10.18.23
Extracorporeal membrane oxygenation (ECMO) is a life-saving medical therapy that provides temporary mechanical circulatory support (MCS) for patients with severe heart or lung failure. 由于扩大临床适应症, 改善患者预后, 以及相关技术的进步, the use of ECMO has increased significantly over the past decade, 目前美国有260多家医院提供体外膜肺氧合.[1]
ECMO并不是一种新的临床治疗方法, the concept of mobilizing this service appears to be an emerging trend in quaternary programs. Mobile ECMO offers access to advanced care for patients during transportation and those in resource-limited areas while increasing the patient volume for ECMO centers. 鉴于此, cardiovascular (CV) leaders need to consider whether mobilizing their ECMO program would serve as an effective way to grow MCS volumes, 在地理上扩大护理, 加强CV伙伴关系.
移动ECMO的显著趋势
- 更紧凑的设备: Advancements in technology have led to the development of more compact and portable ECMO machines. These smaller devices make it easier for healthcare providers to supply ECMO support to patients outside of traditional hospital settings, 包括在护理机构之间的运输过程中.
- 专门的运输小组和协议: Healthcare systems that offer mobile ECMO often have a dedicated ECMO transport team with the expertise to safely move critically ill patients on ECMO from one facility to another. These systems have also developed standardized protocols for transport to ensure patient safety during this process.
- 救护车ECMO: Some health systems are establishing partnerships with ambulance companies in order to equip these vehicles with ECMO so that MCS can be initiated on site or during transportation to a tertiary or quaternary medical center. This added capability can potentially improve outcomes for patients in critical condition who require ECMO immediately.
- 远程医疗与远程支持的整合: Telemedicine and remote-monitoring technologies can be integrated into mobile ECMO programs to allow ECMO specialists to provide guidance and support to healthcare teams at different facilities, 从而实现更有效和及时的护理.
- 扩大适应症: Over time, the criteria for initiating mobile ECMO support have expanded. As a result of increased experience and research—due in large part to the use of ECMO during the COVID‑19 pandemic—ECMO is now used for various respiratory and cardiac conditions that were previously deemed unsuitable.
- 改进培训和教育: 随着移动ECMO的使用越来越广泛, provider organizations are offering specialized training and education for healthcare professionals involved in ECMO services. This often includes interdisciplinary and simulation-based activities, which allow clinicians to practice their ECMO management skills across a variety of scenarios, 例如在运输过程中或在野外.
建立必要的伙伴关系
An important component of ECMO mobilization is establishing community or regional partnerships to provide ECMO transport via a hub-and-spoke model, 如图1所示. While the minimum number of annual ECMO cases needed to sustain an ECMO center is often debated, various studies conclude that an inverse linear relationship between mortality rate and volume exists, with 30 being the lowest number of recommended annual cases.[2]
如图2所示, higher-volume ECMO centers may have reduced mortality rates and improved outcomes. Regional partnerships can support the concentration of patients to one site, 导致更加协调和有效的护理, 更好的患者预后, 改善资源分配, 以及ECMO专业知识和管理的持续进步.
图1: ECMO轮辐运输模型
图2: Risk-Adjusted Relationship between Hospital ECMO Volume and Mortality Rate[3]
在发展这些重要的网络伙伴关系时, hospitals and health systems will need to ensure proper transportation and transfer agreements, 以及提供商认证, 都就位了.
- 运输协议: Referring and accepting hospitals will need to establish a transport agreement detailing the responsibilities, 负债, 以及各方的绩效标准.
- 转让协议: Referring and accepting hospitals will need to establish a transfer agreement documenting the parties’ agreement to transport patients between their facilities.
- 供应商资格审查: Care team members will need to be credentialed at all community partner facilities where they could provide ECMO services.
