Extracorporeal Membrane Oxygenation Specialists Research Articles

Clinician Prediction of Survival vs Calculated Prediction Scores in Patients Requiring Extracorporeal Membrane Oxygenation.

Determining appropriate extracorporeal membrane oxygenation (ECMO) candidacy ensures appropriate utilization of this costly resource. The current ECMO survival prediction scores do not consider clinician assessment of patient viability. This study compared clinician prediction of survival to hospital discharge versus prediction scores. The aim of this study was to compare clinician prediction of patients' survival to hospital discharge versus prognostic prediction scores (Respiratory ECMO Survival Prediction [RESP] or Survival After Veno-Arterial ECMO [SAVE] score) to actual survival. This was an observational descriptive study from January 2020 to November 2021 conducted with interviews of nurses, perfusionists, and physicians who were involved during the initiation of ECMO within the first 24 hours of cannulation. Data were retrieved from the medical record to determine prediction scores and survival outcomes at hospital discharge. Accuracy of clinician prediction of survival was compared to the RESP or SAVE prediction scores and actual survival to hospital discharge. Accurate prediction of survival to hospital discharge for veno-venous ECMO by nurses was 47%, 64% by perfusionists, 45% by physicians, and 45% by the RESP score. Accurate predictions of patients on veno-arterial ECMO were correct in 54% of nurses, 77% of physicians, and 14% by the SAVE score. Physicians were more accurate than the SAVE score, P = .021, and perfusionists were significantly more accurate than the RESP score, P = .044. There was no relationship between ECMO specialists' years of experience and accuracy of predications. Extracorporeal membrane oxygenation clinicians may have better predictions of survival to hospital discharge than the prediction scores. Further research is needed to develop accurate prediction tools to help determine ECMO eligibility.

Implementing an Adult Extracorporeal Membrane Oxygenation Program During the COVID-19 Pandemic.

In response to the needs of patients infected with COVID-19, an interdisciplinary team was assembled to implement an adult extracorporeal membrane oxygenation (ECMO) program in the surgical ICU of a West Texas tertiary care hospital. Use of Extracorporeal Life Support Organization (ELSO) guidelines was essential to the development of this effort. The aim of this project was to develop, implement, and evaluate an adult ECMO program. A logic model was used in designing and evaluating the adult ECMO program. A 35-hour ECMO specialist training course was developed, and training began in August 2020, a month before implementation of the project began. Patient outcomes were measured between September 2020 and December 2021. Descriptive statistics were used to measure the clinical outcomes of interest. Seventeen newly trained ECMO specialists included experienced critical care nurses and respiratory therapists. Protocols were developed for the initiation of ECMO, and tracked patient outcomes included survival off ECMO, survival to discharge, major and minor complications, and length of stay. Nine patients had COVID-19 and demonstrated an 11.11% mortality rate after adult ECMO program implementation. Use of the ELSO professional guidelines to design and develop this project led to the achievement of a sustainable ECMO program. Hospital leaders can now implement adult ECMO programs amid other demands for resources that may be created by future pandemics.

Cannulate, Extubate, Ambulate: How the Pandemic Accelerated Development and Implementation of Early Mobility for Patients Requiring Extracorporeal Membrane Oxygenation

Objective: Extracorporeal membrane oxygenation (ECMO) is a lifesaving modality that was in great demand for persons with severe COVID-19 infection. Although mobility of these patients has previously been safely reported anecdotally, there were no established guidelines to implement in a greatly expanded patient population, as occurred in the pandemic period. We describe the development and implementation of a program (Cannulate, Extubate, Ambulate) for team-based safe mobilization. Methods: The 3-phase protocol advances based on patient alertness/ability to actively participate. A physical therapist determined initial stage and progression and recommended mobility activities for carryover by nurses and/or ECMO specialists between skilled sessions. Results: The mobility program has been successfully implemented for 104 patients with severe COVID-19 without significant adverse events. Most patients (51%) ambulated while cannulated, and 60% were able to discharge directly home after hospitalization. Conclusions: This safe, effective program allowed extension of physical therapy goals in a highly complex patient population during a time of very high demand. Making early mobility a team goal enhanced buy-in, instead of relying exclusively on rehabilitation providers for mobilization. Utilization of the Cannulate, Extubate, Ambulate program may assist other programs to minimize complications of immobility in the ECMO population.

