This document discusses coordinating an extracorporeal membrane oxygenation (ECMO) service with patient retrieval. It compares the ECMO models in Australia and New Zealand, with New Zealand having a single national ECMO service based in Auckland that provides retrieval services across the country. Maintaining adequate caseload volume is important for outcomes, and a national/regional centralized model can help with this by concentrating experience. Successfully managing competing demands and indication creep is also discussed.

1. Coordinating an ECMO Service with
Retrieval
Dr Shay McGuinness
Specialist & Director of Research
Cardiothoracic & Vascular ICU
Auckland City Hospital
New Zealand

2. Disclosures
• No relevant disclosures

3. Australia vs. New Zealand

4. Australia vs. New Zealand

5. Australia vs. New Zealand

6. Australia vs. New Zealand
• 24.7 million people
• 3% are indigenous
• 75 million sheep
• 4.7 million people
• 15% are indigenous
• 27.6 million sheep

7. Australia vs. New Zealand
• 24.7 million people
• 3% are indigenous
• 75 million sheep
• 4.7 million people
• 15% are indigenous
• 27.6 million sheep
5:1
3:1
1:5

8. Australia vs. New Zealand
Bledisloe Cup wins since 2002

9. Australia vs. New Zealand
1
Bledisloe Cup wins since 2002

10. Australia vs. New Zealand
1 All of the rest
Bledisloe Cup wins since 2002
1:15

11. Australia vs. New Zealand
1 All of the rest
Bledisloe Cup wins since 2002
1:15

12. Australia vs. New Zealand
1 All of the rest
Bledisloe Cup wins since 2002
1:15

13. What about ECMO?

14. What about ECMO in 2018?
• Australia
– 31 ECMO centres (at least)
– 1 per 800,000 people
• ? 300-350 patients p.a.
– Average 9-11 patients/site/year
– Many sites are probably <3/year

15. What about ECMO?
• Australia
– 31 ECMO centres (at least)
– 1 per 800,000 people
• ? 250-300 patients p.a.
– Average 8-10 patients/site
• New Zealand
– Single national service
• Around 45-50 patients p.a.
– 10-15 retrievals
Two very different models
How did this happen?

16. In NZ…
• First ECMO done in 1993 at Greenlane Hospital.
• Sporadic cases over the following few years – both adults and
children/neonates
• Move to the new Auckland City Hospital in 2002 saw ECMO at
two ICUs (CVICU and PICU) – “single service, two sites”

17. In NZ…
In 2005 discussion amongst the 5 tertiary (cardiac) centres about
developing a national ECMO service;
• The other 4 centres had tried ECMO on the occasional patients
• Results mixed
• Requirement for capital investment in new equipment
• Recognition that ECMO had a learning curve and a maintenance of skills
requirement

18. In NZ…
Agreement from everyone to stop using ECMO as long as Auckland
provided a comprehensive retrieval service:
• Aim was to have the capacity to place patients (adult/paeds/neonates)
on VA or VV ECMO at any hospital in NZ and transfer them safely back to
Auckland.
• A response time of <6hrs (from accepting case to commencing ECMO)
– Equity of access was an important consideration

19. In NZ…
Agreement from everyone to stop using ECMO as long as Auckland
provided a comprehensive retrieval service:
• Aim was to have the capacity to place patients (adult/paeds/neonates) on
VA or VV ECMO at any hospital in NZ and transfer them safely back to
Auckland.
• A response time of <6hrs (from accepting case to commencing ECMO)
– Equity of access was an important consideration
The NZ National ECMO Service commenced in
September 2005

20. In Australia…
• First ECMO in 1990
• ECMO was available in around 15 hospitals in 2004
• Patient numbers were very low
Hastings CCR 2008
• Mostly used following cardiac surgery
• No transport capability until 2007

21. 2009

22. 2009
Lancet 2009

23. 2009
Lancet 2009

24. 2009
Lancet 2009
Davies et al. JAMA Nov 2009

25. Since 2009…
Australia:
• Rapid increase in ECMO use and
centres
• Establishment of better retrieval
capability
• Mostly organised on a state level

26. Since 2009…
Australia:
• Rapid increase in ECMO use and
centres
• Establishment of better retrieval
capability
• Mostly organised at a state level
NZ:
• Steady increase in numbers
• Recognition as a national
service by the MoH
– ?Funding to follow
• No strong desire from
other ICUs to have a service
(Although some interest in having the capacity
to initiate ECMO in emergency situations)

27. Since 2009…
NZ:
• Steady increase in numbers
• Recognition as a national
service by the MoH
– ?Funding to follow
• No strong desire from
other ICUs to have a service
(Although some interest in having the capacity
to initiate ECMO in emergency situations)
0
10
20
30
40
50
60
201720162015201420132012201120102009200820072006200520042003200220012000
NZ ECMO Sevice
Adults Paeds Total

28. National/Regional vs. Widespread

29. National/Regional vs. Widespread
Advantages:
• Concentrates experience
• Equipment and consumable savings
• Critical mass for the “add-ons”
– Research
– QI/Governance
Disadvantages:
• Travel for families
• Loss to follow-up
• Requires retrieval service

30. National/Regional vs. Widespread
Advantages:
• Concentrates experience
• Equipment and consumable savings
• Critical mass for the “add-ons”
– Research
– QI/Governance
Disadvantages:
• Travel for families
• Loss to follow-up
• Requires retrieval service
Advantages:
• Keeps patients/family close to home
• Less delay in initiation
• Maybe better surge capacity for
pandemics
• Maybe better equity of access
Disadvantages:
• Very real potential for loss of currency:
– Both at sites and for retrieval teams
– Particularly for “unusual” indications

