In this video, registered nurse Mary Frances Quinn outlines care by exploring different ways to achieve and main ECMO care competency along with the importance of simulation training for ECMO care providers. She will also provide a look at the larger ECMO care team that extends beyond the ICU staff.
@PennMDForum So today, I'm gonna talk about the ECMO Care team after cannulation and I have no disclosures. So we're gonna talk a little bit about uh ways to achieve and maintain competency, talk about the importance of simulation. And we're gonna talk a little bit about the larger ECMO team. So my second favorite quote of all time, never doubt that a small group of thoughtful committed citizens can change the world because it's the only thing that ever has Margaret Mead. And if you just simply replace citizens with clinicians, you know, it's our entire world, but our entire world is actually very small just because we are actually the loudest voice in the room, doesn't mean we're not still one of the smaller groups and smaller communities in the medical field. And so we know that a dedicated expert, dedicate, dedicated expert team has a direct effect on patient survival. The better, you know, the more, you know, the better the patients are gonna do. Absolutely. And they're very clear guidelines as to what that team is. When you look at S O, it talks about the ECMO specialist who's trained in all aspects of the ECMO care our pen medicine model is more of a hybrid model. So we have our E C L S, our extracorporeal life support primers who are our 24 hour in-house perfusionist and they function as our ECMO specialists. And then we have our E C L S specialists, our ECMO certified nurses who have specially trained um solely in the H V IC U. And they're the most senior nurses with the most experience and they're able to maintain the pump and manage the patient. We have a P P S C R MP S and P A s who provide that uh with E C O experience who manage the day to day care along with our house staff of residents and fellows, our IC U intensivist physicians, both anesthesia, surgery and medicine. And our program directors, coordinators and educators, which the key point is that we are dedicated to the care and treatment of the E C O population. Our E O coordinator is our ECMO coordinator. He's a phd, he's one of the smartest people in the room and his first love is V D, but he is our ECMO coordinator. He's not also the VD coordinator and taking call on Friday night and a nurse manager. You know, he's our ECMO coordinator, which is very important that he, he doesn't have that multiple role as far as achieving initial competency. Very easy. Just look to your experts, the L O guidelines for training and continuing education are right there. We develop program guidelines because those L I L O guidelines are purposely vague to a degree because you have to think about your specific program and what it can support. You have to define your standard of competency and you have to create that introductory training for all aspects. So our center of excellence, a application has a very clear cut guideline as to exactly what the expectation is for all of our ECMO care providers. What the intensivist, what the cannulated physicians, the fellows and the residents are expected to know and do the training that our A P P S go through to help them manage these patients perfusion and registered nurses exactly what we're gonna do. So, our introductory training at Penn Medicine, our introductory ECMO course, which funnily enough was designed with me and my good friend Dorian Coy sitting in the front many, many years ago is a 16 hour multidisciplinary course. Everyone is invited. We based it of course on the L O guidelines and it's a lot of didactic education about all aspects of the ECMO care. And it includes very high fidelity sim scenarios with circuit drills, case reviews and discussions. We offer it three times a year, both at Hup and Presby. So essentially six times a year and it's organized by our ECMO coordinator and our educators. The schedule is made up a year ahead of time. It's sent out to all the stakeholders and it's offered to everyone. It's primarily nursing, but it's offered to everyone. A P P S fellows residents, excuse me. And it is an introductory course, but we strongly recommend that everyone attends regardless of their E O experience because we don't just teach you what ECMO is. We don't just teach you how ECMO works, but we teach you how we manage patients at Penn. We teach you about the physicians who maybe don't necessarily advocate for an S fa right away. Or we talk about low flow ECMO versus R flow right flow ECMO. We try to let um the staff kind of understand the different philosophies from our different practitioners and our different patients. And we have a very fluid aspect to our class that allows for that drop in. So if I know one of the anesthesia fellows wants to participate in the SI M for insertion, I'll just text them maybe 10, 15 minutes ahead of a time so they can run up from the O R if they have time. Um You don't, you know, we're not really rigid. You don't have to be there from beginning to end and we validate competency based on course attendance. We do case reviews and discussions. We have a written examination, we do those circuit drills that I talked about. It's a hands on demo. I need to know that, you know exactly how to hand crank, how to make changes, how to switch the ECMO to the 02 tank, if there's some catastrophic failure of the digital blender and then the practice validation, the bedside learning, that's gonna be, you know, mentoring and education. Our coordinator stops by, I'm around all the time and our senior ECMO specialists are always there to answer questions and for those in the moment learning opportunities. And of course, we know that simulation is key simulation is directly related, not necessarily, it hasn't, there hasn't been like a real direct correlation to improve survival, improve mortality, but there's a 100% correlation to improved comfort. The more you simulate, the more comfortable you're comfortable, you're gonna be in your practice. So simulation is really the key uh portion of our class. So, you know, we can, we can, you know, get really fun. Um We'll have simulations multidisciplinary SIMS in the room. Excuse me, this the picture on the right is from our old room. We've since upgraded our digs. Um And there's always the debate of the type of simulation. Is it gonna be some like high fidelity sim Man with an ECMO simulator, which is great, but it's expensive and it takes a lot of time to learn. And I got to tell you Mr Blanket and I have been a friend for a really long time and I've done a lot of good Sims with Mr Blanket. He and I are, are great buddies. But the one thing that I can't make, the one thing that even sale couldn't Jerry rig together is the actual circuit. And so all I can do is caution everyone here who might be thinking about starting a program or the next time you're upgrading your equipment, you need to include the training and education as part of that budget. So when you're looking for that new extra corporal