center application number: _30_____ (to be filled in by elso) web view2015. elso award for ... as a...

This page is confidential for ELSO Administrative use only. All correspondence will be sent to both the Primary Contact and Medical Director.

Please read the Instructions Completely

Please choose which Award you are applying for:

( ) Center of Excellence The Gold and Platinum Level Awards will be designated amongst the applications that are established and have invested time. A minimum score must be achieved on the Excellence in Life Support application in order to be designated as a Center of Excellence.

$3,500 fee USD 3 year Award Period Must be a member of ELSO for at least 3 years Must have supported an average of 5 patients per year for the past 5 years Must have reported all patients to the ELSO registry Must complete all sections of the ELSO Award Application

( ) Center on the Path to Excellence These programs are on the Path to Excellence, but have not yet demonstrated the extraordinary achievement in all categories as required for the Center of Excellence Designation. These programs desire recognition for their adherence to the ELSO Guidelines in providing ECLS patient care and are working towards the requirements for designation as a Center of Excellence.

$2,000 fee USD 3 year Award Period Must be a member of ELSO Must complete sections 1, 2, 3 and 4

Primary Application Contact Information

ELSO Center Name:Click here to enter text.

Primary Contact Name:Click here to enter text.

Address: Click here to enter text.


City: Click here to enter text. State: Click here to enter text. Zip: Click here to enter text.

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ELSO Award Application © 2015 Extracorporeal Life Support Organization

ELSO Award for Excellence in Life SupportCenter of Excellence Application

2015


2015E-mail Address: Click

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Medical Director Contact Information

( ) Same as Primary Contact

Medical Director Contact Name: Click here to enter text.



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Your Initials and Signature Verify that you have:____ Read and Verified all of the information entered herein.____ Read and Acknowledge the policies and procedures of the ELSO Award for Excellence in

Life Support.

Electronic Signature: Click here to enter text.



2015To

receive the Award at the fall ELSO meeting:o Application period is through June 1. Applications received during this time period will be considered

for the Award of Excellence. The designation will be awarded at the fall USA ELSO conference, and will continue for a period of 3 years.

To receive the Award at EURO ELSO:o Application period is through March 1. Applications received during this time period will be considered

for the Award of Excellence. The designation will be awarded at the spring EURO ELSO conference, and will continue for a period of 3 years.

Save the application form on your computer as a new word document, using the title:

YourCenterELSOApplication.docx(Example: MillionDollarBabiesHospitalELSOApplication.docx)

Please read the entire application and the policies and procedures before beginning the application. The application questions are designed to allow each center to describe in detail the important aspects of their ECMO program. It is not necessary to provide additional elements in answers that do not request additional information.

When examples of projects, processes, or initiatives are requested,specific examples should only be used once. For instance, the same example may not be used for both a quality initiative and a best practice journey. If examples are repeated, only one question will be given credit. The other will automatically be scored as a “does not meet”.

Use spell check and grammar check. It may be helpful to compose answers in a word processing program and copy/paste into the document.

Remove all identifiers in the application. The city, institution, staff names, or other identifiers should not be used in answering questions. All attachments should have center-specific headings & information removed or blacked out. Applications will be returned if they are not de-identified.

The following supporting documentation is required to be attached at the time of application submission. Missing supporting documentation will result in not meeting the standards of those questions. Attachments should be de-identified with center-specific headings and content blacked out or removed.

o ELSO Award for Excellence in Life Support Equipment and Resource Questionnaireo Agenda for the most recent ECMO Training Courseo Initial water drill checklist or scenarioo Recent annual written testo Recent continuing education water drill checklist or scenario

Submit completed application and all required attachments electronically to [email protected].

Submit check or credit card payment. See payment form for details. Download ELSO Excellence in Life Support Award Documents


Instructions

https://www.elso.org/Excellence/ApplicationSupportDocuments.aspx

mailto:[email protected]


2015Center Application Number: (To be filled in by ELSO)

1. Systems FocusProvide generalized background information about your institution.

1.1 Has your center been a member of the Extracorporeal Life Support Organization (ELSO) for at least 3years? How many patients have been supported with ECLS at your center per year in the last 5 years? Count each patient once. (List patients/year and any variances)

For Path of Excellence Applications, please note if you have had patients and in which populations, or mark as Not Applicable.

2010 2011 2012 2013 2014NeonatePediatric

AdultTotal ECMO

Patients

Click here to enter text.

1.2 Are there any patients in your institution on extracorporeal life support (specifically a pump with an oxygenator) that are not reported to the registry and why?


1.3 Check all of your specialty services available on a 24-hour/day on-call basis? (Describe plan for any services not available)

Cardiology General surgeryCardiovascular surgery NeonatologyAnesthesiology NeurosurgeryInterventional Radiology GeneticsBiomedical Engineering Social WorkNeurology NephrologyCritical Care Specialist PulmonologyHospitalist Hematology/OncologyInfectious Disease GastroenterologyOtherClick here to enter text.



