Write a manuscript following the ECMO outline attached and Literature identification worksheet attached. . 1500 words maximum. references included in the attachment in PDF.Tentative title: ECMO In The age of COVID and Why We Need an Interdisciplinary
Approach to Mitigating Ethical Dilemmas.

Concise statement of manuscript’s purpose:
At the fore front of COVID treatment in the critically ill, it remains a major
source for ethical dilemma amongst critical care nurses. This manuscript will
focus on multiple ethical battles engaged in delivering high cost, high technology
driven critical care and their impact on the nursing profession.

Intended audience (who you will be writing to):
physicians and critical care nurses, clergy, ethics committees.
As the Corona virus continue to lay waist across our lands disproportionately
affecting the disenfranchised we have found hope in the modern technology and
in those whom wield their power. With advances in healthcare also come
uncharted ethical dilemmas such as unilateral approaches to saving lives,
implantation of cost reductions to make it more affordable/profitable, and burnout
and stress amongst healthcare providers.
1. Ethical dilemma #1:
a. unilateral approaches to saving lives)→ ECMO is pushed a liable option however
the survival rate may remain low with futile outcome.
b. Physicians overselling ECMO → more experience under their belt/to be ECMO
c. Limited ECMO machines, who gets to decide who gets cannulated for ECMO?
2. Ethical Dilemma #2: Ethic and palliative care evolvement in ECMO discussions and
goals of care.
i. How should the initiation and withdrawal decision be made?
1. How long should they stay on ECMO?
2. Indications for withdrawing
3. Should we include do not ecmo in advance directive? And consider
it a new code status?
3. Ethical dilemma #3:
a. Ethical dilemma regarding sufficient ECMO RN training comparing to
perfusionists: In one local hospital, 3 days of didactic and 4 bedside orientation
shifts allows the most mediocre RN to be considered a proficient ECMO
specialist. Although highly skilled, nurses lack the foundational education and
clinical hours to master the complexities of ECMO in a dying patient. In other
hospitals, the RNs may stabilize the patient until out of the house perfusionist
arrives, but the instate that that patient is getting a highly skilled and highly
educated provider whose sole focus is on one patient. When you assume the risk
of adding more ECMO nurses to reduce the cost of having more perfusionist, you
unfortunately diminish the care for these patients at the most critical time.
b. Criteria to be ECMO nurse? How many years of experience and how is it decided
who becomes an ECMO nurse?
4. Ethical Dilemma #3:
a. ECMO RN- patient ratio: No specific protocol in place. At a local hospital, the
nurse run ECMO program started in 2018 with a 2:1 ratio (1 ECMO nurse and
one primary nurse for 1 patient). Due to ECMO nurse shortage and nurses’
shortage, the required ECMO: patient ratio changed to 1:1. In the recent months
and with increase COVID patients needing for ECMO, increase burnout amongst
ICU nurses, the leadership team are implementing a new requirement of 1 ECMO
nurse overseeing 3 patients. We have begun to take the junior ICU primary nurses
and expanding their duties to take responsibility of managing some of the ECMO
operations based off of a two hour “Primary ECMO RN Education” didactic
5. Burnout and moral distress of ECMO RN:
a. With the increase responsibility, no incentive, increase workload and minimal
training, the intensive care unit is facing a great moral distress amongst nurses.
Personal incentive for the RN responsibility rises but compensation remains
stagnate. No incentive to excel at this other than moral to do more.
6. Recommendations:
a. Need additional studies for safe ECMO to patient ratio, goal of care discussion
and involvement of palliative care and ethics committee. Setting realistic goals
and plan of care with caregivers.
7. Conclusion:
8. Reference List:
** This is a newer topic and I was unable to find many lit articles regarding
ECMO:patient ratio. If you guys have any ideas, recommendations, or have witnessed
other dilemmas in ECMO centers, I’ll appreciate the insight.
Literature Identification Worksheet
Title: ECMO In The age of COVID and Why We Need an Interdisciplinary Approach to Mitigating Ethical Dilemmas.

manuscript’s purpose:
At the fore front of COVID treatment in the critically ill, it remains a major source for ethical dilemma amongst critical
care nurses. This manuscript will focus on multiple ethical battles engaged in delivering high cost, high technology
driven critical care and their impact on the nursing profession.
Ethical Dilemmas covered: ECMO goals of care decision, withdrawal of care for ECMO patients, how long do they
remain on ECMO? who decides it? Underutilization of palliative care and ethic committee, and safe RN ECMO
specialists staffing ratios.
Type of article (e.g.,
research, clinical
guidelines, case study,
quality rating)
Clinical Guidelines
Methods (Who? What? Where? How? Key findings or info that would be
[especially note sample and research
important to present in my manuscript
design, and nature of intervention if it
is relevant to you])
1- Use to cite and explanation the
– ELSO is Extracorporeal Life
current process to train ECMO nurse
Support Organization: It
specialists continuing education
provides support to institutions
delivering extracorporeal life
2- Use to site the ELSO
support through continuing
recommendation for stopping
education, guidelines
ECMO for futility.
development, original
research, publications and
maintenance of a
comprehensive registry of
patient data.
Shekar et al.
Clinical guidelines

