Extracorporeal Membrane Oxygenation Simulation Research Articles

Pulmonary artery catheter and veno-arterial ECMO training for cardiology fellows: evaluation of a simulation-based program

Abstract Funding Acknowledgements None. Introduction Proficiency in pulmonary artery catheter (PAC) use and extracorporeal membrane oxygenation (ECMO) therapy is crucial for delivering high-quality critical care and improving patient outcomes in cardiac intensive care units (CICUs). Both procedures are conducive to immersive simulation training. Our study focuses on evaluating the efficacy of a simulation-based training program in these specific domains for cardiology fellows. Methods Cardiology fellows participated in two blended learning courses: one on PAC and one on veno-arterial ECMO. The PAC course consisted of a pre-course test of 12 multiple-choice questions assessing knowledge of indications, contraindications, and interpretation of PAC, a 45-minute didactic lecture, followed by a case-based, hands-on simulation training session for 60 minutes. The ECMO course consisted of a pre-course test of 15 multiple-choice questions assessing indications, contraindications, ECMO physiology, and circuit management, a 30-minute didactic lecture, followed by a case-based, hands-on simulation training session. Fellows completed a multiple-choice post-course test within 72 hours post-simulation training. All test questions were designed by experts in cardiac critical care. Results A total of 18 cardiology fellows completed the PAC simulation and 16 completed the ECMO simulation. For the PAC group the average score on the pre-exam was 60%, while on the post exam, the average score increased significantly to 86%, representing a 26% increase (p=0.04). For the ECMO training, the average score on the pre-exam was 67%, and on the post exam, the average score increased substantially to 90% in the ECMO exam, there was a 23% increase in the average post-exam score compared to the pre exam was recorded (p=0.05). Conclusion Simulation-based training in PAC and ECMO has a highly positive impact on the knowledge acquisition of cardiology fellows, with statistically significant increases in average post-exam scores in both areas. These findings not only validate the value of immersive simulation-based training programs but also underscore the need for further investigation into the implementation of educational initiatives aimed at enhancing care in cardiogenic shock.

Efficacy of a Single Day Extracorporeal Membrane Oxygenation Training Course for Critical Care Air Transport Team Eligible Personnel.

Extracorporeal membrane oxygenation (ECMO) is an advanced medical technology that is used to treat respiratory and heart failure. The U.S. military has used ECMO in the care of combat casualties during Operation Enduring Freedom and Operation Iraqi Freedom as well as in the treatment of patients during the recent Coronavirus Disease 2019 pandemic. However, few Military Health System personnel have training and experience in the use of ECMO therapy. To address this dearth of expertise, we developed and evaluated an accelerated ECMO course for military medical personnel. To compare the efficacy of an accelerated ECMO course for Military Health System critical care teams. Seventeen teams, each consisting of a physician and nurse, underwent a 5-h accelerated ECMO course. Similar to our previous live-tissue ECMO training program (phases I and II), each team watched prerecorded ECMO training lectures. Subjects then practiced priming the ECMO circuit, cannulating ECMO, initiating ECMO, and correcting common complications on an ECMO simulation model. An added component to this phase III project included transportation and telemedicine consultation availability. Training success was evaluated via knowledge and confidence assessments, and observation of each team attempting to initiate ECMO on a Yorkshire swine patient model, transport the patient model, and troubleshoot complications with the support of telemedicine consultation when desired. Seventeen teams successfully completed the course. All seventeen teams (100%) successfully placed the swine on veno-arterial ECMO. Of those, 15 teams successfully transitioned to veno-arterial-venous ECMO. The knowledge assessments of physicians and nurses increased by 12.2% from pretest (mean of 62.1%, SD 10.4%) to posttest (mean of 74.4%, SD 8.2%), P < .0001; their confidence assessments increased by 41.1% from pretest (mean of 20.1%, SD 11.8%) to posttest (mean of 61.2%, SD 18.6%). An abbreviated 1-day lecture and hands-on task-trainer-based ECMO course resulted in a high rate of successful skill demonstration and improvement of physicians' and nurses' knowledge assessments and confidence levels, similar to our previous live-tissue training program. When compared to our previous studies, the addition of telemedicine and patient transportation to this study did not affect the duration or performance of procedures.

