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Gottula AL, Qi M, Lane BH, Shaw CR, Gorder K, Powell E, Danielson K, Ciullo A, Johnson NJ, Tonna JE, Hinckley WR, Koshoffer A, Al-Araji R, Bartos J, Benoit J, Hsu CH. Prehospital Ground and Helicopter-Based Extracorporeal Cardiopulmonary Resuscitation (ECPR) Reduce Barriers to ECPR: A GIS Model. PREHOSP EMERG CARE 2024:1-9. [PMID: 38739864 DOI: 10.1080/10903127.2024.2355652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/03/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Evidence suggests that Extracorporeal Cardiopulmonary Resuscitation (ECPR) can improve survival rates for nontraumatic out-of-hospital cardiac arrest (OHCA). However, when ECPR is indicated over 50% of potential candidates are unable to qualify in the current hospital-based system due to geographic limitations. This study employs a Geographic Information System (GIS) model to estimate the number of ECPR eligible patients within the United States in the current hospital-based system, a prehospital ECPR ground-based system, and a prehospital ECPR Helicopter Emergency Medical Services (HEMS)-based system. METHODS We constructed a GIS model to estimate ground and helicopter transport times. Time-dependent rates of ECPR eligibility were derived from the Resuscitation Outcome Consortium (ROC) database, while the Cardiac Arrest Registry to Enhance Survival (CARES) registry determined the number of OHCA patients meeting ECPR criteria within designated transportation times. Emergency Medical Services (EMS) response time, ECPR candidacy determination time, and on-scene time were modeled based on data from the EROCA trial. The combined model was used to estimate the total ECPR eligibility in each system. RESULTS The CARES registry recorded 736,066 OHCA patients from 2013 to 2021. After applying clinical criteria, 24,661 (3.4%) ECPR-indicated OHCA were identified. When considering overall ECPR eligibility within 45 min from OHCA to initiation, only 11.76% of OHCA where ECPR was indicated were eligible in the current hospital-based system. The prehospital ECPR HEMS-based system exhibited a four-fold increase in ECPR eligibility (49.3%), while the prehospital ground-based system showed a more than two-fold increase (28.4%). CONCLUSIONS The study demonstrates a two-fold increase in ECPR eligibility for a prehospital ECPR ground-based system and a four-fold increase for a prehospital ECPR HEMS-based system compared to the current hospital-based ECPR system. This novel GIS model can inform future ECPR implementation strategies, optimizing systems of care.
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Affiliation(s)
- Adam L Gottula
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
- Max Harry Weil Institute for Critical Care Research and Innovation, Ann Arbor, Michigan
| | - Man Qi
- Department of Geography and Geographic Information System, The University of Cincinnati, Cincinnati, Ohio
| | - Bennett H Lane
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Christopher R Shaw
- Department of Emergency Medicine, Division of Critical Care, Oregon Health and Science University, Portland, Oregon
| | - Kari Gorder
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio
| | - Elizabeth Powell
- Department of Emergency Medicine, The University of Maryland, College Park, Maryland
| | - Kyle Danielson
- AirLift Northwest, University of Washington, Seattle, Washington
| | - Anna Ciullo
- Department of Emergency Medicine, University of Utah, Salt Lake City, Utah
| | - Nicholas J Johnson
- Department of Emergency Medicine & Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Joseph E Tonna
- Department of Emergency Medicine, University of Utah, Salt Lake City, Utah
| | - William R Hinckley
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
- UC Health, Air Care and Mobile Care, Cincinnati, Ohio
| | - Amy Koshoffer
- University of Cincinnati Libraries, The University of Cincinnati, Cincinnati, Ohio
| | - Rabab Al-Araji
- The Cardiac Arrest Registry to Enhance Survival, Atlanta, Georgia
| | - Jason Bartos
- Center for Resuscitation Medicine, The University of Minnesota, Minneapolis, Minnesota
| | - Justin Benoit
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Cindy H Hsu
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
- Max Harry Weil Institute for Critical Care Research and Innovation, Ann Arbor, Michigan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
