Outcomes of the first 30 cases of an adult extracorporeal membrane oxygenation program: strategies to manage the "learning curve" and implications for intensive care unit risk adjustment models.
BACKGROUND
We established an adult extracorporeal membrane oxygenation (ECMO) service for cardiorespiratory support in April 2009. Complex therapies may show a learning curve and volume-outcome relationship.


OBJECTIVE
To describe our model of care, casemix and outcomes for the first 30 cases together with unique features of this service and potential strategies to manage the learning curve.


METHODS
Data were obtained from the intensive care unit database, medical record and minutes of multidisciplinary ECMO review meetings.


RESULTS
The model of care was based heavily on that used at an experienced ECMO centre following Extracorporeal Life Support Organization guidelines. ECMO was established as an ICU-managed, multidisciplinary service with collaboration from other specialties using standardised policies and procedures, staff training and formal case review. A specific budget was allocated to training and education and a clinical perfusionist was present on site for the first 10 cases. Seventeen patients received venoarterial (VA) and 13 received venovenous (VV) ECMO. Median duration of ECMO was 7 days for VA and 15 days for VV ECMO. Median ICU stay was 22 days. Twenty patients were referred from 13 hospitals throughout Queensland. Hospital mortality was 47% for VA ECMO and 15% for VV ECMO. The unique features of this service are the use of a Levitronix CentriMag system as well as the Rotaflow system, and the use of extended daily haemodiafiltration using the Fresenius 4008s ARrT plus connected into the ECMO circuit. The clinical implications of conducting plasma exchange and sustained low-efficiency dialysis via direct ECMO circuit connection using the Fresenius ARrT machine, and using a second system for ECMO support, were notable challenges.


CONCLUSIONS
Satisfactory outcomes were achieved using an ICU-based multidisciplinary approach with a broadly based education strategy with additional clinical perfusionist support to manage the learning curve.
Critical Care Research Group, University of Queensland, Brisbane, QLD, Australia. dan_mullany@health.qld.gov.au
Daniel V
DV
Mullany
Taressa N
TN
Bull
William
W
Hunt
Kiran
K
Shekar
Bruce
B
Thomson
John F
JF
Fraser
Marc
M
Ziegenfuss
D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D002985:Clinical Protocols; D015331:Cohort Studies; D003422:Critical Care / Q000458:organization & administration*; D015199:Extracorporeal Membrane Oxygenation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods; D005260:Female; D006333:Heart Failure / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D015397:Program Evaluation; D011793:Queensland; D012131:Respiratory Insufficiency / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D020379:Risk Adjustment; D016896:Treatment Outcome; D055815:Young Adult