Competent Management of Patients Receiving ECMO and CRRT

Q Our unit is going to start caring for patients receiving extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). How can I develop and maintain competence in managing these patients?A Marci Ebberts, MSN, RN, CCRN-K, replies:Expanding a critical care unit’s capability to provide advanced therapies for the most critical patients is a challenging decision that requires institutional commitment. Developing a high-acuity program is a multifactorial process and can result in critically ill patients being kept on the unit instead of being transferred to another setting. Intensive care unit nurses caring for these patients must develop and maintain competency in applying these therapies, which require planning and administrative support to ultimately ensure patient safety. True collaboration among different disciplines and nurses in various roles—manager, professional development, advanced practice, and clinical staff—is required for successful implementation of high-acuity programs.Critically ill patients are at high risk for multiorgan dysfunction. Acute kidney injury is a common consequence among patients in the intensive care unit.1 These patients require renal replacement therapy, which can be delivered intermittently through traditional hemodialysis. For patients who are hemodynamically unstable, however, CRRT offers the benefits of dialysis without the abrupt fluid shifts that can lead to further hemodynamic compromise.2 Likewise, patients who require pulmonary or cardiac support during an acute decompensating illness may benefit from venovenous or venoarterial ECMO. The use of ECMO has increased rapidly in the past decade, in part because of advances in technology and research demonstrating its potential success in treating severely ill patients with little chance of survival.3Clinical practice guidelines, professional organizations, and resources from device manufacturers establish the necessary foundation for beginning a CCRT or ECMO program. Specifically, the Extracorporeal Life Support Organization has numerous and comprehensive resources and best practices for initiating an ECMO program.4,5 A comparable resource for CRRT is the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative. Modeling a new program after a more experienced one with an established recipe for success is another useful strategy, but it does require collaboration. Unfortunately, competition within a market can sometimes pose challenges (eg, obtaining patients, attracting physicians), so finding a mentoring hospital in another part of the country may be easier.Some successful programs have published reports of their journey, such as “Training and Maintaining: Developing a Successful and Dynamic Continuous Renal Replacement Therapy Program” by Pryzbal et al,2 published in AACN Advanced Critical Care in 2017, and “Developing an Extracorporeal Membrane Oxygenation Program” by Jones-Akhtarekhavari et al,6 published in Critical Care Clinics, also in 2017. I highly recommend that stakeholders establishing a new program review these publications as their journey begins.Device companies often include educational resources as part of the contract for purchasing new capital equipment. A nurse educator or a professional development practitioner should be at the table when such contracts are discussed to ensure that appropriate and flexible education options are made available. Nursing instruction may best begin with education offered by the device company, but nursing education professionals should evaluate the education materials and tailor them to the specific needs and limitations of the hospital.Medical device companies are often quick to say that every nurse should attend a class, but they may not consider the financial impact of requiring nurses to leave the unit and spend hours in a classroom. Are there other ways to educate nurses outside of a classroom? Can classroom time be shortened and augmented by other educational tools? Initial education may consist of didactic training, computer-based learning, reading of guidelines and literature, and attendance at in-service trainings that provide hands-on opportunities to use the equipment. Some nurses may learn better by watching videos to study and reinforce key points. Keep in mind that company-provided videos are often long and dry, and busy nurses may lose interest. In this day of smartphones and free video-editing applications, videos that home in on the most important points can be created quickly and easily, and such videos may more successfully engage nurses.The timing of initial nursing education is an important consideration: education provided after skills are required is not an option, but education provided too early can also be ineffective. Learning a new skill immediately before it is needed is the best scenario. To set up an integrated, successful program launch, ensure that equipment is available, the pharmacy is prepared, physicians have had the necessary training, and order sets and policies have been updated to reflect the new patient populations. Once a go-live date has been established, work backward to build the best time frame for providing education.One approach to consider is training a core group of nurses to be the initial experts or “superusers.” Once that group has established some confidence in caring for patients receiving ECMO and CRRT, they can serve as a resource to answer questions or resolve issues that arise while training other nurses. Although establishing a superuser model may present a staffing challenge—it can be difficult to ensure the availability of a competent nurse on every shift—it has been shown to be effective for teaching high-acuity, low-frequency skills.2,7Some centers may average several patients receiving CRRT or ECMO each week, but a hospital that is just beginning to treat these patients may be slow to establish a consistent volume. Therein lies a familiar dilemma in nursing: nurses need expertise to be able to safely care for patients, but they need patients to develop expertise. Thus developing competency in high-risk, low-volume skill sets presents a challenge.8 Competency and confidence are intertwined yet distinct. Nurses must achieve competence in caring for complex patients before patients are admitted, but their confidence may take time to develop. In addition to a comprehensive initial training plan, the nurses who will manage these technologies may benefit from frequent, layered education, as the time between achieving “competency” and actually caring for a patient may be substantial.A successful method for maintaining competency may be incremental learning, in which small bits of previously learned information are reinforced through short, focused simulations.9 For example, set up a CRRT machine in an empty room and mimic an alarm situation. When nurses respond, ask them to resolve the alarm while verbalizing the troubleshooting tips taught in the initial training. Also, offer them an opportunity to ask questions or clarify any points of confusion. Conducting multiple “microsimulation” drills between the initial education and the reality of caring for patients receiving CRRT or ECMO will help improve nurses’ confidence over time.Once a key group of nurses has fulfilled the requirements for initial competency, institutions must provide a safety net of “just-in-time” resources.10 Reference manuals are useful, but they can be too comprehensive. Quick-reference cards with frequently asked questions, troubleshooting tips, and a phone number to call for help can be laminated and attached to the equipment. Hospitals can create videos for reference, and QR code technology can be used to make the videos easily accessible from a smartphone.11Nurses who infrequently care for complex patients still need to demonstrate competency at least annually, and the frequency with which they provide care may not be sufficient for them to remain comfortable using the technology.10 An established model for assessing competency, such as the method developed by Donna Wright,12 gives a reliable framework around the ongoing demonstration of competencies. When nurses safely care for patients who require high-risk modalities, they demonstrate their competence by avoiding complications, anticipating obstacles, integrating multiple sources of information, and facilitating patient improvement— the best evidence that nurses are indeed competent to care for these complex patients.