Regional ECMO

Coordination- 10 years in 10

minutes HoltMurray,MD

DepartmentofCriticalCareMedicine

FEMA Principles of Emergency Management

Comprehensive

Progressive

Risk-Driven

Integration

Collaborative

Flexible

Professional

Lessons learned from H1N1

•  ECMOoutreachto“Spoke”hospitals•  Earlyidentificationandreferral• Capacityof“Hub”hospital•  EffectofincreasedECMOvolumeondailyoperations

• Adaptivestaffingmodels

Outreach and Early

Identification

Critical Components

• Physicianstaffing• Nursingstaffing• Perfusionstaffing•  ECMODevices• Disposablesupplies•  ICUCapacity

Inventory Assessment

RESP Score

Challenges of ECMO Response Planning

• Highresourceutilization•  Lagtime• Unabletoassessbenefitearly

Dynamic Criteria <50%Capacity

•  StandardselectioncriteriaandStandardexclusioncriteria•  Age<65y/o•  Mechanicalventilation<10days

•  Approximatesurvival>57%

50-80%Capacity•  Enhancedselectioncriteriaandenhancedexclusioncriteria

•  Age<60y/o•  MechanicalVentilation<7days•  Nopre-ECMOcardiacarrest•  Pplat<40cmH2O

•  Approximatesurvival>76%survival

>80%Capacity•  Stringentselectioncriteriaandenhancedexclusioncriteria

•  Age<50y/o•  Mechanicalventilation<5day•  Nopre-ECMOcardiacarrest•  Pplat<40cmH2O

•  Approximatesurvival>92%survival

PA Hospitals

Shared goals

•  Savethemostlives•  Ensurecapacitytocareforthosethataremostlikelytobenefit

•  Solidarityandsupportfordifficultdecisions• Providesimplicityandclarityfor“spoke”hospitals

Benefits of a Regional Approach

Fairness Transparency

MaximizeBenefit

Coordinationofresources

PA Regional Coalitions

Public Health Emergency Management

Ethics and Challenges

•  Selectioncriteria•  Age•  ICUadmissionv.Transplant

•  Stoppingrules• Overcapacitysystems• VentilatorandICUbedshortages

Timeline

15Mar.

Italy,FranceandSpainhealthsystemsclearlystressed

16Mar.

UPMCECMOcriteriacapacityandinventoryreviewed

20Mar.

UPMCSystemWideresponseplanandagreement

25Mar.

WesternPennsylvaniacollaborationbegins

30Mar.

FirstdiscussionswithUniversityofPennsylvania

2Apr.

RegionalCMOgroupandHealthDepartmentannouncecoordinatedcriteriaandplan

7Apr.

WeeklyStatewidediscussionsbegin

17Apr.

Consensusagreementacrossthestate

ELSO Phases of Response

State

Region

System

Hospital