Nursing workforce, education, and training challenges to implementing extracorporeal membrane oxygenation services in Australian intensive care units: A qualitative substudy.

BACKGROUND: The use of extracorporeal membrane oxygenation (ECMO) is increasing in the management of critical care patients. ECMO service delivery requires an organisation-supported approach to ensure appropriate resources to deliver training, equipment, capacity, staffing, and the required model of care for quality care delivery. The aim of this nested substudy was to explore challenges specific to nursing staff in ECMO services in Australian intensive care units. METHODS: This was a nested substudy within a qualitative study using semistructured focus group discussions conducted with 83 health professionals, which included 40 nurses. There were 14 focus groups across 14 ECMO centres participating in the binational ECMO (EXCEL) registry of Australia and New Zealand. An inductive thematic analysis focused on the nurse's experiences of the barriers and facilitators for nursing in providing an ECMO service. RESULTS: Four themes emerged relating to the nurse's experience of implementing ECMO services: workforce requirements, workload demands, models of care, and level of experience. The complexity and intensity of caring for ECMO patients may need to be considered an additional factor in the burnout in critical care nurses. Current nursing ratios and responsibilities in critical care need to be considered, with the opportunity for the development of specialist advanced practitioner nursing roles. CONCLUSION: This study highlights the challenges for nursing in providing ECMO services in the intensive care setting. The complexity and intensity of ECMO is challenging and leads to concerns regarding burnout and workforce preparedness. New models of care need to be considered to mitigate the barriers for nursing identified across ECMO centres.

Incidence of death or disability at 6 months after extracorporeal membrane oxygenation in Australia: a prospective, multicentre, registry-embedded cohort study.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is an invasive procedure used to support critically ill patients with the most severe forms of cardiac or respiratory failure in the short term, but long-term effects on incidence of death and disability are unknown. We aimed to assess incidence of death or disability associated with ECMO up to 6 months (180 days) after treatment. METHODS: This prospective, multicentre, registry-embedded cohort study was done at 23 hospitals in Australia from Feb 15, 2019, to Dec 31, 2020. The EXCEL registry included all adults (≥18 years) in Australia who were admitted to an intensive care unit (ICU) in a participating centre at the time of the study and who underwent ECMO. All patients who received ECMO support for respiratory failure, cardiac failure, or cardiac arrest during their ICU stay were eligible for this study. The primary outcome was death or moderate-to-severe disability (defined using the WHO Disability Assessment Schedule 2.0, 12-item survey) at 6 months after ECMO initiation. We used Fisher's exact test to compare categorical variables. This study is registered with ClinicalTrials.gov, NCT03793257. FINDINGS: Outcome data were available for 391 (88%) of 442 enrolled patients. The primary outcome of death or moderate-to-severe disability at 6 months was reported in 260 (66%) of 391 patients: 136 (67%) of 202 who received veno-arterial (VA)-ECMO, 60 (54%) of 111 who received veno-venous (VV)-ECMO, and 64 (82%) of 78 who received extracorporeal cardiopulmonary resuscitation (eCPR). After adjustment for age, comorbidities, Acute Physiology and Chronic Health Evaluation (APACHE) IV score, days between ICU admission and ECMO start, and use of vasopressors before ECMO, death or moderate-to-severe disability was higher in patients who received eCPR than in those who received VV-ECMO (VV-ECMO vs eCPR: risk difference [RD] -32% [95% CI -49 to -15]; p<0·001) but not VA-ECMO (VA-ECMO vs eCPR -8% [-22 to 6]; p=0·27). INTERPRETATION: In our study, only a third of patients were alive without moderate-to-severe disability at 6 months after initiation of ECMO. The finding that disability was common across all areas of functioning points to the need for long-term, multidisciplinary care and support for surviving patients who have had ECMO. Further studies are needed to understand the 180-day and longer-term prognosis of patients with different diagnoses receiving different modes of ECMO, which could have important implications for the selection of patients for ECMO and management strategies in the ICU. FUNDING: The National Health and Medical Research Council of Australia.

Association of Respiratory Parameters at Venovenous Extracorporeal Membrane Oxygenation Liberation With Duration of Mechanical Ventilation and ICU Length of Stay: A Prospective Cohort Study.

