Development of an Electronic Medical Record for Extracorporeal Membrane Oxygenation and Its Role in a Multidisciplinary Team

Abstract:

As the extracorporeal membrane oxygenation (ECMO) program at our institution has grown and our staffing model has evolved into a multidisciplinary team, our method of ECMO charting has also evolved, using an electronic medical record (EMR) with electronic checklists, progress notes, and remote access. Using our EPIC charting platform, version 1 of our EMR was implemented in 2015. It has been revised three times, and remote access deemed necessary to properly support our staff and patients. Our current, yet still evolving, remotely accessible, ECMO EMR incorporates hourly charting and protocol-based checklists for procedures such as initiation of support, shift handoffs, circuit checks, and patient transport. Perfusionists are required to fill out thrice daily progress notes, notes for bedside/operating room procedures, and patient transport. We present a format for centers looking to implement a comprehensive EMR for ECMO patients. An expanding ECMO program required a change to our staffing model, and an EMR with electronic checklists and remote access facilitated the transition to a multidisciplinary team. Protocol-based checklists ensure consistency during procedures, transports, and shift changes. The remote access and required progress notes create a safer team approach and keep our perfusionists engaged when specialists are sitting ECMO.

OVERVIEW

The use of extracorporeal membrane oxygenation (ECMO) has increased over the years, a fact that has been demonstrated at our institution by a threefold increase in annual ECMO cases between 2015 and 2019. With an expanding ECMO program, our staffing model has evolved into a multidisciplinary team including perfusionists and select respiratory therapists (RTs) and registered nurses (RNs) trained as ECMO specialists who manage the ECMO circuit bedside. This transition from perfusionists to RN/RT staffing led to standardization in how patient care is managed and documented. We present a single-center technique for ECMO charting using our institution’s Epic Systems software (EpicCare EMR, Verona, WI, www.epic.com) to create a comprehensive electronic medical record (EMR) using protocol-based checklists, required procedure notes, hourly documentation of circuit parameters, and remote access.

DESCRIPTION

Checklists

In our current EMR, we include electronic checklists for ECMO initiation, shift changes, and in-hospital ECMO transport. Each item within our checklists has response options of yes, no, or N/A as well as the ability to attach a brief note. The responses are time-stamped and identified with the perfusionist or ECMO specialist who logged in to Epic to complete the list.

The ECMO initiation checklist is broken down into pre-initiation, initiation, and post-initiation (Figure 1) and contains crucial steps and verifications pulled from our standardized adult ECMO initiation protocol. At shift change, the oncoming perfusionist or ECMO specialist completes the shift change checklist (Figure 2). This checklist promotes a full assessment of the circuit, patient, and backup supplies. Alarm settings are reviewed as part of this checklist, and values are entered into the ECMO document flow sheet (Figure 3). The alarm settings are also reviewed before any in-hospital transport of an ECMO patient as part of our in-hospital transport checklist (Figure 4). This checklist is broken down into pre-transport and post-transport. The post-transport checklist is completed once the patient is returned to the cardiothoracic intensive care unit.

Figure 1.

Initiation checklists. ACT, activated clotting time; FiO₂, fraction of inspired oxygen.

Figure 2.

Shift change checklist. HCT, hematocrit; O₂, oxygen; Sat, venous saturation.

Figure 3.

Alarm settings documentation. DeltaP, transmembrane pressure; Part, arterial line pressure; Pven, venous line pressure; SvO₂, venous saturation.

Figure 4.

In-hospital transport checklists.

Procedure/Progress Notes

Our perfusion department is responsible for the initiation and discontinuation of ECMO as well as any bedside procedures, transport, and operating room (OR) procedures performed on ECMO patients. The attending perfusionist completes a required electronic procedure note after any of these events. These notes are found under our perfusion-specific Smartphrases list and include perfusion ECMO rounds—ECMO progress note; bedside ECMO procedure note; Perfusion Interhospital ECMO transport note; and OR ECMO note (Figure 5). The standardized bedside ECMO and OR ECMO procedure notes use asterisks to indicate areas that need to be filled out by the perfusionist (Figure 6).

Figure 5.

Smartphrases list for ECMO perfusion notes.

Figure 6.

Bedside procedure and OR ECMO notes. ABGs, arterial blood gases.

A perfusionist completes an ECMO progress note each 8-hour shift, even if an ECMO specialist is sitting bedside. These notes incorporate pre-populated data from the Epic record and manually entered information from the perfusionist (indicated with asterisks) to include additional cannula size and location, additional devices present, shift blood products given, time and date of note completion, and recommendations/considerations (Figure 7).