A document that presents
recommendations that have
been put together by a team of
interdisciplinary ECMO
providers from around the
world. Recommendations are
based on available evidence,
existing best practice
guidelines, ethical principles,
and expert opinion
1- Recommends maintain a 1:1 patient
nurse ratio when on ECMO. 2:1
when capacity is at contingency Tier
2 and crises levels.
2- Redeployment of perfusionist to
bedside ECMO (not having primary
RN learn basic ECMO skills in a
two-hour class!)
3- Indication and contraindication for
ECMO in adult COVID.. are
hospitals following the guidelines
and not cannulating people >65
years old? No!
4- Consent should explicitly involve
discontinuation of ECMO care in the
absence of recovery of lungs, heart
or both WITHIN AN
5- Ethical issues “Patient selection and
timing of discontinuation of ECMO
support pose significant ethical and
moral challenges in regular ECMO
care, but especially so during a
pandemic. ECMO centers should
develop predetermined “consensus
criteria” encompassing all aspects of
ECMO care in COVID-19 patients”
6- Recommendation for ethics and
palliative care team before
cannulation and throughout the
ECMO course.
Lucchini et al.,

Retrospective observational
study. Data from nursing
activity score (NAS) were
collected for seventy-two
– Use to support staffing issues:
“Our findings suggest that in ECMO
patients a nurse-to-patient ratio equal to 1:1,
should be guaranteed in accordance to the

consecutive months from
January 2010.
Total of 2606 patients
enrolled. ECMO patients
enrolled 95 (4%) with 3141
ECMO days.
ECMO patients NAS median
= 87.0
Non ECMO pts median NAS
= 67.2
national health regulations and
Note: pronig pts, hourly I/Os, number of
of ECMO sites/bleeding risks/assessment all
affect workload.
*study approved by ethics committee
*used NAS tool to measure workload
and SPSS to analyze the data
**Limitation: “This is a retrospective
single-centre study. Conclusions may
have some bias related to the
individual centre.”
C., and Alfeeli,
A., (2020)
Abrams et al.,
Research/ qualitative

International survey scenario-based survey.
Qualitative descriptive
Interviewed 19 nurses working
in Kuwait.
**Critique: very small sample size
and location of study.
– Electronic, cross-sectional,
scenario-based survey.

Nurses reported encountering
significant challenges including
heavy workload. And better
interdisciplinary communication.

Only 29.5% involved bedside nurses
in treatment decisions for ECMO

539 physicians in 39 countries
completed the survey.
This study is the first to
characterize the ethical
attitudes and opinions of 539
physicians across 39 countries
and six conti- nents who have
experience managing adult
patients receiving venovenous

Less than 30% always or very often
involve nurses in ECMO decision
Only half of all respondents agreed
that ethics consultation is important
when making difficult decisions
regarding withdrawal of lifesustaining therapies,
Only two-thirds of respondents
reported that they very often or
always discuss the possibility of
ECMO with- drawal in case of
futility with the patient or surrogate
Gannon et al.,

To evaluate a critical care
nurse ECMO cur- riculum
that may be reproducible
across institutions.
301 ICU nurses new to
Limitation to ECMO teaching curriculum in
their study:
“Our study has some limitations. The
curriculum was the only means of teaching
that we measured, limiting the ability to
compare the effect of this teach- ing method
with others. When comparing written
knowledge examination scores between
groups, we did not adjust for any potential
confounders, such as personal history of
ECMO experience outside our institution,
duration of nursing experience, or duration of
ICU experience. We examined no patient or
clinical measures. Therefore, we are unable to
demonstrate whether this curriculum has any
association with improved quality of patient
care or clinical out- comes. Finally, pre
course and post course examination questions
were the same and were not validated”
Courtwright et
al., 2016
descriptive study

retrospective, descriptive
cohort study of all ECMO
ethics consultation cases in
the CSICU at a large
academic hospital between
2013 and 2015.
113 pts placed on ECMO.

