ECMOlogy – Page 2 – ECMO Advantage

ECLS Team Selection

It’s the season for college in my house – admission packets, orientation, decisions about what to study…it’s all vaguely familiar. I think every ECLS program goes through a similar process when deciding about their education process. Who will take care of the ECMO patient? Who will take care of the ECMO pump and circuit? How do you find them and choose them? An application process may not be a bad idea. What qualifications do you think your team should have at a minimum? ELSO has guidelines that will help you determine what those minimum qualities are. Should you have them obtain references? References offer valuable information and lets a leader see what a prospective specialist is thought of by their co-workers. It may be worthwhile to have a screening test and determine what their baseline knowledge is. Should you have an interview process? Leaders learn so much about individuals in an interview. How does this person communicate? How do they present themselves? Interview techniques tease out many variables and may help identify the best possible ECLS team members for your program.

It is true that many ECLS programs have a problem with attrition. It’s not uncommon to lose 50% by end of the first year. Staff resignations may start with the very first day of class: they sit down, ready to learn and then “POW” – it’s overwhelming to them. Extracorporeal Life Support is not an easy concept. It’s not just a matter of a pump and some tubing – hook it up to a patient and go. The typical ECLS class is long and involved. Staff members are required to learn and be tested on physiology related to VV or VA ECMO, systems management, equipment and circuitry troubleshooting and anticoagulation management. Or they finish class, make it through orientation and then sit by themselves at an ECLS patient’s bedside. The reality of how critically ill that patient is, and more importantly, how dependent that patient is on their skills and knowledge is too much to bear, and they quit the team.

Finding out if the team member is going to be able to handle the critical stress that will be a part of every day care is an important part of the selection process. Some ECMO programs have a detailed process for picking team members that isn’t fully complete until they finish orientation. A developed mentorship program can be incredibly beneficial. Most institutions have a mentoring program for new staff – can you modify your existing process for your ECLS team? If a leader maintains the thought that new ECLS staff must be nurtured and encouraged along the way – especially the first year – they will have an increased likelihood of keeping that staff member engaged and happy in their work.

If this is all new to you and your institution, or if you have a unique aspect to your ECLS team selection process – lets chat about it. Leave me a comment!

I am hopeful that we have made the right decisions with our child about college. I am certain he has met their application requirements. Now all that remains is for the college to mentor him through his first year, and for him to complete the process and graduate!

There is no ‘I’ in Team!

Team
Noun – A group of individuals that come together for a cooperative effort, to achieve common goals. A functional family.

Team Of 8 Blue People Holding Up Connected Pieces To A Colorful Puzzle That Spells Out "Team," Symbolizing Excellent Teamwork, Success And Link Exchanging Clipart Illustration Graphic The ECMO Team is definitely a functional family. It exists for a common purpose: to provide the best possible care for an extremely critically ill patient. The team is usually formed out of a larger group of people. Teams have complimentary skills and work through a coordinated effort to achieve the goal. Naresh Jain states “Team members need to learn how to help one another, help other team members realize their true potential and create an environment that allows everyone to go beyond his or her limitations.”

How does that relate to extracorporeal life support? Don’t you just need a physician and a perfusionist? The nurses are already taking care of the patient; and other health care providers are involved. Why do you have to have a defined team – what’s the point?

The difference with ECMO or ECLS is the intensity of care. The level of involvement is different for these patients. The increased risk of dying and the possibility of complications are beyond anything that could happen to an ‘ordinary’ ICU patient. The stress of that can not be highlighted enough. Everyone who has an encounter with that patient will be touched. And everyone who touches the patient should have an advanced knowledge of what is happening.

How do you develop an ECMO Team? Who do you have to have? Who do you want to have?

Well first you have to have a leader. I believe the leader should be a champion for extracorporeal life support. They should be knowledgeable of the inner workings of the institution, the philosophy of medicine that is expounded and how the ICUs work as teams. The leader is going to bring about the beginning of the ECLS program and assure its performance over time, with reproducible results.

The leader will assemble the team – bringing to the table all the disciplines that are required to take care of the patient. The team will include nursing, perfusion, nursing, or respiratory care ECMO Specialists, respiratory, as well as medicine. It will include ancillary personnel such as blood bank, laboratory, radiology, and pharmacy. The leader should also consider how the ECMO patient affects those outside of direct patient care. That may include the administration side with the involvement of the marketing group, the business center and finance. There are so many different aspects of the team and all need to be considered.

How do you bring about the team? That particular feeling of camaraderie? A unique and smooth ability to function under pressure and deal with the issue at hand? I think it begins with education. Providing education to all members of the team assures that everyone is starting from the same point of reference. Leaving out key members of the healthcare team can be disastrous. The ECMO training course is a special event, allowing nurses to work with physicians, perfusionists to work with the new ECMO specialists in a non-stressful environment where all can interact without fear of reprisal. The course is often the first step in building those relationships that become so important at the bedside.

After education, the next step is involvement; in daily patient care, case reviews, team meetings and inservices. Every member has something to contribute or, even better, to learn from the experiences of others.