Figure 7.

ECMO progress note. ABG, arterial blood gas; Fr, French; LPM, liters per minute; O₂HB, oxygen carrying hemoglobin; pCO₂, partial pressure of carbon dioxide; pO₂, partial pressure of oxygen; RPMs, rotations per minute; SvO₂, venous saturation; VV, venovenous.

Documentation Flow Sheet

Documentation of equipment and disposables, time ECMO was initiated and discontinued (Figure 8), and a perfusion record (Figure 9) are found within our ECMO flow sheet. The ECMO circuit, disposables, and time of initiation are entered as soon as possible. Drop down menus for “ECMO circuit” and “Dual lumen cannulas” allow us to select the appropriately used item. Perfusion parameters are documented manually each hour. Brief notes can be added to any documented parameter for clarification. The type of mechanical circulatory support can be selected from a drop-down menu for “ECMO flow.” If venoarterial (VA) ECMO is selected, an additional row for “vent flow (L/min)” is included, allowing us to document, if present, flow through a left ventricular (LV) vent.

Figure 8.

ECMO circuit documentation.

Figure 9.

Perfusion record documentation. DeltaP, transmembrane pressure; mmHg, millimeters of mercury; SvO₂, venous saturation; Temp, temperature in Celsius; vent, left ventricular vent.

DISCUSSION

Our project began in the summer of 2014, and after consideration of our electronic documentation options and much collaborative work with our information technology (IT) department, the first version of our EMR for ECMO patients was integrated into our institution’s Epic Systems software (EpicCare EMR) in December 2015. As discussed in previous publications, there are challenges to entering perfusion data into Epic when on cardiopulmonary bypass or ECMO (1–3). For our institution’s needs, it was decided that the most straightforward approach to electronically document ECMO parameters in Epic was to create an ECMO documentation flow sheet. This flow sheet is not a separate perfusion module created by Epic Systems. It is a flow sheet modified by our in-house Epic team to include parameters we found necessary for a thorough ECMO record. The initial goal in 2014 was to simply transfer items from our paper record into Epic. These items included equipment used, hourly charting, and a shift checklist. Working closely with the IT department, our vision was described and an initial flow sheet template was created for review. Modifications were suggested and, after multiple back-and-forths, the result was the earliest version of our EMR. Over the course of the last 5 years, as the caseload has increased, as different ECMO/temporary ventricular assist device (tVAD) platforms have been added, and as our staffing model has changed, refinements and additions to the documentation flow sheet have been made that enhance the role of our ECMO EMR within our multidisciplinary team and allow for capture of items required by the Extracorporeal Life Support Organization (ELSO) registry.

EMRs allow vast amounts of data to be stored, accessed, analyzed, and reported by providers. Within our Epic ECMO documentation flow sheet, our team can analyze trends, both numerically and graphically, for any of the parameters we monitor during an ECMO run. For example, the transmembrane pressure (ΔP) over time can be visualized graphically (Figure 10), or multiple parameters, such as circuit flow, ΔP, and sweep, can be selected and represented on the same graphical image (Figure 11). Parameter values that are out of range are highlighted within the flow sheet (see partial pressure of oxygen [pO₂]; Figure 9). Both of these features can be used to guide decision-making and delivery of care. Furthermore, the information included in our documentation flow sheet is extensive, and because it is in electronic format, data can be queried to report to registries, for the use of quality metrics, and to monitor compliance.

Figure 10.

Graph of change in DeltaP over time. DeltaP, transmembrane pressure.

Figure 11.

Graph of DeltaP, flow, and sweep gas flow over time. DeltaP, transmembrane pressure; VA flow, circuit flow in LPM.

The addition of standardized electronic checklists promotes safety and consistency during ECMO initiation, shift changes, and transports. Based on the American Society of ExtraCorporeal Technology Standards and Guidelines, our checklists are read and verified with yes, no, or N/A options available for confirmation (4). By using electronic checklists, confirmations are time-stamped and the perfusionist or ECMO specialist completing the list is documented. This level of accountability fosters checklist adherence. As Schwendimann et al. discovered in their single-center observational study of adherence to the WHO surgical safety checklist, there are three factors that encouraged adherence to the checklist: feeling like part of a team, sharing a goal of patient safety, and full staff participation (5). Anyone involved in the ECMO patient’s care can log in to Epic and see that all members of our perfusion and ECMO specialist team participate in checklist completion.

