**10. Miscellaneous topics**

*Advances in Extracorporeal Membrane Oxygenation - Volume 3*

not necessarily be limited to:

cardiogenic shock

(4) Duration of support

• Death on support

neurologic, etc.)

(6) Outcomes

(5) Blood and blood product utilization

• Successful weaning from support

• Death despite successful weaning

**9.3 Continuous quality improvement (CQI)**

Time from admission/intubation to initiation of

Mortality despite successful weaning from

*Suggested topics for continuous quality initiatives*

ECMO support

ECMO

as profit/loss margins must be tracked in the context of program growth and success. Additional benchmarking information should also be considered and tracked in real-time to help monitor the evolution of a program—and should include, but

(2) Primary indications for support and etiologies of respiratory failure and/or

• Major factors contributing to patient death (i.e., multi-organ failure,

Such summary data should be in addition to the extensive amount of clinical and

As discussed above, the tracking of outcome data should be a key component to helping measure program growth and success. Such initiatives must be established from the onset and involve the program champions—both clinical and administrative leaders to be successful. While it is important to review cases in the context of

circuit data that is collected and tracked in the ELSO registry (see above).

**Topics for review Potential desired outcome**

Anticoagulation protocol Reduction in bleeding and bleeding related

Medication utilization Opportunities for potential cost savings

Antibiotic utilization Integration in an antibiotic stewardship program

complication.

outcomes

Family/patient satisfaction scores Opportunities to improve communication with families,

Reduction in blood product utilization

Improved satisfaction metrics

Reduction in multi-drug resistant infections Reduction in opportunistic infections

Potential impact on improving weaning and survival

Improving overall outcomes and survival to discharge.

(1) Patient demographics (i.e., age, gender, and major comorbidities)

(3) Type of support (VV, VA, eCPR, and cannulation)

**44**

**Table 3.**

#### **10.1 Referral sources engagement**

Once the complex set of internal processes, personnel, and patient care skills are established, the ECMO program has the potential to serve patients in a wide area around the ECMO center. To assure that other hospitals and emergency facilities have the information to know of the resources available, and when to engage them, the primary facility should engage a multi-pronged approach to raise awareness and clinical decision-making skills of potential patient care partners. As with all endeavors, this should be done in the WIIFM (What's In It For Me) with the patient and practitioner at the outlying facilities interests' in mind. A good place to begin this is to address the benefits to the patient, the current science that supports the need for ECMO, the parameters for consideration of ECMO support, the process to easily move the patient, and the resources to enhance education of the topic. This is accomplished by marketing informational materials, individual outreach to create awareness, an education program that includes lectures, publication of successes, a plan for follow-up communication to the referring institution to help them understand the results of their referrals, and finally, by creating branding that helps the referral sources easily retain a connection to the program.

#### **10.2 Marketing**

Marketing materials should ideally be created to reflect the ECMO program as a larger system of care around ARDS and shock. In addition to the organization housing the ECMO program, clear guidance on referral processes (see Call Center Section), there should also be some succinct explanation of the use of VV and VA ECMO, parameters for initiation of referral, as well as references to studies supporting the decision. Consideration should be given to having two sets of guidance; one for critical access lower acuity facilities/ER's and one geared toward facilities with ICU care directed by intensivists, as the threshold for referral will be different.

#### **10.3 Outreach**

The personal touch of a visit cannot be underestimated when establishing trusted referral center status for complex procedures such as ECMO. It affords a chance to create personal trust, as well as allowing answers to questions are procedures and

processes for transfer, and expectations for communication regarding patient status from the ECMO center. The outreach should be well versed on all of these processes, as well as having the ability to provide physician to physician conversations to answer any outstanding issues.

#### **10.4 Education**

Education is a valued commodity for referring physicians and clinicians when learning a new resource for their patients. The education can include multiple formats to meet the needs of the audience including lectures, educational brochures, webcasts, publications regarding outcomes and patient stories, and conferences at the ECMO center on topics related to ECMO such as current ARDS and shock therapies.

#### **10.5 Follow-up communication**

While clearly an avenue to enhance education, follow-up communication is also an important tool to create the interpersonal relationship that develops trust between the organizations. It is very important for referring provider to learn the "end of the story" regarding patients that were sent for therapy. In addition, this provides a transition of care so that appropriate ongoing care can be provided to the patient in their home medical community. This also establishes that trust of the referring providers that patients sent for a specific therapy will be sent back to the home community for the care that can be provided in that setting.

#### **10.6 Branding**

As the use of ECMO increases, the need to create a memorable brand for the program becomes a key component to establishing the reputation of the ECMO center that is distinguishable from other future programs. The program should ideally be branded as a part of the larger cardiothoracic-vascular/pulmonary/ critical care program of the institution. This allows the halo of the organization's programs to create synergistic enhancement quality outcomes and growth opportunities.

