The Journal of ExtraCorporeal Technology No 56-3 | Page 20

R . K . H . Shappley et al .: J Extra Corpor Technol 2024 , 56 , 94 – 100 95
Table 1 . STEP Follow-up timeline .
Age at Decannulation
Evaluation timepoint *
Tests administered
( Years-months )
0to3 – 11
1st Birthday
Bayley-III
2nd Birthday
Bayley-III
3rd Birthday
WPPSI-4 ; PPVT-4 ; EVT-2 ; ABAS-3 ; BASC-3
5th Birthday
WPPSI-IV ; PPVT-4 ; EVT-2 ; ABAS-3 ; BASC-3 ; ChAMP ; VMI-VI ; Purdue
4 – 0to5 – 11
6 months post-discharge
WPPSI-IV ; PPVT-4 ; EVT-2 ; ABAS-3 ; BASC-3 ; ChAMP ; VMI-VI ; Purdue
18 months post-discharge
WPPSI-IV ; PPVT-4 ; EVT-2 ; ABAS-3 ; BASC-3 ; ChAMP ; VMI-VI ; Purdue
6 – 0to15 – 11
6 months post-discharge
WISC-5 ; PPVT-4 ; EVT-2 ; ABAS-3 ; BASC-3 ; ChAMP ; VMI-VI ; Purdue
18 months post-discharge
WISC-5 ; PPVT-4 ; EVT-2 ; ABAS-3 ; BASC-3 ; ChAMP ; VMI-VI ; Purdue
16 – 0 to Adulthood
6 months post-discharge
WAIS-IV ; PPVT-4 ; EVT-2 ; ABAS-3 ; BASC-3 ; ChAMP ; VMI-VI ; Purdue
18 months post-discharge
WAIS-IV ; PPVT-4 ; EVT-2 ; ABAS-3 ; BASC-3 ; ChAMP ; VMI-VI ; Purdue
* All patients receive further evaluations as needed .
Bayley-III Scales of Infant and Toddler Development ( Bayley-III ). We Wechsler Preschool and Primary Scales of Intelligence – Fourth Edition ( WPPSI-IV ). Peabody Picture Vocabulary Test-Fourth Edition ( PPVT-4 ). Expressive Vocabulary Test-2nd Edition ( EVT-2 ). Adaptive Behavior Assessment System , Third Edition ( ABAS-3 ). Behavior Assessment System for Children , Third Edition ( BASC-3 ). Child and Adolescent Memory Profile ( ChAMP ). Beery Visual Motor Integration Test , Sixth Edition ( VMI-VI ). Purdue Pegboard Test ( Purdue ). Wechsler Intelligence Scale for Children , Fifth Edition ( WISC-5 ). Wechsler Adult Intelligence Scale , Fourth Edition ( WAIS-IV ).
and 2021 [ 1 , 15 ]. A few studies examined the impact of a comprehensive follow-up approach on pediatric patients after ECMO model [ 3 , 5 , 7 ]. These studies were primarily crosssectional , mono-disciplinary , and only studied a small population of interest , like neonates , congenital heart disease , or congenital diaphragmatic hernia [ 3 , 5 ]. However , to date , literature has yet to show the successful development and implementation of an effective Pediatric ECMO discharge program in non-European healthcare models . Like most other Children ’ s hospitals , our hospital did not have a defined evaluation and follow-up process for all our ECMO survivors . We depended on the ICU and discharging teams to identify deficits and ensure adequate follow-up , which led to many missed opportunities for our ECMO survivors .
We propose an intentional discharge protocol , STEP , where the long-term side effects of ECMO and post-discharge followup are explained to caregivers . The pre-discharge assessments are confirmed to be completed , ECMO-specific recommendations are sent to primary care pediatricians , and timely and complete neurodevelopmental follow-up is scheduled . We hypothesize that STEP implementation will improve compliance with the recommended follow-up based on ELSO standards and 1987 guidelines [ 1 , 2 , 15 – 17 ] to 90 % or greater .
Methods
STEP was conducted at a tertiary-care children ’ shospitalin the mid-south U . S . A . as a quality improvement initiative . University of Tennessee Health Science Center Institutional Review Board approved the study on February 5 , 2018 , with a waiver of informed consent granted before study initiation ( 17-05517-XP ). A multi-disciplinary team , including an intensivist , developmental-behavioral pediatrician , neurologist , neuropsychologist , and audiologist , met and reviewed the at that time current guidelines and additional literature and implemented them based on institutional resources and included more intensive neurodevelopmental follow-up ( Table 1 ). 1997 ELSO Recommendations for ECMO Follow-Up were later revised in 2021 , but we kept our guidelines unchanged for the study period . It was determined that baseline neurology consultation would be done on all patients and MRI if clinical concerns by the primary team or neurologist . Still , later , this changed to a neurology consultation if the clinical team had a clinical concern and performed if concerns were raised by the primary or neurology team . Discharge lists were kept by an MRI ICU team and sent to neuropsychologists , who coordinated with developmental behavioral pediatrics to avoid duplicating tests and clinic visits . Recommendations for audiological evaluation , PT , OT , and SLP were given to the discharging team and parents . A letter with the ELSO recommendations was given to the parent and mailed to the PCP .
The primary aim was to measure compliance with our institutional discharge protocol based on the 1997 ELSO Recommendations for ECMO Follow-Up . These include neurology and audiology evaluation , P . T ., O . T ., S . L . P . consultation , and neuroimaging . Secondary aims included timely evaluation for developmental delay post-ECMO through neuropsychological examination ( Table 1 ).
All pediatric ECMO patients one day to 17 years of age who survived hospital discharge before and after program implementation between January 2011 and April 2020 were included in the study . Patients were excluded if they underwent ECMO cannulation and / or decannulation at another institution and those transferred to another institution after ECMO . The study excluded non-English-speaking patients due to