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Critical Care and Resuscitation

Extracorporeal Membrane Oxygenation Appropriateness: An Interdisciplinary Consensus-Based Approach

Nurok, Michael MBChB, PhD*; Warsh, Jonathan PhD; Griner, Todd RN, MSN, NEA-BC; Kharabi, Mayumi RN, MSN, CNL§; Castongia, Joseph MHA§; Overbeck, Cali MHA§; Krueger, Lisa LCSW, ACM-SW; Coleman, Bernice PhD, ACNP-BC, FAAN; Ramzy, Danny MD, PhD*; Chung, Joshua MD*; Chan, Alice RN, MSN, CNS, CCRN; Ley, Eric MD*; Kubendran, Sindhu MPH; Parrish, Neil MBA; Yu, Zhe MD, MPH; Langberg, Michael MD#; Finder, Stuart PhD**; Rosen, Bradley T. MD, MBA, FACP, SFHM††; Kaplan, Robert S. PhD; Sax, Harry MD*; Arabia, Francisco MD, MBA*

Author Information
doi: 10.1213/ANE.0000000000002723
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Abstract

Extracorporeal membrane oxygenation (ECMO) is a high-cost, high morbidity technology for which appropriateness is not well defined. Appropriateness may be viewed in terms of whether a medical technology is able to achieve a patient’s minimally acceptable outcome without excessive clinical burden.

On average, only half of patients placed on ECMO survive, although the variability in outcome is significant and seems to be related to specific features of each case.1,2 ECMO is often used in time-pressured situations where robust evaluation of its appropriateness cannot be considered before initiation. Currently available scoring systems provide limited guidance on which populations of patients are likely to benefit from ECMO as well as what quality of life may be expected.1–4

From 2014 to 2016, approximately 75% of ECMO cases at our center were venoarterial (VA) and the remainder were venovenous (VV). Our primary causes of VA ECMO were acute heart failure and myocardial infarction, whereas acute respiratory distress syndrome represented the majority of cases of VV ECMO. We report on our experience with a regular interdisciplinary rounding process focused on appropriateness of ongoing ECMO care in a high-acuity, quaternary medical center intensive care unit (ICU). Before this intervention, care planning and consensus building among clinicians treating ECMO patients were becoming increasingly time consuming and difficult to resolve. Opinions of certain team members tended to prevail despite concern by others about appropriateness or effectiveness of ECMO. Although not formally measured, anecdotally these disagreements led to moral distress among caregivers and confusion within families presented with differing views of the likelihood of a good outcome by clinicians with different perspectives on care, consistent with established ICU research.5,6 This experience undermined trust and made stopping ECMO for lack of physiologic benefit very difficult, sometimes requiring chains of command to resolve the multiple perspectives.

The goal of this work was to develop a consensus-based process to achieve interdisciplinary agreement on appropriateness of care, along with secondary aims to reduce divergent messaging from individual team members to patients and families and to decrease the length of stay on VA or VV ECMO.

METHODS

In January 2015, the medical and surgical directors of the cardiac surgery ICU instituted daily ECMO rounds at our 886-bed hospital with other disciplines attending on an ad hoc basis. In September 2015, a more robust and formal, interdisciplinary team, consisting of intensivists, surgeons, nurses, social workers, supportive care medicine (palliative care), and health care ethics, began to round at a fixed time and day of the week. Each contributing discipline provided its unique perspective on care. Members of senior hospital leadership (eg, chief executive officer, chief operating officer, chief nursing officer) occasionally dropped in to observe and lend support to this rounding initiative.

The daily and later weekly rounds focused on patient preferences (eg, a strong desire for functional independence versus a willingness to rely on others for care) and coordination of ECMO management. Where possible, emphasis was placed on whether ongoing ECMO support was consistent with a patient’s minimally acceptable outcome, maximally acceptable burden, and relative likelihood of achieving either.a Available scoring systems1,2 were used, when applicable, along with judgment by experienced clinicians on likely outcomes of any patient on ECMO. Substituted judgment was elicited by primary caregivers (family, loved ones) if the patient had not previously provided clarity on these issues. Rounds focused on building consensus within the various disciplines represented on the medical team about the perceived effectiveness and appropriateness of ongoing therapy, in view of the understood patient values. The interprofessional clinical team strived to deliver consistent messages, at weekly family meetings, about the patient’s projected outcome and likely post-ECMO course.

