**6. People**

#### **6.1 Structure and team building**

The ECMO team skill set crosses a variety of normal reporting structures within the hospital, as well as contracted services used in hospitals, including surgical services, nursing, laboratory, perfusion, physicians—employed and independent. Hence, thought must be placed into creating a strong team-based culture among a group of individuals who may have primary team affiliation across multiple departments.

The use of multidisciplinary teams to develop project goals can serve as the first team building structure. Recognition of the team publicly can serve to bond the team more closely, and debriefings can prevent "silo formation" as individuals must often integrate in and out of the ECMO team due to patient volume and clinical needs. To cement this sense of team, the leaders of the departments that support the ECMO program should have regular meetings to discuss issues that arise, including productivity and interpersonal issues. Finally, the executive champion of the program should assure that there is accountability from all parties to the success of the program through goals and metrics, periodic meetings of the entire group of stakeholders, and shared public recognition of the successes of the program.

#### **6.2 Who watches the patients?**

Early in the development of any ECMO program, there must be a strategy for establishing "who watches what"—specifically, while nursing will always have bedside management of the patient, there must be consideration given as who has dedicated responsibility for the ECMO pump and circuit. As with any technology or "machine" that is directly connected to a patient—and provides critical life-saving support—there must be institutional guidelines and protocols regarding who monitors the functional status of the pump and circuit assuring safe and continuous functionality. In addition, the specific roles and responsibilities of this individual also need to be clearly defined. Various staffing models exist as described below.

#### *6.2.1 Perfusionist based*

Perfusionist is ideal bedside ECMO care providers, while initiating an ECMO program. Their advantages are considerable experiences in managing patients requiring extra-corporeal support as a function of their primary job responsibilities in the operating room supporting cardiac surgery procedures. Their training, credentialing, and licensure will often include formal experiences in managing patients requiring short-term mechanical circulatory support, including ECMO, outside of the operating room environment. A perfusionist-based model is appealing, however there are resource and financial limitations of this model. Perfusionists are usually limited in number (especially if they are also supporting an active clinical cardiothoracic surgical program) and their perspective is from a different care model which is focused around staffing limited time intervals in the operating room rather than 24/7 ICU-based ECMO care management. They are also an expensive resource for 24/7 daily ECMO use in the ICU. Given their availability and cost (and depending on how a program "employs" perfusionists—salary, per diem, hourly, contract employees, etc.), other care models are preferred for providing bedside ECMO support, particularly for veno-veno ECMO patients.

**37**

*6.2.3 Hybrid models*

*Clinical and Administrative Steps to the ECMO Program Development*

RN/RT ECMO specialist staffing models are becoming widely accepted and utilized in programs nationally—these programs and the combination structure of RT and RN staffing pools are mainly volume dependent to maintain competence. RNs have many advantages with regards to their inherent familiarity with the complexities and challenges in managing sick patients who require various life-support therapies. For example, in many programs, nurses manage renal replacement therapy technologies, wean and manage ventilators directly, and even have ownership in the management of both short- and long-term cardiac/ventricular support therapies. An additional advantage is, as a function such nurses are often extremely experienced in the management and assessment of critically-ill patients, they can serve as a valuable resource in other areas of immediate patient care—and potentially with volume and competence that become a primary care model for the more stable ECMO patient. Although respiratory therapists (RT) often have extensive experience in the management—and independent assessment—of patients requiring mechanical ventilatory support, it has only been relatively recently that their experiences and training in pulmonary mechanics and respiratory physiology, have they as a profession, been engaged as ECMO specialists. In theory, since most busy intensive care units are often staffed with a high volume of RNs and RTs, who are clinically high performing and engaged, the addition of monitoring ECMO pumps and circuits might not require a substantial investment in human resources and expanding staffing models. As such, using RNs and RTs might be viewed as being potentially less expensive—it is important to recognize that prior to using this human resource to monitor ECMO patients, a substantial investment in extensive ongoing education and training to maintain competence is needed. There are many courses offered by large ECMO programs, professional societies, and ELSO (see below) that can assist in the training of bedside ECMO specialists. Significant advantages in the ECMO specialist staffing model, already described as financially fiscal, also include continuity of nursing-based care provided by hospital staff who have an investment in the organization and unit, as well as the patients they serve.

