Recommendations From the Professional Advisory Committee on Nursing Practice in the Care of ECMO-Supported Patients

Development and validation of the novel nursing activities in the care of extracorporeal membrane oxygenation-supported patients scale

BACKGROUND

Nurses are members of multidisciplinary teams providing care to extracorporeal membrane oxygenation-supported patients (ECMO-SP). There are no valid and reliable measurements available to assess nursing activities in the care of ECMO-SP.

AIM

To develop and evaluate psychometric properties of a new 27-item nursing activities in the care of ECMO-SP scale.

STUDY DESIGN

A convenience sample was recruited of 76 registered nurses (mean age 41.3 ± 8.7; 71% female) in Israel. The nurses participated in an online survey with software Qualtrics, between March and June 2022. Content and construct validity, as well as internal consistency of the scale were evaluated. The participants also completed the perceived knowledge and skills in the treatment of ECMO-SP scale. The correlations between nursing activities in the care of ECMO-SP and ECMO knowledge were examined using Pearson's correlation.

RESULTS

Exploratory factor analysis extracted four factors, and seven items were excluded from the 27-item scale making it a 20-item scale in its final form. Internal consistency was acceptable for the total scale (α = 0.84) and the four subscales: Factor 1: Nursing care of ECMO-SP not related to the ECMO device (α = 0.90), Factor 2: Activities on ECMO device in emergency (α = 0.82), Factor 3: ECMO device calibrating and monitoring (α = 0.72), and Factor 4: Medication and blood administration through ECMO device (α = 0.73). When examined in confirmatory factor analysis, the 20-item scale yielded acceptable fit indices. A positive correlation was found between perceived ECMO knowledge and all four factors of the nursing activities in the Care of ECMO-SP scale.

CONCLUSIONS

The 20-item scale examining nursing activities in the care of ECMO-SP is ready for use for clinical, educational, and research purposes.

RELEVANCE TO CLINICAL PRACTICE

Because there are still no standards for nursing care of ECMO-SP and no agreed quality indicators, this novel scale may help in building such standards and quality indicators.

Performance Assessment of Anti-Xa Assay-Based Heparin Dosing Protocol in Pediatric Patients on Extracorporeal Membrane Oxygenation

BACKGROUND

The use of extracorporeal membrane oxygenation (ECMO) in the postoperative cardiac critical care setting is evolving. Anticoagulation monitoring is among the most challenging aspects of pediatrics. However, there is no consensus on the optimal dosing and monitoring of unfractionated heparin in this setting. To address this, we developed an anti-Xa assay-based protocol derived from the best available clinical and anecdotal evidence of ECMO use and assessed its effectiveness in achieving the anti-Xa assay therapeutic target.

METHODS

This prospective single-arm study was conducted in the pediatric carcardiac-surgery intensive care unit of a large tertiary hospital. We used two different anti-Xa assay intensity levels based on the patients' bleeding status.

RESULTS

The median patient age was 7 (interquartile range [IQR]: 5-11.25) months, and the median weight was 5.7 (IQR: 3.8-13.82) kg. The median ECMO duration was 6 (IQR: 4.5-7.5) days. The bleeding protocol was used for most patients. Seventy percent achieved the anti-Xa assay therapeutic target during the study period (median: 75.5 h, IQR: 60.5-117.5 h). Hemorrhagic complications were reported in 40% of the patients, and thrombotic complications were reported in 25%. The median length of stay was 37 (IQR: 22-43) days, with a survival-to-discharge rate of 75%.

CONCLUSIONS

Despite a failure to achieve the anti-Xa assay target within the first ECMO days, most patients achieved the target by the median ECMO duration. Moreover, using two different anti-Xa assay levels reduced thrombotic complications.

Developing a competency framework for extracorporeal membrane oxygenation nurses: A qualitative study

AIM

To develop a competency framework applicable to Chinese extracorporeal membrane oxygenation (ECMO) nurses.

DESIGN

A qualitative study was performed following the consolidated criteria for reporting qualitative research.

METHODS

Semi-structured interviews based on the critical incident technique were conducted among 21 ECMO care providers recruited from five well-known ECMO centres in Guangzhou, China. Interview transcripts were coded and analysed using the constant comparative method. The data collection period lasted from November 2021 to April 2022.