device, what is the actual education that comes along? What are your videos? What, where is your lesson plan? Where are your tip sheets? Where are all the things that I need to make sure that my staff knows how to use this incredibly complicated piece of equipment. And if they make one minor mistake, that's a big issue. And how much of that are you gonna bring with you when you train my staff? And how much am I gonna get to keep? Because I can make bricks out of straw, but I can't actually manufacture a new pump head when it breaks while we're using it. And that's the stuff that really adds up that you don't really think about. So think about that before you buy that equipment or while you're buying that equipment as far as maintaining competency. So, so the big question, right? You have eight or 10 extra corporal support platforms. I I you got 50 or 60 nurses, 20 plus fellows, 25 perfusionist. You have a coordinators, you have, you know, respiratory therapy, you have house staff fellows. How do you make sure they're all competent. I, I, that's, I'm actually asking you because I, I don't know the answer to that. That's what I'm still trying to figure out. So, if anybody can give me some advice, that would be great. Ok. How do we make sure they're all competent through an enormous amount of hard work because maintaining competency, that's what keeps me up at night. Right. Maintaining competency is tough. I can teach an intro to echo course in my sleep. But at, on Saturday night, at 7:30 or 8:00 when I'm getting a phone call because something's happening. That's, that's what keeps me up at night. So, you know, you have to map out your minimum expectations, something as simple as what's the maximum amount of time someone can be away from ECMO before you actually have to retrain them. You know, a fellow that goes off for six months to do another fellowship. And the first night back he or she is gonna can, that's ok. Or the nurse who goes out for an F M L A for three or six months, the first night back, she's gonna take care of an ECMO patient. Hm. Let's think about that. So you got to keep track of all that stuff every day. You know, our charge nurses keep track of work, nursing hours, how many events in Foley to look at our, uh, infection rate. But we also keep track of all of the nurses who actually take care of ECMO patients so that we can kind of take a look and realize that someone hasn't been in an ECMO room because they've been pre accepting for the last three months because they're gonna be a little rusty. You gotta think about that continuing education, the C M E and ce credits, especially in E C O specialties, memberships in those professional societies. So set your standards. What are your standards? An annual E C O review, a bi annual Ebo review. How often are you gonna be required to do competency validation reviews, exams, circuit drills, clinical reps to come back in emails in services or flyers that you can post around the unit. By the way, the only ones that are, are ever read are the ones in the bathroom. So, you know, just make sure you're taking care of that and then practice that programmatic commitment to the education that we have with our dedicated educators, individualizing the training to our institution and creating a space. So we have an incredible team. We have Salem Olia, our coordinator, the extra corporal specialist, my co-partner in crime, Anna Remi, who's my co ECMO educator, our leadership on the unit, Corin, Mark Chris Jamie and Robin, who make sure that I can actually do what I actually do. And Kelly, our previous nurse manager who helped us to build our first insight two simulation lab who who had the vision to actually take an enormous room on our unit and dedicate it to, to education and to simulation. Each week. We dedicate an entire week as education. Every month. We have some sort of class, whether it's balloon or ECMO, mechanical circulatory support or an advanced principals class. We do bedside uh AC L S training at Ashley Trin. One of our nurses uh is an AC L S instructor and she doesn't just certify them in AC L S. We also incorporate cardiac surgical resuscitation principles based on the cow's philosophy to make sure that we're up to date. And then of course setting up for circuit drills and simulations. And so ultimately, and then, you know, and then we get Salem who builds pumps in his garage on the weekends to make everything even better. All of our education is uh is on our Microsoft Teams platform. It's in an app for our H B IC U Mechanical Support education. It's been about a year long project. Every single lecture that I did that I I have in class is the powerpoint is narrated and loaded onto this app. So anyone can listen. We do all of our homegrown videos because the videos that the companies give us are great, but we need our own. So Salem and I with an iphone and you know, in our SIM lab are making these videos. I swear to God. I don't have the strength to end up on tiktok, but I'll do it if I need to just to get that out there. Um And then again, all of our flyers um you know, so that people know how to use our uh what we do. We have to create that culture of excellence, creating ECMO super users with advanced training. We go over hot topics. Um Some of the things that we highlight North South syndrome, the um unique Canula, the RVAD with the oxygenator or as I like to call it the assad special um anticoagulation, the multi platforms, the Ella, the low flow strategies. Our newest um uh uh training that we've implemented in a few weeks ago, our ECMO insertion assistant where we're certifying senior ECMO nurses uh to be able to assist in the insertion to set up the sterile field. They're not actually like hubby, the cannula, they're not holding the wire, but they're setting up the field. They're, they're getting sterile themselves um to be able to help with our ECMO alerts so that they can go out. And then the ex extended E O team is incredibly important, not just the people who are directly taken care of, but think about all of your consulting services because our unit, our ECMO unit is closed. So every summer I get invited to the cardiology boot camp. I get to meet all of the new cardiology fellows and I tell them how we run physical therapy, respiratory therapy. I've done talks for social work for radiology, palliative care. Our ECMO alert program. We created a whole ECMO road show where we go to other units, we call it, help us to help you. So we go through everything about how we put someone on ECMO and what they can do to help us. Again. I've done talks for consulting groups for the A P P Fellowship for the School of Nursing, respiratory physical therapy, social work. I just recently did two talks about um impella and ECMO for cardiac sonographer to make sure that they don't accidentally set off bubble, you know, alarms and ultimately pulling them all together is really what is gonna make that program the most unique. There's lots and lots of resources, there's lots of guidelines. You just have to kind of think about it, narrow it down to your program. Focus, set your guidelines and then stick to them.