Characteristics of Extracorporeal Membrane Oxygenation Education Vary in Entry-Level Doctor of Physical Therapy Programs: Results of a National Survey : Journal of Acute Care Physical Therapy

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ORIGINAL STUDY

Characteristics of Extracorporeal Membrane Oxygenation Education Vary in Entry-Level Doctor of Physical Therapy Programs

Results of a National Survey

Driscoll, Jenna; Elkins, Jeananne

Author Information
Journal of Acute Care Physical Therapy: October 2022 - Volume 13 - Issue 4 - p 159-165
doi: 10.1097/JAT.0000000000000188

Abstract

Physical therapy (PT) in the intensive care unit (ICU) or cardiac care unit is an important element of interdisciplinary team care because the physical therapist is the functional movement specialist in health care.1 Therefore, physical therapists must be familiar and comfortable with the various advanced technologies used in this setting to provide safe and effective therapy.2 One of the advanced technologies increasingly used in the ICU is extracorporeal membrane oxygenation (ECMO). Extracorporeal membrane oxygenation is an advanced life support modality designed to address severe circulatory or respiratory failure.3 In the past, PT would be held until the patient was taken off ECMO; however, with the recent shift toward decreasing sedation levels and increasing early mobilization,4,5 physical therapists are now expected to treat patients while still on this modality.

BACKGROUND

The ECMO device provides both gas exchange and circulatory support.3 A centrifugal pump is used to pass venous blood across a semipermeable gas exchange membrane, where oxygen diffuses into the blood and carbon dioxide diffuses out of the blood. The configuration of the device is dependent upon the purpose of ECMO therapy. If respiratory support is required, venovenous ECMO drains deoxygenated blood from a central vein, and blood is likewise reinfused through a central vein. When support requirements are hemodynamic in nature, venoarterial ECMO drains deoxygenated blood from a central vein and returns oxygenated blood into the arterial system. The location of the cannulae can impact the effectiveness of the circuit, as well as the ease of performing early mobilization.3

The relevance of PT for patients on ECMO has increased since the onset of the COVID-19 pandemic. Venovenous ECMO is now commonly employed in critically ill patients with COVID-19 acute respiratory distress syndrome that is refractory to lung-protective mechanical ventilation and pronation.6 Venoarterial ECMO is also used in COVID-19 as a bridge to recovery for severely compromised cardiovascular function patients, such as COVID-associated myocarditis, ischemic cardiac injury, and decompensated heart failure.6,7 In very severe cases, a combination of these 2 modalities has been used.6

Published literature presents evidence addressing early mobilization and PT for patients on ECMO. Randomized controlled trials are not yet published, but case series and cohort studies help delineate the role of PT in patients receiving extracorporeal support.8–17 Both a large retrospective cohort study and a systematic review demonstrated a strong safety profile during the completion of standing and ambulation activities despite using femoral cannula sites.10,18

A common theme in the literature on the mobilization of patients on ECMO is the need for an integrated multidisciplinary team that includes physical therapists as functional movement specialists. Risks of mismanagement during PT must be recognized, including hemodynamic instability, cannula displacement, cannula kinking or fracture, and leaks or thromboses in the tubing.5,18,19 Well-delineated roles and responsibilities to ensure safety, as well as a stepwise monitoring approach, are essential for successful mobility.3,19–22 Therapists must communicate clearly with the nurse or the ECMO specialist, monitor cannula security, assess hemodynamic variables and airway patency, and appropriately adjust or terminate a session.20,22 To accomplish this, physical therapists must first understand ECMO. This is especially critical during the COVID-19 pandemic when demand for PT in the ICU is high, and entry-level therapists may be expected to manage complex patients with limited additional training.

Education literature pertaining to the efficacy of ICU simulation and hands-on experience does not specifically address ECMO training of physical therapist students or practicing physical therapists.23–29 The extent to which ECMO-related education is included in acute care/cardiopulmonary curricula is unknown. Furthermore, Commission on Accreditation in Physical Therapy Education (CAPTE) requirements do not currently recommend competency with this modality. However, practice in this area closely relates to included topics of ventilation, respiration, and gas exchange.30

PURPOSE

While the evidence demonstrates the safety, feasibility, and benefit of PT concurrent with ECMO intervention, literature addressing the education of entry-level doctor of physical therapy (DPT) students in ECMO is lacking. Our purpose is to describe ECMO-related education characteristics in entry-level DPT programs and examine any correlations among these characteristics. Results may assist in developing future curricula and may help identify obstacles to such development.

