Extracorporeal membrane oxygenation credentialing: where do we stand?

Developing a generalizable pediatric ECMO emergency checklist for clinical specialist: Progress and challenges

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) emergencies require skilled clinical specialist (CS) who manage ECMO circuits. While tools for assessing CS skills have been published, there is significant variation in protocols and circuit design. This study aims to further develop these checklists to produce a generalizable ECMO skill assessment with adequate validity evidence to support its use as a summative evaluation tool.

METHODS

An initial survey determined variation in ECMO circuit components and configurations, and the original checklists and simulations were altered through a modified Delphi process. The finalized checklist and simulation were then assessed for validity and reliability. Three trained raters assessed ten simulations from five subjects at two different institutions using two circuit designs. Data analysis was conducted using a fully crossed subject x rater x circuit generalizability (G) and decision (D) study.

RESULTS

The G-study coefficient was 0 with 0% variance across subject and circuit. The greatest variance was among raters (28.7%). Significant variance was also associated with the subject and pump type relationship (27%).

CONCLUSION

Despite the rigorous process used to modify the assessment, generalizability was poor. Lack of familiarity with center-specific circuit design played a key role. Future endeavors in ECMO skill assessment should focus either on developing and validating site-specific tools or standardizing circuit designs.

An International Survey of Extracorporeal Membrane Oxygenation Education and Credentialing Practices

Background

The use of extracorporeal membrane oxygenation (ECMO) has grown rapidly over the past decades because of evolving indications, advances in circuit technology, and encouraging results from modern trials. Because ECMO is a complex and highly invasive therapy that requires a multidisciplinary team, optimal education, training, and credentialing remain a challenge.

Objective

The primary objectives of this study were to investigate the prevalence and application of ECMO education and ECMO practitioner credentialing at ECMO centers globally. In addition, we explored differences among education and credentialing practices in relation to various ECMO center characteristics.

Methods

We conducted an observational study of ECMO centers worldwide using a survey querying participants in two major domains: ECMO education and ECMO practitioner credentialing. Of note, the questionnaire included ECMO program characteristics, such as type and size of hospital and ECMO experience and volume, to explore the association with the two domains.

Results

A total of 241 (32%) of the 732 identified ECMO centers responded to the survey, representing 41 countries across the globe. ECMO education was offered at 221 (92%) of the 241 centers. ECMO education was offered at 105 (98.0%) high-ECMO volume centers compared with 136 (87.5%) low-ECMO volume centers (P = 0.005). Credentialing was established at 101 (42%) of the 241 centers. Credentialing processes existed at 52 (49.5%) high-ECMO volume centers compared with 51 (37.5%) low-ECMO volume centers (P = 0.08) and 101 (49.3%) Extracorporeal Life Support Organization centers compared with 1 (2.7%) non-Extracorporeal Life Support Organization center (P < 0.001).

Conclusion

We found significant variability in whether ECMO educational curricula are offered at ECMO centers. We also found fewer than half of the ECMO centers surveyed had established credentialing programs for ECMO practitioners. Future studies that assess variability in outcomes among centers with and without standardized educational and credentialing practices are needed.

A Scoping Review and Appraisal of Extracorporeal Membrane Oxygenation Education Literature

Background

Despite a recent rise in publications describing extracorporeal membrane oxygenation (ECMO) education, the scope and quality of ECMO educational research and curricular assessments have not previously been evaluated.

Objective

The purposes of this study are 1) to categorize published ECMO educational scholarship according to Bloom’s educational domains, learner groups, and content delivery methods; 2) to assess ECMO educational scholarship quality; and 3) to identify areas of focus for future curricular development and educational research.

Methods

A multidisciplinary research team conducted a scoping review of ECMO literature published between January 2009 and October 2021 using established frameworks. The Medical Education Research Study Quality Instrument (MERSQI) was applied to assess quality.