Another attractive option is a combination of various specialists—often as a function of the acuity of the patient and the needs of the program at any given time. Such a model takes advantage of the strengths of each type of healthcare professional. Even though such models can be difficult to implement as protocols defining individual roles and when and how handoffs can occur, nevertheless, with a strong collaborative team, a hybrid model can be successful. For example, for "routine" (if such exists) veno-veno cases of isolated respiratory failure in an otherwise hemodynamically stable patient, a perfusionist might help initiate therapy, provide the first 24 hours of support, and once the patient is deemed stable on ECMO, care is handed off to a RT or RN ECMO specialist. On-call perfusion support for technical questions and issues can then be easily provided from home and might not require immediate bedside support. Veno-arterial cases, especially in post-cardiotomy patients, might be more complex, and therefore might require more direct involvement of perfusionists given their experiences of managing such patients in the operating room. The challenge in a hybrid model is to determine either objectively or subjectively the clinical parameters that would allow for an appropriate hand-off between one type (or level) of provider to another (i.e. perfusionist to RN/RT ECMO Specialist). Regardless of the care model provided, there must be collaboration between the team members to build evidence-based standardized protocols, as well as

*DOI: http://dx.doi.org/10.5772/intechopen.84838*

*6.2.2 Nursing/respiratory therapy (RN/RT) based*

*Clinical and Administrative Steps to the ECMO Program Development DOI: http://dx.doi.org/10.5772/intechopen.84838*

#### *6.2.2 Nursing/respiratory therapy (RN/RT) based*

*Advances in Extracorporeal Membrane Oxygenation - Volume 3*

The ECMO team skill set crosses a variety of normal reporting structures within

The use of multidisciplinary teams to develop project goals can serve as the first team building structure. Recognition of the team publicly can serve to bond the team more closely, and debriefings can prevent "silo formation" as individuals must often integrate in and out of the ECMO team due to patient volume and clinical needs. To cement this sense of team, the leaders of the departments that support the ECMO program should have regular meetings to discuss issues that arise, including productivity and interpersonal issues. Finally, the executive champion of the program should assure that there is accountability from all parties to the success of the program through goals and metrics, periodic meetings of the entire group of stakeholders, and shared public recognition of the successes

Early in the development of any ECMO program, there must be a strategy for establishing "who watches what"—specifically, while nursing will always have bedside management of the patient, there must be consideration given as who has dedicated responsibility for the ECMO pump and circuit. As with any technology or "machine" that is directly connected to a patient—and provides critical life-saving support—there must be institutional guidelines and protocols regarding who monitors the functional status of the pump and circuit assuring safe and continuous functionality. In addition, the specific roles and responsibilities of this individual also need to be clearly defined. Various staffing models exist as

Perfusionist is ideal bedside ECMO care providers, while initiating an ECMO program. Their advantages are considerable experiences in managing patients requiring extra-corporeal support as a function of their primary job responsibilities in the operating room supporting cardiac surgery procedures. Their training, credentialing, and licensure will often include formal experiences in managing patients requiring short-term mechanical circulatory support, including ECMO, outside of the operating room environment. A perfusionist-based model is appealing, however there are resource and financial limitations of this model. Perfusionists are usually limited in number (especially if they are also supporting an active clinical cardiothoracic surgical program) and their perspective is from a different care model which is focused around staffing limited time intervals in the operating room rather than 24/7 ICU-based ECMO care management. They are also an expensive resource for 24/7 daily ECMO use in the ICU. Given their availability and cost (and depending on how a program "employs" perfusionists—salary, per diem, hourly, contract employees, etc.), other care models are preferred for providing bedside ECMO

support, particularly for veno-veno ECMO patients.

the hospital, as well as contracted services used in hospitals, including surgical services, nursing, laboratory, perfusion, physicians—employed and independent. Hence, thought must be placed into creating a strong team-based culture among a group of individuals who may have primary team affiliation across multiple

**6. People**

departments.

of the program.

described below.

