Lindsay Johnston, M.D. and Stephanie Sudikoff, M.D. examine the logistics of establishing an Extracorporeal Membrane Oxygenation simulation program.

Lindsay Johnston, M.D. and Stephanie Sudikoff, M.D. present the first of a two-part overview on establishing an Extracorporeal Membrane Oxygenation simulation program. This first installment focuses on the logistical issues supporting this program.

What is ECMO?

Developed in the 1970s, Extracorporeal Membrane Oxygenation (ECMO) is used in the management of the most critically ill patients, and allows for temporary support of cardiac and/ or pulmonary function using a mechanical circuit, including a pump, a membrane oxygenator, and a heat exchanger. ECMO was initially utilized for short-term support for newborns with acute, potentially reversible causes of respiratory failure, such as meconium aspiration syndrome, persistent pulmonary hypertension of the newborn, and congenital diaphragmatic hernia. (K Van Meurs et al, ECMO Extracorporeal Cardiopulmonary Support in Critical Care, 3rd Ed 2005) It is typically offered as an option for therapy when predicted mortality with conventional management is estimated to be >80%. Its use has been expanded to include respiratory and cardiovascular support for children and adults with other potentially reversible conditions.

Initiating therapy with ECMO requires surgical cannulation of the great vessels, most often the carotid artery and internal jugular vein in neonates. Blood is drained from the patient through the venous cannula, and flows to a collection chamber, called the bladder. The blood is then pumped to the membrane oxygenator, where oxygenation and CO2 elimination occur. Blood is returned to the patient via the arterial cannula, after passage through the heat exchanger, which allows for maintenance of normothermia. Appropriate levels of oxygen and CO2 in the patient’s blood can be maintained by titrating the pump flow and adjusting the gas flow across the membrane oxygenator. This allows for support of much of the patient’s cardiopulmonary function.

 Traditional Methods for Training ECMO Teams:

Traditional training in ECMO management typically consists of didactic lectures supplemented with hands-on training using a water-filled ECMO circuit. In this model, trainees are not given the opportunity to incorporate real-time changes in the patient’s clinical status into their plan of care. Additionally, and perhaps most importantly, this method does not address the issues of team behavior and effective communication among a multidisciplinary group of providers.

Drs. Anderson and Halamek were the first to publish on ECMO simulation. Their group linked a neonatal mannequin with a standard neonatal ECMO circuit primed with artificial blood. Participants preferred the degree of realism achieved when training included simulation, as the circuit could demonstrate physiologically appropriate pressures and vital signs could be adjusted to reflect the particular clinical scenario. Compared with traditional methods, learners spent much more time engaged in active learning (78% vs. 14%), and could develop cognitive, technical and behavioral skills that would have been challenging to recreate with traditional didactic training. (JM Anderson et al, Simul Healthcare 2006; 1:220-227)

Why Start an ECMO Simulation Program?

Patient Safety:

ECMO teams care for the most critically ill patients using a highly complex technology that is significantly different than conventional critical care equipment. To be effective, providers require specialized training to be able to appropriately manage a patient on this type of support. There are a multitude of factors that increase the risk of medical errors in these cases, and a robust curriculum for initial training and continuing education are vital to help protect patients from possible adverse outcomes.

The frequency of ECMO cases at a given institution is unpredictable and can vary significantly from year to year. With advances in medical care for hypoxic respiratory failure and pulmonary hypertension, the incidence of neonatal respiratory ECMO runs has been decreasing over time. There was a peak of approximately 1,500 cases per year in the early 1990s, and this has decreased to less than 600 cases in 2010. (ELSO Registry Report, International Summary January 2011) As the volume decreases, the time interval between ECMO cases increases. This could potentially lead to a decrease in the care team’s comfort with this complex technology.

Furthermore, true emergencies on ECMO occur infrequently. For example, raceway rupture, cardiac tamponade, air entrainment in circuit, pneumothorax, and oxygenator failure occur in about 0.3%, 0.5%, 4.9%, 6%, and 6% of ECMO runs, respectively. There is an extremely low likelihood that a particular healthcare provider would have personal experience dealing with any one situation. However, in emergencies on ECMO, prompt and correct steps to rectify the situation are vital. The rate of patient survival for the conditions above ranges from 32-70%, and depends heavily on the provider’s management of the problem. (ELSO Registry Report, International Summary January 2011) An ECMO simulation program allows each provider to have a standardized experience and gain confidence managing a wide variety of scenarios, ranging from routine management decisions to rare but potentially catastrophic events.

Additionally, new technologies are frequently developed to enhance the ECMO circuit. Centrifugal pumps have been taking the place of the standard roller-head pumps, and new oxygenators have been developed to replace the silicone membrane oxygenator. It is essential that staff members have an opportunity to familiarize themselves with the new equipment, and it is desirable that this learning occurs prior to utilizing the new equipment on patients. ECMO simulation allows for this orientation to occur without potential danger to patients.

