Addressing the challenges of ECMO simulation

Ambulatory extracorporeal membrane oxygenation simulator: The next frontier in clinical training

BACKGROUND

Current medical simulators for extracorporeal membrane oxygenation (ECMO) are expensive and rely on low-fidelity methodologies. This creates a challenge that demands a new approach to eliminate high costs and integrate with critical care environments, especially in light of the scarce resources and supplies available after the COVID-19 pandemic.

METHODS

To address this challenge, we examined the current state-of-the-art medical simulators and collaborated closely with Hamad Medical Corporation (HMC), the primary healthcare provider in Qatar, to establish criteria for advancing the cutting-edge ECMO simulation. This article presents a comprehensive ambulatory high-realism and cost-effective ECMO simulator.

RESULTS

Over the past 3 years, we have surveyed relevant literature, gathered data, and continuously developed a prototype of the system modules and the accompanying tablet application. By doing so, we have successfully addressed the issue of cost and fidelity in ECMO simulation, providing an effective tool for medical professionals to improve their understanding and treatment of patients requiring ECMO support.

CONCLUSIONS

This paper will focus on presenting an overall ambulatory ECMO simulator, detailing the various sub-systems and emphasizing the modular casing of the physical components and the simulated patient monitor.

A quality improvement initiative to increase adult ECMO decision-making abilities in a perfusion education program: The use of 3D ECMO simulation

INTRODUCTION

Adult and pediatric ECMO procedures have been increasingly established as conventional life-saving modalities in critical care services across the world. Since 2017, a multidisciplinary team of program advisors for our perfusion education program have aimed to increase cardiovascular perfusion (CVP) student ECMO exposure and improve clinical decision-making. In this QI intervention, the use of 3D computer-based simulation was assessed in establishing a standardized process to improve the diagnosis and treatment of adult ECMO complications among first year CVP students.

METHODS

The Califia 3D Patient Simulator was incorporated into the curriculum for first year CVP students (n = 26) along with traditional lecture for the adult ECMO complication laboratory session. Pre-class knowledge assessments using de-identified polling software were compared to post-class assessments following the first assigned learning activity. Assessments from students that received simulation before lecture (SIM, n = 15) were compared to students receiving lecture before simulation (LEC, n = 11). User experience questionnaires (UEQ) consisting of 26 questions for six scales of simulation instruction were administered to measure the comprehensive impression of the student experience.

RESULTS

Overall median [IQR] pre- and -post knowledge assessment scores were 74% [11] and 84% [11], respectively (p = 0.01). There were no significant differences in pre-class assessment scores between the SIM and LEC groups (74.0% and 74.0%, respectively, p = 0.959). The LEC group achieved higher median post-assessment scores than the SIM group (84% vs 79%, p = 0.032). Among the 26 UEQ survey scales, 23 were positively evaluated (>0.8), and three were a neutral evaluation (-0.8 to 0.8). Cronbach Alpha-Coefficients of >0.78 were measured for attractiveness, perspicuity, efficacy, and stimulation. The coefficient for dependability was 0.37. 25 (96.2%) students indicated that 3D simulation was beneficial to improving ECMO clinical decision-making.

CONCLUSIONS

In this QI intervention, the implementation of computer-based 3D simulation following lecture was perceived by learners to help improve the diagnosis and treatment of ECMO-related complications.

Development of pediatric multidisciplinary extracorporeal membrane oxygenation simulations: A novel educational program to enhance team communication and emergency preparedness

INTRODUCTION

Pediatric extracorporeal membrane oxygenation (ECMO) is a high risk, low-volume technology. Infrequency of this technology and associated complications may translate to unfamiliarity of identification and management of potentially life-threatening events, which may require knowledge and procedural skills to be performed quickly. Providers involved in managing ECMO must be able to promptly identify and initiate management for such events, particularly when surgical colleagues are not readily available.

METHODS

A multidisciplinary ECMO simulation program was implemented in a tertiary children's hospital. Over 18 months, a prospective, observational study was conducted evaluating simulations involving circuit and patient emergencies, teamwork and communication behaviors and technical skills. An on-line survey was sent to participants following sessions to evaluate post-simulation confidence, lessons learned and potential barriers to implementation of necessary skills and behaviors.