Ambulatory extracorporeal membrane oxygenation simulator: The next frontier in clinical training.

Current medical simulators for extracorporeal membrane oxygenation (ECMO) are expensive and rely on low-fidelity methodologies. This creates a challenge that demands a new approach to eliminate high costs and integrate with critical care environments, especially in light of the scarce resources and supplies available after the COVID-19 pandemic. To address this challenge, we examined the current state-of-the-art medical simulators and collaborated closely with Hamad Medical Corporation (HMC), the primary healthcare provider in Qatar, to establish criteria for advancing the cutting-edge ECMO simulation. This article presents a comprehensive ambulatory high-realism and cost-effective ECMO simulator. Over the past 3years, we have surveyed relevant literature, gathered data, and continuously developed a prototype of the system modules and the accompanying tablet application. By doing so, we have successfully addressed the issue of cost and fidelity in ECMO simulation, providing an effective tool for medical professionals to improve their understanding and treatment of patients requiring ECMO support. This paper will focus on presenting an overall ambulatory ECMO simulator, detailing the various sub-systems and emphasizing the modular casing of the physical components and the simulated patient monitor.

ECMO simulation: How much, who to train, and a review of cost, fidelity and performance.

Extracorporeal Membrane Oxygenation (ECMO) is a high-risk, low-volume procedure requiring repetition, skill and multiple disciplines with fidelity of communication. Yet many barriers exist to maintain proficiency and skills with variable cost and fidelity. We designed and implemented a low-cost monthly ECMO simulation and hypothesized providers would have increased familiarity and improved teamwork. We also review some key elements of cost, fidelity and evaluation of effectiveness. A structured, 1-hour ECMO simulation was performed on a customized mannikin on a monthly basis in 2022. Qualitative surveys were administered to each member post-simulation. Answers were categorized by theme, including satisfaction of patient care, evaluation of self and team dynamics, and areas for improvement. Most participants were satisfied with their ability to take care of the patient, with common themes of communication and coordination of roles. Identified areas of improvement were mostly limited to technical skills, and soft skills such as communication and teamwork. We designed and implemented a low-cost, monthly and multi-disciplinary ECMO simulation program with overall positive feedback and identified areas for improvement. There remains variability in cost, fidelity and evaluation of performance and retention. There may be a need to create guidelines for ECMO simulation training that can be applied at all institutions utilizing ECMO for patient care.

IoT-based mock oxygenator for extracorporeal membrane oxygenation simulator.

Training is an essential aspect of providing high-quality treatment and ensuring patient safety in any medical practice. Because extracorporeal membrane oxygenation (ECMO) is a complicated operation with various elements, variables, and irregular situations, doctors must be experienced and knowledgeable about all conventional protocols and emergency procedures. The conventional simulation approach has a number of limitations. The approach is intrinsically costly since it relies on disposable medical equipment (i.e., oxygenators, heat exchangers, and pumps) that must be replaced regularly due to the damage caused by the liquid used to simulate blood. The oxygenator, which oxygenates the blood through a tailored membrane in ECMO, acts as a replacement for the patient's natural lung. For the context of simulation-based training (SBT) oxygenators are often expensive and cannot be recycled owing to contamination issues. Consequently, it is advised that the training process include a simulated version of oxygenators to optimize reusability and decrease training expenses. Toward this goal, this article demonstrates a mock oxygenator for ECMO SBT, designed to precisely replicate the real machine structure and operation. The initial model was reproduced using 3D modeling and printing. Additionally, the mock oxygenator could mimic frequent events such as pump noise and clotting. Furthermore, the oxygenator is integrated with the modular ECMO simulator using cloud-based communication technology that goes in hand with the internet of things technology to provide remote control via an instructor tablet application. The final 3D modeled oxygenator body was tested and integrated with the other simulation modules at Hamad Medical Corporation with several participants to evaluate the effectiveness of the training session.

Development of pediatric multidisciplinary extracorporeal membrane oxygenation simulations: A novel educational program to enhance team communication and emergency preparedness.