Results

A total of 1,028 references were retrieved; 36 were selected for review. ECMO education studies frequently targeted the cognitive domain (78%), with 17% of studies targeting the psychomotor domain alone and 33% of studies targeting combinations of the cognitive, psychomotor, and affective domains. Thirty-three studies qualified for MERSQI scoring, with a median score of 11 (interquartile range, 4; possible range, 5–18). Simulation-based training was used in 97%, with 50% of studies targeting physicians and one other discipline.

Conclusion

ECMO education frequently incorporates simulation and spans all domains of Bloom’s taxonomy. Overall, MERSQI scores for ECMO education studies are similar to those for other simulation-based medical education studies. However, developing assessment tools with multisource validity evidence and conducting multienvironment studies would strengthen future work. The creation of a collaborative ECMO educational network would increase standardization and reproducibility in ECMO training, ultimately improving patient outcomes.

Development of a Standardized Assessment of Simulation-based Extracorporeal Membrane Oxygenation Educational Courses

Background

In 2020, the Extracorporeal Life Support Organization education task force identified seven extracorporeal membrane oxygenation (ECMO) educational domains that would benefit from international collaborative efforts. These included research efforts to delineate the impact and outcomes of ECMO courses.

Objective

Development of a standardized online assessment tool to evaluate the effectiveness of didactic and simulation-based ECMO courses on participants’ confidence, knowledge, and simulation-based skills; participant satisfaction; and course educational benefits.

Methods

We performed a prospective multicenter observational study of five different U.S. academic institution–based adult ECMO courses that met Extracorporeal Life Support Organization endorsement requirements for course structure, educational content, and objectives. Standardized online forms were developed and administered before and after courses, assessing demographics, self-assessment regarding ECMO management, and knowledge examination (15 simple-recall multiple-choice questions). Psychomotor skill assessment was performed during the course (time to complete prespecified critical actions during simulation scenarios). Self-assessment evaluated cognitive, behavioral, and technical aspects of ECMO; course satisfaction; and educational benefits.

Results

Out of 211 participants, 107 completed both pre- and postcourse self-assessment forms (97 completed both pre- and postcourse knowledge forms). Fifty-three percent of respondents were physician intensivists, with most (51%) practicing at academic hospitals and with less than 1 year of ECMO experience (50%). After the course, participants reported significant increases in confidence across all domains (cognitive, technical, and behavioral, P < 0.0001, 95% confidence interval [CI], 1.2–1.5; P < 0.0001, 95% CI, 2.2–2.6; and P = 0.002, 95% CI, 1.7–2.1, respectively) with an increase in knowledge scores (P < 0.001; 95% CI, 1.4–2.5). These findings were most significant in participants with less ECMO experience. There were also significant reductions in times to critical actions in three of the four scored simulation scenarios. The results demonstrated participants’ satisfaction with most course aspects, with more than 95% expressing that courses met their educational goals.

Conclusion

We developed and tested a structured ECMO course assessment tool, demonstrating participants’ self-reported benefit as well as improvement in psychomotor skill acquisition, course satisfaction, and educational benefits. Course evaluation is feasible and potentially provides important information to improve ECMO courses. Future steps could include national implementation, addition of questions targeting clinical decision making to further assess knowledge gain, and multilanguage translation for implementation in international courses.

Interprofessional ECMO telerounding: a novel approach to neonatal ECMO clinical participation and education

OBJECTIVE

Determine the feasibility, strengths, and barriers of offering extracorporeal membrane oxygenation (ECMO) telerounding to neonatal intensive care unit (NICU) care providers.

STUDY DESIGN

NICU providers were invited to join ECMO rounds by teleconference. Data were collected on telerounding participation and ECMO concepts discussed. A survey was sent to all providers.

RESULTS

From March 2018 to February 2020, telerounding on 24 neonatal ECMO patients (168 ECMO days) was performed in a Level IV NICU. A mean of four providers joined telerounds per ECMO day with an increase from 3 to 6 providers over the study period. Nearly all respondents felt telerounding lowered barriers to attending ECMO rounds (94%), promoted engagement (89%), and improved continuity of care (78%). Barriers to ECMO telerounding were suboptimal audio connections and limited ability to participate in the clinical discussion.