To gauge the potential impact of our interdisciplinary appropriateness process on ECMO length of stay, data on number of days on ECMO and ECMO type were collected for all ECMO cases from January 2014 to December 2016 from the Cedar-Sinai internal data warehouse. Median length of stay on ECMO was calculated by year and by type of ECMO. Spearman correlation was used to examine changes in ECMO use over time. Time-driven activity-based costing (TDABC) was used to calculate the incremental cost of the interdisciplinary rounding team. TDABC estimates the costs of a clinical service by combining information about the process of care (specifically, the time and quantity of labor and nonlabor resources utilized to perform each activity) with the unit cost of each resource used to provide the care.7 An institutional review board waiver was received for this quality improvement work.

RESULTS

We successfully implemented an interdisciplinary appropriateness process for patients on ECMO that resulted in real-time assessment of all 92 cases placed on support during the intervention period. Anecdotally, this process decreased the perception of interdisciplinary disagreement around ECMO and improved the quality and consistency of messages delivered to families.

The time on ECMO decreased for patients receiving VA support from a median of 6 days in 2014 to 5 days in 2015 (Q1–Q3, 2.5–8) and in 2016 (Q1–Q3, 1–8). For VA ECMO, this reduction was associated with a significant negative trend from 2014 to 2016 (Spearman ρ = −0.16; 95% confidence interval, −0.30 to −0.02; P = .03). A decrease was not observed for patients requiring VV support (Table). The incremental costs (calculated using TDABC7 analysis) of the multidisciplinary weekly rounding team (the sum of prorated salary cost of personnel who participated) were about the cost of 1 hour on ECMO. The savings in personnel costs from reducing length of stay on VA ECMO (compared to the preintervention period) meant that the multidisciplinary rounding team delivered care that was potentially more consistent with patient and family preferences at lower total cost to the hospital.7

Table.
Table.:
Median Days on ECMO Per Calendar Year

To better understand our results, we retrospectively reviewed a sample of 9 cases placed on ECMO during the intervention period to establish whether the use of ECMO in these patients was consistent with ECMO guidelines that subsequently had been developed by a hospital-wide task force in early 2016. The task force guidelines were created based on those available from the Extracorporeal Life Support Organization, peer-reviewed literature on ECMO outcomes, and experienced clinician opinion where data were lacking. The guidelines recommend that in the first 3 weeks of an ECMO run, patients should be withdrawn if 4 or more organ systems have failed, and after 3 weeks, the recommendations are to withdraw ECMO if 3 or more organ systems have failed.b

On review of these 9 ECMO cases, we found that all cases were appropriately placed on ECMO by the new hospital guidelines. In 4 of 9 cases, however, use of the task force guidelines alone would have delayed the withdrawal of patients from ECMO while waiting for families and loved ones to accept the interdisciplinary team’s recommendation that ongoing ECMO was no longer appropriate.

DISCUSSION

Interdisciplinary care is increasingly being suggested as a mechanism to optimize value in health care.8 Our intervention was successful at creating an interdisciplinary consensus-based appropriateness process for ECMO and at improving joint messaging to patients and families with a view to optimizing their experience of care. Before this appropriateness process, coordinating care for ECMO patients was time consuming and difficult. A secondary aim of this project was to determine any association between our improved care process and time on ECMO. Time on ECMO correlates with higher cost of personnel time attending to these patients.7 In absolute numbers, the time on ECMO decreased for patients receiving VA support but increased for patients requiring VV support in the year of the intervention returning to baseline the subsequent year. This result may have been random variation among the small sample size of patients undergoing the relatively long duration (several weeks) of VV support.

The length of stay reduction for VA ECMO in absolute numbers and by extension—cost savings—was observed during the period of our intervention. Cost savings in the ICU are generally thought to be difficult to achieve.9 Even if this was not true, there were good reasons to avoid inappropriate care independent of cost.10 Our statistical methods do not allow conclusion that the observed decrease in time on VA ECMO during the period of our intervention was due to our initiative. This decrease may have occurred independently of the intervention. It is also possible that other confounding causes occurring simultaneously contributed to the observed changes. A concurrent control group not exposed to the intervention would have been required to adequately assess whether a change was due to our rounding process. Alternatively, a more sophisticated statistical analysis—beyond the scope of this manuscript—would have been required.11

