Maintaining quality outcomes with a rapidly growing ECMO program [Meeting Abstract]
Introduction: Our institution's Adult ECMO Program started in 2015 and continues to see exponential growth with an average of 89% annual increase in volume. When demand for ECMO exceeds available resources, the multiple teams, resources and processes involved in the care of these patients are challenged to provide excellent outcomes. Our program made specific changes to accommodate increased volume while maintaining quality. Our growth directly impacted staff exposure and expertise, locations of ECMO care, emergent bedside cannulations, and utilization of equipment and supplies.
Result(s): Our team coordinated comprehensive training courses to increase the number of ECMO-credentialed physicians and advanced practice providers. We then focused on improving bedside cannulations. We provided cannulation didactic and simulation training for a cohort of critical care nurses, created a single ECMO Perfusion activation number, and increased available primed circuits. We also rebuilt our cannulation carts, using an exchange process for immediate replenishment of supplies. All carts were streamlined to one lay out and were expanded across the hospital in five different locations. We increased our equipment inventory from 9 to 15 consoles and introduced a more cost-effective ECMO system. Last, we implemented ECMO safety rounds, a biweekly bedside audit of existing safety measures that also allowed for real-time staff education.
Conclusion(s): Our patient outcomes continue to meet the national ELSO benchmarks for survival rates. As our growth continues, all areas require ongoing assessment and evaluation to maintain best practices. With proper planning and resources, quality patient outcomes can be maintained
Creating a cohort of nursing experts to assist in emergent bedside cannulations [Meeting Abstract]
INTRO: Our Adult ECMO Program cannulates most of our patients in the operating room (OR). However, in the past year, our bedside cannulation volume increased from 13 to 27 across six inpatient units. Because we expect cannulations outside of the OR to increase, the Adult Langone Emergency Response Team (ALERT) nurses were identified as the ideal providers to assist in bedside cannulations.
METHOD(S): Our ECMO Team developed a cannulation program to meet the educational needs of the 20 ALERT nurses. The ECMO Directors and Coordinator held a two hour didactic course, reviewing cannulation procedures, ECMO configurations and nursing roles in a bedside cannulation. We distributed pre & post self-assessments to evaluate the nurses' confidence levels. The ECMO Team then invited ALERT nurses to observe planned cannulations, providing an ideal setting for learning and reflection of the cannulation process. ALERT nurses identified areas for improvement that could aid in emergent initiation of ECMO outside of the OR. The program concluded with a one hour simulation session that provided an opportunity for both teams to clarify expectations of future cannulations.
RESULT(S): Using the Wilcoxon Signed-rank test, we found a statistically significant improvement in pre & post self-assessment scores (p-value <0.001). Direct feedback from ALERT nurses included further clarification for ECMO team activation process, terminology of surgical supplies and additional resources needed to support a bedside cannulation. The program allowed for both teams to strengthen their collaboration that will ultimately result in improved workflow, communication and patient outcomes
Respiratory care in familial dysautonomia: Systematic review and expert consensus recommendations
BACKGROUND:Familial dysautonomia (Riley-Day syndrome, hereditary sensory autonomic neuropathy type-III) is a rare genetic disease caused by impaired development of sensory and afferent autonomic nerves. As a consequence, patients develop neurogenic dysphagia with frequent aspiration, chronic lung disease, and chemoreflex failure leading to severe sleep disordered breathing. The purpose of these guidelines is to provide recommendations for the diagnosis and treatment of respiratory disorders in familial dysautonomia. METHODS:We performed a systematic review to summarize the evidence related to our questions. When evidence was not sufficient, we used data from the New York University Familial Dysautonomia Patient Registry, a database containing ongoing prospective comprehensive clinical data from 670 cases. The evidence was summarized and discussed by a multidisciplinary panel of experts. Evidence-based and expert recommendations were then formulated, written, and graded using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. RESULTS:Recommendations were formulated for or against specific diagnostic tests and clinical interventions. Diagnostic tests reviewed included radiological evaluation, dysphagia evaluation, gastroesophageal evaluation, bronchoscopy and bronchoalveolar lavage, pulmonary function tests, laryngoscopy and polysomnography. Clinical interventions and therapies reviewed included prevention and management of aspiration, airway mucus clearance and chest physical therapy, viral respiratory infections, precautions during high altitude or air-flight travel, non-invasive ventilation during sleep, antibiotic therapy, steroid therapy, oxygen therapy, gastrostomy tube placement, Nissen fundoplication surgery, scoliosis surgery, tracheostomy and lung lobectomy. CONCLUSIONS:Expert recommendations for the diagnosis and management of respiratory disease in patients with familial dysautonomia are provided. Frequent reassessment and updating will be needed.