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2
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Moynihan KM, Taylor LS, Siegel B, Nassar N, Lelkes E, Morrison W. "Death as the One Great Certainty": ethical implications of children with irreversible cardiorespiratory failure and dependence on extracorporeal membrane oxygenation. Front Pediatr 2024; 11:1325207. [PMID: 38274466 PMCID: PMC10808631 DOI: 10.3389/fped.2023.1325207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/22/2023] [Indexed: 01/27/2024] Open
Abstract
Introduction Advances in medical technology have led to both clinical and philosophical challenges in defining death. Highly publicized cases have occurred when families or communities challenge a determination of death by the irreversible cessation of neurologic function (brain death). Parallels can be drawn in cases where an irreversible cessation of cardiopulmonary function exists, in which cases patients are supported by extracorporeal cardiopulmonary support, such as extracorporeal membrane oxygenation (ECMO). Analysis Two cases and an ethical analysis are presented which compare and contrast contested neurologic determinations of death and refusal to accept the irreversibility of an imminent death by cardiopulmonary standards. Ambiguities in the Uniform Determination of Death Act are highlighted, as it can be clear, when supported by ECMO, that a patient could have suffered the irreversible cessation of cardiopulmonary function yet still be alive (e.g., responsive and interactive). Parallel challenges with communication with families around the limits of medical technology are discussed. Discussion Cases that lead to conflict around the removal of technology considered not clinically beneficial are likely to increase. Reframing our goals when death is inevitable is important for both families and the medical team. Building relationships and trust between all parties will help families and teams navigate these situations. All parties may require support for moral distress. Suggested approaches are discussed.
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Affiliation(s)
- Katie M. Moynihan
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
- Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Lisa S. Taylor
- Office of Ethics, Boston Children’s Hospital, Boston, MA, United States
| | - Bryan Siegel
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Natasha Nassar
- Clinical and Population Translational Health, Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Efrat Lelkes
- Department of Pediatrics, MaineGeneral Medical Center, Augusta, ME, United States
| | - Wynne Morrison
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
- Divisions of Critical Care and Palliative Care, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
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Kopanczyk R, Lisco SJ, Pearl R, Demiralp G, Naik BI, Mazzeffi MA. Racial and Ethnic Disparities in Veno-Venous Extracorporeal Membrane Oxygenation Mortality for Patients With Severe COVID-19. ASAIO J 2024; 70:62-67. [PMID: 37815999 DOI: 10.1097/mat.0000000000002072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023] Open
Abstract
Racial/ethnic disparities in mortality were observed during the coronavirus disease-2019 pandemic, but investigations examining the association between race/ethnicity and mortality during extracorporeal membrane oxygenation (ECMO) are limited. We performed a retrospective observational cohort study using the 2020 national inpatient sample. Multivariable logistic regression was used to estimate the odds of mortality in patients of difference race/ethnicity while controlling for confounders. There was a significant association between race/ethnicity and in-hospital mortality ( p < 0.001). Hispanic patients had significantly higher in-hospital mortality compared with White patients (odds ratio [OR] = 1.39, 95% confidence interval [CI] = 1.16-1.67, p < 0.001). Black patients and patients of other races did not have significantly higher in-hospital mortality compared with White patients (OR = 0.82, 95% CI = 0.66-1.02, p = 0.07 and OR = 1.20, 95% CI = 0.92-1.57, p = 0.18). Other variables that had a significant association with mortality included age, insurance type, Charlson comorbidity index, all patient-refined severity of illness, and receipt of care in a low-volume ECMO center (all p < 0.001). Further studies are needed to understand causes of disparities in ECMO mortality.
