Emergency Physician-Initiated ECPR Program for OHCA

Out-of-hospital cardiac arrest (OHCA) has a low rate of survival, with 3%-10% of patients surviving to hospital discharge, and an even smaller number experiencing good functional status at discharge.1,2 If patients experiencing OHCA fail to achieve sustained return of spontaneous circulation, this severely limits their opportunity for successful survival. Extracorporeal cardiopulmonary resuscitation (ECPR), utilizing venoarterial extracorporeal membrane oxygenation (ECMO), is increasingly being used as a mechanism to improve survival and neurologic outcomes in these patients.1,2 Initiation of ECPR as soon as possible is critical to achieve positive results. Historically, ECPR has been initiated in the ICU or cardiac catheterization unit, leading to delays while the patient is transported to these units. Using emergency medicine physicians to start ECPR immediately upon arrival to the emergency department (ED) is a strategy to minimize time lost during the arrest, as these physicians are onsite in the ED, well versed in managing cardiac arrests, and experienced in gaining vascular access. A Regional Model for ECPR in the ED Recognizing the advantages of using emergency physicians to initiate ECPR, a regional emergency physician-initiated program has been developed and operating in San Diego County over the past 14 years.3 The program began at a single hospital and expanded as it demonstrated positive outcomes. After rolling it out across the entire county, the group has recently published data on their first year of experience across the county's 3 ECPR-receiving hospitals. In the program, emergency medical services identify patients experiencing OHCA who qualify for potential initiation of ECPR and alert the receiving hospital. Upon arrival, emergency physicians determine the patient's eligibility, and if eligible, cannulate the patient to initiate ECPR.2 In the first year of data collection, the countywide program demonstrated 32% neurologically intact survivorship, which represented an improvement over the historical rates of 8%.2 Dr Zack Shinar, ECPR medical director of Sharp Memorial Hospital in San Diego, notes the success of the program took time and consistent effort. “It took years to prove that emergency physicians could successfully provide this service—overcoming logistical, cultural, and clinical challenges along the way. After demonstrating feasibility at our hospital, and then replicating success at two additional sites, we launched a countywide program to divert eligible cardiac arrest patients to designated ECPR centers.” He attributes the program's success to key measures that the team continues to refine. “We identified 3 key metrics: capturing patients who would benefit from ECMO, transporting them to the hospital quickly, and initiating ECMO in a timely manner. We have achieved all three to varying degrees, though we continue to focus on improving patient capture and reducing cannulation times in the years ahead.” Preparing Clinicians for ECPR Activation Efficient and effective training of emergency physicians was also a critical part of the San Diego program's success, resulting in 100 emergency physicians trained as cannulators through a 1-2 day course. Training is a major barrier to broadly implementing emergency physician-initiated ECPR, and simulation training has been explored at other centers as a strategy to prepare physicians and nurses for ECPR situations.4 Simulation training has included education on critical actions such as cannulation, circuit priming, circuit connection, and initiating ECPR flow.4 Outside of the United States, some countries are also exploring the potential of prehospital ECPR, with the ECPR team dispatched to the patient to avoid the time lost in transport to an ECPR-capable center.5 This continued expansion effort builds on the positive results shown in San Diego County, which demonstrated ECPR can be successfully scaled, by leveraging structured training, multidisciplinary coordination, and emergency physician integration. SARAH SNOBELEN is a clinical pharmacist and medical writer and editor. She specializes in writing continuing education content for health care professionals.