Effect of hospital case volume on clinical outcomes of patients requiring extracorporeal membrane oxygenation: a territory-wide longitudinal observational study

Abstract

Background: The utilization of extracorporeal membrane oxygenation (ECMO) has increased rapidly around the world. Being an overall low-volume high-cost form of therapy, the effectiveness of having care delivered in segregated units across a geographical locality is debatable.Methods: All adult extracorporeal membrane oxygenation cases admitted to public hospitals in Hong Kong between 2010 and 2019 were included. "High-volume" centers were defined as those with >20 extracorporeal membrane oxygenation cases in the respective calendar year, while "low-volume" centers were those with ≤20. Clinical outcomes of patients who received extracorporeal membrane oxygenation care in high-volume centers were compared with those in low-volume centers.Results: A total of 911 patients received extracorporeal membrane oxygenation-297 (32.6%) veno-arterial extracorporeal membrane oxygenation, 450 (49.4%) veno-venous extracorporeal membrane oxygenation, and 164 (18.0%) extracorporeal membrane oxygenation-cardiopulmonary resuscitation. The overall hospital mortality was 456 (50.1%). The annual number of extracorporeal membrane oxygenation cases in high-and low-volume centers were 29 and 11, respectively. Management in a high-volume center was not significantly associated with hospital mortality (adjusted odds ratio (OR) 0.86, 95% confidence interval (CI): 0.61-1.21, P=0.38), or with intensive care unit mortality (adjusted OR 0.76, 95% CI: 0.54-1.06, P=0.10) compared with a low-volume center. Over the 10-year period, the overall observed mortality was similar to the Acute Physiology And Chronic Health Evaluation IV-predicted mortality, with no significant difference in the standardized mortality ratios between high-and low-volume centers (P=0.46). Conclusions:In a territory-wide observational study, we observed that case volumes in extracorporeal membrane oxygenation centers were not associated with hospital mortality. Maintaining standards of care in low-volume centers is important and improves preparedness for surges in demand.

Extracorporeal Membrane Oxygenation: Beyond Conventional Indications

“…Barbaro et al demonstrated that the annual extracorporeal membrane oxygenation (ECMO) patient volume has a potential impact on case-mix-adjusted hospital mortality rate for patients supported by ECMO [3]. However, a recent paper challenged this observation and did not show an associated between the hospital volume and the ECMO outcome [82]. ECMO is resource intensive technology and that might limit its use [83].…”

“…However, subsequent studies from the extracorporeal life support organization (ELSO) showed that the use of V-V ECMO in COVID-19 is associated with an in-hospital mortality of 36.9-51.9% at 90 days [80,81]. Similarly, in a French retrospective single healthcare system analysis, the estimated probability of death at 60 days post-ECMO initiation was 31% [82]. Most recently, in a comparative analysis of COVID Critical Care Consortium, the use of V-V ECMO in comparison to mechanical ventilation only was associated with a significantly reduced mortality especially in patients less than 65 years old and with a PaO 2 /FiO 2 < 80 mm Hg or with driving pressures >15 cmH2O during the first 10 days of mechanical ventilation [83].…”

Heterogeneity in clinical practices for post‐cardiotomy extracorporeal life support: A pilot survey from the PELS‐1 multicenter study

“…The current clinical scenario pushes every cardiac surgery unit to provide an ECLS service besides the normal cardiac surgery activity, regardless of the center's ECLS case load. Nevertheless, to optimize outcomes, it is recommended that centers performing ECLS for cardiac failure achieve a minimum ECLS volume of 30 cases per year, with a substantial proportion being for cardiac failure 11,12,13,15 . This survey revealed that several hospitals providing V‐A ECLS for post‐cardiotomy shock perform ≤30 V‐A ECLS cases per year, and these low‐volume centers are mainly non‐academic.…”

“…Nevertheless, to optimize outcomes, it is recommended that centers performing ECLS for cardiac failure achieve a minimum ECLS volume of 30 cases per year, with a substantial proportion being for cardiac failure. 11,12,13,15 This survey revealed that several hospitals providing V-A ECLS for post-cardiotomy shock perform ≤30 V-A ECLS cases per year, and these low-volume centers are mainly non-academic. Both low-volume and high-volume centers seem to be aligned on several clinical practices, including access to other mechanical circulatory support devices or the presence of ECLS specialists.…”

Bridging hope: South Africa’s ECMO reporting journey begins

“…In this issue of AJTCCM , Van Zijl et al [13] retrospectively report the outcomes of all patients supported with VV- and VA-ECMO at Netcare Milpark Hospital, a high-volume centre (defined as >20 cases per year [14] ) in Johannesburg, SA, that treated 107 patients over >2 years during a period predating the COVID pandemic. Most patients (73%) had respiratory failure as their indication for ECMO, with 54% of the cohort receiving VV-ECMO.…”