CONCLUSION

ECMO telerounding is well-received by NICU providers. It can improve provider participation, complement existing in-person ECMO rounds, and ECMO education.

Development of Validated Checklists to Evaluate Clinical Specialists in Pediatric ECMO Emergencies Using Delphi Method

Extracorporeal membrane oxygenation (ECMO) is a low-volume, high-risk modality of care. Clinical specialists (CS) who manage ECMO circuit emergencies vary in background and approach to circuit emergencies based on institutional training standards, leading to variation that may impact the quality of care. Validated checklists to assess CS performance are crucial to eliminate disparities and improve efficiency. This study focused on the development and validation of checklists to evaluate the clinical performance of ECMO CS in three ECMO circuit emergencies. A research team with diverse clinical background from our institution developed the first iteration of three ECMO emergency checklists: (1) venous air, (2) arterial air, and (3) oxygenator failure. A modified Delphi technique with a panel of 11 national content experts in ECMO was used to develop content validity evidence. Rating scales from 1 to 7 were used to evaluate each checklist item. The response rate for three rounds of Delphi was 100%. Items with mean score >4 were kept, and new item recommendations were added based on comments from the panel. The venous air, arterial air, and oxygenator failure checklists were revised from 10, 13, and 9 items to 12, 12, and 10 items, respectively. A Cronbach's α of 0.74 during the second round of responses indicated an acceptable degree of agreement. This study demonstrated content validation of three ECMO emergency checklists to assess performance of ECMO CS using a consensus-based Delphi technique. Future validity evidence should be acquired by implementing these checklists in the simulation environments.

Position Paper on Global Extracorporeal Membrane Oxygenation Education and Educational Agenda for the Future: A Statement From the Extracorporeal Life Support Organization ECMOed Taskforce

OBJECTIVES

The purpose of this position paper is two-fold: first, to describe the state of extracorporeal membrane oxygenation education worldwide, noting current limitations and challenges; and second, to put forth an educational agenda regarding opportunities for an international collaborative approach toward standardization.

DESIGN

Relevant medical literature was reviewed through literature search, and materials from national organizations were accessed through the Internet. Taskforce members generated a consensus statement using an iterative consensus process through teleconferences and electronic communication.

SETTING

In 2018, the Extracorporeal Life Support Organization convened the ECMOed Taskforce at two structured, face-to-face meetings of 40 healthcare practitioners and educators with expertise in caring for the extracorporeal membrane oxygenation patient and in extracorporeal membrane oxygenation education.

PATIENTS

None.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The ECMOed Taskforce identified seven educational domains that would benefit from international collaborative efforts. Of primary importance, the Taskforce outlined actionable items regarding 1) the creation of a standardized extracorporeal membrane oxygenation curriculum; 2) defining criteria for an extracorporeal membrane oxygenation course as a vehicle for delivering the curriculum; 3) outlining a mechanism for evaluating the quality of educational offerings; 4) utilizing validated assessment tools in the development of extracorporeal membrane oxygenation practitioner certification; and 5) promoting high-quality educational research to guide ongoing educational and competency assessment development.

CONCLUSIONS

Significant variability and limitations in global extracorporeal membrane oxygenation education exist. In this position paper, we outline a road map for standardizing international extracorporeal membrane oxygenation education and practitioner certification. Ongoing high-quality educational research is needed to evaluate the impact of these initiatives.

