Simulation training for extracorporeal membrane oxygenation

Abstract

Extracorporeal membrane oxygenation (ECMO) is a complex treatment. Despite this, there are a lack of training programs designed to develop relevant clinical and nonclinical skills required for ECMO specialists. The aim of the current study was to describe the design, implementation and evaluation of a 1-day simulation course for delivering training in ECMO.
A 1-day simulation course was developed with educational and intensive care experts. First, the delegates received a lecture on the principles of simulation training and the importance of human factors. This was, followed by a practical demonstration and discussion of the ECMO circuit, console components, circuit interactions effects and potential complications. There were then five ECMO simulation scenarios with debriefing that covered technical and nontechnical issues. The course culminated in a knowledge-based assessment. Course outcomes were assessed using purpose-designed questionnaires.
We held 3 courses with a total of 14 delegates (9 intensive care nurses, 3 adult intensive care consultants and 2 ECMO technicians). Following the course, 8 (57%) gained familiarity in troubleshooting an ECMO circuit, 6 (43%) increased their familiarity with the ECMO pump and circuit, 8 (57%) perceived an improvement in their communication skills and 7 (50%) perceived an improvement in their leadership skills. At the end of the course, 13 (93%) delegates agreed that they felt more confident in dealing with ECMO.
Simulation-training courses may increase knowledge and confidence in dealing with ECMO emergencies. Further studies are indicated to determine whether simulation training improves clinical outcomes and translates to reduced complication rates in patients receiving ECMO.

Full text

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Annals of Cardiac Anaesthesia | Apr-Jun-2015 | Vol 18 | Issue 2 1
Background: Extracorporeal membrane oxygenation (ECMO) is a complex treatment. Despite this, there
are a lack of training programs designed to develop relevant clinical and nonclinical skills required for ECMO
specialists. The aim of the current study was to describe the design, implementation and evaluation of a
1-day simulation course for delivering training in ECMO. Methods: A 1-day simulation course was developed
with educational and intensive care experts. First, the delegates received a lecture on the principles of
simulation training and the importance of human factors. This was, followed by a practical demonstration and
discussion of the ECMO circuit, console components, circuit interactions effects and potential complications.
There were then fi ve ECMO simulation scenarios with debriefi ng that covered technical and nontechnical
issues. The course culminated in a knowledge-based assessment. Course outcomes were assessed using
purpose-designed questionnaires. Results: We held 3 courses with a total of 14 delegates (9 intensive
care nurses, 3 adult intensive care consultants and 2 ECMO technicians). Following the course, 8 (57%)
gained familiarity in troubleshooting an ECMO circuit, 6 (43%) increased their familiarity with the ECMO
pump and circuit, 8 (57%) perceived an improvement in their communication skills and 7 (50%) perceived
an improvement in their leadership skills. At the end of the course, 13 (93%) delegates agreed that they felt
more confi dent in dealing with ECMO. Conclusions: Simulation-training courses may increase knowledge
and confi dence in dealing with ECMO emergencies. Further studies are indicated to determine whether
simulation training improves clinical outcomes and translates to reduced complication rates in patients
receiving ECMO.
Key words: Extracorporeal membrane oxygenation; simulation; training
Simulation training for extracorporeal
membrane oxygenation
Roberta Brum, Ronak Rajani1, Elton Gelandt2, Lisa Morgan2, Nira Raguseelan2, Salman Butt2,
David Nelmes1, Georg Auzinger2, Simon Broughton2
Department of Education and Simulation, Weston Education Centre, King’s College Hospital, Departments of 1Education
and 2Intensive Care Medicine, King’s College Hospital, London, SE5 9RS, UK
Received: 16-10-14
Accepted: 04-03-15
teamwork and leadership that are required to
be an ECMO specialist. An integration of both
these clinical and nonclinical skills is vital to
minimize mortality and complications in the
high risk and complex patients that require
ECMO.
The aim of the current study was to describe
the design, implementation and evaluation of a
1-day simulation course for delivering training
in ECMO.
