ECMO competency after education provided by an ECMO nurse educator versus competency after education provided by a circulatory perfusionist.

Introduction:

In a large metropolitan medical center, a group of Cardiac ICU (CICU) nurses was selected to engage in ECMO (extracorporeal membrane oxygenation) training. Specifically, 17 nurses were ICU competent but needed orientation to the complexities of patients requiring ECMO therapy.

Participants:

All the nurses involved in this quasi-experimental examination were competent to deliver ICU therapy in this high-acuity 22-bed CICU. The median length of experience of the target ICU nurses was 3.7 years. Both baccalaureate and associate degree nurses were selected to receive this orientation. All the nurses involved were also well-versed in circulatory support using the intra-aortic balloon pump, respiratory support using advanced ventilation techniques, and pressure monitoring using invasive lines (arterial, pulmonary, etc.). The nurses involved were competent to care for patients experiencing a coronary infarct as well as patients just coming from the operating room following a coronary bypass procedure. The CICU unit used for this examination is closed to new nurses. A minimum of one year of experience as a nurse, preferably in a high-acuity environment, is a prerequisite for employment and assignment to this unit.

Content For Competency:

ECMO training was identified as a gap in the competency of the unit’s nursing workforce. Specifically, there were not enough nurses competent to operate the ECMO pump and the circuit for this treatment. In this unit, when ECMO was being used as a therapy, there were two nurses assigned to the patient. One of the nurses is dedicated to operating the pump, and the other is assigned to ensure the stability of the patient. In general, this unit is a closed unit. This means that the staff of this unit are not used to supplement staffing in other units of the medical center. The converse is also true. No staff from other units are used to supplement the workforce of this unit.

The development of the ECMO content to be covered was gathered by a circulatory perfusionist and an expert-level ECMO nurse. Then, prior to developing and delivering the course outline to the nurses, the medical staff (cardiology and cardiothoracic/vascular surgery) added and deleted items from the outline. The medical staff then approved the topics on the course outline that would ultimately be delivered to the nurses.

The nurses were divided into two groups to efficiently carry out the orientation, so a meaningful ECMO knowledge transfer occurs. One group of eight nurses was put under the guidance of the expert ECMO nurse who was involved in crafting the course content. The nine remaining nurses received orientation to this therapy from the cardiac perfusionist who also crafted some of the competency outline. The nurses who were oriented to ECMO were selected based on their interest in this therapy and in growing their nursing practice. Some of the traits of each group are presented below:

Nurse-Led Training:

• Eight nurses
• Three male nurses
• The average longevity as an ICU RN was 3.4 years.
• Seven of the nurses were baccalaureate-prepared nurses.

Perfusionist Led Training:

• Nine nurses
• One male nurse
• The average longevity as an ICU RN was 3.8 years.
• Five of the nurses were baccalaureate-prepared nurses.

The essential purpose of this study is to determine if there is any difference in the competency of the new ECMO nurses after course completion based on who taught them the content; the ECMO perfusionist or the nurse.

It was determined that 36 hours were required to deliver the content and engage in the bedside activities required for competence. For instance, decreasing or increasing the flow of blood through the membrane was reviewed. Also covered was the use of ECMO in conjunction with IABP so that there is pulsatile blood flow.

Post-Intervention Activities:

It was self-evident that, at the start of this study, the nurses were not competent to independently manage an ECMO pump/therapy. After reviewing the content delivered by a circulatory perfusionist or an expert-level ECMO nurse, an assessment was completed. The assessment contained 50 questions, 10 of which were posed in each of the five domains of ECMO competency (Chidume et al., 2023).

To be determined competent, eight of the ten questions in each domain must have been answered correctly. If a domain resulted in more than 2 missed questions, the domain was remediated for the orientee by the preceptor. Both the expert-level ECMO nurse and the circulatory perfusionist had three orientees that required remediation in at least one domain. The circulatory perfusionist had two nurses, and there were three domains that failed to demonstrate competence. However, the expert-level ECMO nurse had only three nurses failing on a single domain, and it was the same domain for all three orientees.

? In addition to the 50-question assessment, the orientees were required to demonstrate competence in the simulation lab on a mannequin patient who presented with major ECMO emergencies. The orientees each completed the simulation independently with their respective preceptors. None of the nurses failed to manage ECMO complications up to and including ECMO emergencies.

Discussion:

The result of this study demonstrated that the expert-level ECMO nurse had orientees who did better on the written assessment than the orientees of the circulatory perfusionist. When looking at the domains that required review, the circulatory perfusionist’s orientees had gaps in domains that could be considered a nursing intervention. For instance, the three orientees missed questions about ECMO circuit care and pressure/transducer errors. The same orientees also had to remediate laboratory studies associated with ECMO and the correct interpretation of the lab results. These skills were a cornerstone of the content delivered by the ECMO nurse and simply glossed over by the circulatory perfusionist.

When debriefing with the preceptors, it appeared that the circulatory perfusionist had a harder time delivering content to the nurses. The perfusionist indicated the nurses were ‘clawing’ at the content of the orientation to get a broad picture of how ECMO meets a physiologic need. The perfusionist also indicated that the family and patient education component required re-work to deliver that content. The process of providing education to the patient/family was in competition with the education that needed to be provided to the nurses to ensure competency. According to this preceptor, ‘lines were blurred’.

Both preceptors felt that a nurse-led set of instructions for ECMO would be delivered smoothly. There would be no question about what the nurse needed to know and what they needed to address first, second, third, and so on.

Further Research:

There are limitations to this examination. First, the parties involved are only found in one medical center. In addition, the simulations of ECMO complications/emergencies were limited to one session with one preceptor. Completion of the return demonstration might occur better at a university level and have a taller complexity level. Finally, the 50-question assessment completed did not exhibit any special-cause variation. As a result, variance analysis or regression were not completed on the study results. Any of these areas would create an opportunity for more research.

References:

Chidume, T., Ware, K. S., Cooper, T., Young, B., & Crumbley, D. (2023). Deliberate practice and cardiopulmonary resuscitation: Integration in the classroom, lab, and simulation. Teaching and Learning in Nursing, 18(2), 339-343.

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