113 pts placed on ECMO. 45 seen by
the ethics committee
initial consultation occurred two days
after initiating ECMO.
The most common ethical issue
involved disagreement about the
ongoing use of ECMO, which
included multiple axes: Disagreement
among health care providers,
disagreement among surrogates, and
disagreement between health care
providers and surrogates over
stopping or continuing ECMO
“ECMO was typically initiated in a
time-sensitive manner, leaving little
room for a sustained conversation
about “stopping conditions” or
acceptable duration of a time-limited
trial from the patient’s perspective.
Early clarification, however, about
acceptable functional outcomes
following ECMO may be helpful in
contextualizing later changes in the
patient’s clinical trajectory”
the majority of consults came from
a member of the nursing staff. As
other authors have suggested,
however, the burdens of providing
interventions believed to be

nonbeneficial fall more heavily on
“bedside” health professionals such
as nurses”
In cases in which clinicians and ethics
consultants recommended
withdrawing ECMO despite surrogate
demands, the consultants were able to
rely on a broader institutional policy
about limiting or not offering
nonbeneficial treatment despite
surrogate requests (13). Although the
policy was not formally invoked in
any case, ethics consultants noted the
availability of the policy in several
cases if consensus could not be
reached. Having a policy for clinicianguided limitation of life-sustaining
treatment in combination with setting
clear expectations may have helped
avoid cases of intractable conflict as
some authors have described”
Abrams et al.,
With the Use
Case studies
Describing different cases and the
ethical dilemma in each case
-DNR with ECMO order? Do not ECMO?
– Awake pt on ECMO with no chance of
recovery. “bridge to nowhere”
– What If pt is awake and refuses to stop
in Adults
Daly, K. &
Camporota, L.
& Barrett, N.
Cross sectional study

Cross sectional international
Electronic questionnaire sent
to 177 worldwide centers with
82% response rate.
Aim was to identify ECMO
staffing arrangements

