Development and Implementation of an ECMO Specialist Training Program: Perfusion’s Role in the Use of High Fidelity Simulation.B E N SWA NSO N MPS , CCP

Disclosures

• I do not have financial relationships to disclose.

• I apologize in an advance for any cliché sports analogies and/or dog memes

• I promise to be done by happy hour.

• This is a lighthearted talk

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Thank you Saint Luke’s

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objective

• Make it through the presentation

• Perfusions role in a ECMO program

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Brief History of ECMO

• Developed in the 1970’s

• VA ECMO Fem Fem/ limited to 5 day runs

• the early 1980s, this veno-arterial mode was changed to veno-venous, but only a few centers persisted with the technology because bleeding and poor outcomes were common

• 2000’s better understanding of the pathophysiology of ECMO and diseases for which it was used led to a rapid re-emergence

• 2007 rapid expansion of ECMO nation wide

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• Major changes in the technology occurred in 2008 with entire ECMO systems being developed by the Maquet, Sorin, and Novalung [3–5]. The Maquet devices were available in the United States in 2009.

• The new devices resulted in much safer, simpler, prolonged management of extracorporeal support and have led to a much wider use of ECMO in respiratory failure.

• Prior to 2009 there were fewer than 100 cases per year, and survival varied widely because of the small numbers in each diagnostic group

• ] Jegger D, Revelly JP, Horisberger J, et al. Ex vivo evaluation of a new extracorporeal lung assist device: NovaLung membrane oxygenator. Int J Artif Organs 2005;28(10):985–99. [4] Zhou X, Loran DB, Wang D, Hyde BR, Lick SD, Zwischenberger JB. Seventy-two hour gas exchange performance and hemodynamic properties of NOVALUNG iLA as a gas exchanger for arteriovenous carbon dioxide removal. Perf

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ECMO #’s

• There are currently over 70,000 cases in the ELSO Registry. 28,271 of these cases are newborn infants with respiratory failure [2].

• 14,851 of these cases are patients managed with ECMO for severe respiratory failure in the pediatric (6929) and adult (7922) age groups [2]

• Fortenberry J. The history and development of extracorporeal support. In: Annich Gail M, Lynch William, MacLarenGraeme, Wilson Jay M, Bartlett Robert H, editors. ECMO: extracorporeal cardiopulmonary support in critical care. United States: Extracorporeal Life Support Organization; 2012. p. 1–10. [2] Paden ML, Conrad SA, Rycus PT, Thiagarajan RR, Registry E. Extracorporeal life support organization registry report 2012. ASAIO J 2013;59(3):202–10.

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ECMO Trends in The U.S.

• McCarthy et al. University of Pennsylvania Health System, Philadelphia, Pennsylvania

• 2002-2012 that included ECMO were used to estimate the total number of U.S. ECMO hospitalizations (n = 12,407).

• No significant trend was observed in overall ECMO use from 2002-2007, but the use did demonstrate a statistically significant increase from 2007-2012 (P = 0.0028).

• The highest in-hospital mortality rates were found in the postcardiotomy (57.2%) and respiratory failure (59.2%) groups. Lung and heart transplant groups had the lowest in-hospital mortality rates

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Extracorporeal Life Support Organization: ECLS Registry Report. InternationalSummary, Ann Arbor. 2016.

ECMO Trends

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Extracorporeal Life Support Organization: ECLS Registry Report. InternationalSummary, Ann Arbor. 2016.

Trends cont….

• The use of ECMO for the treatment of ARDS in the United States increased by over 400% between 2006 and 2012

• Trends in Extracorporeal Membrane Oxygenation for the Treatment of Acute Respiratory Distress Syndrome in the United States Barret Rush, MD1,2, Katie Wiskar, MD1 , Landon Berger, MD1,3, and Donald Griesdale, MD, MPH

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End result

End Result =

Massive need for bedside ECMO management

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Who up to the task of Bedside ECMO Management?

• ELSO requires one of these options

• Physician

• Perfusionist

• ECMO specialist (Completed program requirements)

ICU nurse

Respiratory Therapist

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Why we need ECMO specialists

• ECMO procedures continue trend up

• Perfusion shortage

• Nursing staff is already here 24hrs

• Highly trained / Skilled

• Cost effective

• Ease to transition of patient care

• Low volume centers (<20 per yr)

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ESLO’s Recommendation on Staffing

• There shall be an ECMO clinical specialist in addition to the ICU nurse or an ECMO trained nurse, as described below, to provide care throughout the course of ECMO

• In clinical settings where the ECMO patient is primarily managed by the ICU nurse (the single care giver model) the ICU nurse should be specifically trained in ECMO patient and circuit management.