METHODS

We created an institutional review board–approved (institutional review board no. CPS20-08-13) anonymous survey based on current literature and the primary author's clinical experience in acute care. The content was reviewed by an independent, secondary faculty member with extensive experience in acute care. The pool of potential respondents included all program directors for CAPTE-accredited entry-level DPT programs in the United States as listed in the American Physical Therapy Association (APTA) directory. Program directors were emailed an invitation to participate in the study. They could choose to directly participate or forward the link to a faculty member knowledgeable about the ECMO curriculum.

The survey instrument included demographic and descriptive data about the program and 12 questions specific to the curriculum, emphasizing ECMO-related education (see Supplemental Digital Content Appendix A, available at: https://links.lww.com/JACPT/A7). At the end of the survey, the participants could convey any comments specific to their curriculum. Statistical analysis was completed using STATA 13.1 (College Station, Texas). Descriptive statistics included frequency of survey responses in each US region, frequency of responses in each age category (<10 years, 11-20 years, 21-49 years, and >50 years), mean and mode for the age of DPT programs, frequency of affiliation with an academic medical center, frequency of responses in each length of acute care class category (<6 weeks, ≥6 weeks), frequency of responses in each characteristic of education category (didactic elements, case studies, and hands-on experience), frequency of specific instructor credentials, and frequency of each possible identified barrier to ECMO education. Categories of responses were created for ease of statistical analysis based on the primary author's clinical and academic experience and discussion between 2 authors. Specifically, characteristics of didactic education were sorted into 3 clinically significant categories: (1) no ECMO-related education, (2) purpose of ECMO + basics of equipment, and (3) purpose of ECMO + basics of equipment + potential emergencies and complications during ECMO. Credentials were also placed into 3 categories for the purpose of analysis: (1) DPT only, (2) cardiovascular and pulmonary specialist (CCS) certification, and (3) other degrees (eg, PhD, EdD, DSc, MSPT, BSPT).

Pairwise correlation statistics were performed to assess potential relationships between program age, affiliation with an academic medical center, length of acute care class, presence of didactic ECMO, ECMO simulation training, ECMO case studies, ECMO hands-on experience, and instructor credentials. Chi-square analysis was performed to examine relationships between specific categorical variables, specifically, affiliation with an academic medical center, and instructor credentials, with the length of acute care class, categories of didactic ECMO, presence of ECMO case studies, presence of simulation training, and presence of hands-on ECMO experience. Further analysis using Fisher exact test was performed to account for the small sample size. In all statistics performed, values were considered significant at P ≤ .05.

RESULTS

Demographics and Descriptive Program Data

Of the 243 US-accredited programs emailed the survey, 31 responded (12.8%). Zip codes were collected and categorized into US Census Bureau Regions.31 Responses were received from 9 regions and 1 from Puerto Rico, as shown in Figure 1. Twenty-six percent of the programs reported being affiliated with an academic medical center. Statistical analysis demonstrated no relationship between the region and program affiliation with an academic medical center (P = .45). The analysis also demonstrated no relationship between the region and the type of ECMO-related education offered (P = .52).

F1
FIGURE 1.:
Survey Responses Categorized by US Region.

The age of the programs ranged from 5 to 92 years with a mean of 28 (SD = 23), a median of 20, and modes of 20, 50. The maturity of most programs was notable, with 32% being 11 to 20 years of age and 29% being older than 50 years. As shown in Table 1, no significant relationships were found between the age of the program and the types of ECMO-related education offered in the classroom. A positive correlation was noted between the age of the program and the presence of hands-on ECMO experience (P = .019).

TABLE 1. - Pairwise Correlations (P Values) Between Program Demographics and ECMO-Related Characteristics
Characteristics Age of Program, y Affiliation With Academic Medical Center Length of Acute Care Class
Didactic ECMO 0.071 0.244 .05a
Case studies ECMO 0.519 .002a 0.209
Simulation ECMO 0.281 0.764 0.534
Hands-on ECMO .019a .0004a 0.515
ECMO, extracorporeal membrane oxygenation.
aStatistical significance.

All programs required students to take an acute care/cardiopulmonary class. The class length varied from less than 6 weeks to 12 weeks, with most DPT programs (77.78%) providing 12 weeks of such education. The only significant correlation discovered regarding the length of acute care class was with didactic ECMO-related education (see Table 1, P = .05).

Characteristics of ECMO-Related Education

Twenty-five (80.65%) programs reported including some level of ECMO-related education in their curriculum, while 6 (19.35%) reported an absence of such education. Regarding the 3 categories of didactic education, 41.94% (n =13/31) provide the most robust level of didactic education (see Figure 2).

F2
FIGURE 2.:
Characteristics of Didactic ECMO-Related Education. ECMO indicates extracorporeal membrane oxygenation.

When asked to report on any critical care case study discussions involving treatment planning for patients on ECMO, 21 (67.74%) respondents indicated that these discussions do not occur. The 10 (32.26%) respondents who reported using case studies further indicated that these discussions occur between students and their PT instructor and do not involve collaboration with other disciplines.