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1.4 Check available support services and/or consultants that are available (Describe plan for any services and/or consultantsnot available)

Blood gas laboratory Chemistry and hematology laboratoryBlood Bank PharmacyCardiovascular operating room with

cardiopulmonary bypass capabilitiesRadiology including cranial ultrasound and CAT scan

Occupational and/or Physical Therapy Developmental/rehabilitation SpecialistNutritionist Pastoral CareInterpreter services


1.5 Outline available inter-hospital transport services for patients on ECLS. If you do not provide ECLS transport services, please detail your plan for transporting patients on ECLS to or from your center in case of emergent need.


1.6 Describe the ECLS Medical Director position responsible for the overall operation of the Center.

Provide medical specialty:


Outline specifics of the scope of Directors responsibilities:


1.7 Describe the ECLS Coordinator position responsibilities in your institution.

Provide description of specialty:


Outline specifics of the scope of Coordinators responsibilities:




20152.Environmental Focus

Provide information about your facility and equipment available for ECLS. Please assure that you have completed the ELSO Equipment and Disposable Resource questionnaire.

2.1 Describe in detail all units/areas in the institution where ECLS is provided. (Include each patient population cared for)


2.2 Describe the general availability of your back-up equipment and components, and their location in relation to your ECLS patient.


2.3 Discuss your plans for equipment and staff utilization in cases of increased ECLS census.




20153. Workforce

FocusFor this application, “ECLS Specialist” refers to the individual your center designates to care for the ECLS circuit.

3.1 Who do you designate as an ECLS Specialist?

Describe specialty(s):


Describe the pre-requisites required prior to applying to be an ECLS Specialist. Include past experience, skills assessments, certifications, etc.


3.2 What is your staffing model for your ECMO patients? (Check all that apply)

1 Specialist per pump, patient has a dedicated nurse 1:1 1 Specialist per pump, patient’s nurse may have 1 or more other patients 1 Specialist for 2 pumps, patients have a dedicated nurse 1:1 1 Specialist for 2 pumps, patient’s nurse may have 1 or more patients Single caregiver model (ECLS specialist is also the patient’s nurse) Other (describe below)


3.3 Who provides primary medical management of the ECLS patient?(Include all individual ECLS populations described in 1.1)


3.4 What resources and clinical expertise are available 24/7 to the ECLS Specialists for ECLS pump and patient management troubleshooting?




20153.5 Who performs

ECLS priming and how do you provide 24/7 coverage for priming?


3.6 Highly stressful events are common during an ECMO run. These events may overwhelm individual staff members and their ability to cope. Staff debriefing processes are defined as programs available for staff where they are able to discuss events or situations,receive support, and learn coping skills. Describe your staff debriefing process that occurs after critical stressful incidents.


3.7 Moral distress is the physical or emotional suffering that is experienced when an individual staff member knows the right thing to do, but constraints make it nearly impossible to pursue the right course of action. How do you provide interventions for individuals in these situations? How do you prevent or mitigate the moral distress that staff may experience when caring for critically ill patients on ECLS?




20154. Knowledge

ManagementProvideECLS Team training and competencies.

4.1 Detail your institution’s initial physician credentialing process for ECLS. Include all attendings, fellows, and residents who care for ECLS patients. Include courses, mentoring, minimum patient requirements etc.


4.2 What annual continuing education and training is required for physicians, including attendings, fellows and residents, to maintain credentials to care for an ECLS patient? Include courses, water drills/simulations, minimum patient requirements etc.


4.3 What specific ECLS training is required for advanced practice nurses or physician assistants who manage ECLS patients? Include initial and continuing education.


4.4 Explain your centers’ initial training program for future ECLS Specialists. Specifically, how do you meet these ELSO Guidelines? Address all four questions regarding guidelines for credit.

a. Describe 24 – 36 hours Didactic Sessions (attach class agenda):


b. Describe your Water Drill and/or Simulation sessions used to teach basic circuit and emergency management skills (attach a water drill checklist or scenario):


c. Describe 16 – 32 hours of Bedside Training Sessions:




2015

d. Describe Final Exam and process:


4.5 What is your continuing education and competency program for the ECLS Specialist? Specifically, how do you meet these ELSO Guidelines? Address all four questions regarding guidelines for credit.

a. Describe Formal Team Meetings: (include agenda details, frequency of education and record keeping):


b. Describe your Water Drill and/or Simulation sessions used to assess competency (attach a water drill checklist or scenario)

.Click here to enter text.

c. Describe Annual Examination process (attach recent annual exam):


d. Describe annual pump time requirements:


4.6 Describe your policy regarding an ECLS Specialist who does not meet continuing education requirements.


4.7 Describe your educational program for bedside nurses to care for an ECLS patient.


4.8 What initial



2015priming education and water drill training are required to be a primer? Include courses, water drills/simulations, minimum patient requirements etc.