*6.2.1 Perfusionist based*

**6.2 Who watches the patients?**

**6.1 Structure and team building**

**36**

RN/RT ECMO specialist staffing models are becoming widely accepted and utilized in programs nationally—these programs and the combination structure of RT and RN staffing pools are mainly volume dependent to maintain competence. RNs have many advantages with regards to their inherent familiarity with the complexities and challenges in managing sick patients who require various life-support therapies. For example, in many programs, nurses manage renal replacement therapy technologies, wean and manage ventilators directly, and even have ownership in the management of both short- and long-term cardiac/ventricular support therapies. An additional advantage is, as a function such nurses are often extremely experienced in the management and assessment of critically-ill patients, they can serve as a valuable resource in other areas of immediate patient care—and potentially with volume and competence that become a primary care model for the more stable ECMO patient. Although respiratory therapists (RT) often have extensive experience in the management—and independent assessment—of patients requiring mechanical ventilatory support, it has only been relatively recently that their experiences and training in pulmonary mechanics and respiratory physiology, have they as a profession, been engaged as ECMO specialists. In theory, since most busy intensive care units are often staffed with a high volume of RNs and RTs, who are clinically high performing and engaged, the addition of monitoring ECMO pumps and circuits might not require a substantial investment in human resources and expanding staffing models. As such, using RNs and RTs might be viewed as being potentially less expensive—it is important to recognize that prior to using this human resource to monitor ECMO patients, a substantial investment in extensive ongoing education and training to maintain competence is needed. There are many courses offered by large ECMO programs, professional societies, and ELSO (see below) that can assist in the training of bedside ECMO specialists. Significant advantages in the ECMO specialist staffing model, already described as financially fiscal, also include continuity of nursing-based care provided by hospital staff who have an investment in the organization and unit, as well as the patients they serve.

#### *6.2.3 Hybrid models*

Another attractive option is a combination of various specialists—often as a function of the acuity of the patient and the needs of the program at any given time. Such a model takes advantage of the strengths of each type of healthcare professional. Even though such models can be difficult to implement as protocols defining individual roles and when and how handoffs can occur, nevertheless, with a strong collaborative team, a hybrid model can be successful. For example, for "routine" (if such exists) veno-veno cases of isolated respiratory failure in an otherwise hemodynamically stable patient, a perfusionist might help initiate therapy, provide the first 24 hours of support, and once the patient is deemed stable on ECMO, care is handed off to a RT or RN ECMO specialist. On-call perfusion support for technical questions and issues can then be easily provided from home and might not require immediate bedside support. Veno-arterial cases, especially in post-cardiotomy patients, might be more complex, and therefore might require more direct involvement of perfusionists given their experiences of managing such patients in the operating room. The challenge in a hybrid model is to determine either objectively or subjectively the clinical parameters that would allow for an appropriate hand-off between one type (or level) of provider to another (i.e. perfusionist to RN/RT ECMO Specialist).

Regardless of the care model provided, there must be collaboration between the team members to build evidence-based standardized protocols, as well as

strong physician buy-in in terms of supporting the individuals who manage the patient and pump at the bedside. Availability for immediate communication, using current technology, should be established between the ECMO specialist and/or perfusionist and the in-house physician. In addition, a strong and collaborative relationship between the ECMO specialist, perfusionist, and the bedside nurse must exist. Everyone must work together—inter-personality or professional conflicts cannot be tolerated and only get in the way of safe and effective patient care. Strong provider leadership, such as a perfusionist team leader, can be extremely effective in helping mentor other providers and serving as a resource for some of the day to day challenges in the management of an ECMO pump and circuit that might involve various disciplines, each of which have various levels of training and experiences.

In addition, while current ECMO pumps and circuits are much more reliable than previous technologies, they will often have more advanced monitoring options. Each specialist involved in the care of the patient must have extensive training and a sound understanding of the functionality and troubleshooting of the entire circuit. Simulation training, as discussed in other chapters, plays a critical role in education and maintaining proficiency and, therefore, should be a key component—when feasible—of every ECMO program.