Finally, you have to continue to build the relationships. ‘Doing’ ECMO is hard. It can take a great big chunk of your professional life and spirit. Building up the people that take care of those sick patients will only make them better caregivers. Remember to involve them in the celebrations. Celebrate the milestones: the number of patients completed, the anniversary of the program; and of course, the amazing success stories. The patient survival stories are what sustain caregivers. The stories help to reignite the passion of the team’s goals. I would encourage teams to stay in touch with their patients. Have a reunion. Seeing the smiles on their faces and hearing their stories is a great moral boost to an ECMO Team.

So go forth and build a great team! Take care of your ECMO patients as a team – and you will have great success!

written by: Micheal Heard, Director of Training and Development…ECMOlogist

The Value of Simulation

How do you learn best? Lecture? Reading materials? Demonstration? They all have value – but the new kid on the block is Simulation! Ok, maybe not that new – the airline industry has been using it forever! Medical and Nursing schools – simulation started in animal labs and human studies. Now we have mannikins to practice on and realistic environments that can produce just about any situation that may present in real life.

ECMO or ECLS is a highly technical skill, requiring both familiarity with equipment (all those buttons!) and circuitry – and of course how they interact with patients. As educators, we deliver the material to ECMOlogists in training – books, slides, checklists – but how do we assure that everything is absorbed? How well did your students retain that information? And more importantly, can the students use the information in a real life situation?

I believe that ECMO education is layering process. Exposure should be varied and repetitive. Starting with a lecture or an elearning module to introduce new skills. These are followed with water-drills, hands on sessions with an expert or super-user. The student then begins to interact with the ECMO system directly and becomes more and more familiar with it.

Simulation allows a realistic atmosphere to be presented. Many institutions have a dedicated simulation lab with personnel to run very hi-fi simulations. But, many institutions are not quite that lucky. Don’t despair! Any one can learn to set up their own simulation lab in a patient room or a conference room. Borrow a CPR manikin and a bed. Set-up a patient room! Include a ventilator if you can and IV poles, etc. Use some of those nursing skills and make your patient comfy. Now you need your ECMO pump with a circuit. The circuit can be ‘primed’ with ‘blood’ to increase the realistic atmosphere. Some people describe using food coloring, chocolate syrup, or drink mixes – anything to give you that nice deep red/blue color. Now here is where the creativity comes in – your patient needs a ‘heart’. A reservoir where volume may be added, removed or air introduced. There are many, many ways to do this. Then add a computer and monitor and start practicing running scenarios where everything that can happen – does!

Simulation is an incredibly valuable tool in education. Perhaps even more so in teaching extracorporeal life support skills. There are so many things that can go wrong, but rarely do on ECMO patients. The ability to ‘practice’ managing these situations before they happen to a real patient will increase the likelihood of successful outcomes.

What about you? Do you use simulation in teaching ECMO? Let me know your experience by sending a comment!

Authored by Micheal Heard, Director of Training and Development …a discussion of all things related to ECMO…

Different Ways: The Stopcock Bridge

I happen to be traveling right now with three amazing ECMO Specialists, ECMOlogists in their own right, who are from three very different parts of the country and from three very different ECMO Centers.

Visiting another center, meeting another ECMO Specialist or attending an ECMO Conference is an opportunity to learn something new. I often take away something that would be just perfect to introduce into my own practice. I love hearing about a new procedure, policy or a piece of equipment that I would never have been exposed to at home. It is such a joy to venture out into the wider ECMO world and pick up new knowledge that will only make your practice better in the long run.

For example, this week I have learned a great deal about Adults. On ECMO. (I know!) All the IV access is on the patient – no access ports for IVs, medications, or lab draws on your ECMO circuit. All very novel for a pediatric based specialist. Such simplicity of the ECMO circuit has a very nice appeal!

It is also nice to share ideas with them as well. The idea of pressure monitoring of the oxygenator, the different ways to wean off ECMO and the notion of a stopcock bridge were just a few we shared.

The use of a bridge, whether a stopcock crystalloid filled one or a simple piece of tubing that remains clamped has always been a part of my practice. Never-ever thought of not having one. Many ECMO programs have eliminated this from their circuits, with reasons ranging from decreasing the possibility of component failure to decreasing connector and tubing use.

What are the benefits of a bridge? The bridge allows continuous flow through the ECMO circuit during any times of separation from the patient. This will maintain the integrity of the circuit and will allow patients to be returned to bypass after time passes. This may happen during emergency component changes or trial-off procedures. Without a bridge, the time that a patient is separated from the circuit must be monitored closely, for after a few minutes, the circuit will clot due to stagnate flow.

In pediatric ECMO the bridge can be an invaluable tool. For example, it allows delivery of super low flows in very small neonates. A 2 kg infant on 200cc/min is on 100 cc/kg! Hardly minimal flow. Using the stopcock bridge will allow the Specialist to wean delivered flow to the patient slowly to 10 – 20 cc/kg/min. This may be done by partially occluding an open bridge (with a Hoffman clamp) allowing recommended blood flow rates through the ECMO circuit, while still weaning flows that are actually delivered to the baby.

However, in adults, the necessity of weaning to such low flows, or having prolonged trial offs does not occur with any regularity. The simplicity of the circuitry allows most emergencies to be handled quickly and easily by just changing the entire circuit.

So – is having a bridge right or wrong? Only your program can decide. Assuming that one way is right (or wrong) is never a good thing. ECMO is ‘done’ in so many different ways – and there is something good about each!