Practice patterns in extracorporeal life support in tertiary cardiac intensive care units in north america: a survey-based analysis from the critical care cardiology trials network

Abstract Funding Acknowledgements Type of funding sources: None. Background The use of veno-arterial (VA) and veno-venous (VV) extracorporeal membrane oxygenation (ECMO) has significantly increased in the last decade. However, there is substantial variability in practice patterns between institutions. To date, the optimal ECMO program model is unclear and possible differences between ECMO centers in staffing, organization and team structure have been poorly characterized. Purpose Our aim was to describe contemporary practices of care for patients undergoing ECMO in tertiary cardiac centers in North America. Methods An 11-question anonymous survey was sent to all participating sites in the Critical Care Cardiology Trials Network (CCCTN), a prospective registry of advanced cardiac intensive care units (CICUs) in North America, coordinated by the TIMI Study Group. The survey evaluated ECMO staffing models, decision-making processes, cannulation and longitudinal care. Results The response rate was 100% (39/39) across CCCTN centers. The decision to proceed with VA ECMO was made as a team in 79% of the cases and in 58.3% of the VV ECMO cases, rather than by an individual specialty. An ECMO consult service was used in 67% of the centers, and integrated with the cardiogenic shock team in 58%. The most common specialty participating in the ECMO service was cardiothoracic surgery (CTS) (73.1%), followed by heart failure specialists (38.5%), with critical care cardiology (CCC) in only 23.1% of the centers (Figure 1A). In the majority of centers, VA ECMO cannulation was performed by CTS alone (46.2%), Interventional cardiology (IC) and CTS (38.5%), and IC alone (7.7%, Figure 1B). Cannulation for VA ECMO was not performed by intensivists at any center. VV ECMO cannulations were performed by CTS in 51.3%, intensivists in 17.9% and IC in 2.6% of the centers. VA ECMO patients were admitted to the cardiovascular surgical intensive care unit in 64.1% of centers, with 20.5 % admitted to the CICU (Figure 1C). VV ECMO patients were admitted to the cardiovascular surgical intensive care unit in 36.8% of sites, and the medical intensive care unit in 34.2%. The most common ECMO specialist model was having a perfusionist at the bedside, followed by nurse specialist (Figure 1D). Specialty services consulted within 24-48 hours of cannulation included physical therapy in 48.7%, palliative care in 30.8%, and bioethics in only 2.6% of centers. Simulation-based ECMO training is performed in 59% of the centers. Half (51.3%) of the centers perform ECPR, while 17.9% reported plans of developing a program. Conclusions Although there is significant variability in ECMO cannulation, location of care, staffing practices in advanced CICUs in North America, a multidisciplinary team approach is common in ECMO centers, with early involvement of physical therapy and palliative care specialists. Further research to establish the optimal model for ECMO programs is of high importance.

Implementation of Extracorporeal Membrane Oxygenation Without On-Site Cardiac Surgery or Perfusion Support: A Tale of Two County Hospitals.

Patients with refractory respiratory and cardiac failure may present to noncardiac surgery centers. Prior studies have demonstrated that acute care surgeons, intensivists, and emergency medicine physicians can safely cannulate and manage patients receiving extracorporeal membrane oxygenation (ECMO). Harborview Medical Center (Harborview) and Hennepin County Medical Center (Hennepin) are both urban, county-owned, level 1 trauma centers that implemented ECMO without direct, on-site cardiac surgery or perfusion support. Both centers 1) use an ECMO specialist model staffed by specially trained nurses and respiratory therapists and 2) developed comparable training curricula for ECMO specialists, intensivists, surgeons, and trainees. Each program began with venovenous ECMO to provide support for refractory hypoxemic respiratory failure and subsequently expanded to venoarterial ECMO support. The coronavirus disease 2019 (COVID-19) pandemic created an impetus for restructuring, with each program creating a consulting service to facilitate ECMO delivery across multiple intensive care units (ICUs) and to promote fellow and resident training and experience. Both Harborview and Hennepin, urban county hospitals 1,700 miles apart in the United States, independently implemented and operate adult ECMO programs without involvement from cardiovascular surgery or perfusion services. This experience further supports the role of ECMO specialists in the delivery of extracorporeal life support.