RESULTS

Ten simulation sessions occurred during implementation. Mean participants per session was 7 (range: 5-11). Eight Pediatric Cardiac Intensive Care Unit attendings, four Advance Practice Nurses, 54 pediatric intensive care unit registered nurses, and 55 pediatric respiratory therapists attended. Tasks with highest self-reported increase in confidence were related to (1) diagnosis (tension pneumothorax, oxygenator failure, and ventricular tachycardia), (2) fluid administration and (3) early and efficient mobilization for ECPR, with less reported confidence increase with technical skills More than 90% of participants provided a task or behavior they would implement if a specific emergency was encountered in real-life following simulation training. Real-life application occurred following simulations with participants reporting direct impact of training on their ability to perform the skill efficiently and correctly.

CONCLUSIONS

Implementation of ECMO multidisciplinary simulations provides structured opportunities for the team to learn and practice ECMO skills together in scenarios they may encounter without surgical presence. Ensuring competency of providers through implementation of such a program may improve patient safety through enhanced team communication, knowledge, and hands-on experience.

Noninvasive fluid bubble detection based on capacitive micromachined ultrasonic transducers

Ultrasonic fluid bubble detection is important in industrial controls, aerospace systems and clinical medicine because it can prevent fatal mechanical failures and threats to life. However, current ultrasonic technologies for bubble detection are based on conventional bulk PZT-based transducers, which suffer from large size, high power consumption and poor integration with ICs and thus are unable to implement real-time and long-term monitoring in tight physical spaces, such as in extracorporeal membrane oxygenation (ECMO) systems and dialysis machines or hydraulic systems in aircraft. This work highlights the prospect of capacitive micromachined ultrasonic transducers (CMUTs) in the aforementioned application situations based on the mechanism of received voltage variation caused by bubble-induced acoustic energy attenuation. The corresponding theories are established and well validated using finite element simulations. The fluid bubbles inside a pipe with a diameter as small as 8 mm are successfully measured using our fabricated CMUT chips with a resonant frequency of 1.1 MHz. The received voltage variation increases significantly with increasing bubble radii in the range of 0.5-2.5 mm. Further studies show that other factors, such as bubble positions, flow velocities, fluid medium types, pipe thicknesses and diameters, have negligible effects on fluid bubble measurement, demonstrating the feasibility and robustness of the CMUT-based ultrasonic bubble detection technique.

A phased intervention bundle to decrease the mortality of patients with extracorporeal membrane oxygenation in intensive care unit

Aim

To evaluate whether a phased multidimensional intervention bundle would decrease the mortality of patients with extracorporeal membrane oxygenation (ECMO) and the complication incidence.

Materials and methods

We conducted a prospective observational study in comparison with a retrospective control group in six intensive care units (ICUs) in China. Patients older than 18 years supported with ECMO between March 2018 to March 2022 were included in the study. A phased intervention bundle to improve the outcome of patients with ECMO was developed and implemented. Multivariable logistic regression modeling was used to compare the mortality of patients with ECMO and the complication incidence before, during, and up to 18 months after implementation of the intervention bundle.

Results

The cohort included 297 patients in 6 ICUs, mostly VA ECMO (68.7%) with a median (25th–75th percentile) duration in ECMO of 9.0 (4.0–15.0) days. The mean (SD) APECHII score was 24.1 (7.5). Overall, the mortality of ECMO decreased from 57.1% at baseline to 21.8% at 13–18 months after implementation of the study intervention (P < 0.001). In multivariable analysis, even after excluding the confounding factors, such as age, APECHII score, pre-ECMO lactate, and incidence of CRRT during ECMO, the intervention bundle still can decrease the mortality independently, which also remained true in the statistical analysis of V-V and V-A ECMO separately. Among all the ECMO-related complications, the incidence of bloodstream infection and bleeding decreased significantly at 13–18 months after implementation compared with the baseline. The CUSUM analysis revealed a typical learning curve with a point of inflection during the implementation of the bundle.

Conclusion

A phased multidimensional intervention bundle resulted in a large and sustained reduction in the mortality of ECMO that was maintained throughout the 18-month study period.

Clinical trial registration

[ClinicalTrials.gov], identifier [NCT05024786].

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.

Extracorporeal Life Support Organization Guideline for Transport and Retrieval of Adult and Pediatric Patients with ECMO Support

DISCLAIMER

This guideline for the preparation for and undertaking of transport and retrieval of patients on extracorporeal membrane oxygenation (ECMO) is intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing ECLS / ECMO and describe what are believed to be useful and safe practice for extracorporeal life support (ECLS, ECMO) but these are not necessarily consensus recommendations. The aim of clinical guidelines are to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Ultimately, healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgement, knowledge and expertise. These guidelines do not take the place of physicians' and other health professionals' judgment in diagnosing and treatment of particular patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient in light of all the circumstances presented by the individual patient, and the known variability and biological behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but ELSO is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.