Centers using 1:1 staffing ratio.
65% uses 1:1 nurse:pt ratio, 14% used
1:2 ratio. 6% used 1:3 ratio and 1%
used 1:4 ratio.
The “ELSO Guidelines for Training and Continuing Education of ECMO Specialists” is a
document developed by the Extracorporeal Life Support Organization (ELSO) as a
reference for current and future ECMO centers. It is to be used as a guideline for
designing training and education programs for ECMO specialists. It is assumed that each
ECMO center must develop their institution specific guidelines and policies for training
ECMO Specialists, which may vary. In the development of these documents and
programs, ECMO Directors and Coordinators must take into account their institution’s
requirements for in-house training programs, and must have policies and procedures
reviewed by appropriate hospital committees. Please note that institutional and personnel
requirements for ECMO programs are addressed in the ELSO document, “Guidelines for
ECMO Centers”, and will not be discussed in this document.
ELSO Guidelines for Training and Continuing Education of ECMO Specialists
Version 1.5
February 2010
Page 1
The term “ECMO Specialist” is defined for the purpose of these guidelines as “the
technical specialist trained to manage the ECMO system and the clinical needs of the
patient on ECMO under the direction and supervision of a licensed ECMO trained
physician. The individual functioning as the ECMO Specialist should have a strong
critical care background in neonatal, pediatric and/or adult critical care and have attained
one of the following:
1. Successful completion of an approved school of nursing and achievement of a
passing score on the state written exam given by the Board of Nursing for that
2. Successful completion of an accredited school of respiratory therapy and have
successfully completed the registry examination for advanced level practitioners
and be recognized as a Registered Respiratory Therapist (RRT) by the National
Board of Respiratory Care (NBRC).
3. Successful completion of an accredited school of perfusion and national
certification through the American Board of Cardiovascular Perfusion (ABCP).
4. Physicians trained in ECMO who have successfully completed institutional
training requirements for the clinical specialists.
5. Other medical personnel such as biomedical engineers or technicians who
received specific ECMO training and have practiced as an ECMO specialist since
the initiation of their programs, and who have completed equivalent training in
ECMO management as the other specialists, have successfully documented
necessary skills as an ECMO specialist, and who have been approved specifically
as an ECMO specialist by the medical director. These personnel can be approved
institutionally as an ECMO specialist under the “grandfather” principle. However
ELSO does not encourage or support the new training of individuals except as
outlined in 1-4 above.
Training of the ECMO will be divided into two parts. Training for new ECMO
programs (centers which have not treated patients) will be covered separately
from training for experienced ECMO programs (centers which have been in
ongoing operation and are training new ECMO specialists).
ELSO Guidelines for Training and Continuing Education of ECMO Specialists
Version 1.5
February 2010
Page 2
Didactic Course: The didactic course should include, but not be limited to the
following topics. Between 24 to 36 hours will be required to cover the following
material. Case presentations are encouraged.
Topics could include, but are not limited to the following:
Introduction to ECMO:
Current status
Risks and benefits
Membrane gas exchange physics and physiology
Oxygen content, delivery and consumption
Shunt physiology
Types of ECMO
Future applications
Physiology of the diseases treated with ECMO:
Persistent Pulmonary Hypertension
Meconium Aspiration Syndrome
Respiratory Distress Syndrome
Congenital Diaphragmatic Hernia
Post-operative congenital heart disease/heart transplantation
Aspiration pneumonia
Pulmonary embolism
Pre ECMO Procedures:
Notification of the ECMO Team
Cannulation procedure
Initiation of bypass
Responsibility of team members
Criteria and contraindications for ECMO including:
Patient Selection
Selection criteria
Pre-ECMO evaluation
ELSO Guidelines for Training and Continuing Education of ECMO Specialists
Version 1.5
February 2010
Page 3
Physiology of coagulation including:
Coagulation cascade
Activated clotting times (ACT’s)
Disseminated intravascular coagulation
Blood products and interactions
Blood product management of the bleeding patient
Blood surface interactions
Laboratory tests
Heparin pharmacology
Use of Amicar, Protamine and other drugs
ECMO equipment including:
Circuit priming
Oxygenator function and blood gas control
ECMO circuit design
ECMO circuit components (cannula, pump, venous return monitor, in-line
saturation monitor, pressure monitor, heater, hemofilter, bubble detector)
Physiology of Venoarterial and Venovenous ECMO:
Daily Patient and Circuit management on ECMO including:
Fluid, electrolytes and nutrition
Infection control
Sedation and pain control
Aseptic technique
Pump/gas flow
Pressure monitoring
Blood product infusion techniques
Circuit infusions
Management of anticoagulation
Circuit checks
Hemofiltrations set-up
Bedside care of the ECMO patient
ELSO Guidelines for Training and Continuing Education of ECMO Specialists
Version 1.5
February 2010
Page 4
Emergencies and complications during ECMO:
Intracranial and other hemorrhage
Cardiac Arrest
Severe coagulopathy
Uncontrolled bleeding
Circuit disruption
Raceway rupture
System or component alarm/failure (pump, bladder, venous return
monitor, oxygenator, heater)
Air embolus
Inadvertent decannulation
Management of complex ECMO cases:
Surgery on ECMO
-post-operative bleeding
Transport on ECMO (inter and intra-hospital)
Weaning from ECMO (techniques and complications):
Clinical indications of pulmonary/cardiac recovery