METHODS
The ECMO Faculty at King’s College Hospital
designed and developed a 1-day course in
INTRODUCTION
Extracorporeal membrane oxygenation
(ECMO) provides support to patients with
life threatening forms of respiratory and/
or cardiac failure, which are unresponsive
to conventional therapy.[1] Despite being
arguably one of the most complex treatments
available in the Intensive Care environment,
there is a distinct lack of recognized training
programs designed to facilitate ECMO
training. With standard training usually being
focused on acquiring the relevant theoretical
knowledge along with direct practical
training, there is an implicit need for training
in the additional skills of communication,
Address for correspondence: Dr. Roberta Brum, Department of Education and Simulation, Weston Education Centre, Kings College Hospital, London,
SE5 9RS, UK. E-mail: robrumm@gmail.com
ACA_128_14R2
ABSTRACT
Access this article online
Website: www.annals.in
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Original Article

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Brum, et al.: Simulation training for ECMO
2Annals of Cardiac Anaesthesia | Apr-Jun-2015 | Vol 18 | Issue 2
conjunction with simulation experts from the Weston
Education Centre. In order to integrate both the clinical
and nonclinical training components required for
successful ECMO delivery, we elected to incorporate
7 key components. The first component required
delegates to read purpose-designed precourse material
and to complete a precourse self-assessment. During the
course itself 6 hierarchical sequential training modules
were delivered. This began with a seminar on the
principles of simulation training and relevant human
factors. Following this, there was an introduction
to the manikin and the simulated ECMO circuit, a
troubleshooting workshop, ECMO scenario training and
cases-based discussion. The course concluded with an
informal assessment and the completion of evaluation
questionnaires.
Precourse material
All participants were given purpose-designed precourse
material. This was comprised of a 52 page “ECMO
workbook” that had been created by specialists at
King’s College Hospital, London. In this, relevant
information pertinent to ECMO was included along
with definitions, indications and technical details.
In addition, troubleshooting tips, treatment and
emergency response algorithms were included. The
“ECMO workbook” concluded with 29 questions to
aid self-assessment. It was a mandatory requirement
for course delegates to complete the manual and
self-assessment prior to the practical component of
the course.
Practical course
Principles of simulation training and relevant human
factors
A medical education expert delivered a 15-min seminar,
which explored the principles of simulation training
and definitions of human factors. This also included a
discussion on the application of relevant human factors
in the clinical environment.
Simulation and manikin introduction
For the practical component of the course, the
delegates were then introduced to the high fidelity
simulation room at King’s College Hospital. This room
was specifically configured to mimic the intensive
care environment. In order to suspend the disbelief
associated to simulation training, relevant observation
charts, clamps, ventilators and monitors were made
available alongside the manikin. The ECMO sessions
themselves were driven by a Gaumard Hal 3201 high
fidelity manikin (Gaumard, Miami, USA). This fully
automated patient simulator permitted the emulation
of a wide spectrum of physical and medical parameters
required for ECMO relevant scenarios. The simulator
was operated remotely via a wireless tablet device, and
on a “pallet items mode” (complete or partial group
of settings preprogrammed), rather than “on-the-fly”
operations (reduced preprogramming and response to
real-time actions), to best reflect immediate changes
to vital parameters scripted for the ECMO scenarios.
For the simulation of hydrodynamics, a liquid filled
reservoir attached to the ECMO machine was used. This
permitted the control of fluid pressure, movement and
flow. There were no physical connections to or from
the ECMO machine.
Extracorporeal membrane oxygenation troubleshooting
This session was a 1½ h practical demonstration of the
ECMO circuit led by senior ECMO specialists. In this
interactive session, the delegates had the opportunity
to (1) name and review circuit components and (2) name
and review the console, its components and relevant
circuit interactions. In addition, delegates had the
opportunity to discuss the effects and emergency
response to complications.