RESULTS

A competency framework for ECMO nurses was identified. It included four domains: knowledge, skills, behaviours and attitudes, containing 33 subcompetencies and 66 items.

RELEVANCE TO CLINICAL PRACTICE

This framework can be a reference for the assessment and training of ECMO nurses.

Factors associated with acute kidney injury in patients undergoing extracorporeal membrane oxygenation: retrospective cohort

OBJECTIVE

To identify factors associated with acute kidney injury in patients undergoing extracorporeal membrane oxygenation.

METHOD

Retrospective cohort study conducted in an adult Intensive Care Unit with patients undergoing extracorporeal membrane oxygenation from 2012 to 2021. The research used the Kidney Disease Improving Global Outcomes as criteria for definition and classification of acute kidney injury. A multiple logistic regression model was developed to analyze the associated factors.

RESULTS

The sample was composed of 122 individuals, of these, 98 developed acute kidney injury (80.3%). In multiple regression, the associated factors found were vasopressin use, Nursing Activities Score, and glomerular filtration rate.

CONCLUSION

The use of vasopressin, the Nursing Activities Score, and the glomerular filtration rate were considered as factors related to the development of acute kidney injury in patients undergoing extracorporeal membrane oxygenation.

Implementing Nurse Extracorporeal Membrane Oxygenation Specialists to Maintain a Sustainable Program

Extracorporeal membrane oxygenation (ECMO) offers hope for patients with acute respiratory distress syndrome when other treatment methods fail. However, ECMO requires continuous hourly management leading to extremely high operating costs. With the onset of the COVID-19 pandemic, the high number of patients on ECMO led to a significant increase in the costs when using perfusionists to manage ECMO. Switching to a nurse-driven model resulted in a 52% decrease in costs related to the hourly management. Changing to a nurse-driven program provided increased nursing support and sustainability, and with determination and support, other ECMO centers can also change to nurse-driven programs.

Development of a Comprehensive Extracorporeal Membrane Oxygenation Program in a Cardiac Transplant Intensive Care Unit: A Quality Improvement Initiative

BACKGROUND

A major academic medical center in the Midwest has expanded their extracorporeal membrane oxygenation (ECMO) program from 8 ECMO cases in 2014 to 97 ECMO cases in 2017. The Extracorporeal Life Support Organization states that standardized policies, procedures, and standards of care are necessary for an ECMO center to be successful.

LOCAL PROBLEM

With the rapid growth of the ECMO program, this medical center has chosen to transition nurses and respiratory therapists into the role of ECMO specialist to bridge the gap in care created by the influx in patients. Currently, no specific set of policies/procedures or standards of care exist for ECMO patients. The primary objective of this study is to improve the self-efficacy of ECMO specialists and bedside nurses through the development of a comprehensive ECMO program that includes standardized policies and procedures, order sets, and evidence-based patient management guidelines.

METHODS/IMPLEMENTATION

The General Self-Efficacy Survey was used to assess the self-efficacy of both the ECMO specialists and the bedside nurses before implementation of the program. An ECMO manual was created that contained education on veno-arterial and veno-venous ECMO, policies and procedures, and patient management guidelines. An EPIC order set was created to ensure the correct protocols and management guidelines were ordered for all ECMO patients. Postimplementation self-efficacy surveys, direct observations, and chart audits occurred to assess program fidelity.

RESULTS

The self-efficacy was assessed of the ECMO specialists and beside nurses 4 months after implementation of policies, procedures, patient management guidelines, and an ECMO order set. The ECMO specialists' self-efficacy survey responses increased by 25% and the bedside nurses' self-efficacy survey responses increased by 27% after 4 months. Direct observation of ECMO specialist handoff to ensure protocol fidelity also occurred. There was a 40% increase in ECMO specialist handoff taking place and a 72% increase in ECMO circuit examination.

CONCLUSIONS

With the significant growth of ECMO patients, policies, protocols, and management guidelines are essential to provide safe care to these patients. There was a statistically significant improvement in the self-efficacy of both the ECMO specialists and bedside nurses. This was shown to directly correlate to an improvement in professional practice behaviors and ultimately improve the quality of patient care provided to ECMO patients.