Implementation of an extracorporeal cardiopulmonary resuscitation simulation program reduces extracorporeal cardiopulmonary resuscitation times in real patients

In Situ Simulation and Clinical Outcomes in Infants Born Preterm

OBJECTIVE

To evaluate impact of a multihospital collaborative quality improvement project implementing in situ simulation training for neonatal resuscitation on clinical outcomes for infants born preterm.

STUDY DESIGN

Twelve neonatal intensive care units were divided into 4 cohorts; each completed a 15-month long program in a stepped wedge manner. Data from California Perinatal Quality Care Collaborative were used to evaluate clinical outcomes. Infants with very low birth weight between 22 through 31 weeks gestation were included. Primary outcome was survival without chronic lung disease (CLD); secondary outcomes included intubation in the delivery room, delivery room continuous positive airway pressure, hypothermia (<36°C) upon neonatal intensive care unit admission, severe intraventricular hemorrhage, and mortality before hospital discharge. A mixed effects multivariable regression model was used to assess the intervention effect.

RESULTS

Between March 2017 and December 2020, a total of 2626 eligible very low birth weight births occurred at 12 collaborative participating sites. Rate of survival without CLD at participating sites was 74.1% in March to August 2017 and 76.0% in July to December 2020 (risk ratio 1.03; [0.94-1.12]); no significant improvement occurred during the study period for both participating and nonparticipating sites. The effect of in situ simulation on all secondary outcomes was stable.

CONCLUSIONS

Implementation of a multihospital collaborative providing in situ training for neonatal resuscitation did not result in significant improvement in survival without CLD. Ongoing in situ simulations may have an impact on unit practice and unmeasured outcomes.

Interprofessional Extracorporeal Membrane Oxygenation Cardiopulmonary Resuscitation Simulations Aimed at Decreasing Actual Cannulation Times: A Longitudinal Study

BACKGROUND

Since 2013, the cardiac intensive care unit (CICU) at Children's National has conducted annual extracorporeal membrane oxygenation cardiopulmonary resuscitation (ECPR) simulations that focus on team dynamics, room setup, and high-quality CPR. In 2019 and 2020, the simulations were expanded to include the surgical and extracorporeal membrane oxygenation (ECMO) teams in an effort to better understand and improve this process.

METHODS

During a 4-week period in 2019, 7 peripheral ECPR simulations were conducted, and through a 3-week period in 2020, 7 central ECPR simulations were conducted. Participants in each session included: 8 to 10 CICU nurses, 1 CICU attending, 1 to 2 ICU or cardiology fellows, 1 cardiovascular surgery fellow or attending, and 1 ECMO specialist. For each session, the scenario continued until the simulated patient was on full cardiopulmonary bypass. An ECMO trainer was used for peripheral simulations and a 3-dimensionally-printed heart was used for central cannulations. An ECMO checklist was used to objectively determine when the patient and room were fully prepared for surgical intervention, and simulated cannulation times were recorded for both groups. A retrospective chart review was conducted to compare actual cannulation times before and after the intervention period, and video was used to review the events and assist in dividing them into medical versus surgical phases. Control charts were used to trend the total ECPR times before and after the intervention period, and mean and P values were calculated for both ECPR times and for all other categorical data.

RESULTS

Mean peripheral ECPR times decreased significantly from 71.7 to 45.1 minutes ( P = 0.036) after the intervention period, and this was reflected by a centerline shift. Although we could not describe a similar decrease in central ECPR times because there were only 6 postintervention events, the times for each of these events were shorter than the historical mean of 37.8 minutes. There was a trend in improved survival, which did not meet significance both among patients undergoing peripheral ECPR (15.4% ± 10% to 43.8% ± 12.4%, P = 0.10) and central ECPR (36.4% ± 8.4% to 50% ± 25%, P = 0.60). The percentage of time dedicated to the medical phases of the actual versus simulated procedures was very consistent among both peripheral (33.0% vs. 31.9%) and central (39.6% vs. 39.8%) cannulations.

CONCLUSIONS

We observed a significant decrease in peripheral cannulation times at our institution after conducting interprofessional ECPR simulations taken to the establishment of full cardiopulmonary bypass. The use of an ECMO trainer and a 3-dimensionally-printed heart allowed for both the medical and surgical phases of the procedure to be studied in detail, providing opportunities to streamline and improve this complex process. Larger multisite studies will be needed in the future to assess the effect of efforts like these on patient survival.

Benefits, key protocol components, and considerations for successful implementation of extracorporeal cardiopulmonary resuscitation: a review of the recent literature

The application of venoarterial extracorporeal membrane oxygenation (ECMO) in patients unresponsive to conventional cardiopulmonary resuscitation (CPR) has significantly increased in recent years. To date, three published randomized trials have investigated the use of extracorporeal CPR (ECPR) in adults with refractory out-of-hospital cardiac arrest. Although these trials reported inconsistent results, they suggest that ECPR may have a significant survival benefit over conventional CPR in selected patients only when performed with strict protocol adherence in experienced emergency medical services-hospital systems. Several studies suggest that identifying suitable ECPR candidates and reducing the time from cardiac arrest to ECMO initiation are key to successful outcomes. Prehospital ECPR or the rendezvous approach may allow more patients to receive ECPR within acceptable timeframes than ECPR initiation on arrival at a capable hospital. ECPR is only one part of the system of care for resuscitation of cardiac arrest victims. Optimizing the chain of survival is critical to improving outcomes of patients receiving ECPR. Further studies are needed to find the optimal strategy for the use of ECPR.

Extracorporeal cardiopulmonary resuscitation in adults and children: A review of literature, published guidelines and pediatric single-center program building experience

Extracorporeal cardiopulmonary resuscitation (ECPR) is an adjunct supportive therapy to conventional cardiopulmonary resuscitation (CCPR) employing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in the setting of refractory cardiac arrest. Its use has seen a significant increase in the past decade, providing hope for good functional recovery to patients with cardiac arrest refractory to conventional resuscitation maneuvers. This review paper aims to summarize key findings from the ECPR literature available to date as well as the recommendations for ECPR set forth by leading national and international resuscitation societies. Additionally, we describe the successful pediatric ECPR program at Texas Children's Hospital, highlighting the logistical, technical and educational features of the program.

A Scoping Review and Appraisal of Extracorporeal Membrane Oxygenation Education Literature

Background

Despite a recent rise in publications describing extracorporeal membrane oxygenation (ECMO) education, the scope and quality of ECMO educational research and curricular assessments have not previously been evaluated.

Objective

The purposes of this study are 1) to categorize published ECMO educational scholarship according to Bloom’s educational domains, learner groups, and content delivery methods; 2) to assess ECMO educational scholarship quality; and 3) to identify areas of focus for future curricular development and educational research.

Methods

A multidisciplinary research team conducted a scoping review of ECMO literature published between January 2009 and October 2021 using established frameworks. The Medical Education Research Study Quality Instrument (MERSQI) was applied to assess quality.

Results

A total of 1,028 references were retrieved; 36 were selected for review. ECMO education studies frequently targeted the cognitive domain (78%), with 17% of studies targeting the psychomotor domain alone and 33% of studies targeting combinations of the cognitive, psychomotor, and affective domains. Thirty-three studies qualified for MERSQI scoring, with a median score of 11 (interquartile range, 4; possible range, 5–18). Simulation-based training was used in 97%, with 50% of studies targeting physicians and one other discipline.