Pediatric extracorporeal membrane oxygenation (ECMO) is a high risk, low-volume technology. Infrequency of this technology and associated complications may translate to unfamiliarity of identification and management of potentially life-threatening events, which may require knowledge and procedural skills to be performed quickly. Providers involved in managing ECMO must be able to promptly identify and initiate management for such events, particularly when surgical colleagues are not readily available. A multidisciplinary ECMO simulation program was implemented in a tertiary children's hospital. Over 18months, a prospective, observational study was conducted evaluating simulations involving circuit and patient emergencies, teamwork and communication behaviors and technical skills. An on-line survey was sent to participants following sessions to evaluate post-simulation confidence, lessons learned and potential barriers to implementation of necessary skills and behaviors. Ten simulation sessions occurred during implementation. Mean participants per session was 7 (range: 5-11). Eight Pediatric Cardiac Intensive Care Unit attendings, four Advance Practice Nurses, 54 pediatric intensive care unit registered nurses, and 55 pediatric respiratory therapists attended. Tasks with highest self-reported increase in confidence were related to (1) diagnosis (tension pneumothorax, oxygenator failure, and ventricular tachycardia), (2) fluid administration and (3) early and efficient mobilization for ECPR, with less reported confidence increase with technical skills More than 90% of participants provided a task or behavior they would implement if a specific emergency was encountered in real-life following simulation training. Real-life application occurred following simulations with participants reporting direct impact of training on their ability to perform the skill efficiently and correctly. Implementation of ECMO multidisciplinary simulations provides structured opportunities for the team to learn and practice ECMO skills together in scenarios they may encounter without surgical presence. Ensuring competency of providers through implementation of such a program may improve patient safety through enhanced team communication, knowledge, and hands-on experience.

ECMO simulation training during a worldwide pandemic: The role of ECMO telesimulation.

Extracorporeal membrane oxygenation (ECMO) is a supportive therapy used in the most severe forms of acute respiratory distress syndrome. Due to its intrinsic complexity and relatively low annual volume, simulation is essential for efficient and appropriate ECMO management. COVID-19 has limited the opportunities for high-fidelity in-person simulation training when many hospitals are looking to expand their ECMO services to battle the ongoing pandemic. To meet this demand, the National Cardiovascular Center Harapan Kita, Jakarta, Indonesia, conducted a 3-day ECMO course entailing online didactic lectures (adult and paediatric stream), water drills and telesimulation. The purpose of the study is to report the evaluation result of this novel model of education during COVID-19 outbreak. Participants were given an ECMO knowledge pre-course and post-course test and a telesimulation evaluation survey at the conclusion and these data were collected. The course was attended by 104 physicians, critical care nurses and perfusionists. Pre-course and post-course assessments showed a significant improvement in ECMO knowledge (60.0% vs 73.3%, respectively). Overall, the participants rated the telesimulation positively, and most found it acceptable to in-person simulation training considering the pandemic restrictions. Despite the complexities of ECMO, our recent experience demonstrates ECMO education and simulation delivered online is feasible, welcomed and supportive of a change in ECMO training course format. As we incorporate more innovative digital technologies, telesimulation may further enhance the quality of future ECMO training.

88 Streaming High-Fidelity ECMO Simulation from a Moving Ambulance

The Trust needed to offer extra-corporeal membrane oxygenation (ECMO) The aim of the study was to deliver high-fidelity ECMO simulation in a moving vehicle while simultaneously allowing candidates and faculty to watch the scenarios take place remotely.A custom video-over-IP system was used to run three camera feeds and a patient monitor output. A laptop captured this in a quad-view format and streamed it to a dedicated video streamer. This was then networked locally via a router with a secondary laptop which displayed the stream. The router was connected to a mobile 4G modem, allowing the secondary laptop to share this video stream via Microsoft Teams (MS Teams). In addition, a USB audio interface and microphones ensured intelligibility while the vehicle was in motion.Teaching groups were made up of 3–4 candidates from the ECMO team and 3–4 candidates from patient transport. Scenarios outlined a paediatric patient, currently on ECMO, being transferred to a specialist hospital in the region via ambulance. One or two candidates from each service would take part in the scenario and the remaining candidates would view the simulation in the centre debrief room. A technician in front of the ambulance controlled the simulator and monitored the streams. The lead ECMO specialist nurse spoke to the technician from the simulation centre via a mobile phone link. The role of a consultant was played by a member of the transport faculty on the ambulance. This allowed the faculty to oversee and prompt when necessary. Using MS Teams meant the stream could be shared with the debrief room at the centre, the control room, and with other interested parties outside of the centre. This created a unique learning experience where all candidates could see each scenario and play an active role in debrief when the ambulance returned to the centre. Successful delivery of this course will improve patient safety during potentially complex ECMO transfers. We hope to invite more remote participants via MS Teams to view the simulations and take part in the debrief, increasing learning opportunities for ECMO and transfer staff.