Development of the Adult ECMO Specialist Certification Examination

The American Society of Extracorporeal Technology Board of Directors, consistent with the American Society of Extracorporeal Technology's safe patient care improvement mission, charged the International Board of Blood Management to write a knowledge and skill certification examination for healthcare personnel employed as adult extracorporeal membrane oxygenation (ECMO) specialists. Nineteen nationally recognized ECMO subject-matter experts were selected to complete the examination development. A job analysis was performed, yielding a job description and examination plan focused on 16 job categories. Multiple-choice test items were created and validated. Qualified ECMO specialists were identified to complete a pilot examination and both pre- and post-examination surveys. The examination item difficulty and candidate performance were ranked and matched using Rasch methodology. Candidates' examination scores were compared with their profession, training, and experience as ECMO specialists. The 120-item pilot examination form ranked 76 ECMO specialist candidates consistent with their licensure, ECMO training, and clinical experience. Forty-three registered nurses, 28 registered respiratory therapists, four certified clinical perfusionists, and one physician assistant completed the pilot examination process. Rasch statistics revealed examination reliability coefficients of .83 for candidates and .88 for test items. Candidates ranked the appropriateness for examination items consistent with the item content, difficulty, and their personal examination score. The pilot examination pass rate was 80%. The completed examination product scheduled for enrollment in March 2020 includes 100 verified test items with an expected pass rate of 84% at a cut score of 67%. The online certification examination based on a verified job analysis provides an extramural assessment that ranks minimally prepared ECMO specialists' knowledge, skills, and abilities (KSA) consistent with safe ECMO patient care and circuit management. It is anticipated that ECMO facilities and ECMO service providers will incorporate the certification examination as part of their process improvement, safety, and quality assurance plans.

Practice patterns in imaging guidance for ECMO cannulation: A survey of the American Pediatric Surgical Association

BACKGROUND

Surgeon-specific variations in pediatric extracorporeal membrane oxygenation (ECMO) cannulation technique are not well characterized. Advances in technology have led to changing techniques with no formal consensus statement for reference.

METHODS

A survey was e-mailed to 1301 members of the American Pediatric Surgical Association (APSA). Categorical data was compared with Chi-squared and Kendall's tau-β tests, and multiple column comparisons were performed with the Bonferroni correction.

RESULTS

Response rate was 19%, with 248 pediatric general surgeons responding to the survey. 89.4% of respondents stated that cannulation was typically performed in the ICU. Venoarterial (VA) ECMO cannulation was more often performed open (88.6%) than venovenous (VV) ECMO (42.2%). Surgeons cannulate for VA ECMO and VV ECMO without imaging guidance 44% and 21.5% of the time, respectively. There was no difference in estimated rate of cannula repositioning by cannulation strategy. For venous and arterial cannulation in VA ECMO, surgeons were more likely to use the femoral as opposed to the neck when children were older than 13 years and weighed more than 35 kg regardless of the presence or absence of preexisting femoral arterial or venous access.

CONCLUSION

Practice patterns for ECMO cannulation are variable among pediatric surgeons. Standardization could reduce the occurrence of unsafe practices and potentially decrease complications and improve patient outcomes.

LEVEL OF EVIDENCE

Level IV.

Rapid Training in Extracorporeal Membrane Oxygenation for a Large Health System

Background: Despite the rapid integration of extracorporeal membrane oxygenation (ECMO) into intensive care units over the past decade, established programs for training critical care clinicians to provide ECMO are lacking.

Objective: To evaluate the development and implementation of a multidisciplinary ECMO training program for the rapid deployment of ECMO training for a high volume of critical care clinicians.

Methods: We performed a prospective cohort study examining a program for rapid training of multiple disciplines of critical care clinicians to deliver ECMO during the implementation of ECMO services across the intensive care units of an academic tertiary care center between October 2018 and January 2019. The multidisciplinary ECMO training program included didactic and simulation-based teaching and emphasized new, universal clinical protocols to improve consistency of care across the institution. Pre- and post-program written examinations evaluated knowledge acquisition, and an electronically distributed program evaluation assessed perceptions of content and delivery.

Results: Among the 97 clinicians who completed the program, 49 (51%) were physicians and 48 (49%) were advanced practice providers from the departments of surgery (n = 42), medicine (n = 29), and anesthesia (n = 26). There was a significant difference in knowledge about ECMO between the pre- and post-program examination score (median [interquartile range] 70% [60–80%] vs. 90% [80–90%], respectively, P < 0.001). The median (interquartile range) individual gain from pre- to post-program score was 20% (10–30%). The program was perceived as useful and applicable to safe care.