Conclusion

ECMO education frequently incorporates simulation and spans all domains of Bloom’s taxonomy. Overall, MERSQI scores for ECMO education studies are similar to those for other simulation-based medical education studies. However, developing assessment tools with multisource validity evidence and conducting multienvironment studies would strengthen future work. The creation of a collaborative ECMO educational network would increase standardization and reproducibility in ECMO training, ultimately improving patient outcomes.

The effect of a structured ECPR protocol aided by specific simulation training in a quaternary ECMO centre: A retrospective pre-post study

Background

There is limited literature exploring the relationship between simulation training and extracorporeal cardiopulmonary resuscitation (ECPR) outcomes. We examined whether there was an association between the implementation of an in situ simulation training program and ECPR utilisation, time to extracorporeal membrane oxygenation (ECMO), and neurologically intact survival.

Methods

In this retrospective pre-post study of in-hospital cardiac arrests (IHCA) and out-of-hospital cardiac arrests (OHCA), we analysed data for all patients recorded as receiving ECPR from September 2009 to December 2020 at our institution, relative to the implementation of an in situ ECPR simulation training program and a standardised procedure for high-quality ECPR. The primary outcome was Cerebral Performance Category (CPC) 1 or 2 at hospital discharge.

Results

There were 27 patients in the pre-intervention period and 39 patients in the post-intervention period. The median ECPR rate per year was 2 pre-intervention and 7 post-intervention (p = 0.073). There was an association between the implementation of the program and decreased median time from OHCA to ECMO flow, from 87 (IQR 78–95) minutes pre-intervention to 70 (IQR 69–72) minutes post-intervention (p = 0.002). Median time from IHCA to ECMO flow was 40 (IQR 20–75) minutes pre-intervention and 28 (IQR 16–41) minutes post-intervention (p = 0.134). Survival with CPC 1 or 2 was 7/27 (25.9%) pre-intervention and 15/39 (38.5%) post-intervention (p = 0.288).

Conclusion

We observed an association between the implementation of an ECPR-specific simulation program and decreased time from OHCA to ECMO flow. There was no association between the implementation of the program and neurologically intact survival at hospital discharge.

Development of a Standardized Assessment of Simulation-based Extracorporeal Membrane Oxygenation Educational Courses

Background

In 2020, the Extracorporeal Life Support Organization education task force identified seven extracorporeal membrane oxygenation (ECMO) educational domains that would benefit from international collaborative efforts. These included research efforts to delineate the impact and outcomes of ECMO courses.

Objective

Development of a standardized online assessment tool to evaluate the effectiveness of didactic and simulation-based ECMO courses on participants’ confidence, knowledge, and simulation-based skills; participant satisfaction; and course educational benefits.

Methods

We performed a prospective multicenter observational study of five different U.S. academic institution–based adult ECMO courses that met Extracorporeal Life Support Organization endorsement requirements for course structure, educational content, and objectives. Standardized online forms were developed and administered before and after courses, assessing demographics, self-assessment regarding ECMO management, and knowledge examination (15 simple-recall multiple-choice questions). Psychomotor skill assessment was performed during the course (time to complete prespecified critical actions during simulation scenarios). Self-assessment evaluated cognitive, behavioral, and technical aspects of ECMO; course satisfaction; and educational benefits.

Results

Out of 211 participants, 107 completed both pre- and postcourse self-assessment forms (97 completed both pre- and postcourse knowledge forms). Fifty-three percent of respondents were physician intensivists, with most (51%) practicing at academic hospitals and with less than 1 year of ECMO experience (50%). After the course, participants reported significant increases in confidence across all domains (cognitive, technical, and behavioral, P < 0.0001, 95% confidence interval [CI], 1.2–1.5; P < 0.0001, 95% CI, 2.2–2.6; and P = 0.002, 95% CI, 1.7–2.1, respectively) with an increase in knowledge scores (P < 0.001; 95% CI, 1.4–2.5). These findings were most significant in participants with less ECMO experience. There were also significant reductions in times to critical actions in three of the four scored simulation scenarios. The results demonstrated participants’ satisfaction with most course aspects, with more than 95% expressing that courses met their educational goals.

Conclusion

We developed and tested a structured ECMO course assessment tool, demonstrating participants’ self-reported benefit as well as improvement in psychomotor skill acquisition, course satisfaction, and educational benefits. Course evaluation is feasible and potentially provides important information to improve ECMO courses. Future steps could include national implementation, addition of questions targeting clinical decision making to further assess knowledge gain, and multilanguage translation for implementation in international courses.

Simulation-Based Emergency Team Training in Pediatrics: A Systematic Review

OBJECTIVES

The rare event of handling critically ill children often challenge the emergency care team. Several studies have investigated effects of simulation-based team training to prepare for such events, but the body of evidence remains to be compiled. We performed a systematic review of the effects of simulation-based team training on clinical performance and patient outcome.

METHODS

From a search of MEDLINE, Embase, CINAHL, and Cochrane Library, we included studies of team training in emergency pediatric settings with reported clinical performance and patient outcomes. We extracted data using a predefined template and assessed risk of bias using the Cochrane risk-of-bias tool for randomized trials 2.0 and the Newcastle Ottawa Quality Assessment Scale.

RESULTS

We screened 1926 abstracts and included 79 studies. We identified 15 studies reporting clinical health care professional performance or patient outcomes. Four studies reported survival data, 5 reported time-critical clinical events, 5 reported adherence to guidelines, checklists or tasks, and 2 reported on airway management. Randomized studies revealed improved team performance in simulated reevaluations 2 to 6 months after intervention. A meta-analysis was impossible because of heterogeneous interventions and outcomes. Most included studies had significant methodological limitations.

CONCLUSIONS

Pediatric simulation-based team training improves clinical performance in time-critical tasks and adherence to guidelines. Improved survival was indicated but not concluded because of high risk of bias. Team performance and technical skills improved for at least 2 to 6 months. Future research should include longer-term measures of skill retention and patient outcomes or clinical measures of treatment quality whenever possible.

Simulation in neonatal care: towards a change in traditional training?

Simulation has traditionally been used in neonatal medicine for educational purposes which include training of novice learners, maintaining competency of health care providers, and training of multidisciplinary teams to handle crisis situations such as neonatal resuscitation. Current guidelines recommend the use of simulation as an education tool in neonatal practice. The place of simulation-based education has gradually expanded, including in limited resource settings, and is starting to show its impact on improving patient outcomes on a global basis. Over the past years, simulation has become a cornerstone in clinical settings with the goal of establishing high quality, safe, reliable systems. The aim of this review is to describe neonatal simulation training as an effective tool to improve quality of care and patient outcomes, and to encourage the use of simulation-based training in the neonatal intensive care unit (NICU) for not only education, but equally for team building, risk management and quality improvement.

CONCLUSION

Simulation is a promising tool to improve patient safety, team performance, and ultimately patient outcomes, but scarcity of data on clinically relevant outcomes makes it difficult to estimate its real impact. The integration of simulation into the clinical reality with a goal of establishing high quality, safe, reliable, and robust systems to improve patient safety and patient outcomes in neonatology must be a priority.

WHAT IS KNOWN

• Simulation-based education has traditionally focused on procedural and technical skills. • Simulation-based training is effective in teaching non-technical skills such as communication, leadership, and teamwork, and is recommended in neonatal resuscitation.

WHAT IS NEW

• There is emerging evidence for the impact of simulation-based training on patient outcomes in neonatal care, but data on clinically relevant outcomes are scarce. • Simulation is a promising tool for establishing high quality, safe, reliable, and robust systems to improve patient safety and patient outcomes.

