EDECMO Episode 12 – The Nurse-Based ECMO Program at Sharp Memorial Hospital with Suzanne Chillcott RN, BSN

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In this episode Joe talks with Suzanne Chillcott, the Mechanical Circulatory Support (MCS) Lead RN at Sharp Memorial Hospital to discuss the nuts and bolts of establishing a “nurse-run” ECLS program.  There is no lack of enthusiasm over the concept of doing ECPR in the Emergency Department.  As most of you already know, we think ECPR is the wave of the future for resuscitation.

So you think  you want to set up the next ED/ICU ECPR program?  You think you want to do ECPR in your Emergency Department or ICU?  But where to begin? Hopefully this episode will hopefully answer many of those questions:

ECLS Program Models

Physician resuscitationists cannulate. But you need an “ECMO team” to prime the circuit, help initiate bypass, trouble-shoot the machine, and manage the patient after bypass is initiated.  But who is going to do that?  Who has jurisdiction over your ECMO program?  Well, if you are working at an institution with an active cardiothoracic surgery program, chances are you already have these roles established; and I  recommend you speak to the Chief of your CT surgery team.  But for the sake of argument lets pretend you are starting an ECMO/ECLS/ECPR program de novo. What are your options?

Well, whomever is going to do this MUST be “in-house.”  In the ED, Emergency Physicians should be cannulating because we are already right there. We are running the code. We should be the ones doing the cannulation. And the same goes for intensivists in the ICU.    There simply isn’t time to call in a specialist to cannulate. The same goes for your ECMO team: they must be “in-house.” It would seem to make sense that perfusionists would be the first-responder ECMO team, however at many institutions (ours included) perfusionists aren’t “in-house 24/7.”  So there are now 3 main ‘models’ to address this:

1. Perfusionist-based: Some facilities, usually teaching hospitals with very active ECMO programs, have in-house perfusionists.  In those cases the perfusionist is usually the “first-responder.”  In some cases the perfusionists handle all bedside activities from start to finish. In other cases the perfusionists help initiate ECMO and RN’s or respiratory therapists (RT’s) will ‘babysit” the machine when active adjustments aren’t being made.
2. RT-based: When Shinar and I were at the University of North Carolina Chapel Hill, we witnessed this type of program.  While the perfusionists there are doing all the heavy lifting, they have trained their RT’s in supervising ECMO.
3. Nurse-based: ICU nurses  are cross-trained in ECMO.  This is the model we use at Sharp Memorial Hospital in San Diego.  ICU nurses are trained in all aspects of ECMO and the ICU staffing is setup such that there is always at least 2 RN’s in the SICU who are ECMO-ready.  If we have an ECPR case in the ED we call the SICU. Quickly those nurses temporarily hand-off their assignments and come to the ED.

Establishing an ECMO Program at Your Hospital

Key Players:

1. CT Surgery
2. Nursing
3. Perfusionists
4. Hospital Administration

   

These are the key components. Of course, if you are doing ECPR in your ED then you also need an ED doctor champion.  If you are reading this, I assume that will be you. So welcome to your new role!

Who Cannulates?

1. CT surgeons
2. Interventional Cardiologists
3. Intensivists/Pulmonologists
4. Interventional Radiologists
5. Emergency Physicians

The Sharp Memorial Hospital ECMO Nursing Training Program

• Staffing:
  • SICU nurses must apply to be on the ECMO team
  • Coveted position
  • + financial differential (the RN’s get paid to cross-cover ECMO)
  • RN works a regular SICU assignment but must also respond to ECPR
• Training:
  • Training Manual
  • One-on-one class: 10-12 hours of training per RN
  • RN must be able to establish circuit within 10 min
  • Ongoing Competency Evaluation every other month to maintain skills:
  1. MAD (mechanical assist device) Lab Day = wet-loop training
  2. Direct wet-loop training in the SICU
  3. Manage a real live patient
• Costs:
  • Capital = Hardware (pump head, heater/cooler, blender, SVO2 monitor) is reusable
    • These are hard costs that are not billable to a patient. Roughly $100,000 per unit. We house 2 unit  = $200,000
  • Disposables (The Circuit and the Cannulae): Used on each patient and billable to the patient.
  • Nursing:
    • Shift coverage (12 hours shifts, 2 RN’s always on-shift) = 25 fully trained nurses
    • Training: 25 nurses @ 10 hours of training @ $50/hr =  $12,500
    • Continuing Competency Evalution training =  2 hrs ever other month @ $50/hr = $600 x 25 nurses = $15,000/yr for ongoing training
    • Premium differential paid to SICU nurses to be on the ECMO team
    • Perfusionist coverage: This is often a contracted rate with a local perfusionist team

A Day in the Life of an RN ECMO Team Member:

• 2 ICU RN’s are always staffed in the SICU
  • staffed so the RN’s are working at opposite sides of the unit so an ECPR case won’t debilitate any arm of the ICU by calling RN’s away.
• ER doctor calls the SICU when a potential ECPR case arrives to the ED
• ECMO RN’s bring, from the SICU (located on the 2nd floor at our facility) to the ED:

1. The ECMO cart – mobile ECMO hardware = pump head, heater/cooler, blender, SVO2 monitor
2. The ECMO supply cart – carries all the disposables (circuits, cannulae, various supplies

• Suzanne describes the logistics of priming the pump, connecting the patient to the circuit, and starting the pump
  • ***PEARL: the goal at initiation of bypass is maximize flow while minimizing RPMs, so the nurse will dial up the RPM until flow is maximized, but no further.
  • SVO2 goal = 70
• ECMO RN calls OR to summon the perfusionist. In our system the perfusionist is on-call and has an established response time
• ECMO RN hands off the pump duties to the Perfusionist and then goes back to their SICU assignment

Policies and Procedures

Please contact any of us if you want to take a look at our policies and procedures  – we are more than happy to share this stuff.

The Late Great Tony Gwynn Could Teach us Something About Success:

Suzanne says it best:  ” The way you gotta look at it…the patients we put on pump are all 100% dead when you start with them. You can’t make them more dead. You can’t make it worse. All you can do is possibly make it better…”

Established success rates, for long-term survival neuro-intact is 27-30% for in-hospital cardiac arrest.  That is significantly better than historical established success of non-ECPR ACLS of 17%.  So even though we almost double the survival of these patients, fully 70% still don’t survive or have neurologic recovery. To take that even further, for out-of-hospital cardiac the survival is dismal…and at this time we don’t even initiate ED ECMO until ACLS has failed – the point at which you would pronounce the patient dead.  So by definition, our starting point 0% survival. So any success is meaningful.

We really need to remind everyone that ECPR success is much like batting averages – a batting average over .300 will get you into the Baseball Hall of Fame!!  One of the greatest baseball hitters of all-time, San Diego favorite Tony Gwynn, FAILED 70% of the time and was one of the greatest hitters of all time; and elected to the Baseball Hall of Fame in Cooperstown.

So lets setup appropriate expectations from the beginning!  And remember, even the great Tony Gwynn occasionally went several ‘at-bats’ without a hit.

Do you have Questions for Suzanne?  You may email her directly at suzanne.chillcott@sharp.com

 Announcements:

Aug 18-21: Emergency Medicine Update.  Bellezzo is speaking on “Resuscitation: State of the Art”

October 21: Bring Me Back to Life conference in Montreal, Canada