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ECMO is a Team Sport

Between 2010 and 2017, the number of ECMO cases and centers nearly doubled according to the ELSO registry report published January 2018. Research has shown that patient outcomes (survival rate and complications) are closely related to the volume of cases at individual centers. In this retrospective, single-institution cohort study at Massachusetts General Hospital in Boston, the institution of a formal multidisciplinary ECMO team resulted in a 14.6% increase in survival to discharge. Prior to the establishment of the formal ECMO team, all adult patients that were cannulated for ECMO, either VV or VA, remained in the ICU that they originated in (CCU, SICU, CSICU, and MICU).

Following the establishment of the formal team, all adult VV ECMO patients received care in the MICU and all adult VA ECMO patients received care in the CSICU. This allowed specific protocols and guidelines to be established and managed in a comprehensive fashion. The formal team consisted of cardiac surgeons, cardiac anesthesiologists, intensivists, cardiologists, ICU nursing staff, perfusionists, respiratory therapists, nutritionists, physical and occupational therapists, and an ethics committee member.

ECMO truly is a ‘team sport’ and should be approached in this manner to improve clinical outcomes and team communication.

Way to go, MGH ECMO team!

Submitted by Jeliene LaRocque RRT-NPS, RRT-ACCS, ECMO Advantage Specialist

ECLS Team Selection

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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 GraphicThe 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

ECMO tech vs ECMO Specialist…Does it really matter?

ECMO tech vs ECMO SPECIALIST…Does it really matter?
Let me answer that before you read on.  YES!!  It matters greatly!

ECMO Advantage has the opportunity to work with many institutions across the United States. We are also able to communicate and associate with other providers of extracorporeal support. One striking thing that I have noticed over the years is the wide range of expectations of the professional sitting behind the ECMO pump. These expectations range from simply having a bedside RN write down numbers and call someone if there is a problem…to a well trained, highly experienced ECMO Specialist (RN, RRT, or CCP) that has full command and understanding of not only the ECMO equipment, but also the disease process, ICU care of that disease process, and how the ECMO support process can best be utilized to provide the most benefit to the patient.

There are several ways to provide ECMO support and there are several devices and configurations of an ECMO system that can be used to support ECMO patients. There are many ways to manage the patient on ECMO. But I believe one aspect of quality care that is often overlooked is the ability of the ECMO Specialist to make all those things work together for the benefit of the patient. That is what we strive for at ECMO Advantage. All of our ECMO Specialists are RN’s, RRT’s, or CCP’s who have ICU backgrounds in addition to their many years as an ECMO Specialist. They all know what it’s like to provide long term care for a critically ill patient in the ICU. They understand the ICU environment and what is involved in the care of a patient on ECMO from the perspective of the ICU healthcare provider. In addition, they have full command and understanding of the ECMO process (that is not to say we are not all still learning!). The combined knowledge, skills, and experiences definitely provide an ECMO Advantage to the clients and patients we serve whether that be in the role of consultant, educator, preceptor, primer, coordinator, or the ECMO Specialist sitting behind the pump.

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