Challenges in the development and implementation of a healthcare system based extracorporeal cardiopulmonary resuscitation (ECPR) program for the treatment of out of hospital cardiac arrest.
INTRODUCTION
Extracorporeal cardiopulmonary resuscitation (ECPR) can treat cardiac arrest refractory to conventional therapies. Many institutions are interested in developing their own ECPR program. However, there may be challenges in logistics and implementation.


AIMS
The aim of our protocol was to demonstrate that an ECPR team was feasible within our healthcare system and that the identification of UPMC Presbyterian as a receiving center allowed for successful treatment within 30 min from EMS dispatch.


METHODS
We developed out of hospital cardiac arrest (OHCA) ECPR protocols for Emergency Medical Services (EMS), EMS communications, and our in-hospital ECPR team. Inclusion criteria indentified patients with a potentially reversible arrest etiology and high probability of recoverable brain injury using a simple checklist: witnessed collapse, layperson CPR, initial shockable rhythm, and age 18-60 years. We trained local EMS crews to screen patients and reviewed the criteria with a Medic Command Physician prior to transport to our hospital.


RESULTS
From October 2015 to March 31st 2018, EMS treated 1165 EMS OHCA cases, transported 664 (57%) to a local hospital, and transported 120 (10%) to our institution. Of these, five (4.1%) patients underwent ECPR. Among excluded cases, 64 (53%) had nonshockable rhythms, 48 (40%) were unwitnessed arrests, 50 (42%) were over age 60 and the remaining 20 (17%) had no documented reasons for exclusion. For ECPR cases, median pre-hospital CPR duration was 26 [IQR 25-40] min. Four patients (80%) received mechanical CPR. Interval from arrest to arrival on scene was 5 [IQR 4-6] min and interval from radio call to activation of ECPR was 13 [IQR 7-21] min. Interval from EMS dispatch to departure from scene was 20 [IQR 19-21] min. Time from EMS dispatch to initiation of ECPR was 63 [IQR 59-69] min.


CONCLUSIONS
ECPR is an infrequent occurrence in EMS practice. Most apparently eligible patients did not get ECPR, highlighting the need for ongoing programmatic development, provider education, and qualitative work exploring barriers to implementation.
['Chonde|Meshe|M|', 'Escajeda|Jeremiah|J|', 'Elmer|Jonathan|J|', 'Callaway|Clifton W|CW|', 'Guyette|Frank X|FX|', 'Boujoukos|Arthur|A|', 'Sappington|Penny L|PL|', 'Smith|Anson J|AJ|', 'Schmidhofer|Mark|M|', 'Sciortino|Christopher|C|', 'Kormos|Robert L|RL|']
D000293:Adolescent D000328:Adult D016887:Cardiopulmonary Resuscitation D003695:Delivery of Health Care D004632:Emergency Medical Services D015199:Extracorporeal Membrane Oxygenation D006801:Humans D008875:Middle Aged D058687:Out-of-Hospital Cardiac Arrest D055815:Young Adult
Extracorporeal cardiopulmonary resuscitation (ECPR) Cardiac arrest Emergency medical services