Single Care Giver Model for ECMO Staffing

Jonathan Kozinn, MD

Department of Anesthesiology and Critical Care Medicine, Saint Luke’s Hospital

Assistant Professor, Anesthesiology, University of Missouri, Kansas City

Disclosures

• I have no conflicts of interests

• I receive no outside funding related to this topic

Acknowledgements

• Troy Sydzyik, MPS, CCP- Course materials, syllabi, statistics all used with permission

Extracorporeal Life Support

• Restores oxygen delivery through either:

Increasing blood oxygen content

AND/OR

Improving Cardiac Output

• Is temporary

• Sustains life while bridging to decision,

device, organ recovery or replacement

4

Postulate: ECMO is no longer experimental

Controversy: Initial Studies Did Not Show Benefit• Zapol; JAMA, 1979

– Inexperience

– older equipment

– too many centers

– inadequate training

– VA-ECMO for respiratory failure

• Morris; Am J of Respiratory and Critical Care Medicine; 1994– older equipment

– High Peak pressures (Inappropriate Ventilation)

– ECMO facilitated CO2 removal

10

>> 70% Survival

Additional Studies Suggesting Benefit• CESAR, Lancet 2009

• ANZA, JAMA 2009

• Referral to an Extracorporeal Membrane Oxygenation Center and Mortality Among Patients With Severe 2009 Influenza A(H1N1), JAMA 2011

• Pham et. Al Extracorporeal membrane oxygenation for pandemic influenza A(H1N1)-induced acute respiratory distress syndrome: a cohort study and propensity-matched analysis. Am J Respir Crit Care Med 2013; 187:

12

J Heart Lung Transplant 2013;32:157–187

ECMO Adult Cardiac

13

ELSO Registry Data 2018

ECMO Adult Respiratory

14

ELSO Registry Data 2018

Extracorporeal Life Support Org. (ELSO)

15

ELSO Registry Data 2018

Our Equipment is Improving

First report of bedside ECMO in adult - 1971

Hill JD, N Engl J Med 286: 629, 1972, From Bartlett

Innovations

• Oxygenator

– PMP hydrophobic hollow fiber

– Increased durability

– High gas exchange performance

– Low pressure drop

• Heparin coated circuits

– Increased biocompatibility

– Less thrombogenic

• Vascular access improved

– Single site cannulation

• Low pressure centrifugal pumps

– Less hemolysis

• Portable

– Miniaturization

18

Innovations: Single-Site Cannulation

Increasing Survival

With ECMO Becoming Standard Therapy, How do we Staff for it?

• Example: Current high intensity life saving continuous therapies:

– Mechanical ventilation

– Dialysis

ECMO Staffing Models• Multiple Caregiver:

– ECLS Specialist is not the bedside nurse: May have one ECLS specialist per pump, or one ECLS specialist for more than one pump

– Bedside Nurse: May be one to one or more than one to one

– ECMO Physician

– Bedside Physician

• Single Caregiver:

– ECLS specialist is the bedside nurse

– Critical Care physician is the bedside physician

• Perfusionists may serve in the role of ECMO specialist

ECMO Team at Saint Lukes

• Single caregiver model for physicians and nurses

• The bedside nurse is also the ECMO nurse

– This nurse is responsible for both the bedside needs of the patient and the management of the ECMO circuit

– Internally developed training program and bedside mentorship

• The critical care physician is also the ECMO physician

– This physician is responsible for both the medical needs of the patient and the management of interaction between the patient and the circuit

– Performs cannulation and decannulationfor VV-ECMO alongside a CT surgeon

• Cardiac surgeons perform VA-ECMO cannulationand are on call for assistance

• Perfusionists are on call, but not in house, 24/7. Round on patients daily to twice daily (once on weekends.)

• Pharmacists are trained in the interaction of medications with the circuit

– Oxygenator will bind certain drugs• Respiratory therapists

• Nutritionists, Physical Therapy, Speech therapy, social work, etc.