31. Why does “adequate volume” matter?
• Most of us recognise that ECMO has a significant learning
curve:
• Lots of focus on the technical aspects
– Cannulation
– Circuit Emergencies
• Less focus on generic patient management
– Ventilation strategies
– weaning
• Little focus on “Institutional Knowledge”
– When to start
– When to stop – Either for success or for failure

32. AJRCCM April 2015
• Data from ELSO registry between 1989 and
2013

33. AJRCCM April 2015

34. What is Adequate Volume?

35. What is Adequate Volume?
AJRCCM Sept 2014

36. What is Adequate Volume?
Suggests that:
• 20 ECLS cases including 12 for ARF
– Incidence (normally) of perhaps 5-10/million/year
– Suggests one centre/2-3 million
• Also recognises that accumulated knowledge
is an important component

37. What is Adequate Volume?
ICM Feb 2018

38. • Minimum of 30 ECLS cases with a “substantial
proportion” being for cardiac support

40. APELSO Data

41. APELSO Data
No change in outcomes over this period:
• Adult respiratory survival around 55%
• Adult cardiac survival around 45%

42. Features and Benefits of a Centralised ECMO
Service
• Service design – leadership, staffing, training including
reaccreditation
• Research and Quality Improvement
• Managing indication creep
• Managing competing demands on resources

43. Indication Creep
• Why is this bad?
– Financial cost
– Opportunity cost e.g. decreased throughput of surgical patients
– Loss of staff motivation
– Loss of support of external colleagues and departments
– Loss of support from managers/funders (or increased opposition)

44. Managing Indication Creep
How can you achieve this?
• Have published guidelines for “who/when to go on”
• Try to get a consensus agreement for borderline cases
• Formal reviews of ECMO outcomes

45. Managing Competing Demands on Resources
• Important because ECMO is high profile and can often become
the scapegoat for unrelated system failings.
• “Disrupting our core business”
– Particularly when accepting “someone else's” patients

46. Managing Competing Demands on Resources
The best approach is:
• Have established indications
• Data is the key;
– Clinical data on outcomes
• Relative to other centres
– Robust data on cost of the service
– Data to counter claims of “opportunity costs”

47. External Relationships
• Establishing ICU/ECMO Networks
– Provide referral guidelines and tools

50. External Relationships
• Establishing ICU/ECMO Networks
– Provide detailed feedback on patient progress
– Follow-up on patients who were declined

51. External Relationships
• Take every opportunity to promote the service and feedback
outcomes
• Try and get agreement for a repatriation policy - if not formally
then at least an “in principle” agreement

52. Transport ECMO

53. Transport ECMO
• It is a cornerstone of being a regional/national centre
• It is not an “afterthought”
– Requires training/resources and commitment

54. Transport ECMO
Overarching principle:
“The risk of transferring the patients should be less than the risk
of them remaining in the referring ICU”

55. Transport ECMO
Secondary principle:
“The additional risks of being transferred on ECMO should be
recognised and minimised as much as possible”

56. Establishing an ECMO Retrieval Service
• Personnel
• Equipment
• Aircraft, Ambulances and Certification

57. Personnel
• Transport team make up varies widely
– Intensivists
– Anaesthetists
– Cardiac Surgeons
– Perfusionists
– ECMO nurses
– Flight nurses
• 2-7 (or more)

59. Personnel
• Team make up should be task and skill based;
– Clinical assessment of the patient
• Requirement/appropriateness/risk-benefit of ECMO
• Alternative strategies
– Establishment of ECMO
• Circuit set-up
• Cannulation (Including positioning – Ultrasound/TOE)
• Management of patient on ECMO
– Transport of the critically ill
• Aviation physiology
• Power/gas supplies in aircraft/ambulances

60. What do we do in NZ?
• Standard team is 4 (sometimes 3)
– Two Intensivists
• Patient assessment
• Cannulation/imaging
• Patient management
– Perfusionist
• Circuit
– Flight nurse
• Aircraft issues – power/gas/communication
• Patient management

61. Equipment
Key points:
1. Power supplies
2. Gas supplies
3. Protect the “vital organs”
– Oxygenator
– Pumphead
4. Structural integrity/security
5. Be self-sufficient

62. How not to do it?!

68. Aircraft, Ambulances and Certification
• Change in focus by NZCAA (and others);
– Previously medical equipment classified as “carry on baggage”
• Secured to the satisfaction of the PIC
• Now classified as part of the aircraft
– Very strict structural standards
• FAR 25.561 (aeroplanes) FAR 27.561 (Helicopters)
• Require 20G downwards and 16 G Forwards restraint for newer models of
aircraft
– Also EMI, Flammability, Electrical load

75. Are ECMO Transports Safe?
• Several published case series and case reports
– Occasional problems with
• Bleeding
• Oxygen supplies
• Power
– Adverse patient outcomes are rare

76. Top Tips for Managing a Major ECMO
Programme
Reputation is everything
1. Clinical outcomes obviously important.
2. Interacting with colleagues at referring sites
• Providing support
– Retrieval service
• Feedback on outcomes
3. Maintaining the support and enthusiasm of your own staff,
colleagues and managers.

77. Summary
• There appears to be an association between caseload and
outcomes for ECMO centres
• Transport of patients on ECMO is generally safe and feasible
Too many centres in Australia?

78. Coordinating an ECMO Service with
Retrieval
Dr Shay McGuinness
Specialist & Director of Research
Cardiothoracic & Vascular ICU
Auckland City Hospital
New Zealand