4.9 Explain your annual continuing education and competency required for ECLS primers. Include courses, water drills/simulations, minimum patient requirements etc.


Application for the Silver Level (Path to Excellence), Stop Here



2015

5. Quality FocusProvide continuous quality improvement activities.

5.1 How does your center maintain knowledge of current ECLS practice? How do you incorporate that new knowledge into your Centers’ clinical practice? Answer all three questions for credit.

a. Describe how you stay current with the latest advances/research/techniques:


b. How do you communicate this knowledge with your team?


Give a specific example demonstrating how your center implemented a recentadvance/research/technique into policy OR procedure OR standards, OR best practice development and initiation. This example must represent work conducted within the last 2 years.

Develop your answer with the advance/research/technique you wanted to implement, how you incorporated it into your practice and contextually within your ECLS program. Include the evidence that shows you successfully implemented the advance/research/technique into practice and how it improved patient care or outcomes.


5.2 Workforce management includes topics such as initial education and training, or continuing education. The term “Best Practice” refers to processes and policies that generally produce exceptional results. Best practices may involve the innovative uses of resources, staff, and technology. What new best practice related to workforce managementwas implemented in your ECLS center in the last 2 years?

Relate a specific example related to the development and initiation of a process specific to workforce management OR education OR training, OR continuing education within your ECLS program in the last 2 years. Describe the need you identified for this new best practice and how it was developed, initiated, and evaluated for effectiveness.




2015

5.3 The value of care we give our patients can be improved by reducing costs, increasing work efficiency, reducing waste, optimizing the use of resources, promoting family centered careorimproving patient outcomes. What initiative have you implemented in your ECLS program to improve the value of the care you deliver to the patient or family?

Give a specific example related to a process that improved the value of care delivered to a patient or family within the last 2 years. The example should be complete and relevant to increasing the value of care.


5.4 List all ECLS related conferences attended by one or more of your team within the last two years. (ELSO, Keystone, SEECMO, EURO ELSO, etc.) Maintain anonymity by listing the individuals by role (coordinator, director, etc.)

Describe the personnel who attend each of the above conferences:


Additionally, list any ELSO committees that individuals from your institution actively participate on:




2015

6. Process OptimizationProvide outcome reviews and developmentally focused care.

6.1 Illustrateyour Centers’ Morbidity and Mortality Review process. Describe a recent review of a case that includes a major complication or death that was discussed with ECLS team members.

Detail your M&M process, including how you incorporate all ECLS team members(physicians, specialists, perfusion, etc.) into this process:


Give a specific example of a recent patient that was presented at an M&M within the last 2 years. Include personnel present, discussion, analysis, and conclusions that may have arisen from the M&M:


6.2 The ELSO Registry provides specific reports to each center to assist in comparing center outcomes to the aggregate international outcomes. Discuss how you review the ELSO Registry data reports and how you utilize theELSO Registry data reports in your centers’ practice.

Describe your process for reviewing and comparing your ELSO center specific patient data, including outcomes and complications:


Give a specific example of how the ELSO Registry data specifically has impacted patient care or driven practice changes within the last two years. Describe the entire process -from identifying the need for data through the change implementation.




2015

6.3 Benchmarking is the process of measuring your own performance against the performance of industry leaders. Utilizing information obtained through benchmarking to improve processes, procedures, and treatment strategies shows a commitment to excellence and improving patient care outcomes. Discuss your center’s benchmarking process. How has it influenced your ECLS Program to adapt best practices to increasean aspect of performance within your Program?

Detail your benchmarking process:


Give a specific example of the development or the revision of a process that can be directly related to Benchmarking a process in the last 2 years. Describe the need you identified for this process change and how benchmarking was used. Must include data to show the improvement in the process:


6.4 Specify your process for monitoring ECLS patient anticoagulation.

Describe the testing structure, protocol, tools or algorithms used for patient anticoagulation management:




2015

7. Patient &Family FocusProvide family education and participation in care.

7.1 Give a detailed explanation of the educational materials you provide to the family of the ECLS patient.


7.2 Family centered care recognizes the vital role families play in ensuring the health and well-being of infants, children, adolescents and family members of all ages. Describe how your center incorporates the family/caregiver into the daily care of the patient on ECLS

How do you include family in the daily care of the patient?


How do you provide appropriate activity/developmental care for each ECLS patient population listed in question 1.1? For those awake andresponsive patients, how do you include them in self-care activities?


7.3 ECLSpatients are often awake and responsive, and may require long ECLS runs. Families are presented with statistics, facts and unknown prognoses for their loved ones. How do you address the potential distress and suffering that may occur in your families and/or patients with the real probability of death or unpredictable outcomes on ECLS?


7.4 How do you follow-up your patients to see what their outcomes are? Describe your medical follow-up plans for each of your ECLS patient population listed in question 1.1.


END OF APPLICATION
