoke model in the United States.
The next presenter, Dr. Meltzer, Clinical Professor of Anesthesiology and Critical Care Medicine, Chief of the Division of Critical Care Medicine and Medical Director of the Cardio-Thoracic Intensive Care Unit at the Ronald Reagan UCLA Medical Center, discussed various care models for staffing ECMO care within a hospital or unit. He stated that ECMO patients must be cared for by an ECMO specialist which can be registered nurses (RNs), registered respiratory therapists (RRTs), or certified clinical perfusionists with advanced training in ECMO. He emphasized that whichever staffing system is utilized, it must fit the specific hospital or institution. Frequent exposure to ECMO care is important to maintain proficiency in caring for these critically ill patients by a multidisciplinary team.
The different staffing models include perfusion-based, RN-based, RRT-based, or hybrid-based ECMO specialists. The perfusion-based model is the traditional model, but has limited availability in some centers as there is currently a national shortage of perfusionists. Perfusionists are typically more experienced in the OR environment and cannot provide nursing care (ECMO-care specific). However, this model is common in areas with low ECMO volumes. Even in those low-volume centers, this model could contribute to workload strain on the perfusionist teams if there is high ECMO demand, possibly limiting the bandwidth for surgical cases requiring cardiopulmonary bypass.
The RN-based model has advantages of providing a 1:1 ratio and, since there is more flexibility in RN’s skill sets, they can be floated to ECMO care in high-demand periods and back to the regular ICU care pool when ECMO care is in lower demand. Disadvantages of the RN-based staffing system include ongoing competency training which is expensive and does require the availability of additional trained personnel (resource specialist) but is best utilized in large-volume ECMO centers. That said, with a large-number of ECMO specialists each individual may not have high numbers to maintain experience so maintenance training is mandatory. The RRT-based staffing model shares the same flexibility benefits and continued competency training disadvantages as the RN-based model. This model may also require perfusionists to assist with cannulation and priming of the system.
The hybrid-based model can take advantage of the “flex” capacity by merging these care teams but heterogeneous backgrounds can lead to challenges for training as each group has a different area of expertise at baseline. It is a safe model and may be needed more commonly as ECMO demand increases. For implementing and selecting an ECMO staffing model, Dr. Meltzer stated it really depends on the type of ECMO requiring staffing, census of ECMO patients for adult and pediatric units and the cost of training and retaining personnel to determine the ideal model for a given hospital. He closed by emphasizing that ECMO care is a “team sport” and building a multidisciplinary team and high volume of ECMO care has been associated with improved outcomes.
The last panelist for this excellent session was Dr. Dhillon, Clinical Associate Professor of Anesthesiology and Division Chief for Critical Care, Director of Quality and Medical Director of the MCS and Transplant ICU at the University of Southern California. Dr. Dhillon’s talk focused on the emotional burden of ECMO programs and opened with summarizing the survival rates and high cost of ECMO in the context of an increasing demand for ECMO support. She also emphasized that these reported financial costs do not include the price the provider pays in terms of burnout, ethical or moral distress and long hours, which contribute to provider turnover and loss of providers, increasing costs to 1.5-3 times a provider’s salary.
These patients have very long hospital stays and an institution’s policies regarding acceptance of patients and morale can vary based on precedent. Poor outcomes can contribute significantly to burnout in healthcare workers including emotional exhaustion, depersonalization and low sense of personal accomplishment. However, one size does not fit all regarding drivers of burnout for different individuals, types of providers and institutions. The complexity of ECMO units can contribute to burnout and moral distress is common, especially in RNs. Moral distress has been found to particularly focus around end-of-life issues and team communication, nonbeneficial therapies and constraints on capacity and resources. The ECMO unit compounds many of these stressors as it has a high mortality rate, large number of end-of-life discussions, increased workload, and many multidisciplinary teams which can cause stress with communications. Dr. Dhillon discussed that the solution is highly dependent on exploring the local culture and understanding that each provider type or hospital is not monolithic and the stressors can vary over time and amongst individuals. There needs to be a mindful approach to addressing flexible scheduling, empowering and engaging providers in quality projects and research and including them in the multidisciplinary approach to protocol development and unit-wide decisions. Dr. Dhillon closed by emphasizing that cherishing the wins is important to maintain morale which helps to shift focus to the benefits of these therapies.