Outcomes in Pediatric Post-Cardiotomy ECMO Support With Modification of Systematic Support Strategy

BACKGROUND

Utilization of extracorporeal membrane oxygenation (ECMO) support in the post-cardiotomy setting is vital to successful perioperative outcomes following pediatric cardiac surgery. Specific analysis of protocolized management strategies and staff preparedness is imperative to optimizing institutional ECMO outcomes.

METHODS

All patients requiring post-cardiotomy ECMO support at a single institution from 2013 to 2019 were retrospectively reviewed. In 2015, several modifications were made to the ECMO support paradigm that addressed deficiencies in equipment, critical care protocols, and staff preparedness. Cases were stratified according to era of ECMO support; patients supported prior to paradigm change from 2013 to 2015 (Group EARLY, n = 20), and patients supported following the implementation of systematic modifications from 2016 to 2019 (Group LATE, n = 26). The primary outcomes of interest were survival to decannulation and hospital discharge.

RESULTS

Median age at cannulation was 24.5 days (IQR 7-96) and median duration of support was 4 days (IQR 2-8). Overall survival to decannulation was 78.3% (65% EARLY vs. 88.5% LATE, P = .08) and overall survival to hospital discharge was 58.7% (35% EARLY vs. 76.9% LATE, P = .004).

CONCLUSION

Systematic modifications to ECMO support strategy and staff preparation are associated with a significant increase in perioperative survival for pediatric patients requiring post-cardiotomy ECMO support.

Human factors in ECLS - A keystone for safety and quality - A narrative review for ECLS providers

INTRODUCTION

Although the technology used for extracorporeal life support (ECLS) has improved greatly in recent years, the application of these devices to the patient is quite complex and requires extensive training of team members both individually and together. Human factors is an area that addresses the activities, contexts, environments, and tools which interact with human behavior in determining overall system performance.

HYPOTHESIS

Analyses of the cognitive behavior of ECLS teams and individual members of these teams with respect to the occurrence of human errors may identify additional opportunities to enhance safety in delivery of ECLS.

RESULTS

The aim of this article is to support health-care practitioners who perform ECLS, or who are starting an ECLS program, by establishing standards for the safe and efficient use of ECLS with a focus on human factor issues. Other key concepts include the importance of ECLS team leadership and management, as well as controlling the environment and the system to optimize patient care.

CONCLUSION

Expertise from other industries is extrapolated to improve patient safety through the application of simulation training to reduce error propagation and improve outcomes.

Magnetic Resonance Imaging-Guided Cardiac Catheterization Evacuation Drills

BACKGROUND

The interventional cardiac magnetic resonance imaging suite combines a cardiac catheterization x-ray laboratory with a magnetic resonance imaging suite. At the study institution, interventional cardiac magnetic resonance imaging procedures (ie, magnetic resonance imaging-guided cardiac catheterizations) have been performed under institutional review board-approved research protocols since 2015. Because the workplace incorporates x-ray and magnetic resonance imaging in a highly technical environment, education about the importance of magnet safety is crucial to ensure the safety of patients and staff.

OBJECTIVE

To promote magnetic resonance imaging safety and staff preparedness to respond in emergency situations in a specialized interventional cardiac magnetic resonance imaging environment.

METHODS

Quarterly in situ evacuation drills with a live volunteer were implemented. A retrospective participant survey using a Likert scale was conducted. Evacuations were timed from the cardiac arrest code alert to safe evacuation or defibrillation if appropriate.

RESULTS

Over 4 years, 14 drills were performed. Twenty-nine of 48 participants responded to the survey, a 60% response rate. Most participants agreed or strongly agreed that the drills were a positive experience (90%) and that the drills increased their confidence in their ability to perform in an evacuation scenario (100%). Room evacuation times improved from 71 to 41 seconds. No patient or staff safety events occurred in the interventional cardiac magnetic resonance imaging environment.

CONCLUSION

Magnetic resonance imaging-guided cardiac catheterization evacuation drills promote preparedness, ensure patient and staff safety, and improve evacuation time in the interventional cardiac magnetic resonance imaging environment.

Checklists Improve Team Performance During Simulated Extracorporeal Membrane Oxygenation Emergencies: A Randomized Trial

Supplemental Digital Content is available in the text.

Objectives:

Extracorporeal membrane oxygenation–related complications are potentially catastrophic if not addressed quickly. Because complications are rare, high-fidelity simulation is recommended as part of the training regimen for extracorporeal membrane oxygenation specialists. We hypothesized that the use of standardized checklists would improve team performance during simulated extracorporeal membrane oxygenation emergencies.

Design:

Randomized simulation-based trial.

Setting:

A quaternary-care academic hospital with a regional extracorporeal membrane oxygenation referral program.

Subjects:

Extracorporeal membrane oxygenation specialists and other healthcare providers.

Interventions:

We designed six read-do checklists for use during extracorporeal membrane oxygenation emergencies using a modified Delphi process. Teams of two to three providers were randomized to receive the checklists or not. All teams then completed four simulated extracorporeal membrane oxygenation emergencies.

Measurements and Main Results:

Simulation sessions were video-recorded, and the number of critical tasks performed and time-to-completion were compared between groups. A survey instrument was administered before and after simulations to assess participants’ attitudes toward the simulations and checklists. We recruited 36 subjects from a single institution, randomly assigned to 15 groups. The groups with checklists completed more critical tasks than participants in the control groups (90% vs 75%; p < 0.001). The groups with checklists performed a higher proportion of both nontechnical tasks (71% vs 44%; p < 0.001) and extracorporeal membrane oxygenation–specific technical tasks (94% vs 86%; p < 0.001). Both groups reported an increase in reported self-efficacy after the simulations (p = 0.003). After adjusting for multiple comparisons, none of the time-to-completion measures achieved statistical significance.

Conclusions:

The use of checklists resulted in better team performance during simulated extracorporeal membrane oxygenation emergencies. As extracorporeal membrane oxygenation use continues to expand, checklists may be an attractive low-cost intervention for centers looking to reduce errors and improve response to crisis situations.

Outcomes of Pediatric Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis

OBJECTIVE

The goal of this work is to provide insight into survival and neurologic outcomes of pediatric patients supported with extracorporeal cardiopulmonary resuscitation.

DATA SOURCES

A systematic search of Embase, PubMed, Cochrane, Scopus, Google Scholar, and Web of Science was performed from January 1990 to May 2020.

STUDY SELECTION

A comprehensive list of nonregistry studies with pediatric patients managed with extracorporeal cardiopulmonary resuscitation was included.

DATA EXTRACTION

Study characteristics and outcome estimates were extracted from each article.

DATA SYNTHESIS

Estimates were pooled using random-effects meta-analysis. Differences were estimated using subgroup meta-analysis and meta-regression. The Meta-analyses Of Observational Studies in Epidemiology guideline was followed and the certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation system. Twenty-eight studies (1,348 patients) were included. There was a steady increase in extracorporeal cardiopulmonary resuscitation occurrence rate from the 1990s until 2020. There were 32, 338, and 1,094 patients' articles published between 1990 and 2000, 2001 and 2010, and 2010 and 2020, respectively. More than 70% were cannulated for a primary cardiac arrest. Pediatric extracorporeal cardiopulmonary resuscitation patients had a 46% (CI 95% = 43-48%; p < 0.01) overall survival rate. The rate of survival with favorable neurologic outcome was 30% (CI 95% = 27-33%; p < 0.01).

