key: cord-0751369-0ap3onog
authors: Sen, Ayan; Blakeman, Stephanie; DeValeria, Patrick A.; Peworski, Dominique; Lanza, Louis A.; Downey, Francis X.; Alwardt, Cory M.; Dobberpuhl, Jeffrey G.; DeMarco, Matthew; Callisen, Hannelisa; Shively, Jennifer; McKay, Kelly; Singbartl, Kai; Sell-Dottin, Kristen A.; D’Cunha, Jonathan; Patel, Bhavesh M.
title: Practical Considerations and Outcomes of Inter-facility ECMO Transfer of COVID-19 Patients During a Pandemic: The Mayo Clinic Experience
date: 2021-03-03
journal: Mayo Clin Proc Innov Qual Outcomes
DOI: 10.1016/j.mayocpiqo.2021.02.004
sha: 5d6d0d91447093737daf9fbef0fcb05b482ab869
doc_id: 751369
cord_uid: 0ap3onog

Inter-facility transport of a critically ill patient with Acute Respiratory Distress Syndrome (ARDS) may be necessary for a higher level of care and/or initiation of extracorporeal membrane oxygenation (ECMO). During the COVID19 pandemic, ECMO has been used for patients with severe ARDS with successful results. Transporting a patient after ECMO cannulation by the receiving facility brings forth logistic challenges including availability of adequate Personal Protective Equipment (PPE) for the transport team and hospital capacity management issues. We report our designated ECMO transport team’s experience with five patients with COVID19 associated severe ARDS after cannulation at the referring facility. Focusing on transport associated logistics, creation of checklists, and collaboration with EMS partners is necessary for safe and good outcomes for patients while maintaining team safety.

Inter-facility transport of a critically ill patient with Acute Respiratory Distress Syndrome (ARDS) from COVID19 may be necessary for a higher level of care and/or initiation of extracorporeal membrane oxygenation. Cannulating the patient at the referring hospital and transporting the patient on ECMO (Extracorporeal Membrane Oxygenation) was first described by Bartlett et al. 1 The concept of traveling to the referring hospital with a portable ECMO system, cannulating the patient at the referring hospital and transporting the patient back to receiving institution on ECMO was then further developed by Cornish et al. 2 It was not widely performed until the 2000s. 3 Since then, civilian and military institutions have undertaken ECMO transport in various forms including ours. 3, 4 Adverse events have been reported in up to 27% of transports at experienced centers 5 and patient selection, team training and efficient utilization of limited resources have been described as important considerations.

Transportation of COVID-19 patients presents a multitude of technical and workflow safety concerns for all members of both sending and receiving facilities regarding effective and safe use of personal protective equipment (PPE) during inter-facility transportation. Communication and pre-planning have been described as key elements to minimize the risk of disease transmission. 6 Haphazard transport of infected cases, especially during complex ECMO transfers can lead to nosocomial spread and endanger staff safety. 7 We report inter-hospital transport of five patients after initiation of VV-ECMO by our ECMO transport team and subsequent transfer to our hospital for higher level of care with key considerations of PPE use for this transfer and transport related issues.

J o u r n a l P r e -p r o o f Methods A case series of five COVID ECMO patients who were transferred to our institution was included in this report by consecutive sampling from our institutional ECMO database.

Our ECMO transport team collaborates with private medical transportation companies (AMR-American Medical Response and Trinity Air Medical) that provide emergency medical services (EMS) as our transport partners. J o u r n a l P r e -p r o o f

Initial reports on use of ECMO for COVID19 and prognosis were modest. 8 In addition, the challenge of initiating VV ECMO during a pandemic with resource implications is important to consider. Our multidisciplinary ECMO Team meets regularly and finalized the selection criteria for COVID19 patients based on our institutional experience and ELSO guidelines. 9, 10 Capacity issues in the ICU were a concern with the local surge in COVID patients.

Based on the international consensus guidelines, our hospital was in contingency capacity through most of this pandemic. 11 In collaboration with hospital leadership, we limited the capacity of COVID ARDS ECMO patients to five in a thirty-bedded intensive care unit. Staff availability was also a factor in transport related decisions due to our designated ECMO transport team model (and not a dedicated team). It should be further noted that other hospitals in the region participated in ECMO support of COVID19 patients and a statewide surge line was used manage and distribute the needs of community hospitals and regionalization of care. This was especially important from a resource and capacity standpoint such that regional hospitals worked in tandem to support all candidates meeting ECMO criteria. Policies were implemented in partnership with AMR, our EMS transport partners, to address PPE recommendations based on transport risk.

A decision was made that all patients under consideration for inter-facility transport would be cared for using airborne isolation during the transport. Requirements of airborne isolation included CAPR, PAPR, or N95 mask with face shield, gloves, and gown. The transport team additionally donned shoe covers, bouffant cap/OR hat, and hospital-provided scrubs. A tabletop exercise was done to focus on PPE donning/doffing checklist criteria, role clarification, patient-centered care, teamwork, collaborative leadership and inter-professional communication. All transport team members completed online educational modules. We do not bring our own blood cooler but receive blood from the sending facility, who have it typed and cross-matched, if needed.

A pre-departure huddle and time out was organized along with the EMS crew (one RN and one EMT) so that everyone was familiar with the donning and doffing criteria/checklist. Each transport team member brings with them their own N95 mask and face shield. Roles and responsibilities were clarified along with coordination and communication issues. Upon arrival at the sending facility, another huddle was done and one RNES ensured the team donned the PPE that was brought with the transport team appropriately.