Although the criteria for initiation of venovenous extracorporeal membrane oxygenation (VV ECMO) are well defined, the criteria and timing for VV ECMO decannulation are less certain. The aim of this study was to describe the ventilation and physiologic factors at the time of VV ECMO decannulation and to determine if these factors have association with mechanical ventilation or ICU length of stay after ECMO decannulation. DESIGN: Multicenter, prospective cohort study. SETTING: Eleven ICUs in Australia. PATIENTS: Adult patients treated with VV ECMO from March 19, 2019, to September 20, 2020. INTERVENTIONS: Liberation from VV ECMO. RESULTS: Of 87 patients receiving VV ECMO, the median age was 49 years (interquartile range, 37-59 yr), 61 of 87 (70%) were male, and 52/87 (60%) had a diagnosis of acute respiratory distress syndrome. There were 24 of 87 patients (28%) who died prior to day 90. No patient required a second run of VV ECMO. In a multivariate models, a higher partial pressure of arterial carbon dioxide (p < 0.01) and respiratory rate at the time of decannulation (p = 0.01) were predictive of a longer duration of mechanical ventilation and ICU length of stay postdecannulation in survivors. Higher positive end-expiratory pressure at ECMO decannulation was associated with shorter duration of ICU length of stay post-ECMO decannulation in survivors (p = 0.01). CONCLUSIONS: A higher partial pressure of arterial carbon dioxide and higher respiratory rate at ECMO decannulation were associated with increased duration of mechanical ventilation and increased duration of ICU stay postdecannulation, and increased positive end-expiratory pressure at decannulation was associated with decreased duration of ICU stay postdecannulation. Future research should further investigate these associations to establish the optimal ventilator settings and timing of liberation from VV ECMO.

Comparison of 6-Month Outcomes of Survivors of COVID-19 versus Non-COVID-19 Critical Illness.

Rationale: The outcomes of survivors of critical illness due to coronavirus disease (COVID-19) compared with non-COVID-19 are yet to be established. Objectives: We aimed to investigate new disability at 6 months in mechanically ventilated patients admitted to Australian ICUs with COVID-19 compared with non-COVID-19. Methods: We included critically ill patients with COVID-19 and non-COVID-19 from two prospective observational studies. Patients were eligible if they were adult (age ⩾ 8 yr) and received ⩾24 hours of mechanical ventilation. In addition, patients with COVID-19 were eligible with a positive laboratory PCR test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Measurements and Main Results: Demographic, intervention, and hospital outcome data were obtained from electronic medical records. Survivors were contacted by telephone for functional outcomes with trained outcome assessors using the World Health Organization Disability Assessment Schedule 2.0. Between March 6, 2020, and April 21, 2021, 120 critically ill patients with COVID-19, and between August 2017 and January 2019, 199 critically ill patients without COVID-19, fulfilled the inclusion criteria. Patients with COVID-19 were older (median [interquartile range], 62 [55-71] vs. 58 [44-69] yr; P = 0.019) with a lower Acute Physiology and Chronic Health Evaluation II score (17 [13-20] vs. 19 [15-23]; P = 0.011). Although duration of ventilation was longer in patients with COVID-19 than in those without COVID-19 (12 [5-19] vs. 4.8 [2.3-8.8] d; P < 0.001), 180-day mortality was similar between the groups (39/120 [32.5%] vs. 70/199 [35.2%]; P = 0.715). The incidence of death or new disability at 180 days was similar (58/93 [62.4%] vs. 99/150 [66/0%]; P = 0.583). Conclusions: At 6 months, there was no difference in new disability for patients requiring mechanical ventilation for acute respiratory failure due to COVID-19 compared with non-COVID-19. Clinical trial registered with www.clinicaltrials.gov (NCT04401254).

The impact of COVID-19 critical illness on new disability, functional outcomes and return to work at 6 months: a prospective cohort study.

BACKGROUND: There are few reports of new functional impairment following critical illness from COVID-19. We aimed to describe the incidence of death or new disability, functional impairment and changes in health-related quality of life of patients after COVID-19 critical illness at 6 months. METHODS: In a nationally representative, multicenter, prospective cohort study of COVID-19 critical illness, we determined the prevalence of death or new disability at 6 months, the primary outcome. We measured mortality, new disability and return to work with changes in the World Health Organization Disability Assessment Schedule 2.0 12L (WHODAS) and health status with the EQ5D-5LTM. RESULTS: Of 274 eligible patients, 212 were enrolled from 30 hospitals. The median age was 61 (51-70) years, and 124 (58.5%) patients were male. At 6 months, 43/160 (26.9%) patients died and 42/108 (38.9%) responding survivors reported new disability. Compared to pre-illness, the WHODAS percentage score worsened (mean difference (MD), 10.40% [95% CI 7.06-13.77]; p < 0.001). Thirteen (11.4%) survivors had not returned to work due to poor health. There was a decrease in the EQ-5D-5LTM utility score (MD, - 0.19 [- 0.28 to - 0.10]; p < 0.001). At 6 months, 82 of 115 (71.3%) patients reported persistent symptoms. The independent predictors of death or new disability were higher severity of illness and increased frailty. CONCLUSIONS: At six months after COVID-19 critical illness, death and new disability was substantial. Over a third of survivors had new disability, which was widespread across all areas of functioning. Clinical trial registration NCT04401254 May 26, 2020.