Process improvement for emergent ECMO cannulation of critically ill COVID-19 and MIS-C pediatric patients

ABSTRACT

Introduction: Children diagnosed with COVID-19 or Multisystem Inflammatory Syndrome in Children (MIS-C) can have rapid clinical deterioration and may require emergent hemodynamic and respiratory support with Extracorporeal Membrane Oxygenation (ECMO). Wolfson Children's Hospital (WCH) is the only free standing children's hospital in Northeast Florida. The 20 bed Pediatric Intensive Care Unit (PICU) averages 1100 admissions per year and is a level 1 trauma center. During the most recent wave of COVID, our hospital saw significantly increased numbers of children with COVID-19 and MIS-C requiring hospitalization and medical treatment in the PICU. The ECMO team at WCH was consulted for initiation of ECMO on several critically ill children with COVID-19 and MIS-C. Some children required extracorporeal cardiopulmonary resuscitation (ECPR). Many of these patients had significant obesity and other co-morbidities complicating patient management including emergent cannulation for ECMO. Cannulating a patient for ECMO during active CPR has poor outcomes that can be further impacted by obesity and an inability to generate adequate blood flow through smaller vessels in obese children. Therefore, our center sought to evaluate patients earlier for ECMO and attempt to avoid ECPR or emergent cannulation. A daily rounding checklist for COVID-19 and MIS-C patients was developed and implemented with a goal of preventing delayed care and enhancing efficient communication among all members of the healthcare team. Purpose: The ECMO team and physician leadership developed a daily rounding checklist to enhance communication with the interdisciplinary team for all COVID-19 and MIS-C patients admitted to the PICU. The checklist is completed by the ECMO Coordinator upon admission for children requiring respiratory and hemodynamic support with daily updates by the ECMO team coordinators, pediatric intensivist, and pediatric surgeon. The checklist ensures that each patient admitted to the PICU with COVID-19 or MIS-C has the following patient information, laboratory and imaging studies documented in the event the patient rapidly deteriorates and requires emergent cannulation for ECMO. Checklist information includes patient weight, BMI, co-morbidities, cardiac echocardiogram to evaluate cardiac function, ultrasound of neck and femoral vessels to determine cannula size, head ultrasound (if applicable), patient's current condition (improving, unchanged, or deteriorating), type and cross, and candidacy for ECMO. The checklist allows all members of the healthcare team to have pertinent patient information readily available allowing expedited initiation of ECMO if needed. Implementation The ECMO Coordinator consults with the attending pediatric intensivist and pediatric surgeon daily. Once the rounding checklist is completed, it is updated daily. If any items have not been completed, the ECMO coordinator recommends completion of missing testing or laboratory studies to the ICU team. Information gained from the ECMO Coordinator rounds is then added to the checklist and distributed to physician leadership, the PICU attending, ECMO medical directors, and the pediatric surgical team. If candidacy of a patient for ECMO is questionable, discussion occurs with the pediatric intensivist, pediatric surgeon, and ECMO medical directors to determine ECMO suitability. For high-risk patients, a primed circuit and catheters are available at the bedside with the ECMO team on standby. Outcomes: The implementation and utilization of this checklist has streamlined the process to determine suitability of children with COVID-19 and MIS-C that may require ECMO support at WCH. The process has enhanced patient care allowing a primed circuit, appropriate sized catheters, and discussion with the cardiovascular team in the event that thoracic cannulation may be required. This checklist is now being utilized for all patients that may require ECMO support allowing improved communication and collaboration between the pediatric intensivists, surgical group, and ECMO team.