Extracorporeal Membrane Oxygenation: Opportunities for Expanding Nurses' Roles.

Abstract

The increasing complexity of contemporary critical care units and improvements in health care technology is mirrored by an increase in the use of extracorporeal membrane oxygenation (ECMO).1 The use of ECMO therapy is escalating, from 2354 cases at 125 ECMO centers in 2010 to nearly 11 000 cases at 265 centers in 2019.2 ECMO supports critically ill patients with refractory cardiac and/or respiratory failure3 and is reserved for the sickest of patients who likely would otherwise die before their heart and/or lungs could recover.4 It has the potential to benefit patients across the life span, from neonates to older adults. While ECMO is a life-saving therapy and serves as a bridge between cardiorespiratory failure and disease recovery or transplant, it presents substantial risks of significant morbidity and mortality.3Although the ECMO circuit has traditionally been managed by perfusionists, in recent years, advanced practice and critical care bedside nurses have solidified their status as competent in high-acuity assessment and have risen to meet the need to reduce costs and improve continuity of care. In many hospitals, nurses are responsible for managing key components of the care of patients on ECMO beyond typical bedside intensive care unit (ICU) care.5 In this article, we will outline the challenges of caring for patients requiring ECMO support and illustrate why critical care bedside nurses and acute care nurse practitioners (ACNPs) are uniquely positioned to meet these challenges and improve care.The use of ECMO buys time for transplant or curative surgery for many children who otherwise would not have survived to adulthood. Although neonatal and pediatric survival rates are slightly higher than in the adult population, the care of patients under 18 requiring ECMO support still presents considerable risks for significant morbidity and mortality.2 In 2019, 975 neonates and 1555 children required ECMO support in the United States, most commonly as a result of congenital cardiopulmonary disorders or acute respiratory distress syndrome.2 In addition to increases in cases among older infants and children, the complexity of cases and the range of indications for ECMO have also increased.6 Despite this rising use of ECMO in the pediatric populations, ECMO support for greater than 21 days has been associated with poorer survival in children, particularly in neonates with congenital anomalies.7There is a high incidence of neurologic and neurodevelopmental morbidities among pediatric survivors of ECMO. A 2018 literature review showed that more than half of former pediatric ECMO patients have a decrease in Pediatric Cerebral Performance Category from baseline of 3 or more points.8 Furthermore, in the included studies, between 31% and 53% of pediatric ECMO survivors had quality of life scores greater than 1 standard deviation less that the scores of other children their age.8 Long-term outcomes should be considered and discussed with parents throughout the course of illness.7 Given these outcomes, the prolonged use of ECMO support also raises ethical dilemmas about when to offer ECMO support and when to withdraw therapy, as well as concerns about informed consent, futility, and moral distress for both patients and family members.6 This complex legal and ethical milieu underscores the importance of support services, such as palliative care, for patients, their families, and health care providers.In the adult population, ECMO is most often used in patients with severe cardiogenic shock or acute respiratory distress syndrome secondary to infection.2 Especially for older patients with more comorbidities prior to cannulation, ECMO carries higher risk for morbidity and mortality in the adult population.3 The Extracorporeal Life Support Organization (ELSO) reports that 60% of adults who require venovenous ECMO and 43% of those who receive venoarterial ECMO survived to hospital discharge or transfer. Only around 29% of adults who received ECMO for cardiopulmonary resuscitation survived.2 For adult patients, ECMO is intended to be an intensive, short-term therapy and is not a permanent solution for cardiopulmonary failure. Longer ECMO support times are associated with a higher likelihood of complications like thromboembolism, hemorrhage, infection, kidney injury, and limb ischemia.3 Even if they live to hospital discharge, adult ECMO survivors have significantly lower health-related quality of life and lower physical functioning scores than other adults their age.9Despite the severity of illness necessitating ECMO support and high likelihood of complications, discussion of the role of palliative care in ECMO literature is minimal. Because of their proximity to patients and training in holistic, integrated care, critical care bedsides nurses and ACNPs are uniquely positioned to deliver primary palliative care to patients on ECMO. In doing so, they can improve communication, support decision-making and goals of care conversations, reduce patients’ symptoms and suffering, and improve the overall quality of life for patients and family members.10 In times when more specialized expertise is required, they can also be a critical liaison with specialist palliative care teams.Although the number of ECMO cases and centers certified to care for these patients have sharply risen in recent years, in-hospital mortality rates have remained relatively consistent at around 40% to 50%.3 Maintaining an ECMO program requires an extensive, specially trained interprofessional team including surgeons, critical care bedside nurses, perfusionists, respiratory therapists, emergency medicine physicians, pulmonologists, cardiologists, and intensivists.11 Because of the complexity of underlying disease processes and the necessary multidisciplinary approach, managing ECMO patients can be very costly and difficult for staff, particularly in hospitals where the ECMO case volume is low.5 After the 2009 H1N1 pandemic saw an increase in ECMO cases and a shortage of prepared, properly staffed ECMO centers, ELSO developed new guidelines for ECMO centers that recognized specially trained critical care bedside nurses as ECMO specialists.12 As ECMO care becomes increasingly nurse-driven, institutions must find new ways to support their nursing staff by providing means for specialized training and professional development. Especially during the COVID-19 pandemic when the use of ECMO as a supportive therapy for severe acute respiratory distress syndrome has increased, it is important to consider the expertise and resources required to successfully care for patients on ECMO and design staffing models that maximize patient safety and quality of care.13Advances in ECMO technology in recent years have made the overall management safer and more streamlined but no less precarious.3 In part because of these advancements, critical care bedside nurses with specialty training in ECMO management are assuming much of the care traditionally assigned to perfusionists.5 This creates opportunities for integrated and