24

Advantages of Single-Caregiver Model

• OWNERSHIP

• Expandability

• Flexibility

• Cost

• Workforce availability

• Job Satisfaction

Ownership

• The patient is the most important component of the circuit

• Avoids diffused responsibility

Eligibility to Become an ECLS Specialist at Saint Luke’s

• Perfusionists- Need a little additional training/competencies

– VAD training, general department competencies

• Nurses- Need a lot of additional training and competencies in order to become an ECLS specialist

– Experience

– Pre-requisite competencies

– Demonstrations of competence

– Must be a CVICU nurse: Agency and float cannot become ECLS specialists

Demonstration of Appropriate Experience and Competency for Nurses: Level System

• Level 1 is a new graduate

• Level 5 is a nurse with several years experience and demonstrated training and competency in:– Management of the hemodynamically unstable patient

– Management of the patient on a ventilator

– Management of Cardiogenic, hemorrhagic, and distributive shocks

– Management of the patient on CRRT

– Management of the patient with an IABP

– Management of active bleeding

– Management of dysrhythmias

– Management of VAD patients

– Management of liver and heart transplant patients

Responsibilities of the Nurse ECLS Specialist• Ongoing nursing care of the

ECMO patient.• Examines the complete circuit for

clots, air, and general integrity • Checks level and temperature of

water for heater-cooler• Checks power supply • Reviews schedule of

anticoagulation and lab tests.• Troubleshoots until problem is

resolved or perfusion arrives.

• Performs and documents the following at the start of shift and on an hourly basis– Complete circuit check– Membrane gas mix and flow– SvO2 readings– Water bath temperature– Pump flow rate– Circuit pressures– Presence/absence of clots or air

Role of the Perfusionist

• Assembling the ECMO circuit and priming procedures

• Initiation

• Circuit change-outs

• Equipment maintenance

• Initial and ongoing education of ECMO clinical specialists

• Resource person for problem-solving

Training Program

Training Program:

Training Program:

Training Program:

Resource guides

Water Drills

• Primed ECMO circuit with a bridge between drainage and return limbs

• Simulation of possible pump failures

• Open book- May use resource guides, just like in real life

Water Drills• Must Identify Circuit Components

• Must be able to troubleshoot circuit and handle failures• Venous Chatter• Kink• Stopcock Fluid Leak• P1a and P1b Pressures• P2 Pressures• Thrombus• Bubble Alarm• Air in Cone• Clot in cone• Cone Failure• Drive Motor Failure• SCPC Failure

• SCP Flow Controller Failure• Oxygenator Gas Exchange Failure• Oxygenator Heat Exchange Failure• Heater Failure• Power Failure• Saturation Monitor Failure-SVO2• Oxygen Blender Failure• Oxygen Analyzer Failure• Decannulation

Exam

• 50 question multiple choice test

• Tests on physiology, pharmacology, patient and circuit management for patients on ECMO

• Passing the test is required to pass the course

Sample Questions

Maintaining Competencies

• Yearly ECMO training including water drills

– Water drills review all the scenarios in the initial training

– Four hour course

• Additional requirements for yearly cardiac education

• Additional requirements for additional stroke education

“Single-Caregiver” Physician• Critical Care physician serves as the ECMO Physician

– Most are also CV Anesthesiologists, so have prior experience working with perfusionists

• Manages both the circuit and the patient

– Adjusts sweeps and flows based on patient condition

– Inspects circuit daily

– Clinical decision maker regarding anti-coagulation

– Writes daily ECMO notes

• Responsible for developing and implementing weaning plan

• Responsible for cannulation and decannulation of VV-ECMO

• On-call 24/7. Always a critical care physician in-house (may not be an ECMO phyisician) who can provide assistance in an emergency.

Results: VV ECMO – Influenza

2013-14Saint Luke’s Hospital

• 11 cases of severe respiratory failure

• Longest support 48 days – lived

• 80% survival to discharge

VV ECMO 2008-2017 - 61 patients

Overall survival to discharge 66%

Results: VA-ECMO (Through October, 2017)St. Luke’s Hospital

• VA ECMO - 36 pts (47%)

• ECPR - 6 pts (33%)

43

Conclusion:• With appropriate implementation, a single caregiver approach may be

used successfully

• Removes a significant burden from perfusionists

– Without single caregiver model, an additional perfusionist may be required to be on call

• Allows more complete “ownership” of patients

• Enables flexibility when the need arises

– During the 2013/2014 H1N1 influenza epidemic, we had nine patients on ECMO at one point in time