Pump/gas flow weaning techniques
ACT changes during weaning
Ventilatory changes during weaning
Trial off/decannulation from low flow
Decannulation procedures:
Personnel needed
Medications required
Potential complications
Vessel ligation
Vessel reconstruction
Percutaneous approach
Post ECMO complications:
Platelet and electrolyte alterations
ELSO Guidelines for Training and Continuing Education of ECMO Specialists
Version 1.5
February 2010
Page 5
Short and long-term developmental outcome of ECMO patients:
Institutional follow-up protocol
Literature review
Ethical and social issues:
Consent process
Parental and family support
Withdrawal of ECMO support
Water-drills: These sessions should be small enough so that each individual has
hands-on experience. A full understanding of all possible circuit emergencies and
the appropriate intervention should be accomplished by the end of this session.
Each trainee should be able to describe and conceptually demonstrate how to
change the major equipment (oxygenator, heat exchange, bladder) in a reasonable
period of time. They should be able to change less complicated components of
the circuit (raceway, pigtails, and checking pump head occlusion on ECMO) in a
pre-established period of time.
Basic Session should include a discussion and demonstration of the equipment
Review of Circuit configuration and function
Access and sample ports to the circuit
“The basic circuit check’
Basic troubleshooting
Pigtail and stopcock changes
Emergency Session, should include training in the management of:
Raceway ruptures
Heat exchanger, bladder, membrane lung changes (assist with procedure only)
Venous/arterial air
Pump head occlusion checks
Power failure
Inadvertent decannulation
Animal Laboratory Sessions: As bedside training sessions are not possible in a
new ECMO center, more extensive laboratory training is required compared to an
experienced center.
The species of animal and the duration of the ECMO training run will vary
depending on the institution’s ability to supply long-term support of animals
during these sessions. ECMO centers typically have used newborn lambs,
adult sheep or piglets. It is recommended that animal labs be conducted for a
continuing 24-72 hour period to decrease the number of animals needed for
ELSO Guidelines for Training and Continuing Education of ECMO Specialists
Version 1.5
February 2010
Page 6
these sessions and to simulate around the clock management of the ECMO
Trainees should be divided into small teams with the instructor for four to
eight hour sessions.
Sessions should include a review of the circuit and the access and sampling
ports and the trainees should practice such tasks such as blood product
administration, IV solution administration, medication administration and
blood gas, ACT, and laboratory sampling. The use of documentation such as
the flowsheet, physician and standing orders should be incorporated used
during this session.
Each specialist should be able to manage the patient on ECMO while the
parameters (ACT, PaO2, and Post PCO2) are altered. It is recommended that
this session should last 8-12 hours.
A session, lasting 4-8 hours, should focus on emergencies including:
Cracked pigtails and connectors
Leaking stopcocks
Raceway rupture
Membrane oxygenator failure
Air in the circuit
Loss of venous return
Inadvertent decannulation
Pump stop scenarios and handcranking
Power failure
For new centers these sessions should be repeated until all team members gain
a solid understanding of the management of the ECMO system and are fully
competent managing simulated ECMO emergencies. After initial sessions,
most centers require one – two additional eight-hour sessions per specialist.
ELSO Guidelines for Training and Continuing Education of ECMO Specialists
Version 1.5
February 2010
Page 7
Didactic Sessions – as above
Water-drills – as above
Animal Sessions: Time in the animal lab is not required for experienced centers,
but may be useful. If animals are not used, additional water drill time can be
Bedside Training: The bedside training time of the new Specialist should be
between 16 and 32 hours in 8 or 12-hour shifts. The preceptor should be an
experienced specialist.
Written Evaluation: Each specialist should have on record a written evaluation
of their skills and competence during all sessions of the ECMO training course
including; course attendance, water-drills, animal lab sessions and examinations.
Written/Oral Exam: Written exam, with pre-determined passing level, covering
didactic and laboratory sessions should be taken by all Specialists.
Institutional Certification: Institutional certification of Specialists will be granted
after successful completion of the ECMO training course (didactic, water
drills/animal labs, bedside training) and successfully passing the oral and/or
written exam.
Formal team meetings, which include:
Case reviews
Updates on ECMO therapy
Quality assurance
Review of ECMO policy and procedures
Administrative information
Frequency of meetings should be based on the size of the team and the volume
of ECMO patients treated.
Attendance records should be monitored and team members should be
required to attend a certain number of meetings as specified by the particular
ECMO center.
ELSO Guidelines for Training and Continuing Education of ECMO Specialists
Version 1.5
February 2010
Page 8
Water-drills: Water drills should be held periodically throughout the year as
specified by the particular ECMO center (every six months is recommended as a
minimum). The exact interval should be based on volume of ECMO patients
treated in the ECMO center.
Annual examination: This is recommended to verify the knowledge and skills of
all specialists. Ongoing evaluation of performance should also be conducted and
reviewed with the Specialist.
Minimum number of hours of pump time: Each center should set a minimum
amount of pump time for the specialist to maintain competency. For example, a