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Affiliation(s)
- Rafal Kopanczyk
- From the Division of Critical Care, Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Steven J Lisco
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Ronald Pearl
- Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, California
| | - Gozde Demiralp
- Department of Anesthesiology, University of Wisconsin, Madison, Wisconsin
| | - Bhiken I Naik
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
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Alizadeh F, Gauvreau K, Mayourian J, Brown E, Barreto JA, Blossom J, Bucholz E, Newburger JW, Kheir J, Vitali S, Thiagarajan RR, Moynihan K. Social Drivers of Health and Pediatric Extracorporeal Membrane Oxygenation Outcomes. Pediatrics 2023; 152:e2023061305. [PMID: 37933403 DOI: 10.1542/peds.2023-061305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Relationships between social drivers of health (SDoH) and pediatric health outcomes are highly complex with substantial inconsistencies in studies examining SDoH and extracorporeal membrane oxygenation (ECMO) outcomes. To add to this literature with emerging novel SDoH measures, and to address calls for institutional accountability, we examined associations between SDoH and pediatric ECMO outcomes. METHODS This single-center retrospective cohort study included children (<18 years) supported on ECMO (2012-2021). SDoH included Child Opportunity Index (COI), race, ethnicity, payer, interpreter requirement, urbanicity, and travel-time to hospital. COI is a multidimensional estimation of SDoH incorporating traditional (eg, income) and novel (eg, healthy food access) neighborhood attributes ([range 0-100] higher indicates healthier child development). Outcomes included in-hospital mortality, ECMO run duration, and length of stay (LOS). RESULTS 540 children on ECMO (96%) had a calculable COI. In-hospital mortality was 44% with median run duration of 125 hours and ICU LOS 29 days. Overall, 334 (62%) had cardiac disease, 92 (17%) neonatal respiratory failure, 93 (17%) pediatric respiratory failure, and 21 (4%) sepsis. Median COI was 64 (interquartile range 32-81), 323 (60%) had public insurance, 174 (34%) were from underrepresented racial groups, 57 (11%) required interpreters, 270 (54%) had urban residence, and median travel-time was 89 minutes. SDoH including COI were not statistically associated with outcomes in univariate or multivariate analysis. CONCLUSIONS We observed no significant difference in pediatric ECMO outcomes according to SDoH. Further research is warranted to better understand drivers of inequitable health outcomes in children, and potential protective mechanisms.
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Affiliation(s)
| | | | | | | | | | - Jeff Blossom
- Center for Geographic Analysis, Harvard University, Cambridge, Massachusetts
| | | | | | - John Kheir
- Departments of Cardiology
- Departments of Pediatrics
| | - Sally Vitali
- Anesthesia, Critical Care, Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Anesthesia, Harvard Medical School, Boston, Massachusetts
| | | | - Katie Moynihan
- Departments of Cardiology
- Departments of Pediatrics
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Hamilton M, Thornton SW, Tracy ET, Ozment C. Quality improvement strategies in pediatric ECMO. Semin Pediatr Surg 2023; 32:151337. [PMID: 37935089 DOI: 10.1016/j.sempedsurg.2023.151337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
Pediatric extracorporeal membrane oxygenation is an increasingly utilized, life-saving technology with high mortality and morbidity. A complex technology employed urgently or emergently for some of the sickest children in the hospital by a large multidisciplinary team, ECMO is an ideal area for using quality improvement strategies to reduce the variability in care and improve patient outcomes. We review critical concepts from quality improvement and apply them to patient selection and management, staffing, credentialing and continuing education, and the variability of management among providers and institutions.
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Affiliation(s)
- Makenzie Hamilton
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke Univeristy, Durham, NC, USA
| | - Steven W Thornton
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Elisabeth T Tracy
- Department of Surgery, Division of Pediatric Surgery, Duke University, Durham, NC, USA
| | - Caroline Ozment
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke Univeristy, Durham, NC, USA.
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Garg A, Lobner K, Song J, Mitchell R, Egbunine A, Kudchadkar SR. Social Determinants of Health in Pediatric Rehabilitation for Children with Traumatic Injury: A Systematic Review. J Pediatr 2023; 259:113459. [PMID: 37172806 PMCID: PMC10524504 DOI: 10.1016/j.jpeds.2023.113459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 01/05/2023] [Accepted: 04/21/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To examine the current evidence regarding health care disparities in pediatric rehabilitation after hospitalization with traumatic injury. STUDY DESIGN This systematic review utilized both PubMed and EMBASE, and each was searched with key MESH terms. Studies were included in the systematic review if they (1) addressed social determinants of health including, but not limited to, race, ethnicity, insurance status, and income level; (2) focused on inpatient and outpatient rehabilitation services posthospital stay; (3) were based in the pediatric population; and (4) addressed traumatic injury requiring hospitalization. Only studies from within the US were included. RESULTS From 10 169 studies identified, 455 abstracts were examined for full-text review, and 24 studies were chosen for data extraction. Synthesis of the 24 studies revealed 3 major themes: (1) access to services; (2) outcomes from rehabilitation; and (3) service provision. Patients with public insurance had decreased availability of service providers and had longer outpatient wait times. Non-Hispanic Black and Hispanic children were more likely to have greater injury severity and decreased functional independence after discharge. Lack of interpreter services was associated with decreased utilization of outpatient services. CONCLUSIONS This systematic review identified significant effects of health care disparities on the rehabilitation process in pediatric traumatic injury. Social determinants of health must be thoughtfully addressed to identify key areas of improvement for the provision of equitable health care.