Other opportunities are also available to decrease ECMO costs. Earlier consensus by interdisciplinary teams may allow families to accept reorientation of care toward comfort and non–life-prolonging measures. Any effort that reduces cycle time for decisions, an opportunity identified in this work, would also be expected to reduce costs by exposing patients to less time on ECMO. Cost reduction can also be achieved by deploying low-cost mix of staff in ECMO programs, such as through educating bedside nurses and respiratory therapists to manage an ECMO circuit instead of high-cost perfusionists. Such cost-improvement opportunities will be important to explore since ECMO is an extremely high-cost treatment, with some payers considering it experimental and, therefore, not reimbursable. If more payers adopt this stance or if reimbursement continues to shift toward value-based payment methodologies, there will be additional pressure on ECMO programs to improve outcomes and lower costs.8 Adhering to a standard of appropriateness is a promising method to optimize value when using ECMO.

ACKNOWLEDGMENTS

We acknowledge the various physicians, nurses, caregivers, and administrative and performance improvement personnel who contributed to the work described in this article. In particular, we thank Vince Aguillon, RN, BSN, CCRN; Jeffrey James R. Lopez, BSN, RN, PHN, PCCN; and Samantha Shobash, BS.

DISCLOSURES

Name: Michael Nurok, MBChB, PhD.

Contribution: This author helped as the guarantor for this work; helped with the conception, design, and execution of the intervention; and helped with analysis and writing the manuscript.

Name: Jonathan Warsh, PhD.

Contribution: This author helped with the conception, design, and execution of the intervention and helped with analysis and writing the manuscript.

Name: Todd Griner, RN, MSN, NEA-BC.

Contribution: This author helped with the conception, design, and execution of the intervention and helped with analysis and writing the manuscript.

Name: Mayumi Kharabi, RN, MSN, CNL.

Contribution: This author helped with the conception, design, and execution of the intervention.

Name: Joseph Castongia, MHA.

Contribution: This author helped with the conception, design, and execution of the intervention.

Name: Cali Overbeck, MHA.

Contribution: This author helped with the conception, design, and execution of the intervention.

Name: Lisa Krueger, LCSW, ACM-SW.

Contribution: This author helped with the conception, design, and execution of the intervention.

Name: Bernice Coleman, PhD, ACNP-BC, FAAN.

Contribution: This author helped with the conception, design, and execution of the intervention and helped with writing the manuscript.

Name: Danny Ramzy, MD, PhD.

Contribution: This author helped with the execution of the intervention.

Name: Joshua Chung, MD.

Contribution: This author helped with the execution of the intervention.

Name: Alice Chan, RN, MSN, CNS, CCRN.

Contribution: This author helped with the conception, design, and execution of the intervention.

Name: Eric Ley, MD.

Contribution: This author helped with the conception and design of the intervention and helped with writing the manuscript.

Name: Sindhu Kubendran, MPH.

Contribution: This author helped with the analysis.

Name: Neil Parrish, MBA.

Contribution: This author helped with the analysis.

Name: Zhe Yu, MD, MPH.

Contribution: This author helped with the conception and design of the intervention and helped with analysis and writing the manuscript.

Name: Michael Langberg, MD.

Contribution: This author helped with the conception and design of the intervention.

Name: Stuart Finder, PhD.

Contribution: This author helped with the conception, design, and execution of the intervention.

Name: Bradley T. Rosen, MD, MBA, FACP, SFHM.

Contribution: This author helped with the conception, design, and execution of the intervention and helped with writing the manuscript.

Name: Robert S. Kaplan, PhD.

Contribution: This author helped with the conception and design of the intervention and helped with writing the manuscript.

Name: Harry Sax, MD.

Contribution: This author helped with the conception and design of the intervention and helped with writing the manuscript.

Name: Francisco Arabia, MD, MBA.

Contribution: This author helped with the conception, design, and execution of the intervention and helped with analysis and writing the manuscript.

This manuscript was handled by: Avery Tung, MD, FCCM.

FOOTNOTES

aAs an example, a patient who stated a minimally acceptable outcome of rigorous physical activity and functional independence, but who required an amputation for limb ischemia and a total artificial heart to be separated from ECMO, would not be considered to have goals consistent with ongoing care. Based on this determination, ongoing treatment on ECMO would not be considered appropriate. Alternatively, a similar patient who stated a minimally acceptable outcome to interact with their children regardless of how much assistance they needed would be considered to have goals consistent with ongoing ECMO.

bThe guidelines referenced here are the work product of a hospital medical executive committee task force. The retrospective application of these guidelines was performed to better understand potential gaps in clinical practice in anticipation of guideline implementation.

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