#### **11. Conclusions**

The initiation of an ECMO program is a comprehensive multidisciplinary project, which must be based on the clinical needs of the patients served. It requires advanced clinical capabilities and decision-making, and clear pathways for patient care to make it high quality and financially sustainable. As such, strong leadership is needed from physician leaders, nursing leaders, and administrative leaders working in a triad professional leadership model.

Once the clinical case for implementation is made, a multidisciplinary team should be identified, and given the ability to work across multiple departments and stakeholders to assure all quality and operational details are aligned and accomplished. The team is encouraged to work using change management format and techniques supported with strong project guidelines to assure that the internal and external resources needed to support ECMO care are identified, captured as project goals, and systematically completed prior to initiation of ECMO patient care. Use of tools such as order sets, access center protocols, and education tools support clinical standardization across the team, and provides a consistency of clinical care.

**47**

**Author details**

provided the original work is properly cited.

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Dianne McCallister, Linda Pilon, Joseph Forrester, Samer Alsaleem, Chakradhar Kotaru, Jennifer Hanna, Gregory Hickey, Rachele Roberts,

Erica Douglass, Matthew Libby and Michael S. Firstenberg\*

The Medical Center of Aurora, Aurora, CO, USA

\*Address all correspondence to: msfirst@gmail.com

*Clinical and Administrative Steps to the ECMO Program Development*

Quality metrics are identified at project initiation and can be supported by ELSO tools allowing comparisons across programs internationally. The commitment to high quality and a relentless curiosity to find improvements that can be made, are critical to provide best practices to this high acuity population. The data and outcomes collected can help educate and encourage referrals from other programs that do not have ECMO capabilities, thus providing added advanced patient care options on regional basis. The literature has previously benchmarked an 18 month ramp up to program initiation as rapid deployment. Using the tools provided by others in the literature, a strong triad leadership process, and a dedicated multidisciplinary team with strong project management support, it is possible to accomplish program initiation in a six-month period in a hospital with an established CV Surgical program. We believe this process is replicable, and provides tools and implementation models that can be used by other hospitals to add needed ECMO support to meet their community needs [8–10].

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

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

*Advances in Extracorporeal Membrane Oxygenation - Volume 3*

answer any outstanding issues.

**10.5 Follow-up communication**

**10.4 Education**

therapies.

**10.6 Branding**

opportunities.

**11. Conclusions**

in a triad professional leadership model.

processes for transfer, and expectations for communication regarding patient status from the ECMO center. The outreach should be well versed on all of these processes, as well as having the ability to provide physician to physician conversations to

Education is a valued commodity for referring physicians and clinicians when learning a new resource for their patients. The education can include multiple formats to meet the needs of the audience including lectures, educational brochures, webcasts, publications regarding outcomes and patient stories, and conferences at the ECMO center on topics related to ECMO such as current ARDS and shock

While clearly an avenue to enhance education, follow-up communication is also an important tool to create the interpersonal relationship that develops trust between the organizations. It is very important for referring provider to learn the "end of the story" regarding patients that were sent for therapy. In addition, this provides a transition of care so that appropriate ongoing care can be provided to the patient in their home medical community. This also establishes that trust of the referring providers that patients sent for a specific therapy will be sent back to the

As the use of ECMO increases, the need to create a memorable brand for the program becomes a key component to establishing the reputation of the ECMO center that is distinguishable from other future programs. The program should ideally be branded as a part of the larger cardiothoracic-vascular/pulmonary/ critical care program of the institution. This allows the halo of the organization's programs to create synergistic enhancement quality outcomes and growth

The initiation of an ECMO program is a comprehensive multidisciplinary project, which must be based on the clinical needs of the patients served. It requires advanced clinical capabilities and decision-making, and clear pathways for patient care to make it high quality and financially sustainable. As such, strong leadership is needed from physician leaders, nursing leaders, and administrative leaders working

Once the clinical case for implementation is made, a multidisciplinary team should be identified, and given the ability to work across multiple departments and stakeholders to assure all quality and operational details are aligned and accomplished. The team is encouraged to work using change management format and techniques supported with strong project guidelines to assure that the internal and external resources needed to support ECMO care are identified, captured as project goals, and systematically completed prior to initiation of ECMO patient care. Use of tools such as order sets, access center protocols, and education tools support clinical

standardization across the team, and provides a consistency of clinical care.

home community for the care that can be provided in that setting.

**46**

Quality metrics are identified at project initiation and can be supported by ELSO tools allowing comparisons across programs internationally. The commitment to high quality and a relentless curiosity to find improvements that can be made, are critical to provide best practices to this high acuity population. The data and outcomes collected can help educate and encourage referrals from other programs that do not have ECMO capabilities, thus providing added advanced patient care options on regional basis.

The literature has previously benchmarked an 18 month ramp up to program initiation as rapid deployment. Using the tools provided by others in the literature, a strong triad leadership process, and a dedicated multidisciplinary team with strong project management support, it is possible to accomplish program initiation in a six-month period in a hospital with an established CV Surgical program. We believe this process is replicable, and provides tools and implementation models that can be used by other hospitals to add needed ECMO support to meet their community needs [8–10].
