Hub and Spoke Network Matthew Bacchetta Director of Adult ECMO Surgical Director - Pulmonary Hypertension Comprehensive Care Center Columbia University Medical Center
Disclosure No financial disclosures
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
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
International Experience Greater acceptance of regionalization Public policy decision Rationalization of complex care
So what do we know about patient volume and critical care?
So what do we know about patient volume and critical care?
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.
Low volume <12 cases/yr Intermediate 12-30 cases/yr High volume >30 cases/yr Mortality is improved in ICUs that admit larger numbers of hematological patients with ARDS
ECMO management is complex
ECMO-Associated Complications Hemodynamic Equipment problems Recognition and correction Infection Limb ischemia Thrombosis / Hemorrhage Hemolysis Miscellaneous
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
Many countries have organized efficient ECMO referral networks
Aero-Medical Transport
The NSW indications for ECMO referral Forrest et al Intensive Care Med, 2011
ECMO Network in England
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
29 Patients: 15 neonates, 7 pediatric, 7 adults Acute respiratory failure Distance: 4-1500 km No patient complications during transportation Survival to discharge: 72%
40 adult Patients: 38 Acute respiratory failure (16 H1N1) 2 had cardiogenic shock Distance: 12-2000 km No major complications during transportation Survive to discharge: 85%
The Mobile ECMO rescue team at La Pitié: 2005-2009 experience for refractory cardiac failure
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) 87 17 (4-243) 20 (4-134)
Mobile ECMO Rescue Team 87 patients 2005-2009 57 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
One year survival = 35%
0-19 20-49 >49 The minimum annual case load most significantly associated with lower mortality was 22 (95% CI, 22 28)
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. 0-19 20-49 >49 The minimum annual case load most significantly associated with lower mortality was 22 (95% CI, 22 28)
Columbia ECMO Transport Service
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
CUMC Results: Survival for ECMO Transport Survival % Decannulation 83% 30-Day 74% Hospital discharge 68%
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
The Procedural Model Get call from a local hospital Put patient on ECMO and say thank you
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
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
The Ideal Regional Center The Hub Expert personnel Surgery Intensive care Nursing Perfusion Available 24/7: Consult services
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
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
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
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
Acknowledgements Columbia ECMO Team Daniel Brodie, MD Alain Coombs, MD