Simulation-based education: deceiving learners with good intent

The level of performance of every clinician and of the overall multiprofessional team relies on the skills and expertise they have individually and collectively acquired through education, training, self-directed learning, and reflection. Simulation-based education (SBE) is playing an increasingly important role in that respect, and it is sometimes said that it is an art to facilitate. Many explanations can justify this assertion. Although there is generally an emphasis on making everything as realistic or "high-fidelity" as possible, it is often futile and this is where the art of simulation comes into play with an element of modulation of realism linked to the intended learning objectives. The atmosphere created by the educators; how the learners are made to engage and interact; how physical, technical, and contextual elements are simulated or represented; and what type of technology is used need to be appropriately adapted to contribute to the immersiveness of any SBE activity. Although it inevitably carries a negative connotation, some form of "deception" is more commonly used than one may think for the benefit of learners during SBE. High levels of realism are sometimes achieved by making learners believe something works or reacts as would be expected in real life, whereas it is achieved in a totally different manner. Learners do not need to know, see, or understand these "tricks of the trade", shortcuts, or artistic or technological aspects, and this can be considered a form of benevolent deception. Similarly, information may be withheld to recreate a realistic situation and push learners to demonstrate specific learning outcomes, but it needs to be practised with caution and be justifiable. These forms of "positive" deception are part of most SBE activities and are used to help learners bridge the reality gap so they can suspend disbelief more easily, exercise critical thinking, and treat the simulation more realistically without damaging the trust they place in their educators. This article will discuss how aspects of SBE activities are often manipulated, modified, or hidden from learners to facilitate the learning experience and present a simulation fidelity model encompassing the environmental, patient, semantical, and phenomenal dimensions.

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.

Advanced Thermochromic Ink System for Medical Blood Simulation

Simulators for extracorporeal membrane oxygenation (ECMO) have problems of bulky devices and low-fidelity methodologies. Hence, ongoing efforts for optimizing modern solutions focus on minimizing expenses and blending training with the intensive care unit. This is particularly evident following the coronavirus pandemic, where economic resources have been extensively cut. In this paper, as a part of an ECMO simulator for training management, an advance thermochromic ink system for medical blood simulation is presented. The system was developed and enhanced as a prototype with successful and reversible transitions between dark and bright red blood color to simulate blood oxygenation and deoxygenation in ECMO training sessions.

A Modular Approach for a Patient Unit for Extracorporeal Membrane Oxygenation Simulator

Despite many advancements in extracorporeal membrane oxygenation (ECMO), the procedure is still correlated with a high risk of patient complications. Simulation-based training provides the opportunity for ECMO staff to practice on real-life scenarios without exposing ECMO patients to medical errors while practicing. At Hamad Medical Corporation (HMC) in Qatar, there is a critical need of expert ECMO staff. Thus, a modular ECMO simulator is being developed to enhance the training process in a cost-effective manner. This ECMO simulator gives the instructor the ability to control the simulation modules and run common simulation scenarios through a tablet application. The core modules of the simulation system are placed in the patient unit. The unit is designed modularly such that more modules can be added throughout the simulation sessions to increase the realism of the simulation sessions. The new approach is to enclose the patient unit in a trolley, which is custom-designed and made to include all the components in a modular fashion. Each module is enclosed in a separate box and then mounted to the main blood simulation loop box using screws, quick connect/disconnect liquid fittings, and electrical plugs. This method allows fast upgrade and maintenance for each module separately as well as upgrading modules easily without modifying the trolley’s design. The prototype patient unit has been developed for portability, maintenance, and extensibility. After implementation and testing, the prototype has proven to successfully simulate the main visual and audio cues of the real emergency scenarios, while keeping costs to a minimum.

Training the component steps of an extra-corporeal membrane oxygenation (ECMO) cannulation outside the clinical setting

Extra-corporeal membrane oxygenation (ECMO) cannulation can be a stressful procedure because a fast cannulation is vital for the patient’s survival. Therefore, it is important to train the steps of cannulation outside the clinical setting. A relatively low budget, easy to use model, was developed to train the most important steps of an ECMO cannulation. Following this, it was evaluated by experts and target group participants. They all completed a questionnaire regarding their experience and opinions on the ECMO model on general aspects and the training of the component steps, rated on a 5-point Likert scale. Twenty-one participants completed the questionnaire. The features and steps of the model were rated with a mean of 3.9 on average. The haptics of the landscape scored least, with a mean of 3.6, although the haptics of the vessels scored highest with 4.0. The rating of the component steps showed that only ‘opening of the vessels’ was scored significantly different between the expertise levels (means experts: 4.0, target group: 3.4, p = 0.032). This low budget model is considered to be a valid tool to train the component steps of the ECMO cannulation, which could reduce the learning curve in the a stressful clinical setting. Level of evidence: II prospective comparative study.