As shown in Table 1, a positive correlation is noted between the use of case studies and a program's affiliation with an academic medical center (P = .002). This relationship was again demonstrated with further analysis using Fisher exact test (P = .01, see Table 2). Three programs (9.68%) reported including critical care simulation–based ECMO training, and 15 programs (50%) reported some level of hands-on ECMO experience. The Fisher exact test likewise revealed a significant relationship between hands-on ECMO experience and affiliation with an academic hospital (P = .001), as shown in Table 2.

TABLE 2. - Results of Analysis of Variables (Fisher Exact Test): Affiliation With Academic Medical Center
Variable and Reported P Value No Affiliation With Academic Medical Center, n Affiliation With Academic Medical Center, n
Length of class: <6 wk 3 0
Length of class: ≥6 wk 16 8
P = .33
No didactic ECMO 6 0
Purpose/basics only 8 4
Purpose/basics/emergency 9 4
P = .33
No case studies 19 2
Case studies 4 6
P = .01a
No simulation 21 7
Simulation 2 1
P = .61
No hands-on ECMO 15 0
Hands-on ECMO 7 8
P = .001a
ECMO, extracorporeal membrane oxygenation.
aStatistical significance.

The programs that reported some opportunity for hands-on ECMO experience were asked to delineate what proportion of their students could take advantage of such opportunity. Sixty-five percent of these programs indicated that “0% to 10%” of students typically receive this type of training. Respondent comments reflected that the hands-on experience occurs in the form of an acute care clinical rotation, with 2 programs noting participation in an ICU visit where the use of ECMO is observed.

Those respondents who indicated the inclusion of ECMO-related education were asked to report on the credentials of the acute care course instructor. The most frequent credential was a DPT degree (n = 18/31). In addition, 60% of programs indicated that instruction is provided by an American Board of Physical Therapy Specialties (ABPTS)–certified CCS. When looking specifically at schools affiliated with an academic medical center, 88% have a CCS instructor teaching the acute care class. Relationships between categories of instructor credentials and ECMO-related education characteristics were analyzed as shown in Table 3. Although instructor credentials did not appear to drive the type of ECMO education offered, a significant relationship was found between instructor CCS credentials and the presence of hands-on ECMO experience (P < .001). In terms of testing student preparedness, 76% of respondents reported that a cognitive assessment is used, with only 1 using technical and behavioral skills assessment. Upon analysis, instructor credentials did not appear to correlate with the type of assessments administered (P = .34).

TABLE 3. - Results of Analysis of Variables (Fisher Exact Test): Instructor Credentials
Variable and Reported P Value DPT, n CCS, n Other Degrees, n
No didactic ECMO 1 0 1
Purpose/basics only 2 5 3
Purpose/basics/emergency 1 10 2
P = .17
No case studies 4 8 3
Case studies 0 7 3
P = .28
No simulation 3 13 6
Simulation 1 2 0
P = .53
No hands-on ECMO 2 2 6
Hands-on ECMO 2 12 0
P = .00a
CCS, cardiovascular and pulmonary specialist; DPT, doctor of physical therapy; ECMO, extracorporeal membrane oxygenation.
aStatistical significance.

When participants were asked to check off perceived barriers to ECMO education and were also given an opportunity to free-text comments (see Supplemental Digital Content Appendix A, available at: https://links.lww.com/JACPT/A7), highly cited barriers were limited teaching time and lack of simulation equipment (see Figure 3). Six respondents indicated that they had not identified the importance of ECMO education. Notably, 2 write-in comments reflected that ECMO management is not a “standard item listed for licensure exam” and is not considered “an entry-level skill.”

F3
FIGURE 3.:
Barriers to ECMO-Related Education. ECMO indicates extracorporeal membrane oxygenation.

DISCUSSION

These results provide the first documented description of ECMO-related education provided by CAPTE-accredited DPT programs. Overall, the results indicate that most programs (80.65%) that responded to the survey provide some level of ECMO education. The degree of didactic education varied among programs, ranging from instruction in the purpose of ECMO and basics of equipment (38.71%) to a more robust didactic curriculum that also includes the management of potential ECMO emergencies and complications (41.94%). These inconsistencies may be related to a lack of specific educational guidelines regarding advanced life support modalities. Although modalities such as ventricular assist devices, intra-aortic balloon pumps, and ECMO are being used more frequently in ICUs, these topics are not yet mentioned in guiding documents such as CAPTE standards for accreditation (2020) or the APTA Acute Care Physical Therapy Minimum Skills Task Force core competency document (2015).30,32