holistic care. With adequate training and a perfusionist available to assist during emergencies, critical care bedside nurses can safely provide comprehensive patient care while monitoring the ECMO circuit.5 A cost analysis undertaken in 2015 of transitioning from perfusionist-led care to specially trained nurse–led care in 1 ECMO center showed that nurse-led care reduced costs by 61% or $366 264 without adversely impacting patient outcomes.12 Overall, transitioning to a model where critical care bedside nurses care for the patient and monitor the circuit lowers costs, reduces the number of staff, and improves continuity of care.In addition to critical care bedside nurses assuming the clinical tasks traditionally assigned to perfusionists, ACNPs are increasingly supplementing the efforts of intensivists who have traditionally managed the medical care of patients on ECMO. ACNPs can coordinate all aspects of a critically ill patient’s care, from obtaining an admission history to developing a differential diagnosis and directing the plan of care. Airway and ventilator management, vasopressor initiation and titration, and sedation and pain management all fall within ACNPs’ scope of practice.1 Although our review of state-specific scope of practice laws for APRNs revealed no mention of ECMO, we believe that ACNPs are well-positioned to manage patients on ECMO. Ensuring institutions have adequate procedures and policies is important in maintaining standards. Although a surgeon should perform ECMO initiation and cannula manipulation, the large majority of day-to-day ECMO management falls within the ACNPs’ scope of practice. Responsibilities including managing changes to the blood flow rate of the ECMO circuit, controlling the amount of carbon dioxide removal, providing anticoagulation, and administering blood products can be managed by a trained ACNP.14 An overview of ACNPs’ scope of practice related to ECMO management is presented in the Table.There are many potential benefits to expanding the role of ACNPs managing the care of patients on ECMO. First, prior studies have reported that ACNP coverage in ICUs reduces costs while maintaining, if not improving, the standard of patient care and safety.1 Second, physicians who staff ICUs often rotate between different units and are not always familiar with the unique needs of patients on ECMO nor do they necessarily have the opportunity to develop relationships with patients and family members. A 2019 study showed that there was a significant association between provider continuity of care and the likelihood of patient discharge.15 Because ACNPs are typically assigned to a single unit, they are able to consistently care for long-term patients and maintain regular communication between rotating medical/surgical residents, fellows, and attending physicians, as well as patients and their family members. Furthermore, managing the care of ECMO patients requires an adequate amount of training and continuing education to maintain proficiency.5 Acute care nurse practitioners’ being assigned to a single ICU provides an advantage in managing ECMO patients; caring for ECMO patients more frequently allows them to maintain proficiency in providing this type of care. With adequate training and experience, ACNPs can become competent in ECMO management.12 They complement the intensivist’s role in managing the care of patients by executing evidence-based clinical pathways, improving continuity of care, and serving as an available resource for other members of the health care team.ACNPs, together with critical care bedside nurses, are uniquely positioned to provide family-focused, high-quality ICU care and can introduce primary palliative care services into the treatment plan when appropriate.10 Because of the severity of their underlying disease and potential for complications, only about half of patients who are sick enough to require ECMO support are expected to survive.2 Among those who do survive, nearly half report long-term cognitive and psychiatric sequelae.16 Patients requiring ECMO support are undoubtedly some of the sickest patients seen in ICUs, and the high probability of mortality and high symptom burden they face reflect a critical need for palliative care services.4 These patients have the potential to benefit from structured goals of care conversations, quality of life assessment, targeted symptom management, and psychological and social support. Acute care nurse practitioners’ education and training in holistic models of care make them excellent candidates for facilitating primary palliative care.17 The NPs’ role as facilitators of palliative care is not limited to the ICU setting but can continue through to the transition to other care settings and eventually home.There are currently no reported studies related to ACNPs’ roles specific to ECMO management, but there are multiple published studies that examine the effectiveness and safety of ACNPs in the cardiothoracic ICU setting. In a randomized controlled trial of patients undergoing cardiothoracic surgery, Goldie et al18 found no difference in hospital length of stay, 60-day readmission rates, number of postoperative complications, or attendance of follow-up appointments between those whose ICU care was led by APRNs and those whose ICU care was led by physician hospitalists. In fact, the same study demonstrated that the patients whose care was led by ACNPs had higher satisfaction scores related to teaching, answering of questions, listening skills, and pain management.18 Skinner and colleagues19 found that there was a significant decrease in mortality among patients in a cardiothoracic ICU after implementing a staffing change that expanded the nurse practitioner role from supporting physician coverage to being the sole in-hospital providers on nights and weekends. The new staffing pattern also decreased costs and allowed medical residents more time in the operating room, all without compromising patient safety.19 None of these studies specifically mentioned ECMO management in their discussion. Given the increasing emphasis on the role of the APRN in ECMO care, this remains a fertile area for research.Expanding the role of critical care bedside nurses and ACNPs managing patients on ECMO supports the mission to deliver holistic, patient-centered care and to lower health care costs without sacrificing quality. In taking on this new responsibility, nurses require education and institutional support to embrace their extended role. In addition to on-the-job, mentored training, high-fidelity interprofessional simulation has been shown to significantly improve nurse knowledge of the ECMO circuit, safety procedures, and emergency troubleshooting.20 Continuing education and regular exposure to high-acuity patients requiring ECMO support is essential to maintaining proficiency.11 Acute care nurse practitioners, in partnership with critical care bedside nurses and other members of the health care team, have the potential to increase hospitals’ capacity to treat patients requiring ECMO support and improve the overall quality of care for this patient population.