center might specify that each Specialist performs at least one 8-hour clinical shift
every eight weeks in order to maintain certification. Re-training should be
undertaken if this standard is not met.
ELSO Guidelines for Training and Continuing Education of ECMO Specialists
Version 1.5
February 2010
Page 9
doi: 10.1111/nicc.12265
An international survey: the role of specialist
nurses in adult respiratory extracorporeal
membrane oxygenation
Kathleen JR Daly, Luigi Camporota and Nicholas A Barrett
BACKGROUND: The last decade has seen an increase in the number of centres able to provide venovenous extracorporeal membrane oxygenation (VV-ECMO) internationally
across different health care systems. To support this growth, a variety of staffing arrangements have been adopted depending on local need and availability of resources, both in terms
of manpower and finances to safely meet the complex needs of the patient and circuit management.
AIM: The aim of the survey was to describe current staffing arrangements of care provision for adult patients on VV-ECMO, with a focus on understanding the professional roles and
responsibilities of staff managing the circuit in order to inform further discussion around different approaches to staffing.
METHODS: We conducted a cross-sectional international survey using an electronic questionnaire emailed to 177 worldwide ECMO centres treating adult patients with acute
respiratory failure. The survey questions were generated through an internal and external iterative process and assessed for clarity, content and face validity.
RESULTS: The response rate was 82%. Respondents managed extracorporeal oxygenation for adult respiratory alone (75%) or in combination with adult cardiac (67%), paediatric
respiratory (62%) and paediatric cardiac (58%). The specialist nurse to patient ratio was 1:1 in 59% of centres, with 24-h/day presence in 74%. Overall, the specialist nurse provided
the 24-h/day management of the circuit, including interventions. Perfusionists were responsible for the technical aspects of circuit management.
CONCLUSIONS: A specialist nurse with perfusion backup is the staffing arrangement implemented by most centres and likely reflects the most efficient use of the professional
competences available.
RELEVANCE TO CLINICAL PRACTICE: Staffing for adult respiratory extracorporeal support has important implications for the planning of workforce, training and education,
quality of service and the number of ECMO beds available.
Key words: Adult intensive care • Advanced practice/nurse specialist roles • Inter-professional collaboration • Respiratory therapies • Service organization/delivery
Extracorporeal membrane oxygenation
(ECMO) is a supportive therapy for patients
with severe cardiorespiratory failure
refractory to conventional management
(Marasco et al., 2008; Brodie and Bacchetta,
2011). ECMO is derived from cardiopulmonary bypass and miniaturized to allow
longer-term support within an intensive
care environment. Venovenous ECMO
(VV-ECMO) provides support for isolated
respiratory failure and requires the cannulation of the venous circulation. Venous
blood is drained from the superior and/or
inferior vena cava and pumped through the
membrane oxygenator and returned into the
right atrium fully oxygenated. The patient’s
own heart then pumps the oxygenated
blood around the body. Venoarterial ECMO
(VA-ECMO) provides support for cardiac
failure and requires the cannulation of both
venous and arterial circulations. Venous
blood is drained from the superior and/or
inferior vena cava and pumped through
the membrane oxygenator back into the
arterial circulation through the ascending
aorta (central ECMO) or the femoral artery
(peripheral ECMO). Modern ECMO circuits
use centrifugal pumps and low-resistance
polymethylpentene gas exchange membrane with heparin-bonded tubing and
percutaneously inserted cannulae. The gas
exchange membrane allows the addition
of oxygen and removal of carbon dioxide
directly from the blood. To provide adequate systemic arterial oxygenation, blood
flows of 4–6 L/min need to be achieved.
ECMO has been provided for critically
ill adults since the 1970s (Hill et al., 1972);
however, early randomized controlled trials
did not support the technique (Zapol et al.,
1979; Morris et al., 1994). The Conventional
Authors: KJR Daly, RN, PhD, Consultant Nurse, Critical Care, Division of Asthma, Allergy and Lung Biology, King’s College London, London, UK; Department of Adult Critical Care,
Guy’s and St Thomas’ NHS Foundation Trust, King’s Health Partners, London UK; St Thomas’ Hospital, 1st Floor East Wing, Westminster Bridge Road, London SE1 7EH, UK;
L Camporota, FFICM, Consultant, Critical Care, Division of Asthma, Allergy and Lung Biology, King’s College London, London, UK; Department of Adult Critical Care, Guy’s and
St Thomas’ NHS Foundation Trust, King’s Health Partners, London UK; St Thomas’ Hospital, 1st Floor East Wing, Westminster Bridge Road, London SE1 7EH, UK; NA Barrett, FCICM,
Consultant, Critical Care, Division of Asthma, Allergy and Lung Biology, King’s College London, London, UK; Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation
Trust, King’s Health Partners, London, UK; St Thomas’ Hospital, 1st Floor East Wing, Westminster Bridge Road, London SE1 7EH, UK
Address for correspondence: Kathleen JR Daly, Division of Asthma, Allergy and Lung Biology, King’s College London, London, UK; Department of Adult Critical Care, Guy’s
and St Thomas’ NHS Foundation Trust, King’s Health Partners, London, UK; St Thomas’ Hospital, 1st Floor East Wing, Westminster Bridge Road, London SE1 7EH, UK
E-mail: Kathleen.daly@gstt.nhs.uk
© 2016 British Association of Critical Care Nurses • Vol 22 No 5
ECMO nursing survey
Ventilation or ECMO for Severe Respiratory Failure (CESAR) trial demonstrated a
significant benefit for patients with severe
respiratory failure when transferred to an
