ECMO Staffing: What You Need to Know to Create a Successful ECMO Program

The use of ECMO has been on the rise within the United States over the past ten years due to the improvement of technology leading to more successes within the adult population. In fact, according to ELSO, hospitals offering ECMO increased to 264 in 2019 up from 108 in 2008. The surprise of the COVID-19 pandemic, has highlighted the importance of establishing the fundamentals of an ECMO program in medical centers around the globe.

The ECMO market is expected to increase from $267 million in 2019 to $371 million in 2027. In order to meet that demand, hospitals are strategically planning out staffing as a lack of perfusionists is highly likely.

The Problem: Lack of Perfusionists

The primary role of the perfusionist includes operating cardio-pulmonary bypass equipment in the operating room to support patients requiring open heart surgery. Their expertise in this area also qualifies them to take care of ECMO patients in the intensive care unit.

However, with only approximately 4,000 perfusionists in the United States, a staffing shortage is likely to occur requiring perfusionists to be both in the OR and the ICU. Compare that with the approximately 2.8 million RNs and 100,000 RRTs in the United States. Many facilities are looking into additional ECMO staffing models that shares the responsibility of ECMO patients. The combination of resources including nursing, respiratory therapy and perfusion could help alleviate these staffing issues while keeping up with the increasing trend.

The Solution: A Modified ECMO Staffing Model

The development of a combined ECMO staffing model is complex. For many years ELSO has strongly supported RNs and RRTs as ECMO specialists and continue to guide new ECMO programs in developing this model. Training and education platforms need to be well established, as for nurses and respiratory therapists, ECMO training is mostly on the job with little formal education experience. It is important that any ECMO specialist becomes proficient at identifying and troubleshooting emergencies.

Common Qualifications to Become an ECMO Specialist

The ECMO specialist should have a strong background in critical care and have at least one of the following:

Completion of an accredited college of nursing and have passed their Board of Nursing exam for their state
Completion of an accredited school of respiratory therapy and are recognized as a Registered Respiratory Therapist (RRT) by the National Board of Respiratory Care (NBRC)
Completion of an accredited school of perfusion and be nationally certified through the American Board of Cardiovascular Perfusion (ABCP)
Be a physician trained in ECMO and completed institutional training requirements for clinical specialists

ELSO Guidelines for Training ECMO Specialists

ELSO has compiled comprehensive guidelines for the training and continuing education of ECMO specialists.

The guidelines can be found here.

Some ECMO centers created a “two career” model, providing two RNs at an ECMO patient’s bedside. One RN as the ECMO specialist, focusing on the operation of the ECMO pump, and the other attending to other ICU RN roles. Author Kathleen JR Daly notes that the advantage of having a nurse as an ECMO specialist is that they are able “to provide 24-hour care, managing all aspects of patients' needs, including administration of medication, and to have the technical skills and knowledge to safely manage the ECMO circuit with perfusion backup for the more complicated aspects of circuit management.”

Vanessa Moll, et al, wrote that the success of an ECMO program relies on these elements:

Institutional commitment
Key personnel with continuous involvement in ECMO management
A physician leader with hospital supported time to develop the program
A formal consultative service to evaluate ECMO candidates

Cost Savings

Hospitals today are under enormous financial pressure and constraints. Financially supporting an ECMO program is a complex task. Today’s perfusionists earn roughly a six-figure salary, occupying a large percentage of a program’s funding. Facilities with ECMO programs remain in similar situations. To off set this cost, programs are utilizing RNs as the primary bedside caregivers monitors for cardiovascular ECMO patients, Thomas Jefferson University’s Department of Surgery saw a cost savings of 61%.

RNs are RRTs are uniquely positioned to be part of the ECMO core team because their formal education incorporates aspects such as acid-base balance, oxygen delivery, cardiopulmonary anatomy as well as cardiopulmonary pathology and physiology. These fundamentals provide ideal understanding for operating the ECMO circuit. By incorporating nursing and respiratory therapy into the ECMO team, programs can reduce expenditures as well as maintain perfusion staffing within the operating room.