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Affiliation(s)
- Anjali Garg
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Katie Lobner
- Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Ariel Egbunine
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sapna R Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
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Moynihan KM, Dorste A, Alizadeh F, Phelps K, Barreto JA, Kolwaite AR, Merlocco A, Barbaro RP, Chan T, Thiagarajan RR. Health Disparities in Extracorporeal Membrane Oxygenation Utilization and Outcomes: A Scoping Review and Methodologic Critique of the Literature. Crit Care Med 2023; 51:843-860. [PMID: 36975216 DOI: 10.1097/ccm.0000000000005866] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
OBJECTIVES To map the scope, methodological rigor, quality, and direction of associations between social determinants of health (SDoH) and extracorporeal membrane oxygenation (ECMO) utilization or outcomes. DATA SOURCES PubMed, Web of Science, Embase, and Cochrane Library databases were systematically searched for citations from January 2000 to January 2023, examining socioeconomic status (SES), race, ethnicity, hospital and ECMO program characteristics, transport, and geographic location (context) with utilization and outcomes (concept) in ECMO patients (population). STUDY SELECTION Methodology followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping review extension. Two reviewers independently evaluated abstracts and full text of identified publications. Exclusion criteria included non-English, unavailable, less than 40 patients, and periprocedural or mixed mechanical support. DATA EXTRACTION Content analysis used a standardized data extraction tool and inductive thematic analysis for author-proposed mediators of disparities. Risk of bias was assessed using the Quality in Prognosis Studies tool. DATA SYNTHESIS Of 8,214 citations screened, 219 studies were identified. Primary analysis focuses on 148 (68%) including race/ethnicity/SES/payer variables including investigation of ECMO outcomes 114 (77%) and utilization 43 (29%). SDoH were the primary predictor in 15 (10%). Overall quality and methodologic rigor was poor with advanced statistics in 7%. Direction of associations between ECMO outcomes or utilization according to race, ethnicity, SES, or payer varied. In 38% adverse outcomes or lower use was reported in underrepresented, under-resourced or diverse populations, while improved outcomes or greater use were observed in these populations in 7%, and 55% had no statistically significant result. Only 26 studies (18%) discussed mechanistic drivers of disparities, primarily focusing on individual- and hospital-level rather than systemic/structural factors. CONCLUSIONS Associations between ECMO utilization and outcomes with SDoH are inconsistent, complicated by population heterogeneity and analytic shortcomings with limited consideration of systemic contributors. Findings and research gaps have implications for measuring, analyzing, and interpreting SDoH in ECMO research and healthcare.
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Affiliation(s)
- Katie M Moynihan
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Anna Dorste
- Medical Library, Boston Children's Hospital, Boston, MA
| | - Faraz Alizadeh
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Kayla Phelps
- Department of Pediatrics, Children's Hospital New Orleans, Louisiana State University, New Orleans, LA
| | - Jessica A Barreto
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Amy R Kolwaite
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
| | - Anthony Merlocco
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN
| | - Ryan P Barbaro
- Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Titus Chan
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Ravi R Thiagarajan
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Fenwick Institute for Pediatric Health Equity and Inclusion, Boston Children's Hospital, Boston, MA
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8
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Discretion Over Discrimination: Toward Good Decisions for Extracorporeal Membrane Oxygenation Use in Patients With Neurological Comorbidities. Pediatr Crit Care Med 2022; 23:943-946. [PMID: 36326459 DOI: 10.1097/pcc.0000000000003078] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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