Clinical practice of emergency department-initiated extracorporeal cardiopulmonary resuscitation for cardiac arrest in adults.

Clinical practice of emergency department-initiated extracorporeal cardiopulmonary resuscitation for cardiac arrest in adults.

HYBRID MODEL FOR TRAINING HYBRID EXTRACORPOREAL MEMBRANE OXYGENATION SPECIALISTS

<h3>Objectives</h3> The latest global pandemic highlighted the need to change and adapt the approach to extracorporeal membrane oxygenation (ECMO) support provision. As one of the most complex and specialised extracorporeal organ support systems, the provision of ECMO tends to be less flexible compared to other services. This abstract outlines a hybrid model of training specialised hybrid ECMO specialist staff that can form the base of running an ECMO service that can adapt to shifting demands. <h3>Design and Methods</h3> Our ECMO centre delivers regular courses for staff aiming to become ECMO specialists. The course is aimed at nurses who have completed their critical care specialisation and have worked in the critical care unit for at least six months. A two-day hybrid course provides them with theoretical knowledge, "wet labs" for hands-on skills and high-fidelity simulations of ECMO emergencies. The content of the course follows the one suggested by the guidelines published by the extracorporeal life support organisation (ELSO). All candidates must complete pre-course and post-course assessments and be signed off for essential practical competencies before working as independent ECMO specialists. In order to maintain the specialisation, they need to complete a fixed number of shifts to ensure adequate experience and exposure. <h3>Results</h3> ELSO recognises that a safe and economically sound model of ECMO provision includes not relying on ancillary services such as perfusion scientists and cardiac surgery. The preferred alternative is training and having experienced ECMO specialists at the bedside. An ECMO centre with hybrid staff that functions both as bedside critical care nurses and ECMO specialists allows for flexibility in changing demand for ECMO support. A set minimum of shifts that the ECMO specialists need to sustain the specialisation ensures that they have enough exposure to maintain safe practice. The hybrid approach to course delivery was dictated by the reality of needing to train the staff during the global pandemic. However, it has clear benefits social distancing aside. It allows for more flexibility and time to focus on practical aspects of caring for a patient on ECMO support. The option to complete theoretical studies at their own time and pace fits adult learning theory. Since the candidates are experienced critical care nurses, they are familiar with concepts of basic physiology, hence the lectures can focus specifically on the physiology of ECMO. A hybrid course design also takes into consideration the practical realities of delivering courses in circumstances requiring social distancing. Adequate progression between the pre-course and post-course tests guarantees engagement with the course material and the impact of the intervention. <h3>Conclusions</h3> As highlighted by international ECMO societies, there is a need to ensure the possibility of expanding ECMO capacity rapidly in case of emergencies. Having hybrid staff can allow the healthcare system to achieve that. Utilising hybrid training methods can help train more staff in a more economically and time-efficient way, even if options for in-person training are limited.

Interprofessional Extracorporeal Membrane Oxygenation Cardiopulmonary Resuscitation Simulations Aimed at Decreasing Actual Cannulation Times: A Longitudinal Study.