Conclusion: Rapid deployment of a multidisciplinary ECMO training program across a large academic center was feasible, achieved knowledge acquisition, and was positively perceived.

Curriculum to Introduce Critical Care Nurses to Extracorporeal Membrane Oxygenation

BACKGROUND

Despite the growing use of extracorporeal membrane oxygenation (ECMO) in intensive care units (ICUs), no standardized ECMO training pathways are available for ECMO-naive critical care nurses.

OBJECTIVES

To evaluate a critical care nurse ECMO curriculum that may be reproducible across institutions.

METHODS

An ECMO curriculum consisting of a basic safety course and an advanced user course was designed for critical care nurses. Courses incorporated didactic and simulation components, written knowledge examinations, and electronic modules. Differences in examination scores before and after each course for the overall cohort and for participants from each ICU type were analyzed with t tests or nonparametric equality-of-medians tests. Differences in postcourse scores across ICU types were examined with multiple linear regression.

RESULTS

Critical care nurses new to ECMO (n = 301) from various ICU types participated in the basic safety course; 107 nurses also participated in the advanced user course. Examination scores improved after completion of both courses for overall cohorts (P < .001 in all analyses). Median (interquartile range) individual score improvements were 23.1% (15.4%-38.5%) for the basic safety course and 8.4% (0%-16.7%) for the advanced user course. Postcourse written examination scores stratified by ICU type, compared with the medical ICU/cardiovascular ICU group (reference group), differed only in the neurovascular ICU group for the basic safety course (percent score difference, -3.0; 95% CI, -5.3 to -0.8; P = .01).

CONCLUSIONS

Implementation of an ECMO curriculum for a high volume of critical care nurses is feasible and effective.

Design of an entrustable professional activity for adult extracorporeal membrane oxygenation

Background

Extracorporeal membrane oxygenation supports severe cardiac or pulmonary failure. There are currently no competency-based standards for extracorporeal membrane oxygenation training.

Methods

Extracorporeal membrane oxygenation experts were interviewed using a structured interview. Responses were audio recorded, transcribed, and validated by respondents. Interviews were coded using grounded theory with a constant comparison method. Themes were developed and used to construct the entrustable professional activity, which was reviewed by the extracorporeal membrane oxygenation experts.

Results

Nine experts were interviewed; all had experience with trainees. Interview themes identified include patient selection, circuit and medical management, multidisciplinary communication, problem-based learning and simulation, and entrustment decisions. Essential functions of the entrustable professional activity were patient selection, circuit management, cannula selection, responding to circuit emergencies/complications, anticoagulation management, weaning, and family/team communication.

Conclusions

Essential functions of an extracorporeal membrane oxygenation entrustable professional activity were defined using data from structured interviews. The resultant entrustable professional activity could be implemented by critical-care programs as a scaffolding for competency-based fellow training.

•

A structured interview is an effective method for an EPA creation.

•

Nine experts with a median 14 years of ECMO experience were interviewed.

•

The essential functions for ECMO care were defined.

•

The ECMO EPA could be used for competency-based critical care education.

A skills acquisition study on ECMOjo: a screen-based simulator for extracorporeal membrane oxygenation

BACKGROUND

Extracorporeal membrane oxygenation relies heavily on didactic teaching, emphasizing on essential cognitive skills, but overlooking core behavioral skills such as leadership and communication. Therefore, simulation-based training has been adopted to instill clinical knowledge through immersive experiences. Despite simulation-based training's effectiveness, training opportunities are lessened due to high costs. This is where screen-based simulators come into the scene as affordable and realistic alternatives.

AIM

This article evaluates the educational efficacy of ECMOjo, an open-source screen-based extracorporeal membrane oxygenation simulator that aims to replace extracorporeal membrane oxygenation didactic instruction in an interactive and cost-effective manner.

METHOD

A prospective cohort skills acquisition study was carried out. A total of 44 participants were pre-assessed, divided into two groups, where the first group received traditional didactic teaching, and the second used ECMOjo. Participants were then evaluated through a wet lab assessment and two questionnaires.

RESULTS

The obtained results indicate that the two assessed groups show no statistically significant differences in knowledge and efficacy. Hence, ECMOjo is considered an alternative to didactic teaching as per the learning outcomes.

CONCLUSION

The present findings show no significant dissimilarities between ECMOjo and didactic classroom-based teaching. Both methods are very comparable in terms of the learner's reported self-efficacy and complementary to mannequin-based simulations.

Simulation training for crises during venoarterial extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) education, in particular with regards to crisis management during the provision of venoarterial extracorporeal membrane oxygenation (VA ECMO), is challenging due to its intrinsic characteristics-a complex, high risk, low volume clinical activity which requires dynamic decision making, interdisciplinary teamwork and communication, and rapid response. Simulation training that focuses on crisis resource management and interprofessional communication is well-suited to address these training needs. Institutional commitment to provide both capital and human resources is instrumental to the success of ECMO training programs. Future multicenter studies with standardized training curricula are required to investigate the impact of ECMO simulation training on patient outcome.

Addressing the challenges of ECMO simulation

INTRODUCTION/AIM

The patient's condition and high-risk nature of extracorporeal membrane oxygenation (ECMO) therapy force clinical services to ensure clinicians are properly trained and always ready to deal effectively with critical situations. Simulation-based education (SBE), from the simplest approaches to the most immersive modalities, helps promote optimum individual and team performance. The risks of SBE are negative learning, inauthenticity in learning and over-reliance on the participants' suspension of disbelief. This is especially relevant to ECMO SBE as circuit/patient interactions are difficult to fully simulate without confusing circuit alterations.

METHODS

Our efforts concentrate on making ECMO simulation easier and more realistic in order to reduce the current gap there is between SBE and real ECMO patient care. Issues to be overcome include controlling the circuit pressures, system failures, patient issues, blood colour and cost factors. Key to our developments are the hospital-university collaboration and research funding.

RESULTS

A prototype ECMO simulator has been developed that allows for realistic ECMO SBE. The system emulates the ECMO machine interface with remotely controllable pressure parameters, haemorrhaging, line chattering, air bubble noise and simulated blood colour change.

CONCLUSION

The prototype simulator allows the simulation of common ECMO emergencies through innovative solutions that enhance the fidelity of ECMO SBE and reduce the requirement for suspension of disbelief from participants. Future developments will encompass the patient cannulation aspect.

The Role of Extracorporeal Membrane Oxygenation Simulation Training at Extracorporeal Life Support Organization Centers in the United States

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) requires a multidisciplinary healthcare team. The Extracorporeal Life Support Organization publishes training guidelines but leaves specific requirements up to each institution. Simulation training has shown promise, but it is unclear how many institutions have incorporated simulation techniques into ECMO training to date.

METHODS

We sent an electronic survey to ECMO coordinators at Extracorporeal Life Support Organization sites in the United States. Participants were asked about training practices and the use of simulation for ECMO training. Descriptive results were reported as the percentage of total responses for each question. Logistic regression was used to identify characteristics associated with simulation use.

RESULTS

Of 94 responses (62% response rate), 46% had an ECMO simulation program, whereas 26% report a program is in development. Most (61%) have been in operation for 2 to 5 years. Sixty-three percent use simulation for summative assessment, and 76% have multidisciplinary training. Access to a simulation center [odds ratio (OR) = 4.7, 95% confidence interval (CI) = 1.7-12.5], annual ECMO caseload of greater than 20 (OR = 2.5, 95% CI = 1.5-5.8), and having a pediatric cardiothoracic intensive care unit (OR = 2.8, 95% CI = 1.2-6.7) are each associated with increased likelihood of mannequin-based ECMO simulation. Common scenarios include pump failure (93%), oxygenator failure (90%), and circuit rupture (76%).

DISCUSSION

Extracorporeal membrane oxygenation simulation is growing but remains in its infancy. Centers with access to a simulation center, higher caseloads, and pediatric cardiothoracic intensive care units are more likely to have ECMO simulation programs. Extracorporeal membrane oxygenation simulation is felt to be beneficial, and further work is needed to delineate best training practices for ECMO providers.

Education for ECMO providers: Using education science to bridge the gap between clinical and educational expertise

A well-organized educational curriculum for the training of both novice and experienced ECMO providers is critical for the continued function of an institutional ECMO program. ELSO provides guidance for the education for ECMO specialists, physicians and staff, which incorporates "traditional" instructor-centered educational methods, such as didactic lectures and technical skill training. Novel research suggests utilization of strategies that align with principles of adult learning to promote active learner involvement and reflection on how the material can be applied to understand existing and new constructs may be more effective. Some examples include the "flipped classroom," e-learning, simulation, and interprofessional education. These methodologies have been shown to improve active participation, which can be related to improvements in understanding and long-term retention. A novel framework for ECMO training is considered. Challenges in assessment and credentialing are also discussed.

The Utility of High-Fidelity Simulation for Training Critical Care Fellows in the Management of Extracorporeal Membrane Oxygenation Emergencies: A Randomized Controlled Trial

OBJECTIVE

Although extracorporeal membrane oxygenation volume has increased, proficiency in the technology requires extensive training. We compared traditional water-drill-based extracorporeal membrane oxygenation training with simulation-based extracorporeal membrane oxygenation training with the hypothesis that simulation-based training is superior.

DESIGN

Randomized controlled trial.

SETTING

Academic medical center.

SUBJECTS

Pulmonary/critical care fellows.

INTERVENTIONS

Participants had a preintervention simulated extracorporeal membrane oxygenation emergency (Sim1-recirculation) then randomized into simulation and traditional groups. Each group participated in three teaching scenarios, via high-fidelity simulation or via water-drills. After 6 weeks and after 1 year, participants returned for two simulated extracorporeal membrane oxygenation emergencies (Sim2-pump failure and Sim3-access insufficiency). Sim2 was a case encountered during teaching, whereas Sim3 was novel. A critical action, necessary for resolution of each scenario, was preidentified for timing.

MEASUREMENTS AND MAIN RESULTS

Primary outcome was time required to perform critical actions. Twenty-one fellows participated in the study (simulation, 10; traditional, 11). Groups had similar scenario scores (p = 0.4) and times to critical action (p = 0.8) on Sim1. At 6 weeks, both groups had similar scenario scores on Sim2 (p = 0.5), but the simulation group scored higher on Sim3 (p = 0.03). Times to critical actions were shorter in the simulation group during Sim2 (127 vs 174 s, p = 0.004) and Sim3 (159 vs 300 s; p = 0.04). These findings persisted at 1 year.

CONCLUSIONS

In novice critical care fellows, simulation-based extracorporeal membrane oxygenation training is superior to traditional training. Benefits transfer to novel scenarios and are maintained over the long term. Further studies evaluating the utility of simulation in other learner groups and for maintenance of proficiency are required.

Simulation for neonatal extracorporeal membrane oxygenation teams

Extracorporeal membrane oxygenation (ECMO) is a highly technical and complex method of life support. Patient and circuit emergencies on ECMO are rare, but in these cases, prompt and correct actions to address the crisis are needed to prevent morbidity and mortality. ECMO simulation programs have gained popularity in recent years, as they provide a standardized educational experience for all members of the inter-professional care team. In addition to providing a context in which to solidify knowledge of ECMO support, participants are also able to focus on vital technical and behavioral skills that are not highlighted in other training methodologies. ECMO simulation can also be used for quality improvement, clinical and educational research, and assessment/credentialing. Multi-organizational international collaboratives have formed, and are working to standardize ECMO education training across institutions; simulation will play an essential role in this process.