Besides didactic education, findings indicate that other types of ECMO-related training are integrated to a lesser extent. With only 3 programs reporting use of simulation-based ECMO training, lack of access to simulation labs may be a principal issue for DPT programs. Simulation effectively improves student confidence when caring for critically ill patients; however, these experiences impose high costs in terms of finances and faculty time.23,33–36 The survey items that dealt specifically with the clinical application of didactic knowledge revealed that one-third of programs that include ECMO in the curriculum provides case study discussions involving treatment planning for patients on ECMO. One-half of those programs includes some opportunity for hands-on ECMO experience. The independent statistically significant relationships between both characteristics (case studies and hands-on ECMO) with a program's affiliation with an academic medical center may reflect a higher level of access to a critically ill population. These relationships also shed light on the need for students and entry-level therapists who practice in these settings to possess skills and behaviors that ensure the safe management of medically complex patients. Since not all DPT programs have access to academic medical centers, entry-level clinicians need to self-advocate for further training when needed. This safety consideration is particularly paramount for overextended acute care rehabilitation departments during the COVID pandemic, considering that the APTA Acute Care core competency document states: “In the majority of situations the entry-level clinician should be able to manage lines and tubes without needing assistance or further training.”32 Based on the high demand for PT staffing, it is plausible that many hospitals may expect entry-level therapists to practice at a level of independence in the ICU rapidly.

This study revealed that the credentials of the acute care instructor might affect the type of ECMO-related education offered. Although no significant relationship was found between instructor credentials and didactic education, case studies, or simulation, a significant relationship was found between credentials and the presence of hands-on ECMO experience. This finding may reflect that board-certified specialists have greater knowledge and skills in advanced life support modalities. In addition, they may impart more value on the importance of hands-on experience in critical care. Despite this correlation, insufficient instructor training was not a commonly identified barrier. This finding implies that most of the respondents are comfortable teaching advanced acute care topics. Notably, the most identified barrier was limited teaching time. Several free-text comments mentioned the burden of covering many topics in a limited number of credit hours. A contributory factor may be that the National Physical Therapy Examination content outline does not specifically include life support modalities other than mechanical ventilation.37 Perhaps DPT programs prioritize other testable topics during curricular development and revision. Considering current test content and respondent comments regarding the advanced skill level of this topic, ECMO may be appropriate for inclusion in a critical care course elective or an acute care residency, specifically geared toward those students interested in working in the ICU setting. Conversely, as trends show an overall increase in chronic disease and our patient populations become more critically ill,38 the inclusion of ECMO in competency documents that guide curricular development may become appropriate.

While the study provided insight into the level and characteristics of ECMO-related education, limitations exist. The low survey response rate potentially introduced some level of nonresponse bias. Studies about surveys of medical professionals have shown that response rates have declined over the past 2 decades, especially with the use of electronic media.39 Specifically, response rates for Web surveys are on average 11% lower than other survey modes.40 However, research shows that response representativeness may be more important than response rate.39,41,42 A meta-analysis of 59 methodological studies concluded that “the non-response rate of a survey, by itself, is a poor predictor of the absolute relative non-response bias.”43 A 2019 analysis of a large, multisite, random study revealed only a scant relationship between survey response rate and nonresponse bias.44 This survey was successfully emailed to every CAPTE-accredited DPT program, and the sample of respondents appeared to be representative of the target population since they were distributed among all 9 US Census Bureau Regions, in addition to Puerto Rico. We recognize, however, that the respondent pool may have been biased toward the inclusion of ECMO (eg, those who do not include ECMO in their program may have chosen not to respond). Therefore, our results relevant to the characteristics of ECMO education may be more meaningful than those pertaining to the number of DPT programs that teach this modality. The response rate could have been improved by administering follow-up communications or a secondary survey mode such as a postal mailing.40

The anonymous mode of survey administration likely helped limit social desirability bias and facilitate truthful responses.45,46 However, the survey was not validated prior to administration and may have been susceptible to self-report bias. The validity of the survey tool could have been assessed with a group of educators similar to the target population. However, the inclusion of an open-ended text box did allow for gathering valuable qualitative feedback that the investigators had not foreseen as probable answers and may be useful in future survey revision.

CONCLUSION

Although most respondents reported including some level of ECMO-related education in their DPT program, the extent and characteristics of the content varied. This study showed an important positive correlation between a program's affiliation with an academic medical center and the likelihood of providing ECMO case studies and hands-on experience. Furthermore, a direct relationship was discovered between instructor credentials and the provision of hands-on experience. More research is necessary to examine the status of acute care hospital-based competency programs and their inclusion of advanced life support modalities such as ECMO. Such information combined with the results of this study may point to the development of formalized curricular guidelines to promote best practice.

ACKNOWLEDGMENTS

The authors acknowledge Dr Christy Brimmer, PT, DPT, for her independent review of the survey instrument.

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