• May 14, 2020

    Systemwide ECMO quality collaborative improves patient outcomes

For critically ill patients with advanced heart or lung failure, extracorporeal membrane oxygenation (ECMO) is available at Baylor University Medical Center and three other Baylor Scott & White Health (BSWH) medical centers. A systemwide coordinated care initiative that aligned the services at these hospitals in North and Central Texas has improved ECMO outcomes across all sites, including a 32 percent reduction in overall mortality.

In addition to Baylor Dallas, ECMO is available at BSW All Saints Medical Center – Fort Worth, BSW Medical Center – Temple, and BSW The Heart Hospital – Plano. Over the last two years, these hospitals have embarked on a coordinated care initiative for quality improvement. In an abstract accepted for presentation at the American Association for Thoracic Surgery 2020 meeting, they report a 32 percent decrease in the overall risk of death between the pre- and post-implementation period (hazard ratio [HR] = 0.68, P = 0.012), with a 49.9 percent decrease in mortality associated with veno-arterial -ECMO (HR = 0.50, P = 0.003).

“We are also seeing significant reductions in in-hospital mortality and the incidence rate of complications and infections,” says Dan Meyer, MD, Chief of Cardiac Transplantation and Advanced Cardiac Circulatory Support, Baylor Dallas. “Outcomes are improving rapidly due to process adjustments, and it is likely that they will continue to improve. These positive outcomes illustrate that our strategy for systemwide ECMO service coordination can serve as a model for other healthcare organizations.”

Central to this initiative was the development of multidisciplinary teams with representatives from each hospital. These teams discussed each aspect of care and developed consensus processes to reduce clinical variation across sites. They also defined standardized exclusion and inclusion criteria and created a checklist to facilitate review of each case.

“The ECMO collaborative is an excellent example of how coordination among hospitals can work very well,” says Michael Mack, MD, Chair of the Cardiovascular Service Line for BSWH. “Through the leadership of Dr. Meyer and Ellie Huff, RN, system Director Cardiovascular Quality and Analytics, they have put together an effective team of people on the ground that puts patients on ECMO, manages them and then weans them off at the appropriate time. We have standardized best practices for ECMO throughout the system.”

To track progress long-term, the team developed a systemwide quarterly ECMO scorecard – the first such ECMO scorecard developed in the nation – that assesses quantitative metrics for operations, outcomes and financials relative to pre-defined benchmarks.

“The scorecard has made all the centers very focused on quality,” Dr. Meyer says. “Everyone in the ECMO collaborative sees the data, allowing us to consistently determine if we are doing better or worse than the national benchmarks.”

ECMO may be appropriate for patients who have acute pulmonary or cardiac failure that is potentially reversible and not responsive to conventional interventions. ECMO can also be used in patients with advanced heart and lung disease as a bridge to transplantation or implantation of a ventricular assist device.

According to Dr. Meyer, “Our cardiac support is often used for patients who have open-heart surgery and cannot separate from the heart-lung machine after surgery. We also use it for in-hospital or in-emergency room cardiac arrests when resuscitation is not possible. Most patients who need pulmonary support have respiratory failure secondary to influenza A or another kind of pneumonia.”  

Regarding ECMO for patients with COVID-19, Dr. Meyer says that it is too soon to really know how to best handle this complicated illness, but the timing of the intervention and resource allocation are important factors to consider. “ECMO outcomes in general are best if a patient has not been on a ventilator for a prolonged period.”

A unique aspect of the BSWH approach is the incorporation of a transport program into the suite of ECMO critical care services. This means the BSWH Rapid ECMO Deployment Team will go to the referring hospital, establish ECMO, and transport the patient to the cardiothoracic intensive care unit at one of the four BSWH hospitals. The 24/7/365 service range extends not only throughout the state of Texas, but also to surrounding states as well. Since 2012, the Rapid ECMO Deployment Team has transported approximately 150 patients.

“This is the first time the hospitals in the North Texas and Central Texas regions are working together  to get these critically ill patients the care they need close to home or transported to the appropriate facility for their condition,” Dr. Meyer says. “We go all over the southwest region to put these patients on ECMO on site and then transport back to the right facility. We are one of the busiest ECMO centers in the United States and internationally. There are very few centers in the world that have the capacity to both transport and treat ECMO patients”

To refer a patient 24/7, call the ECMO referral center. The on-call physician will be notified.