Extracorporeal membrane oxygenation (ECMO) is a life-saving medical therapy that provides temporary mechanical circulatory support (MCS) for patients with severe heart or lung failure. Due to expanded clinical indications, improved patient outcomes, and advancements in related technologies, the use of ECMO has increased significantly over the past decade, with over 260 hospitals in the US now offering ECMO.[1]
While ECMO is not a new clinical therapy, the concept of mobilizing this service appears to be an emerging trend in quaternary programs. Mobile ECMO offers access to advanced care for patients during transportation and those in resource-limited areas while increasing the patient volume for ECMO centers. In light of this, cardiovascular (CV) leaders need to consider whether mobilizing their ECMO program would serve as an effective way to grow MCS volumes, expand care geographically, and strengthen CV partnerships.
Notable Trends in Mobile ECMO
- More Compact Equipment: Advancements in technology have led to the development of more compact and portable ECMO machines. These smaller devices make it easier for healthcare providers to supply ECMO support to patients outside of traditional hospital settings, including during transport between care facilities.
- Dedicated Transport Teams and Protocols: Healthcare systems that offer mobile ECMO often have a dedicated ECMO transport team with the expertise to safely move critically ill patients on ECMO from one facility to another. These systems have also developed standardized protocols for transport to ensure patient safety during this process.
- Ambulance ECMO: Some health systems are establishing partnerships with ambulance companies in order to equip these vehicles with ECMO so that MCS can be initiated on site or during transportation to a tertiary or quaternary medical center. This added capability can potentially improve outcomes for patients in critical condition who require ECMO immediately.
- Integration of Telemedicine and Remote Support: Telemedicine and remote-monitoring technologies can be integrated into mobile ECMO programs to allow ECMO specialists to provide guidance and support to healthcare teams at different facilities, thereby enabling more efficient and timely care.
- Expanded Indications: Over time, the criteria for initiating mobile ECMO support have expanded. As a result of increased experience and research—due in large part to the use of ECMO during the COVID‑19 pandemic—ECMO is now used for various respiratory and cardiac conditions that were previously deemed unsuitable.
- Improved Training and Education: As the use of mobile ECMO becomes more widespread, provider organizations are offering specialized training and education for healthcare professionals involved in ECMO services. This often includes interdisciplinary and simulation-based activities, which allow clinicians to practice their ECMO management skills across a variety of scenarios, such as during transportation or in the field.
Building the Necessary Partnerships
An important component of ECMO mobilization is establishing community or regional partnerships to provide ECMO transport via a hub-and-spoke model, as illustrated in figure 1. While the minimum number of annual ECMO cases needed to sustain an ECMO center is often debated, various studies conclude that an inverse linear relationship between mortality rate and volume exists, with 30 being the lowest number of recommended annual cases.[2]
As shown in figure 2, higher-volume ECMO centers may have reduced mortality rates and improved outcomes. Regional partnerships can support the concentration of patients to one site, leading to more coordinated and efficient care, better patient outcomes, improved resource allocation, and continued advancement in ECMO expertise and management.
Figure 1: ECMO Hub-and-Spoke Transportation Model
Figure 2: Risk-Adjusted Relationship between Hospital ECMO Volume and Mortality Rate[3]
When developing these essential network partnerships, hospitals and health systems will need to ensure proper transportation and transfer agreements, as well as provider credentialing, are in place.
- Transport Agreement: Referring and accepting hospitals will need to establish a transport agreement detailing the responsibilities, liabilities, and performance standards for each party.
- Transfer Agreements: Referring and accepting hospitals will need to establish a transfer agreement documenting the parties’ agreement to transport patients between their facilities.
- Provider Credentialing: Care team members will need to be credentialed at all community partner facilities where they could provide ECMO services.
If your organization doesn’t have an internal department for either ground or air transportation, you’ll also need to partner with a reliable transportation company. Due to the additional risk and training required to operate ECMO while in air, it is especially critical to find a service provider that excels in aircraft maintenance and is willing to comply with any necessary rig modifications, additional training, and operational guidelines related to the mobile ECMO program. Establishing close partnerships with local companies will enable a quick response time while ensuring a high level of trust for the ECMO team, both of which are vital to the success of the program.
Developing a Best-in-Class Program
When developing a mobile ECMO program, start by determining the geographic areas you want to serve, as the location and reach of the program will generate associated requirements and considerations.
- A multistate operation, especially one that intends to work with nonaffiliated healthcare organizations, requires additional up-front work to ensure appropriate provider credentialing is obtained and maintained by all physicians participating in the program.
- The geographic reach of a program will also dictate the type of transportation needed. If you are serving local health systems, an ambulance would be a sufficient mode of transportation; however, if you are servicing systems in multiple states, you may need to consider a helicopter or fixed-wing aircraft.
