ECMO Transport without Physicians or Additional Clinicians

Abstract

Background: Extracorporeal membrane oxygenation (ECMO) has accelerated rapidly for patients in severe cardiac or respiratory failure. As a result, ECMO networks are being developed across the world using a “hub and spoke” model. Current guidelines call for all patients transported on ECMO to be accompanied by a physician during transport. However, as ECMO centers and networks grow, the increasing number of transports will be limited by this mandate. Objectives: The aim of this study was to compare rates of adverse events occurring during transport of ECMO patients with and without an additional clinician, defined as a physician, nurse practitioner (NP), or physician assistant (PA). Methods: This is a retrospective cohort study of all adults transported while cannulated on ECMO from 2011-2018 via ground and air between 21 hospitals in the northeastern United States, comparing transports with and without additional clinicians. The primary outcome was the rate of major adverse events, and the secondary outcome was minor adverse events. Results: Over the seven-year study period, 93 patients on ECMO were transported. Twenty-three transports (24.7%) were accompanied by a physician or other additional clinician. Major adverse events occurred in 21.5% of all transports. There was no difference in the total rate of major adverse events between accompanied and unaccompanied transports (P = .91). Multivariate analysis did not demonstrate any parameter as being predictive of major adverse events. Conclusions: In a retrospective cohort study of transports of ECMO patients, there was no association between the overall rate of major adverse events in transport and the accompaniment of an additional clinician. No variables were associated with major adverse events in either cohort.

Patient care during interfacility transport: a narrative review of managing diverse disease states

“…Teams consisting of a critical care transport nurse, a paramedic, and an ECMO specialist (perfusionist, specially trained nurse, or respiratory therapist) are sufficient and are associated with similar patient outcomes when compared to teams without a physician, nurse practitioner, or physician assistant. [25] Complications during transport of ECMO patients occur between 28% and 40% of transports. The majority (62%-65%) of patient-related complications include loss of tidal volume, hypovolemia, and circulatory instability, which can be associated with failures or limitations of medical equipment or issues associated with air transport.…”

Interfacility Transport of Critically Ill Patients

“…Despite the intuitive attractiveness of physician CCT team members, their inclusion remains controversial and devoid of supporting data within the United States (81). Furthermore, individual associations address neither transport physicians or other clinicians (physician assistants‚ nurse practitioners‚ respiratory therapists [RTs]), nor their scope of practice during transport.…”

Extracorporeal membrane oxygenation in the forensic setting: A series of 19 forensic cases

“…Because ECMO is predominantly offered only in major academic medical centers, it is also likely that ECMO‐related forensic cases are concentrated in medical examiner jurisdictions that include a major academic medical center [5]. Patients who died while on ECMO may have been transported long distances from local hospitals that are outside of the jurisdiction of the certifying medical examiner and in some instances may not be under the direct supervision of a physician during transport [6]. Therefore, coordination between the certifying medical examiner and the local law enforcement agency where the injury originally occurred is often required for these cases.…”