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Designing an Extracorporeal Cardiopulmonary Resuscitation Protocol

It Is Time to Address Quality

Han, Jason J.; Hoenisch, Kelly; Bermudez, Christian

doi: 10.1097/MAT.0000000000000965
Editorial
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SDC

From the Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.

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Submitted for consideration November 2018; accepted for publication in revised form December 2018.

Disclosure: The authors have no conflicts of interest to report.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML and PDF versions of this article on the journal’s Web site (www.asaiojournal.com).

Christian Bermudez is a senior author.

Correspondence: Jason Han, Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, 3400 Spruce St, 6 Silverstein Pavilion, Philadelphia, PA. Email: Jason.Han@uphs.upenn.edu.

Extracorporeal cardiopulmonary resuscitation (ECPR) refers to the use of temporary mechanical support as an adjunct to standard CPR in patients with cardiovascular collapse. Although it is a relatively recent practice, there have been nearly 5,000 cases of ECPR to-date according to the extracorporeal life support organization (ELSO) registry.1 As the use of ECPR increases, the remaining challenge is to ensure the quality of ECPR is commensurately improving. The motivation is both clinical and financial. Clinically, although ECPR has undoubtedly led to meaningful extension of life in many cases, as a bridge to recovery, transplantation or a durable device, there is clear room for improvement in utilization of ECPR as only 20–32% of patients under current standard practices have been shown to survive to discharge.1–4 Inappropriate or suboptimal initiation of ECPR can lead to difficult medical and ethical conundrums that may adversely affect the patient, families, and even the clinicians. Financially, the Center for Medicare Services (CMS) recently announced a decision to reduce the reimbursement amount for peripheral extracorporeal membrane oxygenation (ECMO)—a cannulation strategy almost always utilized in ECPR—incentivizing a more careful and judicious use of this technology.5

On the one hand, improving the quality of ECPR relies on the accumulation of more experience and evidence-based knowledge. However, another crucial aspect of quality improvement is to be able to efficiently and objectively apply what we know during ECPR ensuring 1) appropriate patient selection and 2) a safe and error-free execution of the procedure. What makes accomplishing this task especially challenging is that ECPR is a fundamentally complex, time-sensitive, technical, and team-based process.6 From the perspective of ECPR responders, they generally have little or no prior knowledge of the patient until their services are requested; yet the call to evaluate a patient is urgent, and decisions must be made within minutes of their arrival to maximize the patient’s chance of survival. It is usually neither convenient nor feasible for them to attain a comprehensive clinical understanding of the patient or to carefully set-up for the procedure. Given the sense of urgency, there is a high likelihood of errors in judgment and execution. Other challenging aspects of this process are social, psychologic, and emotional elements, requiring the clinical team to navigate the emotions and chaotic dynamic of the resuscitation group that has certain expectations in a code setting. As has been acknowledged about Code situations, these factors render decision-making vulnerable to error and bias.6

Given the challenging and error-prone circumstances surrounding ECPR, there is a desirability for more structured protocols, not only at an institutional but also at a national level. These are tools that can be used to 1) to streamline the decision-making process leading to the involvement of ECPR responders, 2) to efficiently and consistently gather relevant information necessary to arrive at a consensus, and 3) to prepare the room for initiation of ECMO. The online supplemental figure (see Figure, Supplemental Digital Content, http://links.lww.com/ASAIO/A405) provides an example of an ECPR protocol that can be distributed to various units throughout the hospital. This content can be designed either on paper or electronically. The value of this protocol is that it does not have to be centered on the tasks of the ECPR responders, but rather on the priorities of the team as a whole. Whenever ECPR is being considered, the primary team can prepare for ECPR even before the arrival of the responders by following the protocol. By the time the ECPR responders arrive, they will have the resources and the information necessary to make these life-altering decisions more efficiently and objectively. These steps are neither time-consuming nor complicated but their potential benefits to patient outcomes by saving time and decreasing the likelihood of leaving out critical pieces of information, are profound. Moreover, implantation of an ECPR protocol that relies on a document to help streamline the process encourages responders to not only use this tool during ECPR but also to measure and to keep track of the team’s performance over time. Measurement is the cornerstone of quality improvement. In physically checking off the criteria and recording the data, the protocol helps the team grow more cognizant of their decision-making process including areas in which they excel and areas in which they have the potential to improve.

In order to maximize the utility of this ECPR protocol, it is important to borrow lessons from the literature surrounding checklists. Initially implemented in the aviation industry, this concept has been validated across many disciplines, where the nature of the operation is complex, and the cost of error is high.7,8 First, like checklists, the ECPR protocol should be efficient and easy-to-use with clear directions, containing only the key items that must be addressed to avoid critical errors, whether in judgment or during the procedure. Second, healthcare providers utilizing the ECPR protocol should understand its purpose is not to be more sophisticated or comprehensive than the human brain, but rather, to acknowledge that humans, no matter how well-trained or specialized, are capable of error especially in high-stress circumstances. Relying on this tool would systematically remind us these appropriate steps every time, with every patient, regardless of the composition of the team and what distractions may exist. Thus, we can expect to eliminate or greatly reduce the possibility of major errors when initiating ECPR.

Although creating a more structured protocol can be a powerful tool for ECPR, we must acknowledge creating them is only the first step. To ensure it is actually helpful to the process, it has to become seamlessly melded into not only the infrastructure but also the culture of the institution. Bringing about this cultural change will not be instantaneous or easy. However, this protocol will help ensure the operator remains on-task to complete the necessary steps without forgetting any essential detail. It shares the responsibilities of information and equipment gathering, so the process can move along expeditiously. It is our hope the protocol becomes accepted as a natural part of the ECPR process in going forward, as it becomes regarded as not only effective but also indispensable.

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Acknowledgment

The authors thank Emilia Flores and the Penn Medicine Center for Evidence-based Practice team for their help in creating and launching the algorithm.

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References

1. Organization, E.L.S: ECLS Registry Report International Summary. 2018. Available at: https://www.elso.org/Registry/Statistics/InternationalSummary.aspx. Accessed October 1, 2018.
2. Conrad SJ, Bridges BC, Kalra Y, Pietsch JB, Smith AH. Extracorporeal cardiopulmonary resuscitation among patients with structurally normal hearts. ASAIO J 2017.63: 781–786.
3. Pabst D, El-Banayosy A, Soleimani B, Brehm CE. Predictors of survival for nonhighly selected patients undergoing resuscitation with extracorporeal membrane oxygenation after cardiac arrest. ASAIO J 2018.64: 368–374.
4. Mendiratta P, Wei JY, Gomez A, et al. Cardiopulmonary resuscitation requiring extracorporeal membrane oxygenation in the elderly: A review of the Extracorporeal Life Support Organization registry. ASAIO J 2013.59: 211–215.
5. Organization, E.L.S: Center for Medicare Services (CMS) - Reimbursement for ECMO. 2018. Available at: https://www.elso.org/Registry/Statistics.aspx. Accessed October 1, 2018.
6. Han JJ, Swain JD. The perfect ECMO candidate. J Am Coll Cardiol 2018.71: 1178–1182.
7. Haynes AB, Weiser TG, Berry WR, et al; Safe Surgery Saves Lives Study Group: A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009.360: 491–499.
8. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006.355: 2725–2732.
Keywords:

extracorporeal cardiopulmonary resuscitation; extracorporeal membrane oxygenation

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