CONCLUSIONS

The use of extracorporeal cardiopulmonary resuscitation is rapidly expanding, particularly for children with underlying cardiac disease. An overall survival of 46% and favorable neurologic outcomes add credence to this emerging therapy.

Implementing Cardiac Surgical Unit-Advanced Life Support Through Simulation-Based Learning: A Quality Improvement Project

BACKGROUND

The European Association for Cardio Thoracic Surgery and the Society of Thoracic Surgeons endorse Cardiac Surgical Unit-Advanced Life Support, a protocol designed specifically for cardiothoracic surgical patients who suffer postoperative cardiac arrests. To enhance patient outcomes and to reduce death rates, cardiothoracic intensive care unit nurses must be able to perform the protocol with confidence, proficiency, and without delays. To this end, simulation-based learning (SBL) is a pedagogical method ideal for optimized learning.

OBJECTIVES

This quality improvement project was designed to implement a post-cardiac surgery resuscitation protocol in a nonacademic, community medical center to enhance nurse knowledge, confidence, and proficiency for optimal patient outcomes.

METHODS

The Cardiac Surgical Unit-Advanced Life Support is an evidence-based resuscitation protocol that was implemented using didactic, hands-on training, and SBL. It was evaluated using knowledge surveys, comparisons in nurse confidence and performance measures, and patient outcomes data.

RESULTS

Nurses' knowledge gains (ie, mean test scores) on our test were statistically significant between 3 time points (F2,60 = 81.204, P < .001). Knowledge significantly increased from pre-education to immediate post-education (P < .001), but declined from immediate post-education to 3-month post-education assessments (P < .001); however, the 3-month post knowledge mean was still higher than the pre-education knowledge mean (P < .001). Nurses were confident in their ability to apply the protocol, although results failed to show a correlation between confidence and performance ability. Statistical significance for delay in cardiopulmonary resuscitation was found between pre- and post-nursing education patient cardiac arrest events (P = .05).

CONCLUSIONS

Didactic and hands-on learning supported knowledge retention over time for cardiothoracic surgical intensive care unit nurses. Improving self-confidence and the application of an unfamiliar resuscitation protocol through SBL and any impact a training program has on patient outcomes will require ongoing practice and more evaluation.

The effect of team and leadership training of advanced life support providers on patient outcomes: A systematic review

AIM

To conduct a systematic review evaluating improvement in team and leadership performance and resuscitation outcomes after such a training of healthcare providers during advanced life support (ALS) courses.

METHODS

This systematic review asked the question of whether students taking structured and standardised ALS courses in an educational setting which include specific leadership or team training, compared to no such specific training in these courses, improves patient survival, skill performance in actual resuscitations, skill performance at 3-15 months (patient tasks, teamwork, leadership), skill performance at course conclusion (patient tasks, teamwork, leadership), or cognitive knowledge PubMed, Embase and the Cochrane database were searched until April 2020. Screening of articles, analysis of risk of bias, outcomes and quality assessment were performed according to the Grading of Recommendations Assessment, Development and Evaluation methodology. Only studies with abstracts in English were included.

RESULTS

14 non-randomised studies and 17 randomised controlled trials, both in adults and children, and seven studies involving patients were included in this systematic review. No randomised controlled trials but three observational studies of team and leadership training showed improvement in the critical outcome of "patient survival". However, they suffered from risk of bias (indirectness and imprecision). The included studies reported many different methods to teach leadership skills and team behaviour.

CONCLUSION

This systematic review found very low certainty evidence that team and leadership training as part of ALS courses improved patient outcome. This supports the inclusion of team and leadership training in ALS courses for healthcare providers.

Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.

Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.

Pediatric Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review

OBJECTIVES

This systematic review aims to summarize the body of available literature on pediatric extracorporeal cardiopulmonary resuscitation in order to delineate current utilization, practices, and outcomes, while highlighting gaps in current knowledge.

DATA SOURCES

PubMed, Embase, Scopus, Cochrane Library, and ClinicalTrials.gov databases.

STUDY SELECTION

We searched for peer-reviewed original research publications on pediatric extracorporeal cardiopulmonary resuscitation (patients < 18 yr old) and were inclusive of all publication years.

DATA EXTRACTION

Our systematic review used the structured Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. Our initial literature search was performed on February 11, 2019, with an updated search performed on August 28, 2019. Three physician reviewers independently assessed the retrieved studies to determine inclusion in the systematic review synthesis. Using selected search terms, a total of 4,095 publications were retrieved, of which 96 were included in the final synthesis. Risk of bias in included studies was assessed using the Risk of Bias in Non-Randomized Studies of Interventions-I tool.

DATA SYNTHESIS

There were no randomized controlled trials of extracorporeal cardiopulmonary resuscitation use in pediatrics. A vast majority of pediatric extracorporeal cardiopulmonary resuscitation publications were single-center retrospective studies reporting outcomes after in-hospital cardiac arrest. Most pediatric extracorporeal cardiopulmonary resuscitation use in published literature is in cardiac patients. Survival to hospital discharge after extracorporeal cardiopulmonary resuscitation for pediatric in-hospital cardiac arrest ranged from 8% to 80% in included studies, and there was an association with improved outcomes in cardiac patients. Thirty-one studies reported neurologic outcomes after extracorporeal cardiopulmonary resuscitation, of which only six were prospective follow-up studies. We summarize the available literature on: determination of candidacy, timing of activation of extracorporeal cardiopulmonary resuscitation, staffing/logistics, cannulation strategies, outcomes, and the use of simulation for training.

CONCLUSIONS

This review highlights gaps in our understanding of best practices for pediatric extracorporeal cardiopulmonary resuscitation. We summarize current studies available and provide a framework for the development of future studies.

Shortening of low-flow duration over time was associated with improved outcomes of extracorporeal cardiopulmonary resuscitation in in-hospital cardiac arrest

Introduction

Quality improvement in the administration of extracorporeal cardiopulmonary resuscitation (ECPR) over time and its association with low-flow duration (LFD) and outcomes of cardiac arrest (CA) have been insufficiently investigated. In this study, we hypothesized that quality improvement in efforts to shorten the duration of initiating ECPR had decreased LFD over the last 15 years of experience at an academic tertiary care hospital, which in turn improved the outcomes of in-hospital CA (IHCA).

Methods

This was a single-center retrospective observational study of ECPR patients between January 2003 and December 2017. A rapid response system (RRS) and an extracorporeal membrane oxygenation (ECMO) program were initiated in 2011 and 2013. First, the association of LFD per minute with the 90-day mortality and neurological outcome was analyzed using multiple logistic regression analysis. Then, the temporal changes in LFD were investigated.

Results

Of 175 study subjects who received ECPR, 117 had IHCA. In the multivariate logistic regression, IHCA patients with shorter LFD experienced significantly increased 90-day survival and favorable neurological outcomes (LFD per minute, 90-day survival: odds ratio [OR] = 0.97, 95% confidence interval [CI] = 0.94–1.00, P = 0.032; 90-day favorable neurological outcome: OR = 0.97, 95% CI = 0.94–1.00, P = 0.049). In the study period, LFD significantly decreased over time (slope − 5.39 [min/3 years], P < 0.0001).

Conclusion

A shorter LFD was associated with increased 90-day survival and favorable neurological outcomes of IHCA patients who received ECPR. The quality improvement in administering ECPR over time, including the RRS program and the ECMO program, appeared to ameliorate clinical outcomes.