Extracorporeal membrane oxygenation simulation scenario
training
The ECMO simulation training commenced with
the demonstration of a scenario. This first scenario
was acted out by some faculty members and was
used to demonstrate what was expected of the
course attendees. Participants were then given the
opportunity to participate in at least one of four
different ECMO simulation scenarios. These were
designed to highlight relevant problems that may
occur in the ECMO context. The first scenario dealt
with the “sweep gas” (the process of gas exchange
in the membrane oxygenator) not being turned
on. The second scenario dealt with the accidental
disconnection of a circuit. The third scenario dealt
with “rattling of the lines” caused by a mismatch
between circuit volume and pump circuit pressure
resulting in turbulence in the system. Finally, the forth
scenario dealt with air in the circuit.
For the simulation practice, the delegates were briefed
on the clinical scenario and were then led into the
simulation room in pairs. Throughout the scenario, there
was an “acting” nurse to assist with any practical aspects
and to provide additional information where required.

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Brum, et al.: Simulation training for ECMO
Annals of Cardiac Anaesthesia | Apr-Jun-2015 | Vol 18 | Issue 2 3
In order to maximize the learning experience, the
remaining delegates were able to observe the scenario
situation unfold via a live video feed in an adjacent room.
At the end of each scenario, a debriefing session was
led by an education expert and ECMO expert. During
this, both clinical and nonclinical skills related to the
scenario were addressed in an interactive manner.
Interactive extracorporeal membrane oxygenation
case-based discussion
Following the simulation training, the delegates
participated in a ½-h discussion of clinical cases in
a seminar-based format. The ECMO expert initially
presented a brief clinical case along with the relevant
physiological and ECMO parameters. This was,
followed by an interactive discussion that addressed
the salient issues. The principal aim of this session
was to encourage delegates to apply the skills they had
acquired in the preceding session in more complex
clinical scenarios. The cases discussed included
issues related to venous-arterial and venous-venous
ECMO.
Assessment and evaluation
At the end of the course, the delegates were required
to complete a 1-h formal assessment to consolidate
the factual learning delivered on the course. This
assessment was comprised of 14 multiple-choice
questions and 16 questions based on short scenarios
and pictures where free text responses were permitted.
Part of the course also required the delegates to
complete an evaluation form to capture their precourse
expectations and to determine whether their learning
objectives had been met. A Likert five-point scale
was used to assess the responses regarding the
ECMO simulation experience. The questionnaire
also contained open-ended questions about specific
aspects of the course and addressed both clinical and
nonclinical skills.
RESULTS
The ECMO simulation course was successfully
delivered on three separate occasions at Kings College
Hospital, Weston Education Centre, from June 2013
to July 2013. During this time, 14 delegates attended
the course and successfully completed all seven
components. There were 9 (64%) intensive care nurses,
3 (21%) adult intensive care consultants and 2 (14%)
ECMO technicians.
Postcourse knowledge assessment
The paper-based assessments (14 multiple choice
questions) were marked by one of the ECMO experts.
The overall average score was 89%. The range of scores
was between 70% and 98%.
Course evaluation
Precourse expectations – clinical and nonclinical skills
All 14 delegates responded the precourse evaluation
questionnaire at the end of the course. There was a bias
for the delegates wishing to develop their technical skills
when compared to their nontechnical skills [Table 1]. For
the technical skills, 7 (50%) delegates expected to learn
how to troubleshoot an ECMO circuit, 6 (43%) how to
manage common circuit problems, 4 (29%) to increase
their familiarity with the ECMO pump/circuit and 4
(29%) to understand patient physiology and respective
changes on ECMO. For the nontechnical skills, 5 (36%)
expected to improve their general confidence with ECMO
and 3 (21%) to improve their communication skills.
Postcourse perceptions – clinical and nonclinical
skills (open-ended questions)
All 14 delegates responded to the postcourse evaluation
questionnaire at the end of the course. In contrast to
the precourse expectations, the course was successful
in that the delegates perceived a development in both
their technical and nontechnical skills [Table 2]. For
the technical skills, 8 (57%) gained familiarity in
troubleshooting an ECMO circuit, 6 (43%) increased their
familiarity with the ECMO pump and circuit and 3 (21%)
improved their understanding of patient physiology and
respective changes on ECMO. For the nontechnical skills, 8
(57%) perceived an improvement in their communication
skills, 7 (50%) an improvement in their leadership skills
and 5 (36%) an improvement in their delegation skills.