A skills acquisition study on ECMOjo: a screen-based simulator for extracorporeal membrane oxygenation

BACKGROUND

Extracorporeal membrane oxygenation relies heavily on didactic teaching, emphasizing on essential cognitive skills, but overlooking core behavioral skills such as leadership and communication. Therefore, simulation-based training has been adopted to instill clinical knowledge through immersive experiences. Despite simulation-based training's effectiveness, training opportunities are lessened due to high costs. This is where screen-based simulators come into the scene as affordable and realistic alternatives.

AIM

This article evaluates the educational efficacy of ECMOjo, an open-source screen-based extracorporeal membrane oxygenation simulator that aims to replace extracorporeal membrane oxygenation didactic instruction in an interactive and cost-effective manner.

METHOD

A prospective cohort skills acquisition study was carried out. A total of 44 participants were pre-assessed, divided into two groups, where the first group received traditional didactic teaching, and the second used ECMOjo. Participants were then evaluated through a wet lab assessment and two questionnaires.

RESULTS

The obtained results indicate that the two assessed groups show no statistically significant differences in knowledge and efficacy. Hence, ECMOjo is considered an alternative to didactic teaching as per the learning outcomes.

CONCLUSION

The present findings show no significant dissimilarities between ECMOjo and didactic classroom-based teaching. Both methods are very comparable in terms of the learner's reported self-efficacy and complementary to mannequin-based simulations.

Extracorporeal membrane oxygenation simulation-based training: methods, drawbacks and a novel solution

Introduction:

Patients under the error-prone and complication-burdened extracorporeal membrane oxygenation (ECMO) are looked after by a highly trained, multidisciplinary team. Simulation-based training (SBT) affords ECMO centers the opportunity to equip practitioners with the technical dexterity required to manage emergencies. The aim of this article is to review ECMO SBT activities and technology followed by a novel solution to current challenges.

ECMO simulation:

The commonly-used simulation approach is easy-to-build as it requires a functioning ECMO machine and an altered circuit. Complications are simulated through manual circuit manipulations. However, scenario diversity is limited and often lacks physiological and/or mechanical authenticity. It is also expensive to continuously operate due to the consumption of highly specialized equipment.

Technological aid:

Commercial extensions can be added to enable remote control and to automate circuit manipulation, but do not improve on the realism or cost-effectiveness.

A modular ECMO simulator:

To address those drawbacks, we are developing a standalone modular ECMO simulator that employs affordable technology for high-fidelity simulation.

Using thermochromism to simulate blood oxygenation in extracorporeal membrane oxygenation

Introduction:

Extracorporeal membrane oxygenation (ECMO) training programs employ real ECMO components, causing them to be extremely expensive while offering little realism in terms of blood oxygenation and pressure. To overcome those limitations, we are developing a standalone modular ECMO simulator that reproduces ECMO’s visual, audio and haptic cues using affordable mechanisms. We present a central component of this simulator, capable of visually reproducing blood oxygenation color change using thermochromism.

Methods:

Our simulated ECMO circuit consists of two physically distant modules, responsible for adding and withdrawing heat from a thermochromic fluid. This manipulation of heat creates a temperature difference between the fluid in the drainage line and the fluid in the return line of the circuit and, hence, a color difference.

Results:

Thermochromic ink mixed with concentrated dyes was used to create a recipe for a realistic and affordable blood-colored fluid. The implemented “ECMO circuit” reproduced blood’s oxygenation and deoxygenation color difference or lack thereof. The heat control circuit costs 300 USD to build and the thermochromic fluid costs 40 USD/L. During a ten-hour in situ demonstration, nineteen ECMO specialists rated the fidelity of the oxygenated and deoxygenated “blood” and the color contrast between them as highly realistic.

Conclusions:

Using low-cost yet high-fidelity simulation mechanisms, we implemented the central subsystem of our modular ECMO simulator, which creates the look and feel of an ECMO circuit without using an actual one.