Supplementary Table 1: Summary of the survey responses
Question Asked Response Options Frequency Percentage
What is your age?
(n=65)
20-25 26-30 32-35 36-40 42-50 50
0 5 13 18 18 11
0.0%
7.7%
20.0%
27.7%
27.7%
16.9%
What gender do you identify with?
(n=65)
Female Male Other
51 14 0
78.5%
21.5%
0.0%
What is your current job?
(n=65)
MD RN RRT Perfusionist NP
18 32 7 6 2
27.7%
49.2%
10.8%
9.2%
3.1%
What is the length of experience, in years, in your current profession?
(n=65)
Less than a year 1-5 years 6-10 years 11-15 years Over 15 years
0 11 22 9 23
0.0%
16.9%
33.8%
13.8%
35.4%
How long have you been working at ACH?
(n=65)
Less than a year 1-5 years 6-10 years 11-15 years Over 15 years
1 16 24 15 9
1.5%
24.6%
36.9%
23.1%
13.8%
Before the Rescue ECLS Program at ACH, have you been involved as part of the care team in providing ECLS (including time as a trainee)?
(n=65)
Yes No
32 33
49.2%
50.8%
Aside from any training you received as part of the ACH Rescue ECLS Program, what type of
education/training have you had in ECLS?
(n=64)
Part of training (i.e., fellowship or residency)
Formal coursework Conferences Workshops Others
27 9 0 5 23
42.4%
14.1%
0.0%
7.8%
35.9%
Approximately how many patients ECLS cannulations (not simulations) have you been involved with?
(n=65)
0 1 2-4 5-9 10 or more
1 1 23 26 14
1.5%
1.5%
35.4%
40.0%
21.5%
What is the value of the ACH Rescue ECLS Program as it currently exists?
(n=64)
Extremely valuable Moderately valuable Non value at all
61 3 0
95.3%
4.7%
0.0%
The Rescue ECLS Program was introduced in a staged fashion (initially no eCPR, initially only VA, etc.). Do you feel that this staged approach was appropriate?
(n=64)
Yes No
I am not sure
47 0 17
73.4%
0.0%
26.6%
Have you been present when an ECLS checklist was used at ACH cannulation?
Yes No
50 7
78.1%
10.9%
(n=64) I don’t remember 7 10.9%
Was the checklist helpful?
(n=62)
Yes No
I am not sure
48 1 13
77.4%
1.6%
21.0%
Have you ever participated in a case debrief led by the ECLS leadership team?
(n=64)
Yes No
I don’t remember
30 29 5
46.9%
45.3%
7.8%
There is a low volume of ECLS cases at ACH. Do you feel you are given enough opportunity to maintain skills necessary for ECLS?
(n=64)
Yes No
I am not sure
31 20 13
48.4%
31.3%
20.3%
Have you participated in any of the ECLS simulation cases?
(n=64)
Yes No
45 19
70.3%
29.7%
Do you feel they are beneficial?
(for respondents who participated in simulations – n=45)
Yes No
45 0
100%
0.0%
Do you feel there are enough of them?
(for respondents who participated in simulations – n=45)
Yes No
24 21
53.3%
46.7%
Have there been barriers to your participation?
(for respondents who did not participated in simulations – n=19)
Yes No
7 12
36.8%
63.2%
As a Rescue ECLS Program we know our patients need to be transported following cannulation.
What sort of considerations need to be discussed related to cannulating or transporting before placing patient on ECLS (select all that apply).
