Hub and Spoke Network

Transcription

1 Hub and Spoke Network Matthew Bacchetta Director of Adult ECMO Surgical Director - Pulmonary Hypertension Comprehensive Care Center Columbia University Medical Center

2 Disclosure No financial disclosures

3 Hub and Spoke Rationale Regionalization of care Expertise in rare and/or complex diseases and their management Concentration of resources Reduced fixed costs within the overall health care system Research: clinical, translational & basic science Centers of Excellence Improved outcomes: National & International standards of care

4 U.S. Experience There is no regionalization of care Solid organ transplantation Extraordinarily complex Resource intensive Personnel intensive Bone marrow transplant Efforts stymied by politics, OPO s, ego, economics How do you share a DRG? Failed Public policy decision

5 International Experience Greater acceptance of regionalization Public policy decision Rationalization of complex care

6 So what do we know about patient volume and critical care?

7 So what do we know about patient volume and critical care?

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10 Outcomes are independent of academic status of the hospital or the presence or absence of intensivists in the ICU. Suggest clinician experience or specific processes of care common to high-volume centers are associated with improved outcome. Investigate the feasibility of regionalizing care in the ICU for select high-risk patients.

11 Low volume <12 cases/yr Intermediate cases/yr High volume >30 cases/yr Mortality is improved in ICUs that admit larger numbers of hematological patients with ARDS

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15 ECMO management is complex

16 ECMO-Associated Complications Hemodynamic Equipment problems Recognition and correction Infection Limb ischemia Thrombosis / Hemorrhage Hemolysis Miscellaneous

17 Experienced Teams Detect, Prevent and manage ECMOassociated complications ECMO should be conducted in association with advanced care centers Heart failure services such VAD, Transplant Advanced lung therapies

18 Many countries have organized efficient ECMO referral networks

19 Aero-Medical Transport

20 The NSW indications for ECMO referral Forrest et al Intensive Care Med, 2011

21 ECMO Network in England

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24 Role of ECMO Transport Teams Extend ECMO care to patients at smaller hospitals Patients gain access to complex tertiary care Facilitate the safe transfer of critically ill patients to specialized centers of care

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27 29 Patients: 15 neonates, 7 pediatric, 7 adults Acute respiratory failure Distance: km No patient complications during transportation Survival to discharge: 72%

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29 40 adult Patients: 38 Acute respiratory failure (16 H1N1) 2 had cardiogenic shock Distance: km No major complications during transportation Survive to discharge: 85%

30 The Mobile ECMO rescue team at La Pitié: experience for refractory cardiac failure

31 Mobile ECMO Rescue Team Centres Patients Median distance Median time N (%) (range), Km (range), min Paris urban agglomeration (7 centres) 25 (29) 4 (4-18) 4 (4-26) Paris region (26 centres) 54 (62) 13 (4-53) 19 (7-46) Outside Paris region (4 centres) 8 (9) 88 (87-243) 60 (64-134) Total (37 centres) (4-243) 20 (4-134)

32 Mobile ECMO Rescue Team 87 patients males, 28 females Mean age: 46.1 [13-76] Etiologies AMI 46% Chronic DCM 16% Other Acute HF= 38% Myocarditis 14 Intoxication 5 Rythmic 4 Post-Partum 3 Hypoxemia 2 Takotsubo 3 Anaphylactic 1 Septic 1

33 One year survival = 35%

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35 >49 The minimum annual case load most significantly associated with lower mortality was 22 (95% CI, 22 28)

36 Pediatric centers with low extracorporeal membrane oxygenation average annual case volume had significantly higher mortality and a minimum volume of 22 cases per year was associated with improved mortality >49 The minimum annual case load most significantly associated with lower mortality was 22 (95% CI, 22 28)

37 Columbia ECMO Transport Service

38 CUMC Results Approximately 150 transports VV ECMO: 75% VA or VAV: 25% Range of Travel: 2 7,100 miles Complications: 2 Equipment related without negative impact

39 CUMC Results: Survival for ECMO Transport Survival % Decannulation 83% 30-Day 74% Hospital discharge 68%

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41 Service Line vs. Procedural Model Any successful regional program must provide a service!!! Consultancy Medical-surgical consultants Service line model vs Procedural model Surgeons like to do procedures Referrals want help and a solution

42 The Procedural Model Get call from a local hospital Put patient on ECMO and say thank you

43 Service Line Model Center for Acute Respiratory Failure ARDS, COPD exacerbation, PE, etc Service line contact number Consult service Standardized In-take form Review by ECMO attending (Pulm ICU) Review by Surgeon led transport team

44 Incoming consult Maintain consultancy role Smarter decision Relationship building Ensure proper care of patient Collect standardized data via intake form Meets ECMO Criteria? NO Provide ICU advice, e.g. vent settings YES ECMO team and transport team leader (surgeon) review case together NO Patient improves? YES NO Manage Locally Agree with ECMO transport? YES NO Transport to NYP/CUMC without ECMO, if both hospitals agree Launch ECMO transport team

45 The Ideal Regional Center The Hub Expert personnel Surgery Intensive care Nursing Perfusion Available 24/7: Consult services

46 The Ideal Regional Center The Hub Advanced disease management programs Heart failure Heart transplant, VAD Lung failure Acute: ALI/ARDS, Pulmonary embolism Chronic lung disease program: ILD, Lung Tx Appropriate case volume: 20, 22, 25 cases/yr? Transport capability

47 The Ideal Referring Hospital The Spokes Trained Personnel who can recognize when a patient needs to be transferred to a higher level of care. ECMO capable to stabilize the patient until a transport team arrives Emergency room initiation and stabilization Financial agreement to share reimbursement in an appropriate distribution Direct line of communication to physicians at the Regional center to discuss management Obtain management advice

48 Conclusions Regional ECMO centers can offer improved outcomes for patients Experienced ECMO Transport teams Volume > 20 cases/year Transports > 10 cases/year Maintain standards of care Compelling public health reasons to regionalize complex care

49 Conclusions Major barriers prevent regionalization Virtually all of these are public policy & hospital reimbursement issues Service line program development Provide consultancy service Manage patients locally when possible Follow up review of patient status

50 Acknowledgements Columbia ECMO Team Daniel Brodie, MD Alain Coombs, MD