Training of Nurses and Continuing Education in ECMO




© Springer International Publishing Switzerland 2017
Chirine Mossadegh and Alain Combes (eds.)Nursing Care and ECMO10.1007/978-3-319-20101-6_12


12. Training of Nurses and Continuing Education in ECMO



Marc A. Priest , Chris Beaty2 and Mark Ogino3


(1)
Nemours Cardiac Center, Alfred I. duPont Hospital for Children, Accredited Pediatric Heart Failure Institute, ELSO Center of Excellence, 1600 Rockland Rd, Wilmington, DE 19803, USA

(2)
Accredited Pediatric Heart Failure Institute, ELSO Center of Excellence, 1600 Rockland Rd, Wilmington, DE 19803, USA

(3)
Alfred I. duPont Hospital for Children, Accredited Pediatric Heart Failure Institute, ELSO Center of Excellence, 1600 Rockland Rd, Wilmington, DE 19803, USA

 



 

Marc A. PriestProgram Manager



ECMO is a low-volume, high-risk procedure and therapy. After completion of an initial education program, it is important to provide ongoing continuing education and clinical competence assessment. In order for continuing ECMO education to be successful, the proper infrastructure for continuing education in ECMO is essential. This chapter will discuss:


  1. 1.


    Essential hospital support

     

  2. 2.


    Staffing models

     

  3. 3.


    Assessment of ECMO clinical competence and quality assurance

     


12.1 Essential Hospital Support


Organizational hospital support is necessary to provide high-quality ECMO care. It takes a collaborative multidisciplinary approach to be successful in the development of a comprehensive ECMO program. Both initial and continuing education standards should be identified for the multidisciplinary care teams. Key hospital support positions would include, but is not limited to:


  1. 1.


    Hospital Administration Representative

     

  2. 2.


    ECMO Steering Committee

     

  3. 3.


    ECMO Program Director

     

  4. 4.


    ECMO Physician

     

  5. 5.


    ECMO Program Coordinator

     

  6. 6.


    ECMO Specialist or Nurse

     

  7. 7.


    Multidisciplinary Support Staff

     


12.1.1 Hospital Administration Representative


Hospital administration will be involved in allocating the necessary resources to support continuing education. Administrative approval of nonproductive time is a key factor in supporting continuing education. Resources and a designated training environment are a part of the organizational operating and capital budget review process. Institutions must embrace and invest in continuing education to ensure efficiency and competency of ECMO teams.


12.1.2 ECMO Steering Committee


The institutional ECMO Steering Committee may include an ECMO Program Director, ECMO Program Coordinator, and delegated members of the multidisciplinary team. Responsibilities of the Steering Committee would include the formulation of guidelines and policies which outline the indications and contraindications for ECMO, clinical management of the ECMO patient, maintenance of equipment, termination of ECMO therapy, follow-up of the ECMO patient, initial and continuing education of the ECMO staff [1]. The Steering Committee will need to define the quality assurance review procedures for annual internal ECMO program evaluation. Obtaining membership to the Extracorporeal Life Support Organization (ELSO) is highly recommended as it is the world’s largest extracorporeal support organization registry with over 61,000 extracorporeal support patients to date and currently over 300 ECMO center members around the world [2]. Institutions can use the ELSO registry and its reports as a benchmark for their annual quality assurance reviews.


12.1.3 ECMO Program Director


The ECMO program director is an ECMO physician that is responsible for the overall operation of the center’s ECMO program [1]. The program director ensures appropriate training and performance, quality improvement, and ELSO data validation and submission. Currently, ELSO recommends each institution’s ECMO program director define the credentialing qualifications of an ECMO physician. Each institution’s medical staff office is responsible for implementing and monitoring compliance of credentialing guidelines for their ECMO physicians [1]. See Appendix 12.1 for a sample of credentialing guidelines.


12.1.4 ECMO Physician


The ECMO physician may be a critical care physician or surgeon that has had specific ECMO training as outlined by their institutional credentialing guidelines. An ECMO physician should be available to provide 24 h on-call coverage to support the ECMO patient. The responsibility of the ECMO program director and ECMO physician is to support and participate in the continuing education of the multidisciplinary ECMO staff.


12.1.5 ECMO Coordinator


The ECMO coordinator may be an experienced intensive care nurse, respiratory therapist with a strong ICU background, or clinical perfusionist with ECMO experience [3]. The ECMO coordinator will have the ultimate responsibility for the supervision and training of the ECMO nonphysician staff. Continuing education of the ECMO staff will depend on the care model of the institution.


12.1.6 ECMO Specialist


An ECMO specialist is any nurse, respiratory therapist, clinical perfusionist, physician, biomedical engineer, or technician who has received ECMO training as an ECMO care provider. The initial training for the ECMO specialist includes a mix of didactic and “hands-on” education. See Appendix 12.2 for a sample training guideline. The ECMO specialist has the primary responsibility for maintaining extracorporeal support as outlined in their institutional protocols. These responsibilities include instituting ECMO setting adjustments under the direction of an ECMO physician, troubleshooting equipment, assessing the ECMO circuit, and responding appropriately to ECMO emergencies [1]. An ECMO specialist will have more intensive continuing education requirements than an ECMO nurse due to the specialist’s increased level of responsibility in monitoring the ECMO circuit and patient.