Simulation training feedback
Table 3 gives the results of the simulation training
feedback using a Likert five-point scale.[2] Prior to the
course attendance, 7 (50%) of the delegates did not feel
confident in dealing with ECMO patients and 5 (36%)
were neutral in their response. At the end of the course 6
(43%) felt “very confident” in managing ECMO patients
and 13 (93%) agreed that they felt more confident in
dealing with ECMO patients following the course.
All 14 (100%) delegates agreed that the simulation
training sessions raised their awareness of the
importance of effective team working, delegating tasks
and good communication skills. There was a consensus
among 12 (86%) delegates that simulation training was

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Brum, et al.: Simulation training for ECMO
4Annals of Cardiac Anaesthesia | Apr-Jun-2015 | Vol 18 | Issue 2
a good learning experience for communication and team
working. The majority of delegates (93%) found the
feedback session to be useful and 12 delegates (86%)
agreed or strongly agreed that they had learnt new
concepts important for patient safety during the day.
All delegates agreed that simulation training would be
a good means to assess competency when dealing with
ECMO patients although 2 (14%) remarked that “some
individuals may not be comfortable with simulation
training” and that “there were limitations as to how real
a simulated ECMO scenario could be.”
DISCUSSION
In the current study, we demonstrate the successful
design and delivery of a 1-day simulation-based training
course in ECMO. We also show that using simulation
training it is possible to deliver both clinical and
nonclinical relevant skills that are important for the
safe delivery and practice of ECMO in an intensive
care environment.
Extracorporeal membrane oxygenation is one of the
most complex treatments available in the intensive
care setting. It requires a unique skill set of both
technical and nontechnical abilities to deal with
unforeseen events and also complications.[1] Despite the
growing need for ECMO specialists and the demands
on existing services, training opportunities in ECMO
are limited. Experience is usually gained either by
a period of mentorship or at the bedside in patients
whom are critically unwell. Although attempts have
Table 1: Technical skills and nontechnical skills hoped to be gained during the course
Technical skills n (%) Nontechnical skills n (%)
Troubleshooting 7 (50) Confi dence in general 5 (36)
Management of common circuit problems and failures 6 (43) Improved communication skills 3 (22)
Increased familiarity with pump and circuit (ECMO machine) 4 (29) Improved situation awareness 1 (7)
Understand patients physiology and physiology changes on ECMO 4 (29) Improved teamwork 1 (7)
Improve clinical management of patient on ECMO 3 (21) Improved leadership 1 (7)
Improve timing skills from diagnosis of failure to action 1 (7) Improved understanding of human factors in complex ECMO situations 1 (7)
ECMO: Extracorporeal membrane oxygenation
Table 2: Perception of technical and nontechnical skills gained during the course
Technical skills n (%) Nontechnical skills n (%)
Improved familiarity with troubleshooting 8 (57) Improved effective communication 8 (57)
Increased familiarity with pump and circuit (ECMO machine) 6 (43) Effective leadership 7 (50)
Improved clinical management of patient on ECMO 4 (29) Improved delegation skills 5 (36)
Improved practical experience/practical skills 3 (22) Increased confi dence 2 (14)
Increased understanding of patients’ physiology and physiology changes on ECMO 3 (22) Better understanding of human factors 2 (14)
Good recap in a realistic environment 2 (14) Anticipation, planning, role defi nition, prioritization 1 (7)
Improved knowledge 1 (7) Teamwork 1 (7)
ECMO: Extracorporeal membrane oxygenation
Table 3: Feedback questions on simulation
After the simulation experience Strongly disagree Disagree Neutral Agree Strongly agree
I feel more confi dent in managing a ECMO patient 1 9 4
I now feel very confi dent in managing a ECMO patient 2 6 6
The debriefi ng sessions were useful 16 7
The session raised my awareness of the importance of effective teamwork
and delegating tasks
410
The session highlighted the importance of good communication skills 4 10
Simulation is a good learning experience for team working and communication 3 11
I have learnt new concepts important for patient safety 3 5 6
I am now more aware of my leadership skills in a resuscitation scenario 1 1 6 6
Simulation is a valuable tool in my training as a doctor/nurse 4 10
Simulation is a good learning experience for clinical skills and knowledge 4 10
I would benefi t from annual simulation courses 31 10
Simulation are useful adjuncts to learning from real-life 2 4 8
ECMO: Extracorporeal membrane oxygenation

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Brum, et al.: Simulation training for ECMO
Annals of Cardiac Anaesthesia | Apr-Jun-2015 | Vol 18 | Issue 2 5
been made to deliver training courses in ECMO, these
seem to be insufficiently equipped to provide both
technical and nontechnical skills across an array of
varied ECMO clinical scenarios. In order to achieve
this, we developed a unique course that utilized the
skills of both experts in teaching and ECMO. Our
course was comprised of a number of key components.
