Published in the September 2014 issue
HOSPITALISTS keep proving their value through their care of complex patients. But very few patients are as complex as those recovering from extracorporeal membrane oxygenation (ECMO), a procedure that uses a machine to oxygenate blood and allow patients’ lungs to heal.
Long used to rescue premature babies, the technique has only recently begun to be utilized in adults. For hospitalists who are treating post-ECMO patients on the wards, the learning curve can be “steep.”
That’s according to Kevin Breger, MD, PhD, medical site director for Legacy Internal Medicine Service at Legacy Emanuel Medical Center in Portland, Ore.
“People are intimidated,” Dr. Breger admits. “Not many of our current hospitalists “and we have about 30 “had any prior experience with post-ECMO patients, and it wasn’t part of their training. We’re all learning as we go.”
Legacy Emanuel, under the direction of surgeon Andrew Michaels, MD, began its formal ECMO program in 2009. The center currently has six machines, all housed in the neuro-trauma ICU. Post-ECMO, patients recover first in the general medicine ICU, which is staffed by intensivists. Hospitalists take over care when patients transition to the floors.
The general indications for ECMO are severe respiratory failure and severe acute respiratory distress refractory to typical ventilatory strategies. “We saw spikes in the number of ECMO patients during H1N1 influenza in both 2009 and 2013,” Dr. Breger points out.
The center has also used ECMO for COPD patients with severe pneumonia, MRSA pneumonia, streptococcal toxic shock, hantavirus pulmonary syndrome and intentional overdose. While the number of post-ECMO cases spikes in the winter, “we generally have between two and six post-ECMO patients at any one time.”
Even out of the ICU, most of these patients are housed in the post-trauma unit. “Many trauma patients have similar problems in their care,” Dr. Breger explains, “so the nursing staff on that unit is best suited to care for patients post-ECMO.”
How complicated is it to coordinate care for these patients? Coming off the machine, many require long-term ventilation with tracheostomy and dedicated respiratory therapy, and many need wound care for the ports of entry for various lines.
In addition, many post-ECMO patients have nutritional issues, while some develop renal failure and need short-term dialysis. Then there are physical, occupational and speech therapy, as well as a psychologist who interacts with patients and families “to help with the anxiety and stress of going through such a traumatic event,” says Dr. Breger. The hospital’s dedicated palliative care team, which is involved as soon as patients are put on the machine, follows patients throughout their hospitalization.
“There are numerous moving parts on multiple levels,” Dr. Breger says. Another challenge is staggeringly long lengths of stay. “We’ve had some patients admitted and discharged through the ECMO program in as little as two or three weeks. But others have been in the hospital for months.”
To help hospitalists up such a steep learning curve, the director of the ECMO program has made several educational presentations. Hospitalists also share stories among themselves on common complications.
One frequent discussion centers around the fact that many of these patients get large venous and/or arterial blood clots because of the locations of catheters inserted during ECMO treatment, Dr. Breger says.
“That’s a complication unique to these patients,” he explains. “We’ve learned to make sure to document in our notes and to mention in signout if there is or is not a blood clot that needs to be monitored.”
Many patients also have IVC filters placed. “Keeping track of who has an IVC filter and when these filters need to come out “that’s another common theme,” he points out.
Given how long patients can stay on the wards, continuity is another problem. “That’s one downside to hospitalists taking care of these patients because we tend to frequently switch shifts,” he says, noting that the hospitalists work five- to seven-day blocks, but not strict seven-on/seven-off. “It would be nice to increase our continuity with these complicated patients.”
And with such long lengths of stay, hospitalists are challenged to effectively communicate patients’ hospital course to a new doctor coming on service.
“If that week happens to be the week of discharge, it’s hard to come up with a cohesive document that can summarize all the important procedures and key elements of the hospitalization,” Dr. Breger says. It’s helped to have a hospitalist in a three-way conversation with both an intensivist and the ECMO surgeon when a patient is first transitioned to the floor.
ICU personnel also now do a better job keeping a running tally of daily notes on post-ECMO patients in the ICU and then passing those notes along to the hospitalists. And the hospitalists have learned to pay particular attention to documenting the procedures patients have had as well as their courses of antibiotics and their active problem or diagnosis lists.
“It’s still a work in progress,” says Dr. Breger, “but we’re learning to standardize our documentation.”
One alternative to having hospitalists manage these patients on the wards would be to have a dedicated physician assistant see these patients through “from start to finish,” Dr. Breger points out. However, as the ECMO program has grown, hospitalists have filled the need for ward management and have the clinical skills to care for these complicated patients.
Right now, all group members take turns caring for these patients. “They’ve all developed a skill set that not many physicians have,” says Dr. Breger. Those skills will only continue to develop because Legacy Emanuel is an acute respiratory illness rescue center.
“We’ve already seen patients come for ECMO from out of state,” he notes. “We’re definitely going to be seeing more and more severely ill patients, with or without ECMO.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.