ECMO-capable intensive care unit (ICU)
for consideration of ECMO (Peek et al.,
2009). Subsequently, during the Influenza
A H1N1 pandemic in 2009–2011, observational data showed surprisingly good
outcomes for patients commenced on
ECMO (Davies et al., 2009; Noah et al., 2011,
Pham et al., 2013). The results of CESAR and
the Influenza A (H1N1) pandemic led to
accelerated uptake of adult VV-ECMO for
severe acute respiratory failure (MacLaren
et al., 2012; Abrams and Brodie, 2013; Paden
et al., 2013; Munshi et al., 2014). Miniaturised, transportable ECMO pumps have
been developed with centrifugal pumps,
and polymethylpentene hollow fibre gas
exchange membranes which have improved
biocompatability, greater efficacy and cause
less ‘blood trauma’ than earlier generations
of ECMO devices (Mendler et al., 1995;
Khoshbin et al., 2005).
Respiratory ECMO is most commonly
indicated in adults with severe, potentially reversible, acute respiratory failure
refractory to conventional ventilation
(Bartlett, 2000; Hemmila et al., 2004;
Cordell-Smith et al., 2006; Maggio et al.,
2007; Mikkelsen et al., 2009; Turner and
Cheifetz, 2013). Relative contraindications
include contraindications to even minimal
anticoagulation and prolonged duration
of potentially injurious mechanical ventilation. There is only one widely accepted
absolute contraindication to ECMO, and
that is multi-organ failure secondary to viral
haemorrhagic fever (Ebola).
The Extracorporeal Life Support Organisation (ELSO) is an international body
representing practitioners of ECMO. In
addition to forming the largest registry of
ECMO cases worldwide, ELSO has produced guidelines pertaining to the ideal
institutional requirements for an ECMO
centre in terms of organizational structure,
staffing, physical facilities, equipment, staff
training, continuing education and ongoing
programme evaluation. These guidelines
recommend that ECMO centres (ICUs
caring for patients on ECMO) should be
located in tertiary hospitals receiving referrals from geographic areas that can support
a minimum of six ECMO patients per year;
however, any centre, regardless of number
of ECMO patients per year, can register with
ELSO (ELSO, 2013).
In England, the Department of Health’s
response to the H1N1 pandemic and the
CESAR study was to commission a dedicated regionalized VV-ECMO service
through the National Specialised Commissioning Team. A tiered model of advanced
respiratory care was created, with the development of a system of referral from local
hospitals through to regional, high-volume
tertiary ICUs. These services deliver specialist consultant-led and delivered retrieval,
assessment, acceptance, and treatment of
patients fulfilling the clinical criteria for
respiratory ECMO. Centres plan for and
manage seasonal variation in activity and
respond on a national basis to unanticipated
surges in demand. In our centre, for the last
5 years, the VV-ECMO survival was 79⋅7%,
ICU survival was 75%, and 6-month survival was 73⋅6%. These are similar to results
reported by the other UK ECMO centres
(N Barrett, personal communication), all
of whom have an ECMO specialist nurse
managing patients 24/7.
According to ELSO, the ECMO specialist
is ‘the technical specialist trained to manage the ECMO system and clinical needs
of the patient on ECMO under the direction and supervision of an ECMO trained
physician’ (ELSO, 2013). Internationally,
specialists come from a range of professional backgrounds, including perfusion,
nursing, physiotherapy and medicine. In
the UK, the staffing arrangement for the
provision for adult VV-ECMO adopted
by the five commissioned centres is the
ECMO specialist nurse, an ICU nurse with
additional specialist training. Currently,
both nationally and internationally, there
are no agreed standards of practice or certification process for ECMO specialists,
with each hospital credentialing staff to an
internally developed standard. However,
concomitantly, with the clinical and technological changes in ECMO, the role of the
ECMO specialist has evolved to manage
the patient–circuit interaction, the clinical
needs of the patient and to ensure the safety
of the ECMO circuit through continuous
surveillance, assessment and troubleshooting as well as preventing and managing
circuit emergencies. Each ECMO centre,
depending on local need and the availability of resources, both in terms of manpower
and finances, has developed its own local
specialist role, training programme and
staffing arrangements. There are also no
internationally agreed frameworks of service provision or defined competencies for
ECMO specialists and the specific roles
within the multidisciplinary clinical team.
The aim of the survey was to identify ECMO
specialist staffing arrangements for the provision for adult VV-ECMO patients, with a
focus on understanding professional roles
and responsibilities of staff providing the
management of the ECMO circuit in order
to inform future discussion around models
of care provision.
We conducted a cross-sectional international
survey using an electronic questionnaire
emailed to 177 worldwide ECMO centres
treating adult patients with acute respiratory failure. Centres were located in Africa
(South Africa), Asia (China, India, Israel,
Japan, Singapore, Saudi Arabia, South
Korea, Taiwan), Europe (Austria, Belgium,
Croatia, Denmark, Finland, France, Germany, Greece, Italy, Ireland, Netherlands,
Norway, Poland, Portugal, Russia, Sweden,
United Kingdom), North America (Canada,
USA), South America (Chile) and Oceania
(Australia). An invitation to participate in
this study was sent to the local co-ordinators
of the 177 ECMO centres. Email addresses
were retrieved from publicly available
database sources and from personal contacts of the authors. Exclusive paediatric
and cardiac ECMO centres were excluded
because we wanted to determine how the
staffing arrangements for the provision for
adult VV-ECMO adopted in the five UK