- Finally, consider reimbursement implications related to the transportation of patients. If there is an ECMO center between the referring hospital and the home organization, CMS may not reimburse the distance from that center to the home hospital. Strategic market selection is key to avoiding these types of disadvantages.
Once a network of care has been established, it is time to start handling requests for patient transport. Programs typically choose between using a call center, where an agent gathers patient information and then transfers the call to the on-call provider, or a direct call number, where calls route directly to the on-call provider. In both cases, if a patient is a candidate for mobile ECMO, the mobile ECMO team would be activated to treat and transport the patient back to the facility.
Due to the urgent nature of patients requiring ECMO intervention, minimizing the steps required for triaging widens the path for success. Therefore, a direct call number to the on-call physician or program manager is best practice, as it enables quick and accurate decision-making, especially if inclusion criteria is shared ahead of time with the referring organization and sufficient education. Distributing mobile ECMO program details via flyers, informational emails, conferences and other professional events, and even direct provider networking will help advertise the program and shorten the lead time from patient identification to mobile ECMO intervention.
Support from organizational leadership is also an essential component to a program’s success. Buy-in is needed in order to:
- Build and maintain collaborative relationships with various clinical and nonclinical hospital departments.
- Ensure all administrative requirements are completed on time.
- Develop and sustain a thorough training program.
- Effectively partner with external transportation companies and healthcare organizations to support the network.
Enterprise-level goal-setting and program management efforts will be critical, especially in the early phases when the program will inevitably experience growing pains.
Select Program Characteristics
Mobile ECMO programs vary by organization based on patient demands. Table 1 illustrates key characteristics of select mobile ECMO programs around the country, which may be helpful to leaders who are considering mobilizing their ECMO programs.
Table 1: Select Mobile ECMO Programs and Characteristics
So Should You Go Mobile? A Summary of Considerations for Leadership
When deciding whether to offer a mobile ECMO program, system leaders must ensure they can provide all the required elements discussed herein. To do so, refer to the recently published Extracorporeal Life Support Organization (ELSO) guidelines, which outline five key components present in all high-quality, successful programs.
Table 2: ELSO’s Top Five Considerations for Building a Mobile ECMO Program
In addition to the above recommendations from ELSO, ECMO program leaders must carefully manage the financial viability of the program, which will include developing a network that supports the level of programmatic volume necessary to generate a positive return on investment. The ECMO program’s quaternary reputation, market share, and ability to grow MCS case volume are all factors that will contribute to a healthy and sustainable program.
As the use and demand for ECMO increases, existing programs may consider whether to offer ECMO transportation. Successful mobile ECMO programs prioritize patient safety and operations. The decision to offer mobile ECMO must be well thought out, with program leaders carefully evaluating the value this life-saving care provides to patients versus the costs and resources required to start and maintain a program of this caliber.
ECG’s CV consulting team is passionate about improving CV care delivery. Since 2010, team members have conducted nearly 300 CV engagements across more than 100 organizations. Our experts focus on providing executive advisory services to the nation’s leading CV programs.
Edited by: Emily Johnson
_________________________
1 Stentz MJ, Kelley ME, Jabaley CS, O'Reilly-Shah V, Groff RF, Moll V, Blum JM, “Trends in Extracorporeal Membrane Oxygenation Growth in the United States,” ASAIO J, Sept/Oct 2019.
2 Abrams, D., Garan, A.R., Abdelbary, A. et al., “Position paper for the organization of ECMO programs for cardiac failure in adults,” Intensive Care Med, February 2018.
3 Verma, A., Hadaya, MD, PhD, J., et al., “A contemporary analysis of the volume–outcome relationship for extracorporeal membrane oxygenation in the United States,” Surgery, June 2023.
4 “First-of-its-kind medical truck launches in the Twin Cities metro to treat cardiac arrest patients,” February 3, 2021 News Release, University of Minnesota.
5 “Mobile Life Support Delivered to Area Hospitals During COVID‑19 Pandemic,” From the Newsroom, UC San Diego Health. “Elements of a Comprehensive ECMO Program,” UC San Diego Health.
6 “About Our Mobile ECMO Transport Team,” NewYork-Presbyterian website.
7 “Penn Medicine Mobile ECMO: A Plan In Motion For At Risk Cardiac and Respiratory Patients,” Penn Medicine Physician Blog.
8 “Mobile ECMO Available to Move Critically Ill Patients to Hopkins,” News & Publications, Johns Hopkins Medicine.
9“Extracorporeal Life Support Organization Guideline for Transport and Retrieval of Adult and Pediatric Patients with ECMO Support,” ASAIO Journal, 2022.