12.1.7 ECMO Nurse


An ECMO nurse is a bedside nurse that cares for ECMO patients and has a modified responsibility for assessing and managing the ECMO system. It is recommended that an ECMO specialist team be available, either on site or on call, to manage advanced circuit issues and ECMO emergencies. The multidisciplinary care model described in the Sect. 12.2 “Staffing Models” section outlines the roles and responsibilities of the ECMO nurse. The continuing education requirements are modified for the ECMO nurse compared to the ECMO specialist, depending on the care model of the institution.


12.1.8 Multidisciplinary Support Staff


The management of the ECMO patient requires a comprehensive multidisciplinary healthcare team and resources from all areas of the organization to optimize care and minimize potential complications associated with extracorporeal life support. Other specialty services outside of the critical care environment may be called upon to provide care to a complex ECMO patient. Rehabilitation specialists including occupational, physical, and speech and language therapies are essential to meet the multidisciplinary needs of the ECMO patient [1]. The support services of blood bank, radiology, and clinical laboratories are required to provide adequate clinical care of the ECMO patient.


12.2 Staffing Models



12.2.1 Traditional Staffing Model


The plan for continuing education will be determined by the designated staffing model used within a given organization. Traditionally, many neonatal and pediatric ECMO centers have used a 2:1 care model with an ECMO specialist to manage the ECMO pump and a bedside nurse for patient care.


12.2.1.1 Recommendations





  1. 1.


    Equipment


    1. (a)


      Centrifugal or roller pump technology

       

    2. (b)


      Multiple areas of pressure monitoring to assess drainage, return, and oxygenator pressures

       

    3. (c)


      Infusion ports as determined by the team

       

     

  2. 2.


    The ECMO specialist’s primary responsibility is to monitor the pump and perform ECMO-associated tasks


    1. (a)


      Performs comprehensive circuit check every 4 h

       

    2. (b)


      Titrates sweep gas flow and FiO2 per-protocol

       

    3. (c)


      Titrates blood pump flow by adjusting rpm per-protocol

       

    4. (d)


      Administers volume to patient in response to patient and circuit hemodynamics per-protocol

       

     

  3. 3.


    ECMO specialists need to identify emergency situations and perform ECMO pump emergency procedures in the following situations:


    1. (a)


      Arterial and venous air

       

    2. (b)


      Accidental decannulation

       

    3. (c)


      Circuit-related complications requiring component changes (pigtails, connectors, tubing, raceway, centrifugal head, oxygenator, circuit change)


      1. (i)


        This may need to be performed with an ECMO specialist

         

       

    4. (d)


      Pump failure requiring hand crank or switch to back up pump

       

     

  4. 4.


    ECMO resources to support the bedside ECMO team will need to be available with 24/7 coverage, and if the resource is outside the hospital, a defined response time will need to be defined.


    1. (a)


      ECMO specialist with advanced training in all aspects of ECMO pump management including: circuit priming, cannulation, decannulation, ECMO circuit troubleshooting, and component/circuit changes. This role is often supported by an ECMO coordinator and/or the perfusion team.

       

    2. (b)


      ECMO physician.

       

     

  5. 5.


    The bedside nurse caring for the ECMO patient has the primary responsibility to care for the patient and not the ECMO system.


    1. (a)


      Requirements


      1. (i)


        Basic understanding of ECMO physiology and emergency procedures

         

      2. (ii)


        ECMO system emergencies are managed by the ECMO specialist

         

       

     


12.2.2 Multidisciplinary Care Model


The advancements in ECMO technology and increase in adult ECMO cases have led to a new staffing model for ECMO patients. The Multidisciplinary Care Model (MCM), also known as the “The Single Caregiver Model,” uses the bedside nurse to care for the patient, while having a modified responsibility for monitoring and managing the ECMO pump with the support of an ECMO-trained multidisciplinary team. A secondary support structure to address ECLS complications must be in place for complex management issues and emergent interventions. The MCM model provides a safe, flexible, and fiscally responsible staffing model for variable ECMO activity [4].


12.2.2.1 Recommendations for MCM





  1. 1.


    Equipment:


    1. (a)


      Centrifugal technology

       

    2. (b)


      Minimal to no monitoring of ECMO pressures

       

    3. (c)


      Simple in an out-loop with no infusion ports

       

     

  2. 2.


    The ECMO nurse’s primary responsibility is to care for the patient


    1. (a)


      Modified ECMO responsibilities


      1. (a)


        Performs simple circuit check every 4 h

         

      2. (b)


        Administers volume to patient in response to patient and circuit hemodynamics per-protocol

         

      3. (c)


        Performs the following ECMO pump emergency procedures:


        1. (i)


          Clamp off ECMO and call for help for:


          1. 1.


            Arterial air: any volume

             

          2. 2.


            Venous air: large volume

             

          3. 3.


            Accidental decannulation

             

          4. 4.


            Massive circuit clot/obstruction of centrifugal head or oxygenator

             

           

        2. (ii)


          Manual hand crank for pump failure (on applicable models)

           

         

      4. (d)


        May include


        1. (i)


          Titration of sweep gas flow and FiO2 per-protocol

           

        2. (ii)


          Titration of blood pump flow by adjusting rpm’s per-protocol

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Oct 1, 2017 | Posted by in NURSING | Comments Off on Training of Nurses and Continuing Education in ECMO
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