These varied from precourse material and self-directed
learning, to didactic lectures, interactive seminars,
practical demonstration, simulation-based training and
case-based discussions. Our initial results demonstrate
that this approach facilitates learning of technical
issues related to ECMO and also fosters the desirable
skills of effective communication and team leadership.
One additional key component of our course was
that our scenarios were drafted in consultation with
medical education experts in order to maximize the
potential to deliver specific learning outcomes relevant
to ECMO emergency situations. We therefore included
problems that might arise in a crisis situation so that
the participants would have a chance to practice the
skills required to troubleshoot these problems.
Simulation training represents an ideal platform to
deliver ECMO training. Firstly it permits the safe
development of relevant clinical skills away from a
direct clinical setting where errors may contribute to
mortality and morbidity. Secondly, it allows the rehearsal
or either unusual or infrequent life-threatening critical
incidents.[3,4] Finally, it also permits the assessment of
ECMO competency prior to clinical engagement and
also meets the continuing educational requirements of
an ECMO clinician.[5]
As well as the permitting the development of technical
skills, simulation training has also been shown to
help individuals achieve fundamental cognitive,
technical and behavioral skills when compared to
didactic teaching.[6] It also facilitates an improvement
in team working attributes and safety.[7] The benefit
of using simulation training for ECMO has been
demonstrated in a number of previous studies.
Anderson et al. showed a decreased number of errors
in ECMO emergencies in those individuals receiving
simulation training.[6] Similarly, Burkhart et al. showed
an improvement in confidence in individuals using
ECMO by incorporating simulation training.[3] Our
results are consistent with these prior studies in
that we show an improvement in both technical and
nontechnical skills for those delegates attending our
course.
LIMITATIONS
There are a number of limitations to the current study.
The principal aim of the current study was to design
an ECMO course that would encompass both training
in technical and nontechnical skills. We recognize that
the number of the attendees to our course was small
and accordingly the results of the feedback need to
be interpreted with caution. Although we are able to
demonstrate an improvement in perceived knowledge,
confidence, leadership and communication skills when
dealing with ECMO scenarios, no long-term clinical
outcome data were available from our course. It is,
therefore, unknown whether attendance at our course
resulted in improved patient outcomes. The authors
acknowledge that there is only limited data suggesting
that simulation training aids the transference of skills
into the clinical domain.[8] Further work is indicated to
determine the longer-term effects of simulation training
in ECMO and to whether our course has achieved Level
4 of Kirkpatrick evaluating training programs results.[9]
CONCLUSIONS
We successfully designed and delivered a 1-day
simulation-training course in ECMO using expertise
from specialists in medical education and intensive
care. Our results suggest that training in ECMO can be
delivered in a safe environment without compromising
patient safety and that such an approach can increase
knowledge and confidence among ECMO practitioners.
Further studies are indicated to determine whether
such training results in improved outcomes for patients
receiving ECMO.
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Cite this article as: ???
Source of Support: Nil, Confl ict of Interest: None declared.