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Staffing Model : ICU Nurse

• Orientated to the Unit

• Experienced in critical care

• Interchangeable with bedside nurse

• Allows for stand alone caregiver model

• Great staffing model for low volume centers

• Ability to staff without calling in extra personnel

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In-house Versus Offsite ECMO Training Programs

O FFSI T E• Range from 1-3 days (one time class)

• Structured and organized

• Average Registration cost $2700 (University of Iowa, University of Michigan)

• Does not include transportation and room and board ($500-1000)

• Requires participants to take time off. ( Family obligations)

• Equipment and disposables are not the same

• Difference in Protocols / nursing care

I N- HOSPITAL PR OG R AM

• Low cost

• Can be difficult to organized

• Learning curve to developing a program

• Familiarity with Staff already in place

• Ability to teach protocols and procedure already in place

• Learn on equipment that are the one they are going to use

Benefits of in house Training Programs

• Extremely important in low volume centers

• Improves safety with regular competency training

• Not just for specialists

• Provider class

• New perfusionists

• Residents

Development and Implementation

• Coordinated effort between

• ECMO Coordinator

• Perfusionists

• Unit educator

• Experienced ECMO

Goal is to create an effective program that is centered on safety, consistent, and easy to understand.

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Brief history of our ECMO program

• Started in 2012

• Piecemealed our first circuit together

• And so it began…….

• Initial training program was 40hrs

• Course was too long, over complicated, under focused, and draining

• 2016 was tasked to redeveloped and direct the ECMO training program

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Questions ask prior to Redevelopment

• Is it possible to scale down our training program without compromising patient care

• What road blocks will be there be in this process

• How can we manage our resources effectively in order to accomplish our goals

• Can this me a sustainable and reusable model

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Develop a system that a system that helps inexperienced caregivers excel

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Training Goals

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Must be developed

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Redefining Training Goals:

• The goal should not be for them to be autonomously treating patients

Rather

• We want ECMO specialists, though collaboration with providers and perfusion, to be able to diagnose and triage the patient accordingly

What---- is happening

Why----- is it happening

Who ------ to call, or can I make the change myself

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What Why When

• Try to focus on around 10 sentinel event that specialists will need to know in order to effectively management the patient in the safest manner.

• Triage the events from lowest to highest priority

• Lowest priority event would require changes an specialist can make

• Med-High require contact of appropriate staff.

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The Importance the 3 W’s

• Identifying a core package of events that can be focused on

• Teach the processes and physiology of these events

• Use of simulation to foster proper identification and ability to triage

• Practice and don’t over complicate

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Use of Simulation

• Allows for concept to placed into practice

• Successful learning models have didactic courses followed by hands on learning. (flipped Classroom Model )

• Helps prepare specialist better understand clinical situations and triage appropriately

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Identifying a core package of events

• Titration of CO2/PO2

• Circuit check (safety)

• Preload Issues

• Afterload issues

• Monitoring issues

• VV recirculation

• Arterial mixing (mixing cloud)

• Code in VV ECMO

• Oxygen failure

• Cannula event

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Developing a didactic course to support training goals

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Didactic course overview

DAY 1 (8 HR S)

• Intro to ECMO

• Physiology of ECMO

• Cannulation

• Circuit overview

• Nursing care

• Complications during ECMO

• Group SIM (1o events)

DAY 2 (3 HR S)

• SIM

• Review 10 events

• Pump failure

• Test

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Simulation / Califia 3.o

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Arterial Mixing

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Circuit check / safety check

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Titration of PO2 / CO2

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Understanding Preload vs Afterload issues

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VV recirculation

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Oxygen failure

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Coding an ECLS patient

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Course implementation

• Beta class fall 2017

• First refined class April 2018

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• Test scores improved

• Increased confidence

• Improved patient care

• Still a work in process

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Future projects

• Quarterly ECMO skills workshop in ICU

• VV ECMO code drills

• Refine Provider class

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Questions?

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