If your organization doesn’t have an internal department for either ground or air transportation, you’ll also need to partner with a reliable transportation company. Due to the additional risk and training required to operate ECMO while in air, it is especially critical to find a service provider that excels in aircraft maintenance and is willing to comply with any necessary rig modifications, 额外的培训, and operational guidelines related to the mobile ECMO program. Establishing close partnerships with local companies will enable a quick response time while ensuring a high level of trust for the ECMO team, 这两点对项目的成功至关重要.
开发一流的课程
在开发移动ECMO程序时, start by determining the geographic areas you want to serve, as the location and reach of the program will generate associated requirements and considerations.
- 多状态操作, especially one that intends to work with nonaffiliated healthcare organizations, requires additional up-front work to ensure appropriate provider credentialing is obtained and maintained by all physicians participating in the program.
- The geographic reach of a program will also dictate the type of transportation needed. 如果你在为当地bet8网站备用bet8娱乐, an ambulance would be a sufficient mode of transportation; however, 如果您在多个州为系统提供bet8娱乐, you may need to consider a helicopter or fixed-wing aircraft.
- Finally, consider reimbursement implications related to the transportation of patients. If there is an ECMO center between the referring hospital and the home organization, CMS may not reimburse the distance from that center to the home hospital. Strategic market selection is key to avoiding these types of disadvantages.
一旦建立了护理网络, 现在是开始处理病人转运请求的时候了. 程序通常会在使用呼叫中心之间做出选择, where an agent gathers patient information and then transfers the call to the on-call provider, 或者直拨电话号码, 在哪里呼叫直接路由到随叫随到的提供者. 这两种情况, 患者是否适合进行移动ECMO, the mobile ECMO team would be activated to treat and transport the patient back to the facility.
Due to the urgent nature of patients requiring ECMO intervention, minimizing the steps required for triaging widens the path for success. 因此, a direct call number to the on-call physician or program manager is best practice, 因为它可以快速准确地做出决策, especially if inclusion criteria is shared ahead of time with the referring organization and sufficient education. 通过传单分发移动ECMO项目细节, 信息的电子邮件, 会议和其他专业活动, and even direct provider networking will help advertise the program and shorten the lead time from patient identification to mobile ECMO intervention.
Support from organizational leadership is also an essential component to a program’s success. 为了:
- Build and maintain collaborative relationships with various clinical and nonclinical hospital departments.
- Ensure all administrative requirements are completed on time.
- 制定并维持全面的培训计划.
- Effectively partner with external transportation companies and healthcare organizations to support the network.
Enterprise-level goal-setting and program management efforts will be critical, especially in the early phases when the program will inevitably experience growing pains.
选择项目特点
Mobile ECMO programs vary by organization based on patient demands. Table 1 illustrates key characteristics of select mobile ECMO programs around the country, which may be helpful to leaders who are considering mobilizing their ECMO programs.
表1: 选择移动ECMO程序和特性
所以你应该转向移动设备吗? 对领导力的考虑总结
在决定是否提供移动ECMO方案时, system leaders must ensure they can provide all the required elements discussed herein. 这样做, refer to the recently published Extracorporeal Life Support Organization (ELSO) guidelines, which outline five key components present in all high-quality, 成功的项目.
表2: ELSO’s Top Five Considerations for Building a Mobile ECMO Program
除了以上来自ELSO的建议之外, ECMO program leaders must carefully manage the financial viability of the program, which will include developing a network that supports the level of programmatic volume necessary to generate a positive return on investment. ECMO项目的四级声誉, 市场份额, and ability to grow MCS case volume are all factors that will contribute to a healthy and sustainable program.
随着ECMO的使用和需求的增加, existing programs may consider whether to offer ECMO transportation. Successful mobile ECMO programs prioritize patient safety and operations. 提供移动ECMO的决定必须经过深思熟虑, with program leaders carefully evaluating the value this life-saving care provides to patients versus the costs and resources required to start and maintain a program of this caliber.
心电图’s CV consulting team is passionate about improving CV care delivery. Since 2010, team members have conducted nearly 300 CV engagements across more than 100 organizations. Our experts focus on providing executive advisory services to the nation’s leading CV programs.
编辑: 艾米丽约翰逊
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