Hacking teamwork in health care: Addressing adverse effects of ad hoc team composition in critical care medicine

BACKGROUND

The continued need for improved teamwork in all areas of health care is widely recognized. The present article reports on the application of a hackathon to the teamwork problems specifically associated with ad hoc team formation in rapid response teams.

PURPOSES

Hackathons-problem-solving events pioneered in computer science-are on the rise in health care management. The focus of these events tends to be on medical technologies, however, with calls for improvements in management practices as general recommendations. The hackathon reported here contributes to health care management practice by addressing improvements in teamwork as the focal problem.

METHODOLOGY

The hackathon event took place over 2.5 days in conjunction with an academic conference focused on group research. Three teams comprised of practicing healthcare professionals, academic researchers and students developed solutions to problems of ad hoc team formation in rapid response teams.

FINDINGS

The event fulfilled several goals. The teams produced three distinct, yet complementary solutions that were backed by both field-based experience and solid research evidence. The event provided the opportunity for two-way translation of research and practice through direct collaboration among key stakeholders. The hackathon produced long term effects through establishing or strengthening collaborations, dissemination of the ideas through presentations, workshops, and publications, and changes in participantsâ work practices.

PRACTICE IMPLICATION

The event demonstrated that hackathons, classically focused on technology, can also offer a spur to innovation around organizational processes. The article provides advice for organizing other hackathons focused on similar topics. The solutions offered by the participants in the event yields the clear insight that multipronged solutions for emergency-oriented teamwork are needed. The hackathon highlighted the scaled of collaboration and effort needed to tackle the many complexities in health care that impact outcomes for providers, patients, and health organizations.

Using briefing, simulation and debriefing to improve human and system performance

Safety, effectiveness and efficiency are keys to performance in all high-risk industries; healthcare is no exception, and neonatal-perinatal medicine is one of the highest risk subspecialties within healthcare. Briefing, simulation and debriefing are methods used by professionals in high-risk industries to reduce the overall risk to life and enhance the safety of the human beings involved in receiving and delivering the services provided by those industries. Although relatively new to neonatal-perinatal medicine, briefing, simulation and debriefing are being practiced with increasing frequency and have become embedded in training exercises such as the Neonatal Resuscitation Program (NRP) of the American Academy of Pediatrics (AAP). This chapter will define these terms and offer examples as to how they are used in high-risk activities including neonatal-perinatal medicine.

Introduction of an Extracorporeal Cardiopulmonary Resuscitation Eligibility Protocol for Paramedics in Atlantic Canada: A Pilot Knowledge Translation Project

Introduction

There is currently no protocol for the initiation of extracorporeal cardiopulmonary resuscitation (ECPR) for out of hospital cardiac arrest (OHCA) in Atlantic Canada. Advanced care paramedics (ACPs) perform advanced cardiac life support in the prehospital setting often completing the entire resuscitation on-scene. Implementation of ECPR will present a novel intervention that is only available at the receiving hospital. Our objective is to determine if an educational program can improve identification of ECPR candidates by paramedics. Establishing paramedic competence will ensure rapid transfer of eligible patients for a potentially life-saving intervention.

Methods

An educational program was delivered to paramedics including a short seminar and pocket card coupled with simulated OHCA cases. A before-and-after study design using a case-based survey was employed. Paramedics were scored on their ability to correctly identify patients suffering OHCA who met the inclusion criteria for our ECPR protocol. A Wilcoxon matched-pairs signed rank test was employed to compare paramedics’ scores before and after the education delivery. A six-month follow-up is planned to assess retention. Qualitative data was also collected from paramedics during simulation to help identify practical issues, potential barriers, and to refine inclusion and exclusion criteria prior to the implementation of our protocol in the prehospital setting.

Results

The median score pre-education was 10 (IQR: 9-10.5) compared to 14 (IQR: 13-15) after education delivery. The median difference between groups was 5. The Wilcoxon matched-pairs test demonstrated a significant improvement in the paramedics’ ability to correctly identify ECPR candidates after completing our educational program z = -2.67, p = 0.0039.

Conclusion

Paramedic training through a didactic session coupled with a pocket card and simulation appeared to be a feasible method of knowledge translation. Six-month follow-up data will help ensure knowledge retention is achieved.

Applying Educational Theory to Interdisciplinary Education in Pediatric Cardiac Critical Care

At the 14th Annual International Meeting for the Pediatric Cardiac Intensive Care Society, the authors presented a simulation workshop for junior multidisciplinary providers focused on cardiopulmonary interactions. We provide an overview of educational theories of particular relevance to curricular design for simulation-based or enhanced activities. We then demonstrate how these theories are applied to curriculum development for individuals to teams and for novice to experts. We review the role of simulation in cardiac intensive care education and the education theories that support its use. Finally, we demonstrate how a conceptual framework, SIMZones, can be applied to design effective simulation-based teaching.

Simulation training for crises during venoarterial extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) education, in particular with regards to crisis management during the provision of venoarterial extracorporeal membrane oxygenation (VA ECMO), is challenging due to its intrinsic characteristics-a complex, high risk, low volume clinical activity which requires dynamic decision making, interdisciplinary teamwork and communication, and rapid response. Simulation training that focuses on crisis resource management and interprofessional communication is well-suited to address these training needs. Institutional commitment to provide both capital and human resources is instrumental to the success of ECMO training programs. Future multicenter studies with standardized training curricula are required to investigate the impact of ECMO simulation training on patient outcome.

Impacts of a Pediatric Extracorporeal Cardiopulmonary Resuscitation (ECPR) Simulation Training Program

OBJECTIVE

To examine the impacts of a large-scale simulation-based extracorporeal cardiopulmonary resuscitation (ECPR) training program in an academic children's hospital.

METHODS

The study followed a quasi-experimental, mixed-method, time series design. Two-hour high-fidelity ECPR simulations were held monthly in the pediatric, cardiac, and neonatal intensive care units. Intensive care unit-specific cases were used in each unit. The learning objectives for all cases were the same. Each simulation included an average of 11 health care professionals, including nurses, physicians, respiratory therapist, and perfusionists. Impacts of training were examined using Kirkpatrick's 4-level model: reactions, learning, behaviors, and results. Participant surveys, semistructured interviews, facilitator observations, applied cognitive task analysis, and hospital code data were used to examine the impacts of training.

RESULTS

From February 2014 to October 2016, a total of 332 health care professionals participated in 29 ECPR simulations. Participants enjoyed the simulations and reported learning gains. Applied cognitive task analysis revealed 2 specific behaviors, coordination of compressions with surgical cannulation and performing sterile compressions, that were targeted for further training. The rate of adherence to the ECPR activation protocol improved from 83% (48/58) before simulations started to 95% (92/97) after simulations (P = .02). ECPR activation time decreased from 7 minutes (interquartile range, 4-9 minutes) before simulations started to 2 minutes (interquartile range, 1-4 minutes) after simulations (P < .01).

CONCLUSIONS

Large-scale simulation-based ECPR training was associated with positive reactions, learning gains, behavioral change, improved adherence to the ECPR activation protocols, and faster activation times. Other children's hospital that perform ECPR should consider simulation-based training.

