Resource Utilization in a Post-pandemic World

Extracorporeal Membrane Oxygenation is a resource intensive therapy;heavily reliant upon specialized equipment, unique disposables, and skilled staff. The Covid-19 pandemic and following events exposed flaws in multiple phases of the care delivery system. The combination of high patient census, acuity, manufacturing delays, and supply chain disruptions led to our center's reassessment of the way in which limited resources are utilized. As a combined pediatric and adult center, we possess the ability to share resources amongst all patient populations. Currently, the majority of our equipment and disposables support a heavier use of Centrimag. We adjusted our general weight guidelines in order to best serve the most patients. (<8kg Sorin Rollerhead, 8-20kg Sorin Revolution, >20kg Centrimag.) Presently, a major challenge is the cessation of production of the -inch Better Bladder. The ECMO Coordinator team collaborated with key physician stakeholders. It was decided that the fluid reservoir and air trap benefits of a bladder outweighed the risks of running without one on our Sorin Rollerhead circuit. We designed a circuit with a 3/8 Bigger Better Bladder. Recognizing the increased risk of clotting with the 3/8 segment, we added a post-oxygenator shunt. This allows for adequate blood flow to maintain circuit integrity, while limiting the amount of flow to the patient. The nationwide nursing shortage is well-known. Though our multidisciplinary ECMO Specialist Team supports nursing and respiratory therapy, the nursing shortage still impacts our staffing models, resulting in the inability to safely staff bedside nurses and ECMO specialists. At times of high census, ECMO patients are cohorted into one geographical location. This allows for a temporary 2:1 staffing model for Centrimag patients. Our goal remains to staff pediatric cases as a 1:1 ECMO Specialist assignment. The ability to obtain this is assessed shift to shift;factoring patient stability, experience of the ECMO specialist, and unit staffing. The collaboration with ICU Nurse Managers, Hospital Supervisors and Central Staffing Office is imperative to the success of staffing model alterations. Our ECMO department has increased its FTEs, implementing a core team to be preassigned to two ECMO beds. The objective is to alleviate the burden on ICU staffing, limiting the number of nurses pulled from staffing grids. In uncertain times, flexibility is vital. It is important to remain vigilant and proactive. Our ECMO program feels that continuous assessment of supplies, equipment, and open communication has been the key to successfully serving our patients.

ECMO Program Quality Improvement Through Educational Resources Amidst Pandemic Staffing Crisis

The COVID-19 pandemic tasked affected healthcare programs to find creative solutions for preserving staff competency amidst high staffing turnover, limited resources, and increased patient acuity. In 2022, our ECMO leadership team aimed to provide additional educational resources to our ECMO specialist team, without adding to the workload of staff burnout. Prior to 2020, our educational structure involved an extensive onboarding process for new ECMO specialists, quarterly hands-on drill simulations, and a yearly recertification exam. From 2020 to 2021, we saw a significant amount of turnover within our ECMO department amidst the pandemic. We ended 2020 with 36 specialists and 2021 with 18 specialists, hiring 12 new specialists. Our ECMO census continued to increase with 72 total runs and average daily census of 2.2 in 2021, up to 99 total runs and average daily census of 2.4 in 2022. 2021 ELSO data showed that 60% of our patient runs contained mechanical errors including air entrainment, cannula problems, circuit exchanges, oxygenator failure, and thrombosis. In order to support our staff with so many new specialists who are expected to care for a higher quantity of patients with more complex morbidities, at the same exceptional quality as our most senior staff, we provided a variety of additional educational resources in 2022. Visual aids were created for our 3 ECMO pumps including pump physiology, basic handling skills, emergencies, and advanced scenarios. We also created a pocket guide combining the educational information taught in the onboarding class with other various resources provided to our staff. ECMO staff members can keep the pocket guide to reference, and to add their own notes as needed. Lastly, a monthly newsletter sent to our staff, containing programmatic updates, educational tips and quizzes, reminders, and helpful links. After surveying our specialists at the end of 2022, we found that >80% of the specialists watch the videos before or during shifts, 100% watch the videos to prepare for water drills, and >80% own a pocket guide. 75% found the additional resources helpful to succeed in water drills and staying prepared to sit pump. Our 2022 ELSO data also showed a decrease to 43% of patient runs containing mechanical errors. MUSC is ELSO-designated platinum-level for both the pediatric and adult ECMO program, signifying the highest level of performance, innovation, satisfaction, and quality. Our goal is to use current practices combined with mentioned innovative strategies to retain this status in the upcoming year.