ECMO networks
The decision to use ECMO in COVID-19 patients relates not only to the
expected benefit of therapy and possible risks, but also to the
availability of ECMO supplies and hospital infrastructure, and personal
and group experience. These last two points are essential when
establishing joint strategies and guaranteeing an adequate organization
of personnel, equipment, facilities, and systems. As with any scarce
resource in times of high demand, mismatches may appear in these
factors, and it is preferable to anticipate with an action plan that
develops a sustainable system to ensure quality of care.
In Spain, in the pre-COVID era, there was no uniform organization for
ECMO care. In some regions (Valencia, Catalonia, or Eastern Andalusia,
for example), there were well-defined programs, with clear action
coordinates for referring patients to ECMO centers, and even with
availability for remote implants and inter-hospital transport. However,
in other areas, each hospital that had the therapy offered it openly to
its secondary and regional reference hospitals in an unorganized way and
without defined patient flows. The same peripheral hospital could send
some cases to its referral hospital for cardiac surgery (and ECMO
therapy) and send other cases to any of the tertiary hospitals in its
environment, without any administrative interference and by simple
decision of the treating doctor.
The arrival of the pandemic, with the sudden increase in the need for
intensive care beds and extracorporeal respiratory support, meant that a
well-defined referral and transfer system needed to be organized from
each regional Health Administration to provide access to the specialized
care needs of the patients of all the first- and second-tier hospitals.
ECMO Reference Hospitals were designated and their satellite hospitals
were specified.
This has planted the seed for an ECMO Network system on a hub & spoke
model which, while not yet fully developed in all areas, seems to
perfectly fit the needs of the new organization and could be
consolidated in the future for all ECMO care nationwide.
Resources:
Training in ECMO must be ensured for all members of the group to be able
to act as reinforcement or replacement in case of illness of the
professionals initially assigned to the ECMO pandemic team.
It is mandatory to periodically update the inventory of available
machines ready for use and to forecast the needs so as to ensure a
constant supply of consumables.
Contact between hospitals:
The success of ECMO therapy is based, among other factors, on an early
implantation when the clinical indication is clear, and this involves
not deferring the decision when the previous therapeutic steps have not
yielded the expected result. In a pandemic situation, this is especially
relevant and therefore there must be frequent communication between the
satellite hospital and the ECMO hospital, assessing the evolution of the
most seriously ill patients and anticipating situations of sudden
deterioration (not infrequent in critically ill COVID-19 patients) in
which the ECMO option is possibly already too late. If the speed of
progression of the disease from dyspnea to ARDS is rapid or unknown, we
recommend early transfer (after tracheal intubation, for example) to an
ECMO center, wherever possible.
This fact is considered critical in the technical document of the
Ministry of Health, and for this reason it explicitly states that ”in
the event that the center does not have the technique, transfer to a
reference center must be considered” and that ”there must be early
contact between centers”, according to clinical and analytical criteria
summarized in Table 1.
Inter-hospital transport:
In our country there are mobile programs for ECMO implantation and
inter-hospital transport of assisted patients (La Fe Hospital in
Valencia, Bellvitge Hospital in Hospitalet de Llobregat-Barcelona,
Virgen de las Nieves Hospital in Granada, among others) that offer
appropriate service to their reference area, but they are a minority in
Spain and otherwise, there are only isolated experiences with remote
implants both in adults and in pediatric patients (Hospital 12 de
Octubre in Madrid).
The hasty reorganization of ECMO assistance necessitated by the pandemic
is a good starting point to try to expand such initiatives and establish
a well-organized network of remote ECMO assistance with all its
possibilities. It seems clear that high-volume ECMO centers,
particularly those serving as a regional benchmark, should establish and
coordinate mobile ECMO teams available 24 hours a day, 7 days a week,
and made up of personnel trained and experienced in transporting
critically ill patients and inserting cannulas.
Among the basic principles on which the constitution of these mobile
ECMO teams should be based, in the context of a pandemic, we can point
out15:
- Design eligibility criteria for transfer between hospitals and share
them with the satellite centers.
- Ensure effective communication and coordination at all times to
shorten response times or to explain to the responsible physicians the
refusal to transfer a patient.
- Identify and promptly address the rate-limiting steps of the process.
- Strict adherence to infection control protocols during patient
transport, with immediate disinfection of the entire circuit and
transport vehicles, to prevent and reduce the risk of cross
contamination.