The Arterial Switch Operation in 2019: How to Do It and How to Teach It

This article presents technical aspects of the arterial switch procedure. The arterial switch procedure is a technically reproducible operation that involves less three-dimensional judgment and fewer difficult sequencing decisions than many other complex cardiac procedures. Hemostasis is the most important principal that must be adhered to mainly through meticulous surgical technique. Meticulous technique will also lead to successful transfer of the coronary arteries. Teaching a surgical trainee how to manage a child who requires an arterial switch procedure requires instruction in the technical aspects of the procedure. However, this is just one component of the overall management of babies requiring this procedure. Attention and training should be directed at all areas of competence that have been emphasized by bodies such as the American College of Surgeons. Simulation is playing an increasingly important role in the instruction of surgical trainees within the domain of congenital heart disease.

Establishing extracorporeal membrane oxygenation team increased number of patients and improved data recording

Background

For patients treated with extracorporeal membrane oxygenation (ECMO), employing a well-coordinated, multidisciplinary team specializing in ECMO has reportedly been effective in delivering better clinical outcomes. This study aims to assess the impact of establishing such a specialized team for patients treated with ECMO.

Method

This retrospective cohort study was performed at a tertiary-care hospital in Japan. We reviewed medical records of all consecutive patients treated with ECMO during October 2010–September 2016. The results obtained in pre-ECMO team cases (PRE group; October 2011–September 2012) and post-ECMO team cases (POST group; October 2014–September 2015) were compared.

Results

The results obtained in pre-ECMO team cases (PRE group; October 2011–September 2012) and post-ECMO team cases (POST group; October 2014–September 2015) were compared. During the study period, 177 patients were treated with ECMO. Before the introduction of ECMO team, an average of 22.7 patients underwent ECMO treatment per year; after establishing ECMO team, this number increased to 36.3 patients per year. ECMO was applied mainly to cardiac arrest patients 52/69 (75%). The PRE (n = 27) and POST (n = 42) groups did not differ with regard to the survival rate to hospital discharge, ECMO duration, ventilator days, and length of hospital stay. However, PaO₂ and positive end-expiratory pressure were significantly higher in the POST group at 6 h after ECMO initiation than those in the PRE group [367 (186–490) vs. 239 (113–430) mmHg, p = 0.047 and 8 (5–10) vs. 7 (5–8) cmH₂O, p = 0.01, respectively]. In addition, data recording the detailed time points of ECMO initiation was conducted in significantly more cases in the POST group (28/126 (22%) than in the PRE group (6/81 (7%); p = 0.01).

Conclusions

Following the establishment of an ECMO team, the survival rate of patients treated with ECMO, ECMO duration, and length of hospital stay were not improved. However, the number of ECMO cases increased and the recording of clinical data was improved.

Extracorporeal Cardiopulmonary Resuscitation in Children of Asia Pacific: A Retrospective Analysis of Extracorporeal Life Support Organization Registry

Background

Recent advances in extracorporeal membrane oxygenation (ECMO) have led to increasing interest in its use during cardiopulmonary resuscitation (CPR). However, decisions regarding extracorporeal CPR (ECPR) in children are difficult as a result of limited studies, especially in Asia Pacific. The objective of this study was to investigate trends in survival and demographic details for children with ECPR in Asia Pacific recorded in the Extracorporeal Life Support Organization (ELSO) registry from 1999 to 2016 and identify the risk factors associated with in-hospital mortality.

Methods

The data of children younger than 18 years of age who received ECPR over the past 18 years in Asia Pacific were retrospectively analyzed. The data were extracted from the ELSO registry and divided into two 9-year groups (Group 1: 1999-2007 and Group 2: 2008-2016) to assess temporal changes using univariate analysis. Then, univariate and multiple logistic regression analyses were performed between survivors and nonsurvivors to identify factors independently associated with in-hospital mortality.

Results

A total of 321 children were included in final analysis, with an overall survival rate of 50.8%. Although survival rates were similar between Group 1 and Group 2 (43.1% vs. 52.5%, χ² = 1.67, P = 0.196), the median age (1.7 [0.3, 19.2] months for Group 1 vs. 5.6 [0.8, 64.9] months for Group 2, t = -2.93, P = 0.003) and weight (3.7 [3.0, 11.5] kg for Group 1 vs. 6.0 [3.4, 20.3] kg for Group 2, t = -3.14, P = 0.002) of children increased over time, while the proportion of congenital heart disease (75.9% for Group 1 vs. 57.8% for Group 2, χ² = 6.52, P = 0.011) and cardiogenic shock (36.2% for Group 1 vs. 7.2% for Group 2, χ² = 36.59, P < 0.001) decreased. Patient conditions before ECMO were worse, while ECMO complications decreased across time periods, especially renal complications. Multiple logistic regression analysis of ECMO complications showed that disseminated intravascular coagulation (DIC), myocardial stunning, and neurological complications were independently associated with increased odds of hospital mortality.

Conclusions

The broader indications and decreased complication rates make EPCR to be applicated more and more extensive in children in Asia Pacific region. ECMO complications such as myocardial stunning are independently associated with decreased survival.

The introduction of a high-fidelity simulation program for training pediatric critical care personnel reduces the times to manage extracorporeal membrane oxygenation emergencies and improves teamwork

Background

Extracorporeal membrane oxygenation (ECMO) is used to support patients with severe respiratory and/or cardiac failure unresponsive to conventional treatments. Despite being one of the most complex supportive therapy used in intensive care unit, there is a still a lack of training programs dedicated to improve both clinical and nonclinical skills. The aim of the current study was to evaluate if the introduction of an ECMO high-fidelity simulation curriculum among personnel reduces the times to manage bedside emergencies and improves the behavioral skills.

Methods

This retrospective study was performed from 2011 to 2016 in a 6-beds general pediatric intensive care unit (PICU) of a tertiary children's hospital. The study population was the PICU personnel. From the beginning of 2011 to the end of 2013, ECMO education was provided without a simulation program. A high-fidelity simulation program instead, was provided from December 2013. Times to manage the most common ECMO emergencies (pump failure, oxygenator change and air embolism management) as well as the behavioral skills of the personnel were evaluated before and after the simulation intervention only in novice learners to reduce the bias related to the natural improvement associated with the bedside practice.

Results

There were a total of 30 ECMO runs and 27 ECMO emergencies over the study period. Ten ECMO emergencies occurred during the pre-simulation period and 17 in the post-simulation period. The median time to change an oxygenator in case of failure was 5.3 (4.80-6.02) min during the pre-simulation period vs. 3.9 (3.50-4.15) min in the post-simulation period (P=0.02). The median time to manage an air embolism emergency was 22 (20.00-23.50) min during the pre-simulation period vs. 15 (13.75-16.50) min in the post-simulation period (P=0.048). Only one episode of pump failure occurred in either the pre-simulation and post-simulation periods. In the pre-simulation period the median cumulative behavioral score was 40 (35.00-44.75) whereas it was 48 (44.5-49.00) in the post-simulation period (P<0.01).

Conclusions

The introduction of a high-fidelity simulation program for pediatric ECMO improved both the times to effective interventions and behavioral skills.

Addressing the challenges of ECMO simulation

INTRODUCTION/AIM

The patient's condition and high-risk nature of extracorporeal membrane oxygenation (ECMO) therapy force clinical services to ensure clinicians are properly trained and always ready to deal effectively with critical situations. Simulation-based education (SBE), from the simplest approaches to the most immersive modalities, helps promote optimum individual and team performance. The risks of SBE are negative learning, inauthenticity in learning and over-reliance on the participants' suspension of disbelief. This is especially relevant to ECMO SBE as circuit/patient interactions are difficult to fully simulate without confusing circuit alterations.