Acute Care Nurse Practitioner-Led Extracorporeal Membrane Oxygenation Simulation Training.

Acute Care Nurse Practitioner-Led Extracorporeal Membrane Oxygenation Simulation Training.

Needs Assessment and System Design of an Extracorporeal Membrane Oxygenation Simulation Learning System.

Nurses require training to manage extracorporeal membrane oxygenation (ECMO). Thus, the aim of this study is to investigate intensive care unit nurse needs and design an ECMO simulation learning system. A systemic needs analysis included interviews and a literature review. Nurses had three learning needs: pre-ECMO placement care, daily care during placement, and care for preparation of removal. The system design includes ECMO care knowledge, practice in simulations, and self-examination with a flexible learning methodology.

Simulation Versus Interactive Mobile Learning for Teaching Extracorporeal Membrane Oxygenation to Clinicians: A Randomized Trial.

Extracorporeal membrane oxygenation has become integral to critical care. Data informing optimal extracorporeal membrane oxygenation education modalities are lacking. We aimed to compare the effect of high-fidelity simulation versus interactive mobile learning on extracorporeal membrane oxygenation knowledge acquisition and retention among clinicians. Observer-blinded, randomized controlled trial. A single academic medical center. Forty-four critical care clinicians with limited extracorporeal membrane oxygenation experience. Participants were randomized to receive: 1) simulation: three high-fidelity training scenarios, 2) QuizTime: 15 total multiple-choice questions delivered over 3 weeks via mobile device, or 3) experiential: no formal training. Participants completed a survey, written knowledge examination, and simulation assessment prior to randomization, immediately following the intervention, and 4 month postintervention. The primary outcome was knowledge about extracorporeal membrane oxygenation assessed by score on the immediate postintervention written examination. Secondary outcomes included performance in extracorporeal membrane oxygenation simulation postintervention and 4 months later assessed by a rater blinded to group assignment. Clinicians randomized to simulation (n = 15), QuizTime (n = 14), and experiential (n = 15) had similar baseline characteristics. Adjusting for baseline knowledge, postintervention examination scores were higher in the simulation group (90.0%; interquartile range, 85.0-90.0%) than the QuizTime group (70.0%; interquartile range, 65.0-80.0%; p = 0.0003) and the experiential group (75.0%; interquartile range, 65.0-80.0%; p = 0.001). Scores did not differ between the groups at 4 months (p > 0.05 in all analyses). In postintervention extracorporeal membrane oxygenation simulations, the simulation group demonstrated shorter time to critical action compared with QuizTime (80.0 s [interquartile range, 54.0-111.0 s] vs 300.0 s [interquartile range 85.0-300.0 s]; p = 0.02) and compared with both QuizTime (45.0 s [interquartile range, 34.0-92.5 s] vs 255.5 s [interquartile range, 102.0-300.0 s]; p = 0.008) and experiential (300.0 s [interquartile range, 58.0-300.0 s]; p = 0.009) at 4 months. Simulation was superior to QuizTime and experiential learning with regard to extracorporeal membrane oxygenation knowledge acquisition. Further studies are needed to ascertain the effect of these interventions on knowledge retention, clinical performance, and patient outcomes.

Advanced Thermochromic Ink System for Medical Blood Simulation.

Simulators for extracorporeal membrane oxygenation (ECMO) have problems of bulky devices and low-fidelity methodologies. Hence, ongoing efforts for optimizing modern solutions focus on minimizing expenses and blending training with the intensive care unit. This is particularly evident following the coronavirus pandemic, where economic resources have been extensively cut. In this paper, as a part of an ECMO simulator for training management, an advance thermochromic ink system for medical blood simulation is presented. The system was developed and enhanced as a prototype with successful and reversible transitions between dark and bright red blood color to simulate blood oxygenation and deoxygenation in ECMO training sessions.