Physicians, perfusionists, practitioners and nursing staff discuss potential etiologies for the decompensation of the ECMO patient. Image Credit: Yale University School of Medicine.
Physicians, perfusionists, practitioners and nursing staff discuss potential etiologies for the decompensation of the ECMO patient. Image Credit: Yale University School of Medicine.

 Multidisciplinary Team Practice:

An ECMO team is, by necessity, multidisciplinary and includes intensive care physicians, surgeons, perfusionists, nurse practitioners, physician’s assistants, respiratory therapists, and nursing staff. Each discipline is educated in an individual silo, but providers are expected to function well with all other members of the healthcare team. Historically, medical training programs did not cover communication and teamwork behaviors, but these skills are not innate; they must be learned and practiced. Since the 1999 Institute of Medicine Report “To Err is Human” revealed that communication issues exist at the root of many sentinel events, initiatives to improve team behaviors have been stressed to improve patient safety. Key principles of teamwork include: clear team structure and role clarity, leadership, situation monitoring, mutual support, and communication.

Simulation has proven ideal for stressful situations that occur infrequently and are high-risk for human error – ECMO certainly fits into this category. Utilizing simulation to train ECMO teams is particularly beneficial for the ability to recreate low frequency, high-risk situations where clear, concise communication could mean the difference between life and death. This can also provide a forum to improve team behaviors among members of the multidisciplinary group of providers, which are vital for patient safety efforts. (Image 1)

Extracorporeal Life Support Organization: Center of Excellence in Life Support

ELSO, the Extracorporeal Life Support Organization, is an international consortium of health care professionals and scientists dedicated to the development and evaluation of novel therapies to support failing organ systems. ELSO recognizes selected ECMO programs with the designation “Center of Excellence in Life Support,” an honor currently bestowed upon approximately 48 programs internationally. This award recognizes programs that promote quality and exceptional care in ECMO. The “Excellence in Life Support Award” signifies to patients and families an institution’s commitment to exceptional patient care. It demonstrates to others in the health care community an assurance of high quality standards, defined patient protocols, and continuing education of staff members. Centers may use the award to market themselves as distinguished leaders in critical care, and it is recognized by US News and World Report and Parents magazines as one of the criteria for highly ranking institutions.

A designated Center of Excellence has demonstrated extraordinary achievement in several categories, including excellence in training and education. Development of an ECMO simulation program fulfills one of the requirements for consideration of this award, a reliable forum for continuing education of ECMO teams.

Who should participate in the development of the ECMO simulation program?

When developing an ECMO simulation program, it is imperative to have representation from all members of the actual multidisciplinary ECMO team, including physicians from all involved specialties (e.g., Neonatology, Pediatric Critical Care Medicine, Adult Critical Care Medicine or Cardiothoracic Surgery), perfusionists, nurses, and respiratory therapists. These individuals will help to ensure that the experiences are relevant and as realistic as possible for their staff. Having these “champions” also allows for “buy-in” from the other members of the team and can improve rates of participation.

Additionally, early involvement and commitment from an institution’s simulation center is vital to the success of the endeavor. The simulation specialists are vital to the initial adaptation of the mannequin to allow for “cannulation” and interaction with the ECMO circuit. To allow for simulation of a wide variety of clinical scenarios and ECMO emergencies, the specialists adjust the circuit pressures, patient monitoring equipment, and vital signs in real-time, thereby enhancing the overall realism of the setting.

Simulation specialists prepare the ECMO mannequin for multidisciplinary team simulations. Image Credit: Yale University School of Medicine.
Simulation specialists prepare the ECMO mannequin for multidisciplinary team simulations. Image Credit: Yale University School of Medicine.

Budget

ECMO simulation programs vary widely with respect to their budgets, but it is possible to create a very realistic learning environment with minimal financial investment. The initial cost depends mainly upon the modifications made to the manikin to allow for interaction with the ECMO circuit, which will be discussed below. At Yale, the initial cost was minimal and covered the purchase of a low-fidelity mannequin with a realistic airway.

The ongoing costs for supporting an ECMO simulation program can be variable. A new circuit is required each time a new scenario is planned, and the cannulae need to be replaced frequently. In most cases, expired circuits and cannula have been utilized for the ECMO simulations at Yale, so the program can be sustained with little ongoing investment by the institution. Budgetary information, if equipment is purchased new, is listed in Table 1. The cost for consumables (e.g., syringes and IV supplies, teaching medications, airway equipment, teaching code cart) can vary widely. Many institutions have supplies, such as intubation equipment, set aside for teaching. At Yale’s neonatal intensive care unit, intubation equipment, syringes and tubing, and teaching medications dedicated for simulation are utilized for all sessions. If the team needs to replenish this equipment, it is typically incorporated into the unit’s operating costs.

Since the program at Yale is deemed important for ongoing training of staff and results in significant improvements in patient safety, the costs for utilizing the staff and resources of the simulation center are supported by the health system.