A Modified ECMO Staffing Model Example: Emory University Hospital

Atlanta’s Emory University Hospital (EUH) is a large established health system providing state of the art care throughout the region. The hospital provides emergent ECMO support for any clinical situation that may arise. Previously, perfusionists operated the ECMO circuit and were required to be present at the bedside 24 hours a day. This created an enormous amount of stress on the entire perfusion department.

Moll et al, wrote that because of the stress on EUH’s system, the cardiac operating room cases were frequently canceled due to the lack of perfusion support. As well as, “significant dissatisfaction among the cardiac surgeons, patients, hospital administration, and perfusionists.”

In order to improve outcomes, EUH and the Emory Critical Care Center (ECCC) developed a hybrid ECMO staffing program between respiratory therapy and perfusion.

How ECC and EUH Trained Staff

Respiratory Therapists underwent intense formal training and every six months required additional education to remain current on protocols and use of technology. Training included rapidly priming an ECMO circuit and performing other emergency circuit interventions. Ideally, a perfusionist would always be available for support however, all therapists were trained for worst case scenarios.

A Modified ECMO Staffing Model Example: Thomas Jefferson University Department of Surgery

Thomas Jefferson University introduced a new adult ECMO program in 2010. The institution educated a multidisciplinary team to deliver ECMO therapy consisting of intensivists, perfusionists and nursing staff.

An outside ECMO consultant, along with ICU nurse educators and perfusionists, provided education to the team. The education consisted of:

Didactic sessions
Hands-on sessions
Competency testing

The institution held this training and testing annually to ensure its team was up to date on all policies and procedures.

Significant Cost Savings

Thomas Jefferson University saw significant cost savings ($366,264) with its modified ECMO staffing model thanks to the omission of the 24/7 surveillance by perfusionists

Although our institution was required to pay a fixed fee per month (monthly retainer fee) regardless of the presence of ECMO cases, our total end cost was still cheaper compared to the total cost of the previous model. This was because of the increase in ECMO circuit availability and therefore increases in the number of ECMO patients in the new model,” write Nicholas C. Cavarocchi, et al.

Technology’s Role in the Modified ECMO Staffing Model

Recirculation is a common complication during VV ECMO. VV ECMO is being used to treat the sickest COVID-19 patients. For most ECMO teams, they know the signs of recirculation but struggle to identify how much is occurring and how remarkably it is affecting the patient. To improve your patient’s therapy and optimize oxygen delivery, it’s important to quantify the amount of recirculation.

Transonic’s ELSA monitor non-invasively confirms and quantifies recirculation by providing the percentage of ECMO flow that is being recirculated. This identifies exactly how much oxygenated ECMO flow the patient is receiving.

ECMO Staffing Companies: A Valuable Tool in Creating an ECMO Staffing Model

For hospitals looking to create or transition to a hybrid staffing model, an ECMO staffing company can help streamline the process.

There are a number of companies that provide extracorporeal related services, including the tools required to create an alternative ECMO staffing model.

One example is ECMO Advantage, founded by Randy Bartilison, a Registered Respiratory Therapist and ECMO specialist, ECMO Advantage gathers experts from around the United States to covers all aspects of an ECMO program including staffing, training and consulting.

“RNs and RRTs functioning as ECMO specialists is actually the best way to provide ECMO support,” Bartilison noted. “Programs that ECMO Advantage works with who transition from perfusion-based to RN/RRT ECMO specialist-based are actually very successful.”

“There is often no formal program structure, current policies and procedures, nor formal training processes. So it's very important to make sure there are solid foundational aspects in place before providing ECMO support. We also often find that there may not be proper ECMO equipment or amount of equipment in place when we begin working with institutions transitioning to RN/RRT ECMO specialist programs,” he said.

While there is some debate about who should be classified as an ECMO specialist, Bartilison notes that it’s not the person’s credentials that make him or her a qualified ECMO specialist, it’s whether they have been properly trained for the role.

ECMO Advantage has worked with ECMO programs throughout the United States and Canada.

To learn more about all they offer visit their website at ecmoadvantage.com

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