Implementation of an ECMO Intensivists-Led Multidisciplinary Team

After January 2018, a dedicated specialist team-based approach to ECMO care (ECIT) was initiated. This was led by a group of ECMO intensivists with accreditation in critical care medicine and had received fellowship training in established ECMO centers or completed an ECMO training course with at least 1 year of experience in the ECIT. Assessment of patient suitability for VV ECMO was a joint team decision rather than an individual one. Selection was guided by protocolized-inclusion criteria, with the final decision for ECMO initiation decided by the ECIT based on the clinical assessment of the patient and the presence of relative contraindications. Other members of the team, consisting of medical intensivists, cardiothoracic surgeons, perfusionists, specialized ECMO ICU nurses, respiratory therapists, and pharmacists continue to provide multidisciplinary care. A group of ICU nurses also received training from international ECMO courses to upskill nursing capability to provide 24-hour bedside support and augment the function of the perfusionists. The ECIT performs daily rounds on ECMO patients, together with the ICU team. Assessment and management of ECMO-related complications, ventilator management, weaning, decannulation, and withdrawal are made by ECMO intensivists, with the multidisciplinary team.

ECMO intensivists also provided nighttime call coverage for consultation (with on-site reviews when required) and on-site assistance during ECMO initiation and the immediate postcannulation care. Perfusionists and a cardiothoracic surgeon continued to be available for consultation during the night, including on-site reviews as required. For retrieval cases, the ECMO intensivist may provide on-site reviews, assist with cannulation using real-time ultrasonography, and hold discussions with the patient’s family members, if appropriate. A review of existing ECMO protocols was also initiated in 2018 by the team. In May 2019, our anticoagulation protocol moved toward a more conservative aPTT target of 45–60 seconds and/or an activated clotting time between 180 and 220 seconds. No other major changes in protocolized ICU or ECMO management were made. Finally, along with initiation of the team-based approach to ECMO care, clinical audits, journal clubs, and multidisciplinary case discussions were organized regularly. ECMO survivors are also followed up in the wards and subsequently in the outpatient setting by ECMO intensivists.