A Modular Approach for a Patient Unit for Extracorporeal Membrane Oxygenation Simulator.

Despite many advancements in extracorporeal membrane oxygenation (ECMO), the procedure is still correlated with a high risk of patient complications. Simulation-based training provides the opportunity for ECMO staff to practice on real-life scenarios without exposing ECMO patients to medical errors while practicing. At Hamad Medical Corporation (HMC) in Qatar, there is a critical need of expert ECMO staff. Thus, a modular ECMO simulator is being developed to enhance the training process in a cost-effective manner. This ECMO simulator gives the instructor the ability to control the simulation modules and run common simulation scenarios through a tablet application. The core modules of the simulation system are placed in the patient unit. The unit is designed modularly such that more modules can be added throughout the simulation sessions to increase the realism of the simulation sessions. The new approach is to enclose the patient unit in a trolley, which is custom-designed and made to include all the components in a modular fashion. Each module is enclosed in a separate box and then mounted to the main blood simulation loop box using screws, quick connect/disconnect liquid fittings, and electrical plugs. This method allows fast upgrade and maintenance for each module separately as well as upgrading modules easily without modifying the trolley’s design. The prototype patient unit has been developed for portability, maintenance, and extensibility. After implementation and testing, the prototype has proven to successfully simulate the main visual and audio cues of the real emergency scenarios, while keeping costs to a minimum.

A High-Realism and Cost-Effective Training Simulator for Extracorporeal Membrane Oxygenation

Medical simulators, employed in extracorporeal membrane oxygenation (ECMO), are burdened with costly equipment and low-fidelity methodologies. This dichotomy necessitated a new approach that eliminates high-costs and integrates with the critical care environment. This is especially applicable after the Coronavirus pandemic, where resources and supplies are evermore scarce. After examining the state-of-the-art and establishing a close collaboration with Hamad Medical Corporation (HMC), the main healthcare provider in Qatar, several criteria were identified to advance the cutting-edge. In this article, a high-realism, cost-effective ECMO simulator is presented. It runs on a novel blood simulation technology along with simulation modules. An instructor tablet application enables instructors to orchestrate the training experience wirelessly with real-time performance. It also includes a novel scenario designer for implementing consistent simulation curricula. A product-level simulator with high-fidelity casings is in the final integration phases. Current results include developing and testing the simulated blood circuit, simulation modules for hemorrhaging, line chattering, air bubbles noise, and a replicated console along with an integrated communications system. Nineteen specialists rated the fidelity of the system as highly realistic during a questionnaire-based study. It is expected to run a second study to evaluate the educational efficacy of the simulator as a first-of-its-kind in the region.

The inaugural Qatar Critical Care Conference with its Qatar Medical Journal Special Issue – An important milestone

© 2019 Hassan, Alinier, licensee HBKU Press. This is an open access article distributed under the terms of the Creative Commons Attribution license CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited.

A skills acquisition study on ECMOjo: a screen-based simulator for extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation relies heavily on didactic teaching, emphasizing on essential cognitive skills, but overlooking core behavioral skills such as leadership and communication. Therefore, simulation-based training has been adopted to instill clinical knowledge through immersive experiences. Despite simulation-based training's effectiveness, training opportunities are lessened due to high costs. This is where screen-based simulators come into the scene as affordable and realistic alternatives. This article evaluates the educational efficacy of ECMOjo, an open-source screen-based extracorporeal membrane oxygenation simulator that aims to replace extracorporeal membrane oxygenation didactic instruction in an interactive and cost-effective manner. A prospective cohort skills acquisition study was carried out. A total of 44 participants were pre-assessed, divided into two groups, where the first group received traditional didactic teaching, and the second used ECMOjo. Participants were then evaluated through a wet lab assessment and two questionnaires. The obtained results indicate that the two assessed groups show no statistically significant differences in knowledge and efficacy. Hence, ECMOjo is considered an alternative to didactic teaching as per the learning outcomes. The present findings show no significant dissimilarities between ECMOjo and didactic classroom-based teaching. Both methods are very comparable in terms of the learner's reported self-efficacy and complementary to mannequin-based simulations.