Since 2013, the cardiac intensive care unit (CICU) at Children's National has conducted annual extracorporeal membrane oxygenation cardiopulmonary resuscitation (ECPR) simulations that focus on team dynamics, room setup, and high-quality CPR. In 2019 and 2020, the simulations were expanded to include the surgical and extracorporeal membrane oxygenation (ECMO) teams in an effort to better understand and improve this process. During a 4-week period in 2019, 7 peripheral ECPR simulations were conducted, and through a 3-week period in 2020, 7 central ECPR simulations were conducted. Participants in each session included: 8 to 10 CICU nurses, 1 CICU attending, 1 to 2 ICU or cardiology fellows, 1 cardiovascular surgery fellow or attending, and 1 ECMO specialist. For each session, the scenario continued until the simulated patient was on full cardiopulmonary bypass. An ECMO trainer was used for peripheral simulations and a 3-dimensionally-printed heart was used for central cannulations. An ECMO checklist was used to objectively determine when the patient and room were fully prepared for surgical intervention, and simulated cannulation times were recorded for both groups. A retrospective chart review was conducted to compare actual cannulation times before and after the intervention period, and video was used to review the events and assist in dividing them into medical versus surgical phases. Control charts were used to trend the total ECPR times before and after the intervention period, and mean and P values were calculated for both ECPR times and for all other categorical data. Mean peripheral ECPR times decreased significantly from 71.7 to 45.1 minutes ( P = 0.036) after the intervention period, and this was reflected by a centerline shift. Although we could not describe a similar decrease in central ECPR times because there were only 6 postintervention events, the times for each of these events were shorter than the historical mean of 37.8 minutes. There was a trend in improved survival, which did not meet significance both among patients undergoing peripheral ECPR (15.4% ± 10% to 43.8% ± 12.4%, P = 0.10) and central ECPR (36.4% ± 8.4% to 50% ± 25%, P = 0.60). The percentage of time dedicated to the medical phases of the actual versus simulated procedures was very consistent among both peripheral (33.0% vs. 31.9%) and central (39.6% vs. 39.8%) cannulations. We observed a significant decrease in peripheral cannulation times at our institution after conducting interprofessional ECPR simulations taken to the establishment of full cardiopulmonary bypass. The use of an ECMO trainer and a 3-dimensionally-printed heart allowed for both the medical and surgical phases of the procedure to be studied in detail, providing opportunities to streamline and improve this complex process. Larger multisite studies will be needed in the future to assess the effect of efforts like these on patient survival.

Implementing Nurse Extracorporeal Membrane Oxygenation Specialists to Maintain a Sustainable Program

Extracorporeal membrane oxygenation (ECMO) offers hope for patients with acute respiratory distress syndrome when other treatment methods fail. However, ECMO requires continuous hourly management leading to extremely high operating costs. With the onset of the COVID-19 pandemic, the high number of patients on ECMO led to a significant increase in the costs when using perfusionists to manage ECMO. Switching to a nurse-driven model resulted in a 52% decrease in costs related to the hourly management. Changing to a nurse-driven program provided increased nursing support and sustainability, and with determination and support, other ECMO centers can also change to nurse-driven programs.

Improving Extracorporeal Membrane Oxygenation Survival in COVID-19. Effect of a Bundle of Care.

Veno-venous extracorporeal membrane oxygenation (ECMO) support surged during the COVID-19 pandemic. Our program changed the model of care pursuing to protect the multidisciplinary team from the risk of infection and to serve as many patients as possible. Patient–healthcare interactions were restricted, and the ECMO bed capacity was increased by reducing the ECMO specialist–patient ratio to 1:4 with non-ECMO trained nurses support. The outcomes worsened and we paused while we evaluated and modified our model of care. The ECMO bed capacity was reduced to allow a nurse ECMO–specialist nurse ratio 2:1 with an ECMO trained nurse assistant’s support. Intensivists, general practitioners, nurse assistants, and physical and respiratory therapists were trained on ECMO. Tracheostomy, bronchoscopy, and microbiological molecular diagnosis were done earlier, and family visits and rehabilitation were allowed in the first 48 hours of ECMO cannulation. There were 35 patients in the preintervention cohort and 66 in the postintervention cohort. Ninety days mortality was significantly lower after the intervention (62.9% vs. 31.8%, p = 0.003). Factors associated with increased risk of death were the need for cannulation or conversion to veno arterial or veno arterio venous ECMO, hemorrhagic stroke, and renal replacement therapy during ECMO. The interventions associated with a decrease in the risk of death were the following: early fiberoptic bronchoscopy and microbiological molecular diagnostic tests. Increasing the ECMO multidisciplinary team in relation to the number of patients and the earlier performance of diagnostic and therapeutic interventions, such as tracheostomy, fiberoptic bronchoscopy, molecular microbiological diagnosis of pneumonia, rehabilitation, and family support significantly decreased mortality of patients on ECMO due to COVID-19.

Development of a Comprehensive Extracorporeal Membrane Oxygenation Program in a Cardiac Transplant Intensive Care Unit: A Quality Improvement Initiative.

