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Roles & Responsibilities of European Perfusionists in ECLS & EuroELSO

Current Involvement & Future Ambitions

Since its first clinical use in the 1950s, the set-up & management of cardiopulmonary bypass (CPB) during cardiac surgery has been the responsibility of the perfusionist. In contrast, when this technology left the operating room from the 1970s onwards to provide longer term support (ECLS), there was no longer worldwide uniformity nor consensus concerning clinical roles or responsibilities. The care and supervision of the ECLS system & patient became a multidisciplinary approach and a specialized training & involvement of the entire team was recognized as being important for quality care.
To provide support to institutions delivering ECLS, the Extracorporeal Life Support Organization (ELSO) was founded in USA in 1989. ELSO established an observational data registry, offers a platform supporting education, training & research, provides practice guidelines and organizes international ECMO meetings. Broad multidisciplinary participation was always strongly encouraged by ELSO, but perfusionists' involvement has been limited in USA, illustrated by little academic input in research, publications and meetings as well as local 'ECMO specialists' or 'ECMO coordinators' being more commonly nurses or respiratory therapists.
For a longtime, there were only small numbers of ELSO registered centers across Europe. Therefore, in 2011, a European chapter of ELSO (EuroELSO) was founded, trying to offer more relevant support and a platform for European ECMO centers.
Ever since the establishment of EuroELSO, the registration of European centers is rapidly growing (Fig. 1) and anno 2014, 81 European ECLS centers from all over Europe are registered (2) of which 71 regularly send in their data.

 Perfusionist Nov14 Fig1Fig. 1 - Numbers of European ELSO registered centers

Similar as in the North American ELSO, a Perfusionist liaison position was established in 2014 within EuroELSO to defend the vision & ambition of European Perfusionists and to guard & ensure their desired level of involvement.

As it was unclear how intensely Perfusionists around Europe are or want to be involved in ECLS, a survey (Survey Monkey) was created. This survey inquired about their roles & responsibilities in the local ECMO programs, as well as their interest & ambition to participate in EuroELSO.
The survey was send around starting May 2014 to the delegates of all countries which are member of the European Board of Cardiovascular Perfusionists (EBCP) with the request to forward it to the Perfusion Department of each cardiac surgery center within their country. The language of the survey was English but a separate survey for France was made in French. The results of the French survey were most of the time very comparable but these results will be indicated/delineated in red.
There was an overall good response (Fig. 2) from all over Europe; except from Greece and Spain (who had some problems forwarding the survey towards their ECLS units) all EBCP countries, including Cyprus, responded.

 Perfusionist Nov14 Fig2Fig. 2 - Responding European centers. Also Cyprus and France (separate survey) responded.

A total of 199 (182+17) centers responded to the (English + French) survey; of the responding centers 70% (75%) have an active ECLS program, nearly 20% (12%) intend to start in the near future.

Only the current (122 + 13) & near future (32 + 2) ECLS centers were asked to complete the entire survey.
To the question if their centers are ELSO registered, only 23% (12%) could confirm and only 14% (0%) are aware of their data being send to the ELSO Registry (Fig. 3).

Perfusionist Nov14 Fig3Fig. 3 - ELSO registered & data reporting centers.

Perfusionist Nov14 Fig4Fig. 4

Perfusionist Nov14 Fig5Fig. 5

The answers to the survey questions concerning clinical roles (Fig. 6 & 7) revealed important involvement of Perfusionists from setting up the circuit until weaning of the ECLS. In most European ECLS centers, physicians are clearly participating in some tasks while nurses & ECMO specialists remain 'invisible' except for patient rounds and data entry. Still, nurses play an important role in the care of the ECLS patient and should receive specialized training as in most centers there is no 24/24 beside support from the Perfusionists.

Perfusionist Nov14 Fig6Fig. 6 - "Who is responsible for the following ECLS related tasks in your center?"

Perfusionist Nov14 Fig7Fig. 7 - “What is the role of a perfusionist in the care of a patient on ECMO?” 

Perfusionist Nov14 Fig8Fig. 8

Perfusionist Nov14 Fig9Fig. 9

The majority of the centers responded that additional training for Perfusionists, physicians & nurses should be compulsory before starting up an ECMO program and also that there should be support from an expert ECLS center.
Most (90-100%) centers agreed that there should be 'Minimum Standards of Care' established to which all ECLS centers should adhere. These Minimal Standards of Care should be written minimal requirements concerning staffing, training, experience, equipment, safety, ...in order to optimize quality of ECLS programs.
To the question concerning amount of clinical involvement, 75% responded being satisfied with the degree of involvement, while 25% have ambitions to become more clinically involved.
Concerning non-clinical involvement; there seem to be a lot of interest to take part in EuroELSO; 85% of the responding centers are interested to attend the annual EuroELSO meeting and 45% are interested to contribute to the scientific (presenter, moderator,...) and practical sessions (hands-on, simulation, ...). Also 45% are eager to be involved in EuroELSO activities. (Fig. 10)

Perfusionist Nov14 Fig10Fig. 10

While anno 2014, 81 European centers are officially registered in EuroELSO (1), only 24 of the 199 survey responding centers reported being ELSO registered. (Fig. 11) Either some chief Perfusionists are not aware of their center being registered or the survey reached different centers. In either case, the survey reached far more centers than the number which are ELSO registered, indicating  that still an important percentage of ECLS centers are not yet ELSO registered.

Perfusionist Nov14 Fig11 Fig. 11

We can summarize that this survey learn us that :

1. European Perfusionists willingly play an important clinical role in local ECLS programs, and also that many perfusionists would like to become more non clinically involved as well.

The limited non clinical involvement remains unclear as perfusionists are already encouraged by ELSO and position papers to take on other roles; roles similar as those expected from the in-house "ECMO coordinators". An ECMO coordinator – typically nurse, respiratory therapist or perfusionist – may assist the medical ECLS director with organizing & implementing the training of the ECMO team, staffing, quality improvement, maintaining equipment & supplies, and ensuring that data are entered into ELSO registry or other database. (4).
Yet today, from the 81 ELSO registered centers, only 6 coordinators are certified Perfusionists, 49 are Medical Doctors and (most of) the remaining 26 are Registered Nurses (2).

2. European perfusionists and European ECLS programs still lack involvement but not interest in EuroELSO.

The main reason for this limited involvement seems to be the lack of information about EuroELSO & its Registry, the lack of awareness concerning its value in the daily practice and some also expressed the concern for needing patient consent to be legally allowed to submit data.
Not lack of support from EuroELSO, nor lack of interest by the perfusionists but communication between EuroELSO and the European Perfusionists seemed insufficient in the past, as when the EuroELSO coordinators position became available for application last year, only nurses applied for the position.

In conclusion, we can say that there is a lot of clinical involvement & non-clinical ambition of Perfusionists in ECLS programs and that there is no reason for the perfusionist to limit this involvement or freeze this ambition while EuroELSO & position papers are encouraging these.

  1. French and English survey (Survey Monkey) about role and responsibilities of Perfusionist in ELSO and European ECLS centers (edited by Leen Vercaemst and analyzed with Survey Monkey)
  2. www.elso.org
  3. Position article for the use of extracorporeal life support in adult patients. A Beckman et al. Eur J of Cardiothoracic Surgery (2011)
  4. Position paper for the Organization of ECMO programs for acute respiratory Failure in Adult Patients. A. Combes et al. Am J of Resp and Crit Care Med (2014)

Presented at the EBCP meeting in Milan, October 10, 2014

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