METHODS

Our efforts concentrate on making ECMO simulation easier and more realistic in order to reduce the current gap there is between SBE and real ECMO patient care. Issues to be overcome include controlling the circuit pressures, system failures, patient issues, blood colour and cost factors. Key to our developments are the hospital-university collaboration and research funding.

RESULTS

A prototype ECMO simulator has been developed that allows for realistic ECMO SBE. The system emulates the ECMO machine interface with remotely controllable pressure parameters, haemorrhaging, line chattering, air bubble noise and simulated blood colour change.

CONCLUSION

The prototype simulator allows the simulation of common ECMO emergencies through innovative solutions that enhance the fidelity of ECMO SBE and reduce the requirement for suspension of disbelief from participants. Future developments will encompass the patient cannulation aspect.

The Role of Extracorporeal Membrane Oxygenation Simulation Training at Extracorporeal Life Support Organization Centers in the United States

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) requires a multidisciplinary healthcare team. The Extracorporeal Life Support Organization publishes training guidelines but leaves specific requirements up to each institution. Simulation training has shown promise, but it is unclear how many institutions have incorporated simulation techniques into ECMO training to date.

METHODS

We sent an electronic survey to ECMO coordinators at Extracorporeal Life Support Organization sites in the United States. Participants were asked about training practices and the use of simulation for ECMO training. Descriptive results were reported as the percentage of total responses for each question. Logistic regression was used to identify characteristics associated with simulation use.

RESULTS

Of 94 responses (62% response rate), 46% had an ECMO simulation program, whereas 26% report a program is in development. Most (61%) have been in operation for 2 to 5 years. Sixty-three percent use simulation for summative assessment, and 76% have multidisciplinary training. Access to a simulation center [odds ratio (OR) = 4.7, 95% confidence interval (CI) = 1.7-12.5], annual ECMO caseload of greater than 20 (OR = 2.5, 95% CI = 1.5-5.8), and having a pediatric cardiothoracic intensive care unit (OR = 2.8, 95% CI = 1.2-6.7) are each associated with increased likelihood of mannequin-based ECMO simulation. Common scenarios include pump failure (93%), oxygenator failure (90%), and circuit rupture (76%).

DISCUSSION

Extracorporeal membrane oxygenation simulation is growing but remains in its infancy. Centers with access to a simulation center, higher caseloads, and pediatric cardiothoracic intensive care units are more likely to have ECMO simulation programs. Extracorporeal membrane oxygenation simulation is felt to be beneficial, and further work is needed to delineate best training practices for ECMO providers.

Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association

Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.

Education for ECMO providers: Using education science to bridge the gap between clinical and educational expertise

A well-organized educational curriculum for the training of both novice and experienced ECMO providers is critical for the continued function of an institutional ECMO program. ELSO provides guidance for the education for ECMO specialists, physicians and staff, which incorporates "traditional" instructor-centered educational methods, such as didactic lectures and technical skill training. Novel research suggests utilization of strategies that align with principles of adult learning to promote active learner involvement and reflection on how the material can be applied to understand existing and new constructs may be more effective. Some examples include the "flipped classroom," e-learning, simulation, and interprofessional education. These methodologies have been shown to improve active participation, which can be related to improvements in understanding and long-term retention. A novel framework for ECMO training is considered. Challenges in assessment and credentialing are also discussed.

Extracorporeal membrane oxygenation in congenital heart disease

This review article will discuss the indications for and outcomes of neonates with congenital heart disease who receive extracorporeal membrane oxygenation (ECMO) support. Most commonly, ECMO is used as a perioperative bridge to recovery or temporary support for those after cardiac arrest or near arrest in patients with congenital or acquired heart disease. What had historically been considered a contraindication to ECMO, is evolving and more of the sickest and most complicated babies are cared for on ECMO. Given that, it is imperative for aggressive survellience for long-term morbidity in survivors, particularly neurodevelopmental outcomes.

Extracorporeal Cardiopulmonary Resuscitation in the Pediatric Cardiac Population: In Search of a Standard of Care

OBJECTIVES

Although clinical and pharmacologic guidelines exist for the practice of cardiopulmonary resuscitation in children (Pediatric Advanced Life Support), the practice of extracorporeal cardiopulmonary resuscitation in pediatric cardiac patients remains without universally accepted standards. We aim to explore variation in extracorporeal cardiopulmonary resuscitation procedures by surveying clinicians who care for this high-risk patient population.

DESIGN

A 28-item cross-sectional survey was distributed via a web-based platform to clinicians focusing on cardiopulmonary resuscitation practices and extracorporeal membrane oxygenation team dynamics immediately prior to extracorporeal membrane oxygenation cannulation.

SETTINGS

Pediatric hospitals providing extracorporeal mechanical support services to patients with congenital and/or acquired heart disease.

SUBJECTS

Critical care/cardiology specialist physicians, cardiothoracic surgeons, advanced practice nurse practitioners, respiratory therapists, and extracorporeal membrane oxygenation specialists.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Survey web links were distributed over a 2-month period with critical care and/or cardiology physicians comprising the majority of respondents (75%). Nearly all respondents practice at academic/teaching institutions (97%), 89% were from U.S./Canadian institutions and 56% reported less than 10 years of clinical experience. During extracorporeal cardiopulmonary resuscitation, a majority of respondents reported adherence to guideline recommendations for epinephrine bolus dosing (64%). Conversely, 19% reported using only one to three epinephrine bolus doses regardless of extracorporeal cardiopulmonary resuscitation duration. Inotropic support is held after extracorporeal membrane oxygenation cannulation "most of the time" by 58% of respondents and 94% report using afterload reducing/antihypertensive agents "some" to "most of the time" after achieving full extracorporeal membrane oxygenation support. Interruptions in chest compressions are common during active cannulation according to 77% of respondents.

CONCLUSIONS

The results of this survey identify wide variability in resuscitative practices during extracorporeal cardiopulmonary resuscitation in the pediatric cardiac population. The deviations from established Pediatric Advanced Life Support CPR guidelines support a call for further inquiry into the pharmacologic and logistical care surrounding extracorporeal cardiopulmonary resuscitation.

Staffing, Equipment, Monitoring Considerations for Extracorporeal Membrane Oxygenation

Although the reasons for the recent growth in adult extracorporeal membrane oxygenation (ECMO) are multifactorial, much of the success may be attributed to the development of well-trained staff and the technological innovations in equipment and monitoring devices used during extracorporeal support. In this article, the authors discuss general educational formats for the ECMO bedside provider, staffing support models, and devices designed to best meet the needs of the patient while simultaneously ensuring the proper delivery of ECMO-related care.

Improving Pediatric Rapid Response Team Performance Through Crew Resource Management Training of Team Leaders

BACKGROUND

Rapid response teams (RRTs) improve the detection of and response to deteriorating patients. Professional hierarchies and the multidisciplinary nature of RRTs hinder team performance. This study assessed whether an intervention involving crew resource management training of team leaders could improve team performance.

METHODS

In situ observations of RRT activations were performed pre- and post-training intervention. Team performance and dynamics were measured by observed adherence to an ideal task list and by the Team Emergency Assessment Measure tool, respectively. Multiple quartile (median) and logistic regression models were developed to evaluate change in performance scores or completion of specific tasks.