A major academic medical center in the Midwest has expanded their extracorporeal membrane oxygenation (ECMO) program from 8 ECMO cases in 2014 to 97 ECMO cases in 2017. The Extracorporeal Life Support Organization states that standardized policies, procedures, and standards of care are necessary for an ECMO center to be successful. With the rapid growth of the ECMO program, this medical center has chosen to transition nurses and respiratory therapists into the role of ECMO specialist to bridge the gap in care created by the influx in patients. Currently, no specific set of policies/procedures or standards of care exist for ECMO patients. The primary objective of this study is to improve the self-efficacy of ECMO specialists and bedside nurses through the development of a comprehensive ECMO program that includes standardized policies and procedures, order sets, and evidence-based patient management guidelines. The General Self-Efficacy Survey was used to assess the self-efficacy of both the ECMO specialists and the bedside nurses before implementation of the program. An ECMO manual was created that contained education on veno-arterial and veno-venous ECMO, policies and procedures, and patient management guidelines. An EPIC order set was created to ensure the correct protocols and management guidelines were ordered for all ECMO patients. Postimplementation self-efficacy surveys, direct observations, and chart audits occurred to assess program fidelity. The self-efficacy was assessed of the ECMO specialists and beside nurses 4 months after implementation of policies, procedures, patient management guidelines, and an ECMO order set. The ECMO specialists' self-efficacy survey responses increased by 25% and the bedside nurses' self-efficacy survey responses increased by 27% after 4 months. Direct observation of ECMO specialist handoff to ensure protocol fidelity also occurred. There was a 40% increase in ECMO specialist handoff taking place and a 72% increase in ECMO circuit examination. With the significant growth of ECMO patients, policies, protocols, and management guidelines are essential to provide safe care to these patients. There was a statistically significant improvement in the self-efficacy of both the ECMO specialists and bedside nurses. This was shown to directly correlate to an improvement in professional practice behaviors and ultimately improve the quality of patient care provided to ECMO patients.

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.

The Effectiveness of Three Different Curricular Models to Teach Fundamental ECMO Specialist Skills to Entry Level Perfusionists

The dramatic increase in the use of extracorporeal membrane oxygenation (ECMO) over the last decade with the concomitant need for ECMO competent perfusionists has raised questions of how well perfusion education programs are preparing entry-level perfusionists to participate in ECMO. While all perfusion schools teach ECMO principles, there is no standardized or systematic approach to the delivery of didactic knowledge and clinical skills in ECMO. Given this variability of ECMO education across and within perfusion schools, the CES-A exam may provide a metric for comparing curricular approaches. The purpose of this study is to examine three different curricular approaches to prepare new perfusion graduates to master the Adult ECMO Specialist Certification exam (CES-A). We examined three different curricular approaches to prepare new perfusion graduates to master the Adult ECMO Specialist Certification exam (CES-A). We hypothesized that there would be no difference in CES-A pass rate, exam score, Rasch measure, and item category scores between SUNY Cardiovascular Perfusion Program (CVP) graduates who completed SUNY’s ECMO Capstone experience (Group III) and CVP graduates who did not select the ECMO Capstone experience (Group II). Further, we studied the performance of a third group of new graduates from an external program that does not offer formal ECMO courses or an ECMO Capstone experience (Group I). Every perfusion graduate in all groups passed the adult ECMO specialist exam. The graduates who as students completed an ECMO Capstone experience (Group III) scored higher on the exam and significantly higher on four exam categories: coagulation and hemostasis (p = .058), lab analysis point of care (p = .035), and monitor patient and circuit (p = .073), and the safety and failure modes (p = .017). Overall the median graduate Rasch measures ranked with Group III demonstrating the highest measure to Group I the lowest measures (not significant atp = .085). There is a positive educational effect due to CVP graduates completion of the ECMO Capstone experience compared to the program standard ECMO-related curricula in the two perfusion programs participating in this study. From this observation a structured ECMO simulation-based program appears to be equally effective as a traditional, typical lecture-only, clinical perfusion preceptorship, while demonstrating a more satisfactory experience with a higher reported case experience. In this study the standard perfusionist education curriculum prepared the new graduate to be successful on the CES-A exam. The three curricular approaches appear to prepare perfusionist graduates to be successful on the Adult ECMO Specialist exam.

