Simulation can help clinicians recognize and treat uncommon and highly complex clinical problems. Four advantages of simulation-based training have been highlighted1: (1) the training program can be modeled according to individual needs, (2) trainees can learn from their mistakes and explore the limits of each technique, (3) skills can be objectively assessed, and (4) immediate feedback can further improve individual and collaborative learning. Moreover, simulation-based training provides a unique opportunity to learn within a group and practice important clinical, communication, leadership, and interpersonal skills.
We report our experience with simulation-based training of extracorporeal membrane oxygenation (ECMO) during the H1N1 influenza pandemic in winter 2009 to 2010.
The Influenza A (H1N1) Pandemic
On April 2009, an outbreak of influenza A (H1N1) occurred in Mexico, whereas 7 other cases were almost concurrently reported in the United States. Rapidly, it became clear that the 2 episodes were related, and the World Health Organization issued advice on the outbreak of an “influenza-like illness in the United States and Mexico.” The disease spread very rapidly, and on June 11, 2009, the World Health Organization declared the H1N1 pandemic, the first global pandemic since the 1968 Hong Kong flu, moving alert level up to phase 6.
A number of authors have reported on risk factors, clinical course, and outcome of the disease: severe hypoxemia, refractory to conventional mechanical ventilation, has been repeatedly described.2–8
Because ECMO may be effective in saving patients with life-threatening acute respiratory distress syndrome (ARDS),9 its use for the treatment of H1N1-related disease was proposed as early as October 12, 2009, by Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators.10 These authors reported of adult and pediatric patients with H1N1 influenza, treated with ECMO from June 1 to August 31, 2009, in 15 intensive care units (ICUs) in Australia and New Zealand, to conclude that “…United States and the European Union might (have expected) to provide ECMO to approximately 800 and 1300 patients during the 2009–2010 winter, respectively.”
The ECMOnet Project
Based on this estimate, on November 5, 2009, the Italian Ministry of Health established a network of selected ICUs (ECMOnet) and identified 2 major urgencies: (1) every ICU in the ECMOnet had to have all the equipment needed to proficiently perform ECMO support, and (2) all the physicians working in the same ICUs had to be quickly and efficaciously trained on how to use ECMO.
Fourteen ICUs were selected based on established experience in (1) treating patients with ARDS, (2) using ECMO to support respiratory and/or cardiac function, and (3) territorial distribution. Of note, 8 (57.1%) of the 14 centers selected had, at that time, no experience with the use of ECMO for the treatment of severe respiratory failure. Based on our expertise, the Italian Ministry of Health asked us to organize 10 sessions of a training course for physicians, perfusionists, and nurses of the ECMOnet.
According to the guidelines developed by the Extracorporeal Life Support Organization (ELSO), training of ECMO should be based on lectures, multiple-choice examinations, water drills, and animal laboratory testing.11 Two major limits characterize this approach: (1) it does not provide any opportunity for trainees to recognize and interpret in real-time situations that do occur in real life, at the bedside, and (2) it requires extensive use of animals.
We rather decided to organize a 3-day training course based on simulation. During the first day, participants were taught about (a) gas exchange during extracorporeal bypass; (b) different types of bypass; (c) general characteristics of the available equipment; (d) management of ventilation, hemodynamics, and coagulation; and (e) weaning from bypass. During the second day, they learnt how to (a) set and prime a real extracorporeal circuit, (b) connect a simulated patient to the bypass, and (c) substitute the extracorporeal circuit, in a full-scale simulated ICU. During the third day, complications possibly occurring during ECMO were simulated (ie, unexpected entrance of air into the circuit, unplanned disconnection, unresponsive hypoxia), and participants had to manage them. To allow each student to actively participate to the practical sessions, small subgroups of trainees were created: whereas the first group was setting and priming the circuit, the second was facing a simulated clinical situation with the third watching the whole scenario by means of a closed-circuit video system. Four instructors were involved: one stayed with the group setting and priming the circuit; one was with the trainees treating the “patient”; one was in the adjacent room, controlling in real time the simulated scenario; and the last one was in the room where simulation was shown on a television screen. Every single practical activity was finally discussed collegially. The same process was repeated 3 times, with different clinical problems proposed to the different subgroups.
