129: Implementation of a Multidisciplinary Pediatric ECMO Cannula Surveillance Protocol

Background: Our center experienced a devastating complication from VV ECMO cannula malpositioning which led to the death of a child secondary to atrial perforation. Root cause analysis identified delayed diagnosis of cannula malpositioning with inadequate inter-provider communication to be opportunities for programmatic improvement. We implemented a new multidisciplinary ECMO cannula surveillance protocol and herein describe pre- and post-implementation results. Methods: Patient charts were manually queried both retrospectively and prospectively per ECMO shift for surveillance protocol components: 1) Q12hr specialist documentation of external cannula position (skin to coil), 2) daily chest x-rays, and 3) weekly echocardiography. Protocol compliance was quantified and ELSO registry data was queried for outcomes. We hypothesized that increased vigilance concerning ECMO cannulae would lead to greater frequency of cannula repositioning. Results: 23 pediatric ECMO runs were examined (Table 1). Primary metrics included percent of shifts with correct cannula position documentation and cannula repositioning events. Cannula position documentation improved from 7% to 87% of shifts after protocol implementation. Slightly more chest X-rays were performed per ECMO day in the post-implementation groups (1.6 vs 1.5); however, the rates of echocardiography per ECMO day were equivalent (0.6). Malpositioned cannulae were repositioned in 36% of ECMO runs post-implementation compared to 25% before implementation; normalized over ECMO run length, this did not reach statistical significance. Conclusion: Close introspection after catastrophic complications can improve programmatic systems reliability and inter-provider communication. Rather than a “complication”, cannula repositioning can be viewed as a necessary patient safety intervention for maintenance of optimal ECMO support.