ECMO networks
The decision to use ECMO in COVID-19 patients relates not only to the expected benefit of therapy and possible risks, but also to the availability of ECMO supplies and hospital infrastructure, and personal and group experience. These last two points are essential when establishing joint strategies and guaranteeing an adequate organization of personnel, equipment, facilities, and systems. As with any scarce resource in times of high demand, mismatches may appear in these factors, and it is preferable to anticipate with an action plan that develops a sustainable system to ensure quality of care.
In Spain, in the pre-COVID era, there was no uniform organization for ECMO care. In some regions (Valencia, Catalonia, or Eastern Andalusia, for example), there were well-defined programs, with clear action coordinates for referring patients to ECMO centers, and even with availability for remote implants and inter-hospital transport. However, in other areas, each hospital that had the therapy offered it openly to its secondary and regional reference hospitals in an unorganized way and without defined patient flows. The same peripheral hospital could send some cases to its referral hospital for cardiac surgery (and ECMO therapy) and send other cases to any of the tertiary hospitals in its environment, without any administrative interference and by simple decision of the treating doctor.
The arrival of the pandemic, with the sudden increase in the need for intensive care beds and extracorporeal respiratory support, meant that a well-defined referral and transfer system needed to be organized from each regional Health Administration to provide access to the specialized care needs of the patients of all the first- and second-tier hospitals. ECMO Reference Hospitals were designated and their satellite hospitals were specified.
This has planted the seed for an ECMO Network system on a hub & spoke model which, while not yet fully developed in all areas, seems to perfectly fit the needs of the new organization and could be consolidated in the future for all ECMO care nationwide.
Resources:
Training in ECMO must be ensured for all members of the group to be able to act as reinforcement or replacement in case of illness of the professionals initially assigned to the ECMO pandemic team.
It is mandatory to periodically update the inventory of available machines ready for use and to forecast the needs so as to ensure a constant supply of consumables.
Contact between hospitals:
The success of ECMO therapy is based, among other factors, on an early implantation when the clinical indication is clear, and this involves not deferring the decision when the previous therapeutic steps have not yielded the expected result. In a pandemic situation, this is especially relevant and therefore there must be frequent communication between the satellite hospital and the ECMO hospital, assessing the evolution of the most seriously ill patients and anticipating situations of sudden deterioration (not infrequent in critically ill COVID-19 patients) in which the ECMO option is possibly already too late. If the speed of progression of the disease from dyspnea to ARDS is rapid or unknown, we recommend early transfer (after tracheal intubation, for example) to an ECMO center, wherever possible.
This fact is considered critical in the technical document of the Ministry of Health, and for this reason it explicitly states that ”in the event that the center does not have the technique, transfer to a reference center must be considered” and that ”there must be early contact between centers”, according to clinical and analytical criteria summarized in Table 1.
Inter-hospital transport:
In our country there are mobile programs for ECMO implantation and inter-hospital transport of assisted patients (La Fe Hospital in Valencia, Bellvitge Hospital in Hospitalet de Llobregat-Barcelona, Virgen de las Nieves Hospital in Granada, among others) that offer appropriate service to their reference area, but they are a minority in Spain and otherwise, there are only isolated experiences with remote implants both in adults and in pediatric patients (Hospital 12 de Octubre in Madrid).
The hasty reorganization of ECMO assistance necessitated by the pandemic is a good starting point to try to expand such initiatives and establish a well-organized network of remote ECMO assistance with all its possibilities. It seems clear that high-volume ECMO centers, particularly those serving as a regional benchmark, should establish and coordinate mobile ECMO teams available 24 hours a day, 7 days a week, and made up of personnel trained and experienced in transporting critically ill patients and inserting cannulas.
Among the basic principles on which the constitution of these mobile ECMO teams should be based, in the context of a pandemic, we can point out15: