The use of extracorporeal membrane oxygenation (ECMO) systems in critical cardiac and respiratory disease has continued to grow steadily in recent years, despite being a highly complex technique with a variable impact on patient morbidity and mortality. In addition to the evidence obtained in clinical trials, expert recommendations such as those published by the Spanish Society of Intensive Care Medicine, Critical Care and Coronary Units (SEMICYUC), in the context of use and indications1 or transport of the technique,2 are very useful. We present our experience with the organization and transfer in ECMO, highlighting organizational and safety aspects that may be useful for other groups to improve the quality of care for these complex patients.

The hospital’s mobile ECMO program grew out of the need to provide secondary transport, i.e., to transfer patients already on ECMO from our center to the referral hospital for cardiac transplant evaluation. Shortly thereafter, and to facilitate access to the technique for patients located in other nearby hospitals, it was decided to expand coverage to include primary transport, i.e., the displacement of an expert team for cannulation and the start of therapy in a hospital without ECMO capacity, followed by transfer to our center with the support.2 The first step was the creation of a multidisciplinary unit, which we call the Mechanical Circulatory Assist Unit (UAMC-HUVN), consisting of intensivists, cardiovascular surgeons and perfusionists. We remain committed to this multidisciplinary organizational model, which enhances the quality of care and covers all events that may occur during cannulation and transport. The model considers the role of the cardiovascular surgeon if surgical cannulation or vascular repair is required, or the role of the perfusionist in managing potential device incidents.

The mobile ECMO team consists of an intensivist, a cardiovascular surgeon and a perfusionist, along with out-of-hospital transport staff (technician and nurse) and, also often one or two resident physicians. We have established an “ECMO code” with the out-of-hospital transport system, and with a single call, two ambulances are activated: a conventional ambulance for staff and supplies; and a second one specific for transfer of the critical patient. Since 2016, at UAMC-HUVN we have performed 40 interhospital ECMO transfers (80% primary transfers), 28 of which (70%) were performed in the last four years. Ten of the transfers (25%) were to a hospital in the same province, while the rest corresponded to interprovincial transport: 17 to Almería (42.5%), eight to Córdoba (20%), four to Jaén (10%) and one to Málaga (2.5%). The clinical characteristics of the patients are shown in Table 1. All transfers were by land. There were no deaths or serious complications during transfer, although five minor complications occurred: three related to the means of transport (low power supply and mechanical failure), one to the patient (hypoxemia), and one to the staff (incorrect labeling of blood products).

In full accordance with the aforementioned SEMICYUC recommendations,2 we would like to highlight the strengths of our mobile ECMO program (Fig. 1):

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  Continuous and effective communication between the participating hospitals, particularly in aspects such as optimization of the pre-ECMO clinical situation, adequate preparation of the patient before team arrival (cannulation of new vascular accesses, need for prior transfusion or preparation of blood products for transport, availability of ultrasound and/or transesophageal probe, light source, etc.), or information for the patient’s family. To strengthen this good relationship between hospitals, lectures have been given at the “donor” centers and joint conferences have been held, thus creating an environment of trust and cooperation.

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  Multidisciplinary decision-making. Once the patient’s medical record is received, all cases are discussed amongst the intensivist (with ECMO experience) and cardiovascular surgeon - and often by several members of each specialty - which promotes shared decision-making and provides reassurance to the specialists. In this way, we gain a better perspective when making decisions and reinforce teamwork, which is associated with better outcomes.3 This is what we call dual opinion or dual assessment in decision-making.

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  Proper transfer planning is essential. We have a specific protocol that is summarized in the form of a checklist (Fig. 2), but prior planning for each case is also crucial:

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    Which hospital are assisting? Have we been there before? How far is it and what is the expected travel time?

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    Do we know the compatibility of materials and connections? Sometimes there may be compatibility problems with the monitoring equipment (electrodes, pulse oximeters, etc.), which we have solved by moving with an autonomous portable monitor and its consumables.

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    What cannulation strategy will we use? What vascular accesses does the patient have?

  
  

  Figure 2.

  Interhospital transfer checklist with ECMO.
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  With experience, we have learned to simplify things within the complexity of this procedure. The transfer material and medication have been reduced to the minimum expression (cannulas and wires, double circuit, surgical material, etc.), and are integrated into two transfer cases (one with medication and consumables, periodically checked by the intensivist; other with surgical material and cannulas, checked by the perfusionist) (Fig. 3A). We included a refrigerator for blood products and oxygen cylinders (from two to four, depending on the distance), but we have left out the gasometer, which is less useful for short transfers. Similarly, we were able to find solutions to problems that arose in some cases, such as checking the electrical system of the ambulance at the exit of the team, minimizing the number of perfusions to facilitate transfers, or obtaining adapters for oxygen/air supply points that we may find in other centers (Fig. 3B).

  
  

  Figure 3.

  A. Interhospital transfer suitcases; B. Various adapters for air and oxygen connections.
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  The professionals are in a period of continuous learning, as it cannot be otherwise.4 The transfer protocol is constantly being revised and updated, which has allowed us to simplify it based on the experience gained. It is a good idea to keep a record of cases and to debrief transfers and possible incidents.5 In the absence of simulations, the incorporation of new professionals into the program is facilitated by progressive participation in transfers, under the supervision of another experienced intensivist, and by the existence of a transfer checklist which, in addition to being a patient safety measure,6 is of great help during the learning phase.

Figure 1.

Key points of the mobile-ECMO program.

In summary, mobile ECMO programs should consist of multidisciplinary teams with problem-solving skills and continuous learning, where communication and shared decision-making are the norm.