Additional modification of our ECMO EMR came with the introduction of standardized shift progress notes and subsequently OR and bedside procedure notes. These communication tools keep perfusionists engaged when a specialist is managing the circuit and allow for closed-loop communication within the entire ECMO team. Each 8-hour shift, a progress note is completed by one of our perfusionists, regardless of who is managing the circuit. At our institution, perfusionists do not remain in-house 24/7, so to complete the required overnight or weekend shift progress notes, our team has remote Epic access. This access allows us to review the patient’s chart, ECMO documentation flow sheet, and checklists before calling in to the specialist for a debrief. Once the debrief is finished, we complete the shift progress note from home. It should be noted that we do require a perfusionist to physically inspect the circuit once every 24 hours if we have 24/7 ECMO specialist coverage.

Our perfusion team provides further support by being present for all procedures and transports after which a standardized note is completed. Unlike the documentation flow sheet, notes are visible across all Epic platforms (Haiku, Canto) (EpicCare EMR) so that any member of our multidisciplinary ECMO team can access them from their phone or iPad. Notes are a beneficial communication tool as any issues that come up during a shift such as a low hematocrit, suction events, products given, or goal changes are noted on shift progress notes and are available to all team members. Procedure notes also play an essential role in our current, standardized VA ECMO weaning trial protocol. As we work to have documentation for weaning trials incorporated into our EMR, we use the procedure note to document perfusion flows, times, resultant pressures, arterial and venous blood gases, and results of the trial.

We recognize that there are limitations to our current system of ECMO documentation, and we acknowledge that accessing patient medical records electronically may raise security concerns. We feel that the benefits of our EMR outweigh the limitations and that security measures in place at our institution protect the patient’s privacy and their protected health information (PHI). Standard security measures within the hospital include password-controlled access, role-based security, and access auditing. To be granted password-controlled access to Epic, the user must sign a confidentiality agreement stating that they will only access a patient’s PHI to perform duties associated with their job. Furthermore, the user will adhere to all requirements of the Federal Health Insurance Portability and Accountability Act Privacy Rule. It is mandatory, at our institution, to change passwords every 2 months. Role-based security limits what an Epic user can and cannot see or do within Epic based on that user’s role within the hospital (e.g., doctor, registered nurse, and physician assistant). In addition, anytime a patient’s record is accessed, it is logged, thus allowing for user activity to be monitored and/or audited. Outside the hospital, for our perfusion team to access the patient’s Epic record from a home computer or tablet, an additional level of security in the form of a personal identification number (PIN) plus an RSA SecurID token (RSA, Bedford, MA, www.rsa.com) is required. The RSA token is an eight-digit number that is randomly generated every minute by an application (app) downloaded in our phones. To log in to Epic remotely, our standard username and password are required along with a passcode made up of our PIN plus the RSA token.

As far as limitations to our charting system, we have found that in an emergent situation, time constraints and computer availability can be challenging. To avoid delays in providing care, we have laminated quick reference cards that hang on each ECMO/tVAD console. These cards include our checklists for priming and initiation, alarm settings, and shift changes. We also have a paper document on which we can chart until we are able to transcribe the data into Epic. This document is not included in the patient's permanent record, but improves accessibility of charting when computer access is limited. In addition, we have our OR and bedside procedure notes that confirm that pressures, flows, and pertinent laboratory results were communicated to the care team throughout the procedure.

We understand that manual, hourly entry of perfusion data is not ideal as entry errors may occur and many data points are missed by not having a direct interface between our ECMO/tVAD platforms and the Epic record. However, typographical errors or documenting a value in an inappropriate cell within the ECMO flow sheet can be caught either by ranges put in place for specific perfusion parameters or during the review process before shift progress note completion. Those perfusion parameters that have ranges in place will alert to an improper entry by changing the font color from black to red and displaying an exclamation point. Another current limitation involves charges to the patient for supplies. When ECMO disposables are entered into the Epic record, they are not directly charged to the patient. We rely on our perfusion team to charge for the proper supplies. This may be addressed in the future. Despite these limitations, we find that our current ECMO charting technique enhances our team approach to ECMO management. Our expanding ECMO program required a change to our staffing model, and an EMR with electronic checklists and remote access has facilitated the transition to a multidisciplinary team. Protocol-based checklists ensure consistency during procedures, transports, and shift changes. The remote access and required progress notes create a safer team approach and keep our perfusionists engaged when specialists are sitting ECMO.