adult centres compared with international
Development and administration
of the online questionnaire
Using an iterative process, the survey questionnaire was developed by three authors
(K. D., N. B., L. C.). This was followed by
internal pilot testing amongst clinicians
within our institution, including consultants, perfusionists, ECMO specialist nurses
and physiotherapists. The pilot was followed by further retesting using an ECMO
co-ordinator from one of the other four UK
centres to refine and finalize question stems,
response formats and to assess face validity
and clarity. Confidentiality was maintained
through the survey software, which did not
identify individual responses.
© 2016 British Association of Critical Care Nurses
ECMO nursing survey
The survey consisted of 10 questions
arranged in two domains: (1) demographic
data and background of each ECMO centre and (2) ECMO circuit management,
roles and responsibilities. The survey was
self-administered using a commercially
available, subscription-based service (Smart
Survey™ ; Smart Survey Ltd, Basepoint Business Centre, Oakfield Close, Tewkesbury,
UK, http://www.smart-survey.co.uk).
In the first domain, participants answered
questions about staffing and case load: structured responses were provided to questions
regarding the training background of the
senior critical care physicians, the patient
population treated, the number of ECMO
patients treated in the previous year (2013)
and the total number of years of experience
in providing ECMO.
The second domain concerned responsibility for circuit management. Participants
reported which specialist was responsible
for all aspects of circuit management.
The questionnaire was answered online
in one session that occurred in 2014. Participants were required to select all answers
applicable to their institution from a series
of predetermined options (>1 specialist per
question likely).
Participants were initially contacted by
email. The ECMO co-ordinator for each
ECMO centre was contacted to participate in the survey. ECMO co-ordinators,
depending on the centre, are nurses, perfusionists, respiratory specialists or doctors.
The email included a cover letter explaining
the purpose of the survey and a link to the
web-based Smart Survey tool and a request
for the ECMO co-ordinator to contribute
information on behalf of their centre. Two
follow-up reminders were sent in the first
and third month following the initial email.
Participation was voluntary, and no incentives were provided for responding to the
survey. The institutional research and development department approved the study
and waived the need for ethical approval
and consent (authorization RJ114/N353).
Analysis of data
Descriptive analyses and frequencies were
calculated for demographic and qualitative
data. We include ‘non verbatim’ statements
provided by each respondent as free text
to support the rationale for the selected
response. Free-text responses were examined to provide clarification to the answers
respondents provided. Data analysis was
© 2016 British Association of Critical Care Nurses
carried out using Prism 6⋅0 software (GraphPad Software, Inc., USA).
Survey respondents
Of the 177 ECMO centres contacted, 146 centres responded (82%). Respondents had the
choice to respond to all the questions or skip
a question (‘I do not know’). In addition, for
some questions, more than one answer was
possible. This will affect the total number of
responses for each question (i.e. the denominator will vary, and the total can amount to
> 100% of the respondents).
Respondents were asked questions relating
to the type of ECMO provided by their
centre, the professional background of the
senior clinician leading their ECMO service
and the number of years their centre had
been providing respiratory ECMO. Respondents managed adult respiratory (109
centres), adult cardiac (98 centres), paediatric respiratory (91 centres) and paediatric
cardiac ECMO (85 centres). The professional background of the senior clinicians
primarily responsible for the management
of ECMO patients was intensivists (116
centres), surgeons (61 centres), anaesthetists
(30 centres) and physicians (25 centres).
The majority of respondents had provided
ECMO for severe respiratory failure for
>10 years (72 centres), with the remaining
centres reporting 6–10 years (19), 3–5 years
(36) and 0–2 years (19), respectively. The
number of adult respiratory patients each
centre, respectively, placed on ECMO in
2013 was 1–10 patients (74 centres), 11–20
patients (26 centres), 21–30 patients (15
centres), 31–40 patients (8 centres) and > 40
patients (18 centres) (Table 1).
Responsibility for the bedside
management of the ECMO circuit
The specialist primarily responsible for the
bedside management of the circuit was a
combination of the ECMO specialist nurse in
86 of 146 (59%) of centres, the ECMO specialist perfusionist in 44 of 146 (30%) of centres,
the ECMO specialist respiratory therapist in
33 of 146 (23%) of centres and the ECMO
specialist doctor in 14 of 146 (9%) of centres. A further 21 centres (14%) that did not
have bedside ECMO specialists reported a
combination of either the bedside nurse with
remote perfusion or medical backup cover in
Table 1 ECMO centres’ background, case-volume,
experience and staffing model
Training background of the senior clinicians
ECMO patient population
Adult respiratory
Adult cardiac
Paediatric respiratory
Paediatric cardiac
Adult respiratory failure patients treated (patients/year)
Experience with ECMO for acute respiratory failure
Responsibility for the bedside management of the
ECMO circuit
ECMO specialist nurse
ECMO specialist perfusionist
ECMO specialist respiratory
ECMO specialist doctor
No ECMO specialist (general
ICU nurse with remote
No ECMO specialist (general
ICU doctor with remote
Ratio of ECMO specialists to patients
2:1 or 2:3

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