Extracorporeal Membrane Oxygenation Appropriateness: An Interdisciplinary Consensus-Based Approach

Nurok, Michael; Warsh, Jonathan; Griner, Todd; Kharabi, Mayumi; Castongia, Joseph; Overbeck, Cali; Krueger, Lisa; Coleman, Bernice; Ramzy, Danny; Chung, Joshua; Chan, Alice; Ley, Eric J.; Kubendran, Sindhu; Parrish, Neil; Yu, Zhe; Langberg, Michael; Finder, Stuart G.; Rosen, Bradley T.; Kaplan, Robert S.; Sax, Harry C.; Arabía, Francisco A.

doi:10.1213/ane.0000000000002723

Cited by 7 publications

(5 citation statements)

References 9 publications

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“…After seeing comparisons to the non-US sites, Los Angeles hospital resolved some of these inefficiencies. 8,14 These efforts were redoubled during the COVID-19 pandemic, when Los Angeles hospital’s ICUs moved toward Paris and Melbourne’s lower cost staffing model by decreasing staffing ratios, reducing use of consultants, and shifting routine bedside care to less-skilled personnel.…”

Section: Discussionmentioning

confidence: 99%

It’s Not Just the Prices: Time-Driven Activity-Based Costing for Initiation of Veno-Venous Extracorporeal Membrane Oxygenation at Three International Sites—A Case Review

Nurok

Pellegrino

Chambrun

et al. 2022

Anesthesia &Amp; Analgesia

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The United States spends more for intensive care units (ICUs) than do other high-income countries. We used time-driven activity-based costing (TDABC) to analyze ICU costs for initiation of veno-venous extracorporeal membrane oxygenation (VV ECMO) for respiratory failure to estimate how much of the higher ICU costs at 1 US site can be attributed to the higher prices paid to ICU personnel, and how much is caused by the US site's use of a higher cost staffing model. We accompanied our TDABC approach with narrative review of the ECMO programs, at Cedars-Sinai (Los Angeles), Hôpital Pitié-Salpêtrière (Paris), and The Alfred Hospital (Melbourne) from 2017 to 2019. Our primary outcome was daily ECMO cost, and we hypothesized that cost differences among the hospitals could be explained by the efficiencies and skill mix of involved clinicians and prices paid for personnel, equipment, and consumables. Our results are presented relative to Los Angeles' total personnel cost per VV ECMO patient day, indexed at 100. Los Angeles' total indexed daily cost of care was 147 (personnel: 100, durables: 5, and disposables: 42). Paris' total cost was 39 (26% of Los Angeles) (personnel: 12, durables: 1, and disposables: 26). Melbourne's total cost was 53 (36% of Los Angeles) (personnel: 32, durables: 2, and disposables: 19) (rounded). The higher personnel prices at Los Angeles explained only 26% of its much higher personnel costs than Paris, and 21% relative to Melbourne. Los Angeles' higher staffing levels accounted for 49% (36%), and its costlier mix of personnel accounted for 12% (10%) of its higher personnel costs relative to Paris (Melbourne). Unadjusted discharge rates for ECMO patients were 46% in Los Angeles (46%), 56% in Paris, and 52% in Melbourne. We found that personnel salaries explained only 30% of the higher personnel costs at 1 Los Angeles hospital. Most of the cost differential was caused by personnel staffing intensity and mix. This study demonstrates how TDABC may be used in ICU administration to quantify the savings that 1 US hospital could achieve by delivering the same quality of care with fewer and less-costly mix of clinicians compared to a French and Australian site. Narrative reviews contextualized how the care models evolved at each site and helped identify potential barriers to change. (Anesth Analg 2022;135:711-8) GLOSSARY CCR = capacity cost rate; CRRT = continuous renal replacement therapy; ECMO = extracorporeal membrane oxygenation; ICU = intensive care unit; RVU = relative value unit; TDABC = time-driven activity-based costing; VA = veno-arterial; VV = veno-venous

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Section: Discussionmentioning

confidence: 99%

It’s Not Just the Prices: Time-Driven Activity-Based Costing for Initiation of Veno-Venous Extracorporeal Membrane Oxygenation at Three International Sites—A Case Review