The courses were held in the Simulation Centre of the Policlinico Hospital in Milan (Italy), equipped with a Laerdal SimMan, a continuous audio and video recording system, standard intensive care monitoring, and a Maquet Servo-I ventilator. A venovenous ECMO bypass was simulated modifying the Laerdal SimMan as shown in Figures 1A and B.
Practically, 2 pieces of tube were fixed as if they were inserted bilaterally in the femoral veins (left for drainage, right for infusion). They passed through the bed into a tank filled with fake blood. The ECMO equipments consisted of a standard Maquet PLS System including a centrifugal pump and a polymethylpentene oxygenator.
From November 2009 to February 2010, 11 sessions of the course were performed (1 session was added to those initially planned to satisfy the great demand). One hundred ninety-three anesthesiologists [104 men and 89 women; mean (SD) age, 36.78 (8.92) years] attended the course (data presented here are limited to physicians because perfusionists and nurses were not directly involved in all practical simulated sessions).
Course Evaluation Data
At the end of the 3-day course, participants evaluated the course as follows:
All participants passed the final test and the practical examination and obtained physician’s Continuous Medical Education credits.
Clinical Outcome Data
From August 2009 to March 2010, 60 critically ill patients with suspected H1N1 and refractory hypoxemia were treated with ECMO in one of the centers of the ECMOnet. The median duration of ECMO treatment was 10 days (interquartile range, 6–18), and overall survival at hospital discharge was 68.3%. Survival was higher (71%) in 49 patients with a confirmed H1N1 diagnosis and lower (55%) in the remaining.12 No difference in survival was observed between centers with (71%, n = 38) or without (64%, n = 22) previous experience in treating patients affected by ARDS with ECMO (P = 0.35).
Others have previously reported on technical and behavioral skills acquired by means of simulated ECMO emergencies.13,14 To our knowledge, this is the first report on the use of simulation to quickly provide cognitive, technical, and behavioral skills to a large number of physicians expected to face a major health threat. This complied with 2 major issues included in the recommendations and standard operating procedures developed by the Task Force for intensive care unit triage during an influenza epidemic or mass disaster of the European Society of Intensive Care Medicine15: (1) training should begin as soon as possible with demonstrations followed by supervised practice, and (2) preparation will depend on adequate training and education of ICU and ward staff and those co-opted to perform new roles.
The results obtained by the group of ICUs of the ECMOnet were in line with the H1N1 ECMO registry by ELSO reporting a survival rate of 196 (61%) of 323 patients from 76 centers.16
Notably, the use of simulation-based training complies with guidelines on ECMO training, but it did not require animal use. This is, in our opinion, a major improvement because animal use for training is discouraged worldwide.17
According to the “Clinical Management of Human Infection With Pandemic (H1N1) 2009: Revised Guidance,”18 ECMO should be considered in patients with refractory hypoxemia but only “…if the treating physicians/facility has established experience in these modalities.” Extracorporeal membrane oxygenation remains a resource-intensive treatment modality with a steep learning curve and requires a nimble, dedicated staff. This concept is further stressed by the “Guidelines for ECMO Centers” published by ELSO,19 which underlines the need for each ECMO center to have a well-defined program for staff training, certification, and recertification.
Simulation-based training is a valuable tool to quickly and properly teach how to use ECMO to ICU personnel, with no need for laboratory sessions.
The authors thank Maquet for providing a complete extracorporeal PLS system and Servo-I ventilator. The authors also are indebted to Alessandro Protti MD - Dipartimento di Anestesiologia, Terapia Intensiva e Scienze Dermatologiche - Università degli Studi di Milano–Italy for reviewing the manuscript.
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