(n=63)
Who to transport without cannulation Which patients to cannulate prior to transport
Additional lines (i.e., cephalad) Chest tubes
Cannulae position Securing of cannulae
Stability of patient for transport once cannulated
Pre-emptive planning for issues that could arise for the period of
transportation Other (Not applicable)
44 46 41 25 49 49 46 43
3
69.8%
73.0%
65.1%
39.7%
77.8%
77.8%
73.0%
68.3%
4.8%
Supplementary Table 2: Examples of quotes obtained during the interviews of ECLS team members
Initial Concerns:
ECLS Training, Competence and Confidence
“… being competent … you don’t want to try something so invasive unless you have everybody in place having some idea of what they should be doing.” [Interview 14, Nursing]
“… we don’t get the opportunity to practice very often, it’s really high stakes when the opportunity comes, so we have to just have some safety nets put in place to help us … some of the tools we have feel redundant to a surgical site that might be doing this consistently, but are built in place for safety, because of the limited numbers we do every year.” [Interview 19, Physician]
Factors
Influencing ACH Rescue ECLS Program Success
“It’s not something that was just simply initiated in PICU … They did a really good job of involving the
multidisciplinary teams, as well as the different units, so that whatever was created, worked for every unit … we work well together as a team.” [Interview 08, Nursing]
“It has great leadership … It has great professional and multidisciplinary input in the steering committee and that means we’re all on the same page in terms of general surgeons, the perfusionists, the OR nurses, ICU staff, and so it runs very smoothly.” [Interview 16, Physician]
“I think the program has really grown … we’ve also learned some important lessons along the way that’s allowed group growth to be fostered … certainly the group is quite collegial.” [Interview 19, Physician]
“Like every program that starts off brand new, we’ve had changes along the way to adapt it and make it safer for the patient, better for the patient, easier for the staff involved … it’s provided better patient care for our patients overall.” [Interview 08, Nursing]
And I think then dealing with … the sort of ethical dilemma that is ECMO … the group was so open minded and flexible and willing to charge along because they believed in it …” [Interview 09, Allied Health Professional]
Perceived Program Value
“… now we’re able to save several children a year who would have died otherwise, so it’s extremely valuable.”
[Interview 16, Physician]
“It gives us an opportunity to give kids a chance to get through to more cardiac specialists … where before we never used to and they would likely not be able to survive to that point. So, I think it was a great implementation
…, and I think it allows us to … have more tools in our toolkit to sustain them.” [Interview 4, Nursing]
“I think it’s a very valuable program that has allowed us to really better care for children … offer them all of the life-saving therapies that would be offered elsewhere.” [Interview 15, Nursing]
“I think it’s very valuable in terms of patient care. It’s provided an alternative for patients… to achieve stability and move on … to additional treatment options, that wouldn’t otherwise be available to them if we didn’t have … this type of support.” [Interview 19, Physician]
“… so we’re dealing with things that are literally inside the heart. If you have complications … that requires a cardiac surgeon’s response. We don’t have that option …it continues to be the number one fear factor here.”
[Interview 09, Allied Health Professional]
“The infrequency of events makes ongoing practice and simulation very important, because people feel uncomfortable if they haven’t done it in a while. And given we only have 6-10 events a year, the team whose doing them are different every time. It’s important to maintain our comfort … with ongoing practice.” [Interview 16, Physician]
Ethical Concerns “I had ethical concerns that if the program wasn’t going to be well-led, then it could be a technology that’s used inappropriately … by that I mean where the net result is that there’s more harm to the child than benefit.”
[Interview 05, Physician]
“… having a clear consent process, which our PICU team directs entirely, of how that’s done in an ethically- appropriate way, and in a way that’s thorough enough for the family, so that they’re not upset.” [Interview 19, Physician]
“… I didn’t know what to expect … ethically … a lot of thought [went] into it …seemed that extra step that we can give kids a chance … So it was hard to get over the ethics part … initially … but now that we’ve done and are somewhat proficient at it … I feel it’s an important resource that we have … it’s a big advance to the children that have used it.” [Interview 11, Nursing]
“I think the greatest concern is implementing a program like this and it failing … it’s a highly complex program to put together. So there were huge hurdles to overcome both internally within the staff of the ICU, because some people didn’t believe it worked. Some people thought that far more kids would die than be saved and it would be a demoralizing thing to do.” [Interview 10, Physician]
Program
Implementation
“ … making sure that your team was experienced and comfortable dealing with a more planned approach, and working out all the kinks, and learning from those things before you start … you want to make sure that you’ve built a program that’s … building people up and giving them confidence in what they’re doing.” [Interview 03, Physician]
