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CEPP: Canadian Extracorporeal Life Support (ECLS) Protocol Project
Andrew Fagan1, Brian Grunau2, Andrew Caddell1
1Division of Critical Care Medicine, Western University, London, Ontario, Canada.
Insights
Extracorporeal life support (ECLS) protocols vary significantly across Canadian centers, with few common elements. This highlights an opportunity for collaboration to standardize best practices and improve patient outcomes in ECLS care.
Area of Science:
- Critical Care Medicine
- Health Services Research
- Medical Protocol Development
Background:
- Extracorporeal life support (ECLS) is linked to high morbidity and mortality, particularly in low-volume centers.
- Most Canadian ECLS institutions are considered low-volume, suggesting a need for standardized practices.
- The existence and uniformity of ECLS protocols across Canadian centers remain unexamined.
Purpose of the Study:
- To investigate the presence and comprehensiveness of Extracorporeal Life Support (ECLS) protocols in Canadian institutions.
- To assess the homogeneity of ECLS protocols across different Canadian centers.
- To identify key elements within ECLS protocols and evaluate their implementation.
Main Methods:
- A mixed-methods approach utilizing purposeful sampling was employed.
- A Delphi panel identified essential elements for ECLS delivery.
- Institutional ECLS documentation was collected and analyzed using deductive coding to assess protocol completeness.
Main Results:
- A framework of 37 key elements across 5 domains (referral, initiation, maintenance, termination, administration) was established.
- Documentation from 13 institutions across 10 Canadian provinces was analyzed.
- Only 5 key elements were consistently present in over 50% of protocols, with significant variation in their application.
Conclusions:
- There is considerable variability in the completeness and content of ECLS protocols across Canada.
- Inconsistent approaches to critical ECLS elements suggest a potential lack of consensus or evidence.
- Developing a common framework for ECLS protocols can foster collaboration, quality improvement, and research initiatives.
Background:
Extracorporeal life support (ECLS) is associated with high morbidity and mortality. Complications and mortality are higher at lower-volume centres. Most Canadian ECLS institutions are low-volume centres. Protocols offer one way to share best practices among institutions to improve outcomes. Whether Canadian centres have ECLS protocols, and whether these protocols are comprehensive and homogenous across centres, is unknown.
Methods:
Purposeful sampling with mixed methods was used. A Delphi panel defined key elements relevant to the ECLS process. Documentation used in the delivery of ECLS services was requested from programs. Institutional protocols were assessed using deductive coding to determine the presence of key elements.
Results:
A total of 37 key elements spanning 5 domains (referral, initiation, maintenance, termination, and administration) were identified. Documentation from 13 institutions across 10 provinces was obtained. Institutions with heart or lung transplantation programs had more-complete documentation than did non-transplantation programs. Only 5 key elements were present in at least 50% of protocols (anticoagulation strategy, ventilation strategy, defined referral process, selection criteria, weaning process), and variation was seen in how institutions approached each of these elements.
Conclusions:
The completeness of ECLS protocols varies across Canada. Programs describe variable approaches to key elements. This variability might represent a lack of evidence or consensus in these areas and creates the opportunity for collaboration among institutions to share protocols and best practice. The key-element framework provides a common language that programs can use to develop ECLS programs, initiate quality-improvement projects, and identify research agendas.
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