economics and ethics of ecmo for cardiac arrest pdf/l… · rn pay differential is $28.45/hr for...
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Economics and Ethics of ECMO for Cardiac Arrest
Ashish S. Shah, MD
Professor of Surgery
Vanderbilt University Medical Center
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E- CPROut of hospital Cardiac Arrest
In hospital cardiac arrest
Trauma
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Out of Hospital Arrest
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Out of Hospital Arrest
n= 695,000
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Out of Hospital Arrest
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Out of Hospital Arrest
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Is ECPR and Public Health Problem?
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In Hosp Arrest
Long Term survival Poor
19% vs 13% at 1 year
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The eCPR ConstituenciesEmergency Medicine
EMS
ECMO Attendings
Cardiologists
Cardiac Surgeons
Perfusion services
Respiratory Services
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Who Cannulates and Where?
ED
Cath Lab
OR
Target/Walmart
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How to pay for it
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6 Intensivist and I do not know the total salaries for the intensivist
11 specialist (10.5 FTEs) – July 2017 through end of December 2017, we have paid $161,554 in total salaries for ECMO
Perfusionists– July 2017 through end of December 2017, we have paid $228,572 in total salaries for ECMO
RN pay differential is $28.45/hr for about 3800 hours would be $108,110.
The only capital equipment request we have at the moment is for the Cardiohelp. The total request is $402,723.78
ICU bed day cost is $10,195 per day
Infrastructure
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Infrastructure
2 nurses per ECMO patient, 1 perfusionist in house whenever a patient is on, Rounding team CV Surg, Intensivist, HF Cardiologist if VA ECMO, nutrition, pharmacy etc.
perfusionists like staying in house - the get a bonus of $125/hr while in house.
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Infrastructure
115 ecmo in 112 pts 40 VV.
ICU rn 1:1 . Ecmo specialist 1:3-1:4. ICU team. Surgeon.
Ecmo specialist RT or RN. ICU rn plus icuRT responsible for pt.
One perfusionist in house responsible forecmo backup. Cannot also do cases.
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Reimbursement/ Margin
Heart Transplant $100k
CABG $30k
Uninsured ECMO -$250,000
ICU bed or OR case lost because of ECMO patients
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800 OHCA
250,000
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Fundamental Questions and Gaps
When to stop
Termination of resuscitationViable bridging strategies
Financial and resource burdenDisability
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ECMO for out of hospital cardiac arrest
Suicide
IVDU
Jane Doe
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To Cannulate or Not?
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To Cannulate or Not?
Is this a public expectation?
Is recovery a realistic expectation?
How do we define successful outcome?
How much disability should the public expect?
Who should bear the cost of the uninsured?
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When to stop?
Is time arbitrary?
Will we know it when we see it?
Defining futility in ECMO
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