Our in-procedure safety measures consisted of limiting the number of people in the ICU room and full airborne PPE use. The in-room team consisted of the surgeon, intensivist (assisting with cannulation or managing the critically ill patient), one perfusionist, one ICU RN and one Respiratory Therapist from the requesting team and one OR Nurse/Scrub Tech. Our RNESs would be on standby outside the room ready to assist as necessary. While negative pressure rooms/pods is our standard of care in the ICU, this was not always feasible in the referring hospitals. After cannulation was completed, the RNES and EMS transport team (RN and EMT) entered the room as the cannulation team stepped out to move the patient to a transport gurney while maintaining full precautions. The perfusionist stayed back in the room to assist with the process. On arrival to the receiving facility, two safety officers were sent (ICU RNs) from the ICU who were familiar with proper donning and doffing procedures. The safety officers brought all necessary PPE supplies (gowns, gloves, surgical masks, alcohol-based hand sanitizer) for the team to don prior to entering the receiving hospital. The primary safety officer was responsible for the arriving ECMO team in the ambulance to follow proper doffing procedures (see Table 4 ). The backup safety officer was then responsible for receiving the equipment from the RNES prior to the team exiting the ambulance and transporting it back to the ICU for decontamination. The backup safety officer is also responsible for wiping down the stretcher, ECMO circuit, ventilator, monitor, IV pumps, and any other equipment. Once the transport team donned new PPE and the equipment has undergone initial decontamination, they proceed through a pre-established route for transporting patients with COVID-19 within the hospital.

Patient characteristics and demography are provided in Table 1 and 2. Majority of patients were young, female (67%) and a high median BMI 31.9 (IQR 25-37). The J o u r n a l P r e -p r o o f median time to intubation for these patients was 4.3 hours (IQR 1.6-130 hrs) and median time from admission to hospital to ECMO cannulation was 3.77 days. Transport related metrics are provided in Table 3 . Median distance covered was 19.7 miles (IQR 17.75-24.6). Referral to cannulation time median was 315 minutes (IQR 248.5-816 mins). Two patients out of the five had diabetes, one had asthma and one had rheumatoid arthritis. Majority of patients had high ventilator requirements with refractory hypoxemia. Eighty percent of them had been proned and one patient could not be proned due to unstable airway/ cricothyroidotomy. All five patients survived ECMO decannulation. The median duration of ECMO run was 30 days with a range from 12 to 88 days.

ECMO for COVID-19 severe ARDS has been successful with survival rates similar to similar to pre-pandemic ARDS outcomes. 13 However, hospital and ICU capacity determines ability to offer this resource intense therapy especially if they are in a contingency or crisis state. While a transport team for safe cannulation and retrieval of patients from referring centers is feasible, the logistics are immense and adequate PPE supplies must be available. At the time of this report, the ELSO Registry has reported 21 patients transported to outside facilities while on ECMO, 16 of which occurred in North America. 14 Good collaboration with transport partners for inter-facility transfer is vital. Our prior experience of a designated team for ECMO transport enabled us to cannulate unstable patients and support them on ECMO, who would have a worse outcome otherwise.

Creation of a checklist, tabletops, and huddles ensured that all necessary steps of J o u r n a l P r e -p r o o f donning and doffing PPE, and transport logistics were followed reducing staff exposure and adverse outcomes. Role clarity, situational awareness, and backup behaviors were encouraged especially when it came to ensuring PPE compliance. Thus far, none of the transport team members have suffered from an exposure.

While risks do exist for transport teams, meticulous preparation, experience of ECMO transports and strict adherence to checklists and protocols ensure team safety. This can be difficult to initiate or maintain during contingency/crisis pandemic surge. Few centers offer aeromedical transport for ECMO patients and the risk of exposure can be high due to a small pool of qualified staff. However, successful COVID ECMO air transports have been described by other teams by streamlining their processes during this COVID-19 pandemic. 15 While COVID-19 numbers may plateau soon as the vaccination efforts go up, it is unclear, with new variants, whether we would ever be able to go back to the pre-pandemic world in the near future. Precautions and protection of transport staff with PPE may well become the new standard of care for mobile ECMO teams.

Overall, our patient outcomes have been satisfactory. All of them were successfully decannulated. Two of them have been discharged and the other two recovering in the hospital. One patient died several days after decannulation due to neutropenic septic shock due to suspected disseminated coccidiomycosis with recurrence of ARDS. Our outcomes are reflective of careful and uniform candidate selection. The ECMO runs were variable and the prolonged run of 88 days in one patient indicate that it is difficult to predict lung recovery especially in young patients with minimal co-morbidities.

Prolonged ECMO runs can lead to capacity management issues, staff burnout and fatigue especially during contingency state in a pandemic.

Conclusion ELSO guidelines recommend that programs with established mobile ECMO programs and with sufficient resources to maintain it, should continue to offer this highly specialized therapy to surrounding hospitals. We report successful mobile ECMO cannulation for COVID associated severe ARDS by an experienced transport team for five patients while adhering to checklists and maintaining staff safety with no known exposure. While heavily resource intensive, maintaining strict PPE protocols is necessary to ensure successful patient and staff outcomes. J o u r n a l P r e -p r o o f 

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