Some of the sickest patients in critical care units are those who require extracorporeal membrane oxygenation (ECMO) therapy. ECMO is a life-sustaining form of cardiopulmonary bypass used to support neonates, children, and adults with cardiac or respiratory failure and is one of the most complex and resource-intensive medical therapies available. While ECMO has become more widespread, it is important to remember that it is an extremely high-risk procedure with significant impact on mortality and morbidity, often due to mechanical failure. Some of the mechanical issues associated with ECMO include bleeding from cannula site, oxygenator failure, tubing rupture, or pump malfunction. Having an expert available to troubleshoot the ECMO circuit is critical to patient survival and outcome. Troubleshooting the circuit is often required to keep the machine continuously running and patients dependent on ECMO to sustain life could die if the circuit flow is not reestablished. Therefore, an immediate application of knowledge and technical skill is required to troubleshoot issues or resolve emergencies and avoid significant patient morbidity or mortality.1 Twenty-four-hour in-hospital support for all emergency troubleshooting is an essential component of operating an extracorporeal life support program in the extracorporeal life support organization guidelines.2 Staffing models used to provide the bedside care and expert troubleshooting vary from center to center. In pediatrics, more complex ECMO circuitry is traditionally used to provide additional central venous access and to monitor blood gases and blood flows continuously because small changes could have a significant patient impact. The more complex ECMO circuitry requires more intensive monitoring, troubleshooting, and emergency response. The approach to establishing a staffing model to provide this expertise varies. However, with the increasing cost of healthcare and reduced reimbursements for providing care, a cost-effective staffing model is becoming as important as a safe staffing model.

TRADITIONAL STAFFING MODEL

Traditionally, pediatric/neonatal patients on ECMO are most commonly cared for by an ECMO specialist. The ECMO specialist is an experienced registered nurse (RN), registered respiratory therapist (RRT), certified clinical perfusionist, or physician with advanced training in ECMO which is provided at an ECMO center.3 Frequent exposure is essential to maintain competence in both operation of the circuit and care of the patient on ECMO.3 The ECMO centers with low patient volumes (<5 per year) often rely on perfusionists with daily use of cardiopulmonary bypass and expertise in extracorporeal life support to provide bedside supervision of the patient and circuit.4 This model stresses a cardiac surgery program often requiring delay of cardiopulmonary bypass cases due to perfusionist unavailability.5 Large-volume ECMO centers (with >30 patients per year) use RN or RRT ECMO specialists to staff patients on ECMO and may have 70 or more specialists at a given time. These programs may rely on perfusionists for priming the ECMO pump during cannulations. A staffing model with 70 ECMO specialists limits individual exposure to troubleshooting events and dilutes the experience across the staff.

ALTERNATIVE STAFFING MODEL

As an alternative to these traditional staffing models, a full-time ECMO core team of RNs and RRTs is increasingly being adopted by many ECMO centers to develop expertise for increasingly complex patients at risk for adverse events and circuit complications. This innovative model uses RNs and RRTs in a full-time advanced ECMO specialist role which may or may not be a second layer of expert support for those providing the bedside care and circuit monitoring for ECMO patients.6,7 Terms such as "primers," "core team specialists," or "advanced ECMO clinicians" are used to label this advanced ECMO role that requires extensive on-the-job training to provide 24-hour in-hospital coverage for priming circuits for cannulations, troubleshooting, or responding to emergencies. Some ECMO centers have those in this role to continue to provide the bedside care of the ECMO patient; others have them in a resource role to help those at the bedside and respond when needed.

In many centers, this nursing or respiratory core team has replaced perfusionists in ECMO programs. One center reports reducing program expenditures by 61% when no longer relying on perfusionists for staffing.8 However, perfusionists are trained in the mastery of extracorporeal technologies and are the most capable of providing the expertise in management and troubleshooting of ECMO circuitry.4 Their oversight is valuable for RNs and RRTs novice to the field. Nevertheless, reliance on perfusionists who are on call away from the hospital on nights, weekends, and holidays leaves a deficit in immediate emergency bedside troubleshooting.

As the healthcare climate continues to change, development of an innovative hybrid ECMO staffing model is imperative and has the potential to be safe, sustainable, and cost-effective. Registered nurses and/or RRTs trained as advanced ECMO specialists, with perfusionist backup if needed, who coordinate care with the bedside nurse, provide a comprehensive 24-hour coverage for both the patient (eg, complex hematological, fluid, and sedation management) and the ECMO circuit (eg, titration of blood flow and sweep gas flow). These highly trained ECMO specialists have the advanced skills and knowledge to troubleshoot at the point of care to ensure timely, safe, and reliable care.

-Nicole O'Connor, DNP, RNC-NIC, PCP-AC

-Joan R. Smith, PhD, RN, NNP-BC

St Louis Children's Hospital

St Louis, Missouri

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