The Effectiveness of Three Different Curricular Models to Teach Fundamental ECMO Specialist Skills to Entry Level Perfusionists.

The dramatic increase in the use of extracorporeal membrane oxygenation (ECMO) over the last decade with the concomitant need for ECMO competent perfusionists has raised questions of how well perfusion education programs are preparing entry-level perfusionists to participate in ECMO. While all perfusion schools teach ECMO principles, there is no standardized or systematic approach to the delivery of didactic knowledge and clinical skills in ECMO. Given this variability of ECMO education across and within perfusion schools, the CES-A exam may provide a metric for comparing curricular approaches. The purpose of this study is to examine three different curricular approaches to prepare new perfusion graduates to master the Adult ECMO Specialist Certification exam (CES-A). We examined three different curricular approaches to prepare new perfusion graduates to master the Adult ECMO Specialist Certification exam (CES-A). We hypothesized that there would be no difference in CES-A pass rate, exam score, Rasch measure, and item category scores between SUNY Cardiovascular Perfusion Program (CVP) graduates who completed SUNY's ECMO Capstone experience (Group III) and CVP graduates who did not select the ECMO Capstone experience (Group II). Further, we studied the performance of a third group of new graduates from an external program that does not offer formal ECMO courses or an ECMO Capstone experience (Group I). Every perfusion graduate in all groups passed the adult ECMO specialist exam. The graduates who as students completed an ECMO Capstone experience (Group III) scored higher on the exam and significantly higher on four exam categories: coagulation and hemostasis (p = .058), lab analysis point of care (p = .035), and monitor patient and circuit (p = .073), and the safety and failure modes (p = .017). Overall the median graduate Rasch measures ranked with Group III demonstrating the highest measure to Group I the lowest measures (not significant at p = .085). There is a positive educational effect due to CVP graduates completion of the ECMO Capstone experience compared to the program standard ECMO-related curricula in the two perfusion programs participating in this study. From this observation a structured ECMO simulation-based program appears to be equally effective as a traditional, typical lecture-only, clinical perfusion preceptorship, while demonstrating a more satisfactory experience with a higher reported case experience. In this study the standard perfusionist education curriculum prepared the new graduate to be successful on the CES-A exam. The three curricular approaches appear to prepare perfusionist graduates to be successful on the Adult ECMO Specialist exam.

Mobile Extracorporeal Membrane Oxygenation for Covid-19 Does Not Pose Extra Risk to Transport Team.

Previous experience has shown that transporting patients on extracorporeal membrane oxygenation (ECMO) is a safe and effective mode of transferring critically ill patients requiring maximum mechanical ventilator support to a quaternary care center. The coronavirus disease 2019 (COVID-19) pandemic posed new challenges. This is a multicenter, retrospective study of 113 patients with confirmed severe acute respiratory syndrome coronavirus 2, cannulated at an outside hospital and transported on ECMO to an ECMO center. This was performed by a multidisciplinary mobile ECMO team consisting of physicians for cannulation, critical care nurses, and an ECMO specialist or perfusionist, along with a driver or pilot. Teams practised strict airborne contact precautions with eyewear while caring for the patient and were in standard Personal Protective Equipment. The primary mode of transportation was ground. Ten patients were transported by air. The average distance traveled was 40 miles (SD ±56). The average duration of transport was 133 minutes (SD ±92). When stratified by mode of transport, the average distance traveled for ground transports was 36 miles (SD ±52) and duration was 136 minutes (SD ±93). For air, the average distance traveled was 66 miles (SD ±82) and duration was 104 minutes (SD ±70). There were no instances of transport-related adverse events including pump failures, cannulation complications at outside hospital, or accidental decannulations or dislodgements in transit. There were no instances of the transport team members contracting COVID-19 infection within 21 days after transport. By adhering to best practices and ACE precautions, patients with COVID-19 can be safely cannulated at an outside hospital and transported to a quaternary care center without increased risk to the transport team.