Staff members are typically compensated for their time spent participating in ECMO simulation. Perfusionists, nurses, and practitioners are typically scheduled for sessions during a regular shift, and their clinical responsibilities are covered for the duration of the simulation. If staff choose to come in when they are not scheduled to work, they are compensated. Physicians have not been financially compensated for their time, but have been eager to participate given the significant benefits to their knowledge and to patient care. Additionally, participation in these sessions is required for continuing education of ECMO team members, and is utilized by the hospital in credentialing physicians to use this technology.

Adaptation of Mannequin

Centers with ECMO simulation programs have a variety of different solutions to allow the mannequin to interact with the ECMO circuit and be placed “on bypass.” These options cover a wide range of fidelity, and include permanent changes to the mannequin to allow for cannulation of an indwelling fluid reservoir to utilization of a high-fidelity manikin positioned on top of ECMO circuit tubing, without requiring any permanent alteration of the mannequin.

The simulation specialists who created the ECMO mannequin for the program at Yale started off by reviewing the pertinent anatomic structures and procedure for cannulation, as well as ideal cannula placement, normal cannula size and flow rates. The mannequin selected was a Laerdal Nursing Baby (Laerdal Medical, Wappinger Falls, NY). The airway was left intact, and the remaining internal structures were removed to accommodate a fluid chamber (a bladder from an expired ECMO circuit) and tubing into which ECMO cannulae could be inserted. (Image 2) The connection points were secured with zip ties and rubber tubing to minimize leakage. The cannulae are connected to a standard neonatal or pediatric ECMO circuit, which is filled with an artificial blood solution.

The mannequin’s cannulas are typically replaced prior to each simulation session, as the connections can sometimes leak due to high pressures from the ECMO circuit. Additionally, both Venoarterial (VA) and Venovenous (VV) ECMO can be simulated, and the cannulae are changed to reflect the appropriate scenario.

At Yale, the mannequin used for ECMO simulation does not have an associated patient monitor. Since it was imperative to have changes in the patient’s clinical status readily available to the team, a monitor with input from SimBaby software is used to display and alter clinically relevant vital signs. Therefore, even though this program is not interacting with the mannequin, the medical team can still utilize this information.

Drs. Lindsay Johnston and Stephanie Sudikoff beside a baby HPS (human patient simulator) at Yale New Haven Hospital. Image Credit: Yale University School of Medicine.
Drs. Lindsay Johnston and Stephanie Sudikoff beside a baby HPS (human patient simulator) at Yale New Haven Hospital. Image Credit: Yale University School of Medicine.

The pressure readings from the ECMO circuit can also be adjusted to reflect various medical emergencies. To accomplish this, flowsheets were initially used to display the desired circuit pressures, and the perfusionists were used as confederates. The simulation specialists then devised a system in which extra tubing is attached to the pressure transducers, and small amounts of fluid can be injected into the system to titrate the pressures to the desired values.

Conclusion

ECMO is a mode of cardiopulmonary support for the most critically ill patients, and inappropriate management decisions can be catastrophic. Traditionally, training of ECMO teams has involved didactic lectures and hands-on practice using a water-filled ECMO circuit. This method does not allow for the interpretation of real-time changes in patient status or multidisciplinary team practice. An ECMO simulation program can provide a forum for practice in the management of routine and of low frequency, high-risk emergency situations. This can lead to benefits in patient safety, improved team behaviors and communication, and can demonstrate a commitment by the institution to high quality standards and the provision of excellent patient care. Developing an institutional ECMO simulation program requires representatives from members of the multidisciplinary ECMO team and the simulation center, as well as commitment from the hospital or health system’s administration. The financial investment can vary depending on the plan for adapting the manikin to interact with the ECMO circuit, but even simple, low-tech solutions can lead to an excellent learning environment for members of the medical team.

Part II of this article will be published in MEdSim on line and will contain information on the structure of the ECMO simulation program at Yale, scenarios, and examples of how ECMO simulation can be utilized for patient safety and quality improvement.

About the Authors

Lindsay Johnston, M.D. is the Co-Director of Pediatric Simulation and a faculty member in the Department of Pediatrics at the Yale University School of Medicine. Stephanie Sudikoff, M.D. is the Medical Director of the SYN:APSE Simulation Center, Yale-New Haven Health System.

(Image 3)

Images: Image 1- Picture of team during simulation, Image 2- Picture of Nick, Image 3- Picture of LCJ/ SS

Table 1. Potential Costs for Equipment for ECMO Simulation Program

Item Cost One-time or Recurring Cost?
Laerdal Nursing Baby $ 2,321.00 One-time
Quadrox iD Oxygenator $1,800.00 Recurring *
Circuit Tubing $850.00 Recurring *
Better Bladder $350.00 Recurring *
Standard VA cannula $244.00 each (x2) Recurring *
Origen VV cannula $195 each (x1) Recurring *
* If unable to utilize expired equipment