“… having guidelines and visual aids and documents for something that’s going to be low frequency and also when you’re going between teams really helps to dispel any miscommunication and misunderstandings. That’s all been clearly laid out in advance.” [Interview 15, Nursing]
“You have to build capacity … I think you need to know what works when you’ve got a closed environment. When we anticipated these children were going to require ECMO, we have a set room where those patients were moved to, the entire team was notified … it couldn’t have been more controlled … it absolutely needed to be staged the way it was done. And I liked that they moved to … controlled environment like the OR, before we rolled out to the ward. I think that was really smart … it was done very appropriately.” [Interview 13, Physician]
“… engage every member of your team especially when you’re doing something infrequently like this. The more people that are educated and involved, the more checks and balances they can provide to each other. … having everybody involved I think has been important and would be important elsewhere. … preparing guidelines and checklists and those sorts of things in advance. Those visual aids and learning aids for a center that would do lower frequency.” [Interview 15, Nursing]
Debriefing “… in the beginning we debriefed every single case; what went well, what didn’t go well, how could it be improved? … I think that this is how you learn … trying to break it down every single time. And people were honest, and they were open about it, and it didn’t feel punitive. And I thought that it was a great way … to develop the program.” [Interview 13, Physician]
“Very thorough. They’re very well done … I feel like it’s a safe place. Everybody can speak up … you can easily talk about what was right or even if something was wrong, without kind of a negative connotation associated to any of that. So, I feel like it’s very valuable learning that people take away … I find it extremely helpful and rewarding.” [Interview 17, Nursing]
“I think they’re a critical part of the process … I think that it would be better if we could do the debrief, or at least an initial debrief, closer to the actual cannulation … doing an initial debrief when there’s been … a critical incident, really close to when the incident ends… especially in situations where the cannulation … or the ECPR wasn’t successful, I think is really important.” [Interview 05, Physician]
“… I think they’re great. I appreciate the fact that we do it as soon as we can …when things are still fresh. I appreciate that it’s often run by someone who’s good at debriefing … it feels like a very safe environment … I feel like everybody is feeling vulnerable, because they all partook ...” [Interview 08, Nursing]
Transport “The transport piece is really important though, because for other centers to go down our pathway and develop a system like ours, they need to have a method to transport to the hospitals … that transport is probably best done by the center that actually is going to accept the patient, because their team’s going to be more experienced. And the point there is that transport can be done safely across significant distances. … transport can be done. But it should be done by the most experienced center, which won’t be the center having a rescue program.” [Interview 10, Physician]
“The transport piece, I think, has been very good … when they know that we’re cannulating they send out a team, they’re very respectful, and I think things move smoothly when the transport team gets here, and patients have done well during transport. Obviously, that’s a very high-risk time, but I don’t think we’ve had any inadvertent complications just during transport … generally, the transport goes smoothly …”[Interview 13, Physician]
“Whenever the team comes I have always found them to be very respectful, and that handover process I find goes very well.” [Interview 15, Nursing]
“… other concerns were technical with regard to how well a transport ECMO program would work because when we started, that was still a relatively new idea … that you could transport children on ECLS … I had concerns about whether there would be mishaps or complications because of the need to move them … moving a child once they’re on ECLS was always considered very perilous. … I’m not aware we’ve had any significant problems with the actual transport part. So that concern was alleviated after the first five or 10 patients … I realised there was a really good team in place that was looking after this part of it.” [Interview 05, Physician]
Relationship with Referral Centre
“I think a key to success is having a really good partnership with your center that’s providing definitive care. And I think that’s been really good. … any changes or any sort of training or whatever, done in collaboration with [our receiving center] is really good. I mean, the Program would not work unless you had that.” [Interview 03, Physician]
“… having the support of the closest facility that does do cardiac surgeries and having their cardiac specialists – having the support of them and having them ready to provide input and advice whenever they can.” [Interview 04, Nursing]
“… clear criteria … about the expectations … how long the cannulating center would be able to hold on to the patient, making sure that’s all well set out in advance … it’s really important that that be clearly spelled out in advance.” [Interview 15, Nursing]
“… the program being supported by the hospital or system that it’s in, I think, is absolutely critical …. I would say any program starting out should probably not be an island. I think that you should be partnered with other hospitals that have had a larger experience with ECLS. …” [Interview 05, Physician]