TELE-ECMO FOR A YOUNG, ACTIVE DUTY SERVICEMEMBER IN A DOMESTIC COVID-19 HOTSPOT

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Through the Joint Tele-Critical Care Network (JTCCN), the U.S. military has demonstrated that tele-critical care (TCC) services can facilitate the safe delivery of critical care beyond the consulting provider's level of training. While TCC has been described in a variety of scenarios, virtual health support of adult extracorporeal membrane oxygenation (ECMO) management has not been previously reported. We present a case of a young, active duty servicemember with COVID-19 pneumonia complicated by acute hypoxemic respiratory failure refractory to conventional therapy who was cannulated for veno-venous ECMO and successfully managed for 72 hours with TCC support. CASE PRESENTATION: A 39 year-old male Active Duty Service Member (ADSM) presented to Naval Medical Center San Diego (NMCSD) with hypoxemic respiratory failure five days after a positive SARS-CoV-2 PCR test. He was given supportive oxygen therapy, Remdesivir and dexamethasone. On hospital day nine, he was intubated for refractory hypoxemia and the ratio of arterial pO2 to fraction of inspired oxygen (P/F ratio) one hour later was 74. Neuromuscular blockade and prone positioning were initiated. Three days later, the P/F ratio remained less than 100. A request to transfer the patient to a local partner facility for ECMO was declined due to lack of bed availability.The San Antonio Military Medical Center (SAMMC) ECMO Team was consulted via TCC and the patient was placed on veno-venous ECMO, as personnel at NMCSD had previously undergone cannulation training. The NMCSD critical care team had round-the-clock secure video teleconferencing connection to the perfusionists and physician ECMO specialists at SAMMC during this time. After 72 hours of tele-ECMO management without complications, a U.S. Air Force Critical Care Air Transport Team safely transferred the patient 1,276 miles by fixed-wing aircraft to SAMMC for ongoing care. DISCUSSION: As the only certified ECMO center in the Department of Defense and one of the few centers in the world with global air transport capability, SAMMC has partnered with NMCSD to provide short-term ECMO care with TCC support. Previously, this capability had not been demonstrated over a period longer than a few hours. Because this patient's clinical decompensation occurred during the peak of the COVID-19 surge in Southern California, rapid transfer to a local ECMO center was not possible. In this case, JTCCN enabled the provision of lifesaving advanced cardiopulmonary support to an ADSM until aeromedical evacuation could be arranged. CONCLUSIONS: This case serves as proof-of-concept for a hub and spoke model of tele-ECMO support to global military medical facilities, demonstrating the potential to bring sophisticated lifesaving technology to medically-austere environments anywhere in the world. REFERENCE #1: Davis K, Perry-Moseanko A, Tadlock MD, Henry N, Pamplin J. Successful Implementation of Low-Cost Tele-Critical Care Solution by the U.S. Navy: Initial Experience and Recommendations. Mil Med. 2017 May;182(5):e1702-e1707. doi: 10.7205/MILMED-D-16-00277. PMID: 29087914. REFERENCE #2: Read MD, Nam JJ, Biscotti M, Piper LC, Thomas SB, Sams VG, Elliott BS, Negaard KA, Lantry JH, DellaVolpe JD, Batchinsky A, Cannon JW, Mason PE. Evolution of the United States Military Extracorporeal Membrane Oxygenation Transport Team. Mil Med. 2020 Dec 30;185(11-12):e2055-e2060. doi: 10.1093/milmed/usaa215. PMID: 32885813. REFERENCE #3: Badulak J, Antonini MV, Stead CM, Shekerdemian L, Raman L, Paden ML, Agerstrand C, Bartlett RH, Barrett N, Combes A, Lorusso R, Mueller T, Ogino MT, Peek G, Pellegrino V, Rabie AA, Salazar L, Schmidt M, Shekar K, MacLaren G, Brodie D. ECMO for COVID-19: Updated 2021 Guidelines from the Extracorporeal Life Support Organization (ELSO). ASAIO J. 2021 Feb 26. doi: 10.1097/MAT.0000000000001422. Epub ahead of print. PMID: 33657573. DISCLOSURES: No relevant relationships by John Hunninghake, source=Web Response No relevant relationships by Phillip Mason, source=Web Res onse No relevant relationships by Jeremy Pamplin, source=Web Response No relevant relationships by Nick Rohrhoff, source=Web Response No relevant relationships by Melissa Rosas, source=Web Response No relevant relationships by Jesse Sherratt, source=Web Response No relevant relationships by Robert Walter, source=Web Response

The Implementation and Outcomes of a Nurse-Run Extracorporeal Membrane Oxygenation Program, a Retrospective Single-Center Study.

