As an emergency physician in an academic medical center, Peter Georgakakos, DO, can list many jobs on his email signature, including assistant clinical professor, medical director of his school’s emergency medical services learning resource center and medical director of the county ambulance service.
While championing the University of Iowa (UI) Health Care launch of an extracorporeal cardiopulmonary resuscitation (eCPR) program, he could have added “choreographer” to the list given the skills needed to get everyone onboard, incorporate their feedback, and then hold simulation training sessions.
The eCPR program is for patients experiencing sudden cardiac arrest and builds on UI Health Care’s internationally recognized extracorporeal membrane oxygenation (ECMO) program for patients with life threatening heart and lung failure.
ECMO is considered a supportive lifesaving therapy, but it is not a treatment. It allows the heart and lungs to rest and recover while providing adequate circulatory support and oxygenation to vital organs.
There are almost 800 ECMO centers in the world, and the Extracorporeal Life Support Organization classifies UI Health Care’s program as one of only 43 platinum-level centers of excellence.
Formerly known as University of Iowa Hospitals & Clinics, UI Health Care is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
At UI Health Care, eCPR involves emergency use of ECMO for patients with cardiac arrest for whom conventional cardiopulmonary resuscitation or automatic external defibrillator hasn’t worked.
Getting the eCPR program launched required years of preparation and planning involving multiple departments and interested stakeholders.
“Because it's a multidisciplinary effort, there wasn't going to be just one department that said, ‘Yep, we're doing this now: Go,’” Dr. Georgakakos explained. “It took so many departments that you needed to find a champion in each step and get stakeholders involved early.”
Arresting developments
Dr. Georgakakos had been interested in eCPR for several years after hearing the concept discussed at emergency medicine conferences. His dream of launching the concept at UI Health Care, however, seemed like it was likely to go unfulfilled until the results of a National Heart, Lung and Blood Institute-funded study were published in November 2020.
The advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation trial—or “ARREST,” for short—showed how effective eCPR could be. The early results were so successful that the institute halted the study as outcomes for cardiac arrest patients getting eCPR treatment were far superior to those receiving standard care.
“There was this idea that [eCPR] had always been kind of this cool thing,” Dr. Georgakakos said. ARREST “was what made it become relevant and that it was an idea that could actually happen in our area.”
One reason for his interest was that, in his role as the medical director for Johnson County, Iowa, emergency medical services, Dr. Georgakakos tracked outcomes for cardiac arrest and thought eCPR may be helpful in reducing geographic inequities.
“I looked at our data from the year before just to see potentially, very roughly, how many of our cardiac arrests that we had responded to would've potentially been considered to be included in that trial had it been in our area,” he recalled. “Almost one in 10 was someone who unfortunately did not survive that potentially could have been considered [for eCPR] and maybe had a good outcome.”
The ARREST findings gave the idea traction, and several informal meetings were held between Dr. Georgakakos, and the leadership of the code blue committee, emergency and cardiology departments and the ECMO team.
Being in the thick of the COVID-19 public health emergency, all these meetings were held virtually, which Dr. Georgakakos believes delayed the start of the program by more than a year.
“There were some very clear steps that needed to be spelled out very explicitly,” Dr. Georgakakos recalled.
“For example, who was going to cannulate,” he added. “In our facility, only vascular surgeons did that and that was going to be a non-starter—practically, it wasn't going to make sense.”
But, after discussions between the cardiologists and the vascular surgeons, who eventually decided it was more practical to have cardiologists inserting the cannula tubes into the patients’ veins. But this required them to get training to do the procedure.
Each step required buy-in from different departments and then training everyone from specialists to paramedics in the new skills. Then group simulations were held, which went from the ambulance to the emergency department, to the cardiac catheterization laboratory. These trial runs exposed various shortcomings in initial plans.
“The simulations were some of the most useful learning experiences we had because there was only so much we could see on paper,” Dr. Georgakakos said. “Even just silly things like when should the paramedics call me while they’re doing a million things, they [simulations] helped them figure out some of the choreography and just doing it helped fix some things you couldn't anticipate.”
Persistence pays off
In addition to the meetings, planning and training, Dr. Georgakakos quipped that his “nagging” was also an essential component in launching the eCPR program back in November.
“My boss was getting real sick of me constantly talking about this,” he said.
Since the launch, the program has been activated four times, with three positive outcomes and with one patient still in recovery, Dr. Georgakakos said, adding that there have been other benefits as well for his emergency department.
“Our collaboration with cardiology in general has vastly improved because we've had so many discussions about these patients that the cooperation we have—even in a patient who doesn't ultimately qualify—has really improved the teamwork dynamic,” he said. “So not only does it help improve patient outcomes, it also improves the teamwork and the collegiality between teams.”
There is talk of expanding the service to include other types of cardiac arrest, including those caused by drug overdoses. “Our toxicologists are very ready to start calling on us to do this,” Dr. Geogakakos said.
For hospitals and health systems looking to start their own eCPR programs, Dr. Georgakakos had some basic advice.
“You have to get stakeholders involved early and know that there will be a lot of barriers,” he said. “You have to have the humility to remember that the priority is getting it implemented—not getting it implemented your way.”
