**7.2 Where is ECMO initiated**

A question that is often asked early in the development of any ECMO program is "where the patients should be cannulated?" While each institution must identify the ideal location for ideal cases, it is critical to recognize the nature of ECMO often dictates therapy must be able to be initiated anywhere within the hospital, including, but not limited to the following locations:

**39**

**Figure 2.**

Museum in Paris, France [18].

*Patient access/call center flow.*

*Clinical and Administrative Steps to the ECMO Program Development*

In fact, depending on the resources available and the resilience of the team, some centers will often consider initiating therapy in unusual out-of-hospital locations with the extreme example being the recent initiation of ECMO in the Louvre

Prior to considering the ideal location for initiating therapy, it is critical to outline those technologies that might be required. As discussed above, while it is important to have an "ECMO Cart" that contains, in a single location, all the key disposables that might be required, there might be a need for less portable equipment. For example, for cannulation, physicians might need immediate access to fluoroscopy and/or transesophageal echocardiography. Such technology might only be readily available in an operating room or catheterization lab. As many operating rooms, especially major trauma centers, and cardiac catheterization laboratories that support STEMI programs will often have access to advanced imaging, the exact ideal location often is dictated not only by physician preference, but also by potential administrative considerations. Such administrative considerations include the availability of a team to support cannulation, how disruptive emergency ECMO

*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*

#### **Figure 2.**

*Advances in Extracorporeal Membrane Oxygenation - Volume 3*

component—when feasible—of every ECMO program.

**7. Guidelines for therapy and patient selection**

training and experiences.

**7.1 Access center/system**

**7.2 Where is ECMO initiated**

• Emergency department

• Catheterization labs

ing, but not limited to the following locations:

• Obstetric labor and delivery suites

• Operating rooms (cardiac and non-cardiac)

• Intensive care units (medical, cardiac, surgical, neuro, etc.)

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

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

In a multiple hospital system of care, there is not generally a need for more than one ECMO center for the system to accommodate the needs for non-CT surgeryrelated ECMO support. A helpful resource to assure patients have rapid transfer to the ECMO program from other hospitals, it is useful to set up a access center process to assure a standardized approach to hand-offs, transport, and tracking of patient movement. Call system personnel trained in the indications for ECMO can assist critical access and other facilities in routing possible ECMO patients for evaluation at the Center of Excellence. Early coordination with the call center leadership will allow them time to develop protocols, education, and coordination with transport services

to assure smooth operations when the first patient call is received (**Figure 2**).

A question that is often asked early in the development of any ECMO program is "where the patients should be cannulated?" While each institution must identify the ideal location for ideal cases, it is critical to recognize the nature of ECMO often dictates therapy must be able to be initiated anywhere within the hospital, includ-

**38**

*Patient access/call center flow.*

In fact, depending on the resources available and the resilience of the team, some centers will often consider initiating therapy in unusual out-of-hospital locations with the extreme example being the recent initiation of ECMO in the Louvre Museum in Paris, France [18].

Prior to considering the ideal location for initiating therapy, it is critical to outline those technologies that might be required. As discussed above, while it is important to have an "ECMO Cart" that contains, in a single location, all the key disposables that might be required, there might be a need for less portable equipment. For example, for cannulation, physicians might need immediate access to fluoroscopy and/or transesophageal echocardiography. Such technology might only be readily available in an operating room or catheterization lab. As many operating rooms, especially major trauma centers, and cardiac catheterization laboratories that support STEMI programs will often have access to advanced imaging, the exact ideal location often is dictated not only by physician preference, but also by potential administrative considerations. Such administrative considerations include the availability of a team to support cannulation, how disruptive emergency ECMO

cases would be to the scheduling and allocation of OR/Cath lab resources, and often "how comfortable" the team is with the procedures. For example, Cath lab teams who are more comfortable with the catheter and wire-base procedures than surgical team might be a better option for peripheral cannulation of ECMO (arterial and venous)—while operating room teams might be better skilled at assisting with central cannulation (especially if the chest is already open). Nevertheless, a core "ECMO team" of providers beyond physicians and perfusions must be identified and included in all communications so that therapy can be initiated efficiently and safely anywhere needed.