Due to a shortage of perfusionists and increasing utilization of extracorporeal membrane oxygenation in the United States, many programs are training nurses as bedside extracorporeal membrane oxygenation specialists (i.e., nurse-run extracorporeal membrane oxygenation). Our objective was to evaluate if a nurse-run extracorporeal membrane oxygenation program has noninferior survival to discharge and complication rates compared with a perfusionist-run extracorporeal membrane oxygenation program. Additionally, to sought to describe increases in extracorporeal membrane oxygenation capacity and the potential for cost savings by implementing a nurse-run extracorporeal membrane oxygenation program.

Checklists Improve Team Performance During Simulated Extracorporeal Membrane Oxygenation Emergencies: A Randomized Trial.

Randomized simulation-based trial. A quaternary-care academic hospital with a regional extracorporeal membrane oxygenation referral program. Extracorporeal membrane oxygenation specialists and other healthcare providers. We designed six read-do checklists for use during extracorporeal membrane oxygenation emergencies using a modified Delphi process. Teams of two to three providers were randomized to receive the checklists or not. All teams then completed four simulated extracorporeal membrane oxygenation emergencies. Simulation sessions were video-recorded, and the number of critical tasks performed and time-to-completion were compared between groups. A survey instrument was administered before and after simulations to assess participants' attitudes toward the simulations and checklists. We recruited 36 subjects from a single institution, randomly assigned to 15 groups. The groups with checklists completed more critical tasks than participants in the control groups (90% vs 75%; p < 0.001). The groups with checklists performed a higher proportion of both nontechnical tasks (71% vs 44%; p < 0.001) and extracorporeal membrane oxygenation-specific technical tasks (94% vs 86%; p < 0.001). Both groups reported an increase in reported self-efficacy after the simulations (p = 0.003). After adjusting for multiple comparisons, none of the time-to-completion measures achieved statistical significance. The use of checklists resulted in better team performance during simulated extracorporeal membrane oxygenation emergencies. As extracorporeal membrane oxygenation use continues to expand, checklists may be an attractive low-cost intervention for centers looking to reduce errors and improve response to crisis situations.

Rapid Cycle Deliberate Practice Versus Traditional Simulation for Training Extracorporeal Membrane Oxygenation Specialists in Circuit Air Emergency Management: A Randomized Trial.

Extracorporeal membrane oxygenation (ECMO) is a highly complex therapy used to support critically ill patients. Simulation-based training of ECMO specialists in the management of ECMO emergencies has been described in the literature, but optimal methods are not currently established. The objective of this study was to compare rapid cycle deliberate practice (RCDP) simulation versus traditional simulation (TS) with reflective debriefing for training ECMO specialists in the management of arterial air emergencies. A prospective, randomized, pre-post interventional design was used to compare the impact of RCDP training with that of TS training on ECMO specialist performance during a simulated ECMO circuit emergency. Participants were divided into 2 training groups-RCDP and TS. Each participant completed a simulated arterial air emergency scenario before training, immediately after training, and again 3 months later. The primary outcome was the time required by individual participants to complete critical clinical actions. Twenty-four ECMO specialists completed the study. Immediately after the training, the RCDP group had faster times to dissociate the patient from the ECMO circuit (11-seconds RCDP vs. 16-seconds TS, P = 0.03) and times to re-establish ECMO support (59-seconds RCDP vs. 82.5-seconds TS, P = 0.01). Follow-up testing at 3 months showed persistence in faster times to re-establish ECMO support in the RCDP group (114-seconds RCDP vs. 199-seconds TS, P = 0.01). Rapid cycle deliberate practice simulation provides a superior curriculum and method of training ECMO specialists in the management of arterial air emergencies in comparison with traditional simulation.