A phased intervention bundle to decrease the mortality of patients with extracorporeal membrane oxygenation in intensive care unit

Yajun Jing, Zhiyong Yuan, Weigui Zhou, Xiaoning Han, Qi Qi, Kai Song, Jinyan Xing, Yajun Jing, Zhiyong Yuan, Weigui Zhou, Xiaoning Han, Qi Qi, Kai Song, Jinyan Xing

Abstract

Aim: To evaluate whether a phased multidimensional intervention bundle would decrease the mortality of patients with extracorporeal membrane oxygenation (ECMO) and the complication incidence.

Materials and methods: We conducted a prospective observational study in comparison with a retrospective control group in six intensive care units (ICUs) in China. Patients older than 18 years supported with ECMO between March 2018 to March 2022 were included in the study. A phased intervention bundle to improve the outcome of patients with ECMO was developed and implemented. Multivariable logistic regression modeling was used to compare the mortality of patients with ECMO and the complication incidence before, during, and up to 18 months after implementation of the intervention bundle.

Results: The cohort included 297 patients in 6 ICUs, mostly VA ECMO (68.7%) with a median (25th-75th percentile) duration in ECMO of 9.0 (4.0-15.0) days. The mean (SD) APECHII score was 24.1 (7.5). Overall, the mortality of ECMO decreased from 57.1% at baseline to 21.8% at 13-18 months after implementation of the study intervention (P < 0.001). In multivariable analysis, even after excluding the confounding factors, such as age, APECHII score, pre-ECMO lactate, and incidence of CRRT during ECMO, the intervention bundle still can decrease the mortality independently, which also remained true in the statistical analysis of V-V and V-A ECMO separately. Among all the ECMO-related complications, the incidence of bloodstream infection and bleeding decreased significantly at 13-18 months after implementation compared with the baseline. The CUSUM analysis revealed a typical learning curve with a point of inflection during the implementation of the bundle.

Conclusion: A phased multidimensional intervention bundle resulted in a large and sustained reduction in the mortality of ECMO that was maintained throughout the 18-month study period.

Clinical trial registration: [ClinicalTrials.gov], identifier [NCT05024786].

Keywords: ECMO; compliance; complication; intervention bundle; mortality.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2022 Jing, Yuan, Zhou, Han, Qi, Song and Xing.

Figures

FIGURE 1
FIGURE 1
The checklist during the ward round following the intervention bundle. ECMO, extracorporeal membrane oxygenation; MAP, mean arterial pressure; CVP, central venous pressure; VTI, velocity time integral; EF%, ejection fraction; ACT, activated clotting time; APTT, activated partial thromboplastin time; FIB, fibrinogen; EN, enteral nutrition; T, temperature; WBC, white blood cells; CRP, C-reactive protein; PCT, procalcitonin.
FIGURE 2
FIGURE 2
Factors associated with mortality of ECMO. ECMO, extracorporeal membrane oxygenation; APECHII, acute physiology and chronic health evaluation; SAVE, Survival after VA-ECMO; RESP, respiratory ECMO survival prediction; mo, month; ECPR, Extracorporeal cardiopulmonary resuscitation; Lac, lactate; CRRT, Continuous renal replacement therapy; LOS, length of stay.
FIGURE 3
FIGURE 3
Factors associated with mortality of V-A and V-V ECMO separately. (A) Factors associated with mortality of V-A ECMO. (B) Factors associated with mortality of V-V ECMO. V-A, venoarterial; V-V, venovenous; ECMO, extracorporeal membrane oxygenation; SAVE, Survival after VA-ECMO; RESP, respiratory ECMO survival prediction; Lac, lactate; mo, month; CRRT, Continuous renal replacement therapy.
FIGURE 4
FIGURE 4
Cumulative observed minus failure (CUSUM) chart for in-hospital mortality after extracorporeal membrane oxygenation (ECMO) treatment. The vertical axis shows the CUSUM value, which increases for each failure or decreases on each success. The horizontal axis shows the number of ECMO treatments and the corresponding period. An upward slope represents a failure rate higher than expected and a downward slope represents a failure rate fewer than expected.

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