RESULTS

Team leader and team introductions (40% to 90%, P = .004; 7% to 45%, P = .03), floor team presentations in Situation Background Assessment Recommendation format (20% to 65%, P = .01), and confirmation of the plan (7% to 70%, P = .002) improved after training in patients transferred to the ICU (n = 35). The Team Emergency Assessment Measure metric was improved in all 4 categories: leadership (2.5 to 3.5, P < .001), teamwork (2.7 to 3.7, P < .001), task management (2.9 to 3.8, P < .001), and global scores (6.0 to 9.0, P < .001) for teams caring for patients who required transfer to the ICU.

CONCLUSIONS

Targeted crew resource management training of the team leader resulted in improved team performance and dynamics for patients requiring transfer to the ICU. The intervention demonstrated that training the team leader improved behavior in RRT members who were not trained.

Rapid Response Extracorporeal Membrane Oxygenation Deployment-Surgical Technique

The availability of extracorporeal membrane oxygenation (ECMO) is the standard of care at most high-acuity congenital heart surgery programs. Extracorporeal membrane oxygenation is also an integral part of managing children with in-hospital cardiac arrest refractory to conventional cardiopulmonary resuscitation (extracorporeal cardiopulmonary resuscitation). In this article, we aim to provide a practical guide to initiate rapid ECMO in a nonoperating room setting.

Procedural training and assessment of competency utilizing simulation

This review examines the current environment of neonatal procedural learning, describes an updated model of skills training, defines the role of simulation in assessing competency, and discusses potential future directions for simulation-based competency assessment. In order to maximize impact, simulation-based procedural training programs should follow a standardized and evidence-based approach to designing and evaluating educational activities. Simulation can be used to facilitate the evaluation of competency, but must incorporate validated assessment tools to ensure quality and consistency. True competency evaluation cannot be accomplished with simulation alone: competency assessment must also include evaluations of procedural skill during actual clinical care. Future work in this area is needed to measure and track clinically meaningful patient outcomes resulting from simulation-based training, examine the use of simulation to assist physicians undergoing re-entry to practice, and to examine the use of procedural skills simulation as part of a maintenance of competency and life-long learning.

Simulation for neonatal extracorporeal membrane oxygenation teams

Extracorporeal membrane oxygenation (ECMO) is a highly technical and complex method of life support. Patient and circuit emergencies on ECMO are rare, but in these cases, prompt and correct actions to address the crisis are needed to prevent morbidity and mortality. ECMO simulation programs have gained popularity in recent years, as they provide a standardized educational experience for all members of the inter-professional care team. In addition to providing a context in which to solidify knowledge of ECMO support, participants are also able to focus on vital technical and behavioral skills that are not highlighted in other training methodologies. ECMO simulation can also be used for quality improvement, clinical and educational research, and assessment/credentialing. Multi-organizational international collaboratives have formed, and are working to standardize ECMO education training across institutions; simulation will play an essential role in this process.

Simulation as a Tool to Ensure Competency and Quality of Care in the Cardiac Critical Care Unit

Cardiac critical care units are high-risk clinical environments. Medical emergencies are frequent and require the intervention of a cohesive, efficient, and well trained interprofessional team. In modern clinical practice there is increased emphasis on safety but also increased lack of acceptance of medical errors and as a consequence, increased litigation. In the past decade, simulation-based learning has arisen as an effective and safe means to learn and practice acute care setting skills. It has been used and studied in different contexts including procedural skills training, crisis resource management and team training, patient and family member communication skills, and health care system quality improvement. Simulation-based education is a relatively recent teaching strategy and evidence of its efficacy continues to grow. Nevertheless, many influential medical societies are now promoting a simulation-based approach for cardiovascular training and continuing medical education. In this article we review the simulation literature in the intensive care unit and evaluate its integration in coronary care units and postoperative cardiovascular intensive care units. We also provide resources for educators and clinicians who wish to implement simulation workshops in these settings.

Nursing Considerations in Pediatric Cardiac Critical Care

OBJECTIVE

The objectives of this review are to describe the education and critical thinking skills that characterize pediatric critical care nursing and how these skills impact patient care and outcomes in pediatric cardiac critical care.

DATA SOURCE

MEDLINE and PubMed.

CONCLUSIONS

Pediatric cardiac critical care nurses manage complex and vulnerable patients requiring various levels of support. Effective care of these patients requires knowledge about the complex anatomy and physiology associated with congenital and acquired heart disease, as well as the effects of mechanical ventilation, mechanical circulatory support, and vasoactive medications. Strong physical examination skills, accurate interpretation of hemodynamic and laboratory data, active participation in bedside rounds, excellent communication skills, meticulous care of invasive monitoring catheters and tubes, and compassionate support of families are among the skills that distinguish a cardiac critical care nurse.

Extracorporeal Membrane Oxygenation for Cardiac Indications in Children

OBJECTIVES

The objectives of this review are to discuss the use of extracorporeal membrane oxygenation following surgery for congenital heart disease, myocarditis and as a bridge to cardiac transplantation. In addition, the latest in circuit equipment, the management of anticoagulation and blood transfusions, and short- and long-term outcomes are reviewed.

DATA SOURCE

MEDLINE, PubMed.

CONCLUSIONS

The use of extracorporeal membrane oxygenation to support children with heart disease is increasing. There is wide variability in the use and management of extracorporeal membrane oxygenation between centers. Many areas of extracorporeal membrane oxygenation management warrant additional research to inform clinical practice and improve patient outcomes, including the use of extracorporeal membrane oxygenation in patients undergoing single ventricle palliation, optimizing strategies for monitoring and titrating anticoagulation therapies, and efforts directed at minimizing the risk of neurologic injury.

Results of Extracorporeal Cardiopulmonary Resuscitation in Children

Background

Survival of children experiencing cardiac arrest refractory to conventional cardiopulmonary resuscitation (CPR) is very poor. We sought to examine current era outcomes of extracorporeal CPR (ECPR) support for refractory arrest.

Methods

Patients who were <18 years and underwent ECPR between November 2013 and January 2016 were including in this study. We retrospectively investigated patient medical records.

Results

Twelve children, median age 6.6 months (range, 1 day to 11.7 years), required ECPR. patients’ diseases spanned several categories: congenital heart disease (n=5), myocarditis (n=2), respiratory failure (n=2), septic shock (n=1), trauma (n=1), and post-cardiotomy arrest (n=1). Cannulation sites included the neck (n=8), chest (n=3), and neck to chest conversion (n=1). Median duration of extracorporeal membrane oxygenation was five days (range, 0 to 14 days). Extracorporeal membrane oxygenation was successfully discontinued in 10 (83.3%) patients. Nine patients (75%) survived more than seven days after support discontinuation and four patients (33.3%) survived and were discharged. Causes of death included ischemic brain injury (n=4), sepsis (n=3), and gastrointestinal bleeding (n=1).

Conclusion

ECPR plays a valuable role in children experiencing refractory cardiac arrest. The weaning rate is acceptable; however, survival is related to other organ dysfunction and the severity of ischemic brain injury. ECPR prior to the emergence of end-organ injury and prevention of neurologic injury might enhance survival.

Extracorporeal Life Support for Pediatric Heart Failure

Extracorporeal life support (ECLS) represents an essential component in the treatment of the pediatric patient with refractory heart failure. Defined as the use of an extracorporeal system to provide cardiopulmonary support, ECLS provides hemodynamic support to facilitate end-organ recovery and can be used as a salvage therapy during acute cardiorespiratory failure. Support strategies employed in pediatric cardiac patients include bridge to recovery, bridge to therapy, and bridge to transplant. Advances in extracorporeal technology and refinements in patient selection have allowed wider application of this therapy in pediatric heart failure patients.