Nurok

Pellegrino

Chambrun

et al. 2022

Anesthesia &Amp; Analgesia

Self Cite

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“…The high cost associated with the ECMO use also may be considered as a critical factor in the decision about using this technology and makes its inappropriate use a high waste for the system (or families in the specific case from this Brazilian cohort) [26]. In times when healthcare labor resources are scarce, it is of utmost importance to consider that the elevated cost of using ECMO is not only associated with the technology price, but much more in the demand for nursing and cardiology assistants and for ICU beds that those patients require [27]. In a Dutch study, the mean cost of ECMO patients was (Euros) 106.263 and 52% of these costs arose from nursing care and only 11% from the ECMO surgery and materials [28].…”

Section: Discussionmentioning

confidence: 99%

Extracorporeal membrane oxygenation in COVID-19 patients and in-hospital mortality: results from the Brazilian Registry using a propensity score matched analysis

Ponce

Marcolino

et al. 2021

Preprint

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Around 5% of coronavirus disease 2019 (COVID-19) patients develop critical disease, with severe pneumonia and acute respiratory distress syndrome (ARDS). In these cases, extracorporeal membrane oxygenation (ECMO) may be considered when conventional therapy fails. This study aimed to assess the clinical characteristics and in-hospital outcomes of COVID-19 patients with ARDS refractory to standard lung-protective ventilation and pronation treated with ECMO support and to compare them to patients who did not receive ECMO. Patients were selected from the Brazilian COVID-19 Registry. At the moment of the analysis, 7,646 patients were introduced in the registry, eight of those received ECMO support (0.1%). The convenience sample of patients submitted to ECMO was compared to control patients selected by genetic matching for gender, age, comorbidities, pronation, ARDS and hospital, in a 5:1 ratio. From the 48 patients included in the study, eight received ECMO and 40 were matched controls. There were no significant differences in demographic, clinical and laboratory characteristics. Mortality was higher in the ECMO group (n = 7; 87.5%) when compared with controls (n = 17; 42.5%), (p=0.048). In conclusion, COVID 19 patients with ARDS refractory to conventional therapy who received ECMO support had worse outcomes to patients who did not receive ECMO. Our findings are not different from previous studies including a small number of patients, however there is a huge difference from Extracorporeal Life Support Organization results, which encourages us to keep looking for our best excellence.

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“…Among these are the surprising efficacy of venovenous versus venoarterial cannulation in patients with hemodynamic instability and ARDS, 51 the efficacy of ECMO even in obese patients, 52 and criteria for appropriateness. 53 CPR. In keeping with the legacy of Dr Safar, this past decade saw A&A continue to expand the boundaries of CPR, publishing widely read narrative reviews on management of cardiac arrest in the OR, 53,54 how best to optimize CPR in the prone position, 55,56 and when delivered by untrained bystanders.…”

Section: Respiratorymentioning

confidence: 99%

“…53 CPR. In keeping with the legacy of Dr Safar, this past decade saw A&A continue to expand the boundaries of CPR, publishing widely read narrative reviews on management of cardiac arrest in the OR, 53,54 how best to optimize CPR in the prone position, 55,56 and when delivered by untrained bystanders. 57 COVID-19.…”

Section: Respiratorymentioning

confidence: 99%

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100 Years of Critical Care in the Pages of Anesthesia & Analgesia

Tung

2022

Anesthesia &Amp; Analgesia

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The founding of Anesthesia & Analgesia (A&A) in 1922 was roughly contemporaneous with the creation of the first intensive care unit (ICU) in the United States at Johns Hopkins in 1923. Throughout the next 100 years, the pages of A&A have mirrored the development of critical care as its own distinct specialty. Although primarily a journal focused on intraoperative anesthesia, A&A has maintained a small but steady presence in critical care research. This review highlights the history and development of critical care publications in the pages of A&A from early observations on the physiology of critical illness (1922–1949) to the groundbreaking work of Peter Safar and others on cardiopulmonary resuscitation (1950–1970), the growth of modern critical care (1970–2010), and the 2020 to 2022 coronavirus disease 2019 (COVID-19) era.

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Extracorporeal Membrane Oxygenation Appropriateness: An Interdisciplinary Consensus-Based Approach

Cited by 7 publications

References 9 publications

It’s Not Just the Prices: Time-Driven Activity-Based Costing for Initiation of Veno-Venous Extracorporeal Membrane Oxygenation at Three International Sites—A Case Review

It’s Not Just the Prices: Time-Driven Activity-Based Costing for Initiation of Veno-Venous Extracorporeal Membrane Oxygenation at Three International Sites—A Case Review

Extracorporeal membrane oxygenation in COVID-19 patients and in-hospital mortality: results from the Brazilian Registry using a propensity score matched analysis

100 Years of Critical Care in the Pages of Anesthesia & Analgesia

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