Simulation training for crises during venoarterial extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO) education, in particular with regards to crisis management during the provision of venoarterial extracorporeal membrane oxygenation (VA ECMO), is challenging due to its intrinsic characteristics-a complex, high risk, low volume clinical activity which requires dynamic decision making, interdisciplinary teamwork and communication, and rapid response. Simulation training that focuses on crisis resource management and interprofessional communication is well-suited to address these training needs. Institutional commitment to provide both capital and human resources is instrumental to the success of ECMO training programs. Future multicenter studies with standardized training curricula are required to investigate the impact of ECMO simulation training on patient outcome.

Towards the design and implementation of a human circulatory system for Extracorporeal Membrane Oxygenation simulation

Extracorporeal Membrane Oxygenation (ECMO) is a lifesaving procedure developed for the care of patients with short-term respiratory and/or cardiac issues (MacLaren et al., 2011). ECMO patients must be monitored twenty-four hours a day by an ECMO-trained multidisciplinary team. The trained healthcare professional needs to watch over fifty variables and rapidly intervene to assess and resolve any given emergency. Hence hands on training is very important for ECMO professionals to develop rapid and correct actions upon different scenarios. Simulation based training (SBT) offers ECMO practitioners an opportunity to develop the skills needed for the initiation of the ECMO procedure and the care of ECMO patients without exposing patients to undue risks (Al Disi et al., 2018). For ECMO to work, cannulation is required to reroute the blood flow to the machine rather than the lung and/or heart. Cannulation is the insertion of a cannula through the blood vessels. In collaboration with Hamad Medical Corporation (HMC), the main healthcare provider in Qatar, the aim of this project is to develop an effective, economical realistic, user-friendly, low-cost, and a multi-functional high-fidelity cannulation simulation mannequin.

Extracorporeal membrane oxygenation simulation-based training: methods, drawbacks and a novel solution.

Patients under the error-prone and complication-burdened extracorporeal membrane oxygenation (ECMO) are looked after by a highly trained, multidisciplinary team. Simulation-based training (SBT) affords ECMO centers the opportunity to equip practitioners with the technical dexterity required to manage emergencies. The aim of this article is to review ECMO SBT activities and technology followed by a novel solution to current challenges. The commonly-used simulation approach is easy-to-build as it requires a functioning ECMO machine and an altered circuit. Complications are simulated through manual circuit manipulations. However, scenario diversity is limited and often lacks physiological and/or mechanical authenticity. It is also expensive to continuously operate due to the consumption of highly specialized equipment. Commercial extensions can be added to enable remote control and to automate circuit manipulation, but do not improve on the realism or cost-effectiveness. To address those drawbacks, we are developing a standalone modular ECMO simulator that employs affordable technology for high-fidelity simulation.

Enhancing Clinical Learning Through an Innovative Instructor Application for ECMO Patient Simulators

Background.Simulation-based learning (SBL) employs the synergy between technology and people to immerse learners in highly-realistic situations in order to achieve quality clinical education. Due to the ever-increasing popularity of extracorporeal membrane oxygenation (ECMO) SBL, there is a pressing need for a proper technological infrastructure that enables high-fidelity simulation to better train ECMO specialists to deal with related emergencies. In this article, we tackle the control aspect of the infrastructure by presenting and evaluating an innovative cloud-based instructor, simulator controller, and simulation operations specialist application that enables real-time remote control of full-scale immersive ECMO simulation experiences for ECMO specialists as well as creating custom simulation scenarios for standardized training of individual healthcare professionals or clinical teams.Aim. This article evaluates the intuitiveness, responsiveness, and convenience of the ECMO instructor application as a viable ECMO simulator control interface.Method. A questionnaire-based usability study was conducted following institutional ethical approval. Nineteen ECMO practitioners were given a live demonstration of the instructor application in the context of an ECMO simulator demonstration during which they also had the opportunity to interact with it. Participants then filled in a questionnaire to evaluate the ECMO instructor application as per intuitiveness, responsiveness, and convenience.Results. The collected feedback data confirmed that the presented application has an intuitive, responsive, and convenient ECMO simulator control interface.Conclusion. The present study provided evidence signifying that the ECMO instructor application is a viable ECMO simulator control interface. Next steps will comprise a pilot study evaluating the educational efficacy of the instructor application in the clinical context with further technical enhancements as per participants’ feedback.