The perceived barriers and facilitators to implementation of ECMO services in acute hospitals
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LETTER
The perceived barriers and facilitators to implementation of ECMO services in acute hospitals Bentley J. Fulcher1, Angus J. Nicholson1, Natalie J. Linke1, Danielle Berkovic2, Carol L. Hodgson1,3* on behalf of the EXCEL Study Investigators and the International ECMO Network © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
Dear Editor, Extracorporeal membrane oxygenation (ECMO) is a highly specialised and invasive intervention that provides lifesaving circulatory or respiratory support for critically ill patients but carries considerable costs and mortality [1, 2]. International studies demonstrate that dedicated high-volume ECMO centres are associated with improved patient outcomes [3]. Australia currently lacks a national framework or guidelines governing ECMO implementation and use, and there is variation in the training of staff between sites and jurisdictions, the ratio of nurses–ECMO patients, the types of equipment used and the treatment of patients between sites [4]. The aim of this study was to identify the perceived barriers and facilitators to implementation of ECMO services in acute hospital intensive care units (ICUs) in Australia. A secondary aim was to determine if there were differences between high- and low-volume ECMO centres. A qualitative study comprised focus groups with multidisciplinary ICU stakeholders across 14 Australian ECMO centres from May 2019 to February 2020. Ethical approval was gained prior to study commencement (The Alfred HREC 534/18). Semi-structured focus groups were conducted and transcribed verbatim (Electronic *Correspondence: [email protected] 1 Australian and New Zealand Intensive Care Research Centre, Monash University, Level 3, 553 St Kilda Road, Melbourne, VIC 3004, Australia Full author information is available at the end of the article Bentley J. Fulcher and Angus J. Nicholson contributed equally to this work. The EXCEL Study Investigators members are listed in “Acknowledgements” section.
Supplement). Inductive coding was used to establish themes which were categorised into the Behaviour Change Wheel (COM-B) domains of capability, opportunity and motivation which allowed barriers and enablers affecting ECMO service behaviour to be identified [5]. Further details of the methods are available in the electronic supplement. Semi-structured focus groups were conducted with 83 multidisciplinary participants from 14 ECMO centres participating in the national ECMO registry in Australia (EXCEL [4]) (eTables 1 and 2). There were 36 (43%) intensivists, 36 (43%) ICU nurses, 4 (5%) intensive care registrars, 4 (5%) ICU managers, 2 (2%) equipment staff and 1 (1%) perfusionist included in the focus groups. Common facilitators to both high- and low-volume centres were an ICU-led service, interdisciplinary support, audits, advanced staff training and equipment optimisation (Fig. 1, eTables 3 and 4). High-volume centres identified hospital buy-in and guidelines as unique facilitators (eTable 4). Low-volume centres identified staff inexperience, variable ECMO
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