SE M I N A R S I N P E R I N A T O L O G Y ] (2018) ]]]–]]]

Available online at www.sciencedirect.com

Seminars in Perinatology

www.seminperinat.com

Education for ECMO providers: Using education

science to bridge the gap between clinical and
educational expertise
Lindsay Johnston, MD, MEda,b,n, Susan B. Williams, MSN, RNC-NIC, CITc,
and Anne Ades, MD, MSEdc,d
a
Division of Neonatal-Perinatal Medicine, Yale University School of Medicine, New Haven, CT
b
Yale—New Haven Children’s Hospital, New Haven, CT
c
Children’s Hospital of Philadelphia, Philadelphia, PA
d
Division of Neonatology, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA

article info abstra ct

Keywords: A well-organized educational curriculum for the training of both novice and experienced
Extracorporeal membrane ECMO providers is critical for the continued function of an institutional ECMO program.
oxygenation ELSO provides guidance for the education for ECMO specialists, physicians and staff, which
Neonatal ECMO education incorporates “traditional” instructor-centered educational methods, such as didactic
Interprofessional education lectures and technical skill training. Novel research suggests utilization of strategies that
Flipped classroom align with principles of adult learning to promote active learner involvement and reflection
Adult learning theory on how the material can be applied to understand existing and new constructs may be
more effective. Some examples include the “flipped classroom,” e-learning, simulation, and
interprofessional education. These methodologies have been shown to improve active
participation, which can be related to improvements in understanding and long-term
retention. A novel framework for ECMO training is considered. Challenges in assessment
and credentialing are also discussed.
& 2018 Elsevier Inc. All rights reserved.

Introduction evidence-based educational strategies. In addition, as

Caring for patients through the cannulation process, the
ECMO run and decannulation is very complex. Successful
management of ECMO patients requires specific baseline
knowledge, technical skills and the ability to successfully
work within an interprofessional and multidisciplinary team.
Development of an ECMO curriculum is critical to ensure
desired learning goals are obtained to allow for optimal
patient management. Ideal ECMO education should
include considerations of adult learning theory, learning
styles, principles of effective curriculum development, and
ECMO care is delivered by teams of providers, establishing
optimal educational strategies requires considerations
of interprofessional collaboration, communication and
teamwork.
Current ELSO recommendations for training ECMO
specialists and providers:
The Extracorporeal Life Support Organization (ELSO) outlines
the required knowledge and technical skills for ECMO

n
Corresponding author at: Lindsay Johnston, MD, MEd, Division of Neonatal-Perinatal Medicine, Yale University School of Medicine, PO
Box 208064, New Haven, CT 06520-8064.
E-mail address: Lindsay.johnston@yale.edu (L.R. Johnston).

https://doi.org/10.1053/j.semperi.2017.12.010
0146-0005/& 2018 Elsevier Inc. All rights reserved.
2 SE M I N A R S I N
specialists.1,2 Recommended training includes a didactic
course and “hands on” water drills. The didactic course for
new ECMO specialists should include prespecified topics
(Table 1) that require approximately 24–36 h of classroom
time.1 Water-drills reinforce the technical skills required to
maintain and troubleshoot complications on a practice circuit
in a simulation laboratory. The optional animal laboratory
experience utilized in new and low volume centers is being
phased out in favor of high-technology simulation. After
completion of the training course, supervised training in the
clinical environment is required before independent practice.
Continuing education is required with thorough documenta-
tion recording participation. Annual written examinations, and
biannual water drills are minimal expectations recommended
by ELSO for ECMO specialists. Performance criteria, certification
and annual competency assessments are diverse and developed
by each individual institution.3,4 These guidelines permit institu-
tional differences, and thus, training may vary significantly
based upon an individual program’s maturity, volume, and
team composition. Programs may have multiple educational
curricula to incorporate training for novice and experienced
ECMO providers, and while this flexibility may be desirable in
order to achieve the goals of an individual ECMO program, this
may contribute to a lack of standardization across centers.
These ELSO guidelines outline a framework for developing
ECMO curricula by defining the specific content needed for
acquisition and maintenance of cognitive and psychomotor
skills.5 This educational strategy dovetails well with Miller’s
Pyramid, which offers a framework for general medical educa-
tion.6 Learners focus first on acquiring new knowledge (“Know,”
which occurs through didactics and self-study), and recognizing
how to apply it (“Knows How,” which occurs during water drills,
case discussions or simulation sessions). They are then given
opportunities to demonstrate this application (“Shows How,”
through performance on an exam, or a performance assessment
during simulation). This learning culminates in a learner being
able to deliver care in the clinical realm (“Does”).
Learning theories
Andragogy or learning in adults, as detailed by Malcolm
Knowles, differs significantly from learning in children, or
Table 1 – ECMO specialist “Didactic” course topics.
Introduction and history of ECMO (broad and institution specific)
Patient selection criteria: neonatal, pediatric, cardiac, ECPR
Circuit component review
Hemodynamics and ECMO flow VA and VV
Physiology of ECMO
Pathophysiology: neonatal, pediatric, cardiac, ECPR, and transport
Precannulation roles: interdisciplinary
Cannulation roles: interdisciplinary
ECMO daily circuit management
Pharmacology
Blood bank and transfusions
Anticoagulation
Complications and troubleshooting: interdisciplinary
Ethical and social issues
Complex surgical case review
Daily patient management
Outcomes
P E R I N A T O L O G Y ] (2018) ]]]–]]]
pedagogy.7 Unlike children, adults have previous experiences
to relate with new knowledge and view the learning environ-
ment as a partnership between learner and instructor rather
than the teacher-centered model favored in childhood edu-
cation. This learner-centered focus allows individuals to
select tasks in order to solve existing problems or challenges
and can be immediately meaningful to their current role. A
variety of teaching methods, with opportunities for active
involvement, is desirable.
Many educational theories have been introduced to explain
the process of learning.8 These learning theories vary with
regards to the process and purpose of learning. Facets of each
theory can be applied to ECMO curriculum design and
education (Table 2). Humanism is relevant for mentoring
and personal growth.9 Behaviorism can be applied to proce-
dural or technical skills training.10 Cognitivism11 and con-
structivism12 can be applied to curricular design and choice of
educational methods. Social cognitivism can be utilized to
improve communication skills, leadership, and teamwork.13
The importance of reflection in the learning process cannot
be underscored. David Kolb’s theory of experiential learning
has many potential applications related to constructivist
theory.14 In this theory, learners enter a cyclical process of
taking part in a concrete experience (such as a patient encounter
or a simulation exercise), reflecting on this experience to
formulate an abstract conceptualization of the process, which is
then tested through active experimentation. In this process, the
experience is not sufficient to cause an individual to create
meaning and understanding about a concept. The facilitator
assists the learner in the reflective process to make connec-
tions, clarify questions, and identify novel applications for the
new material. Educators training ECMO providers should
incorporate opportunities for reflection into their learning
sessions to ensure that optimal learning is occurring.
Learning styles
Instructors should recognize that adults vary in their pre-
ferred learning styles, and different individuals will likely
learn optimally in diverse situations. There are a number of
models that describe different learner characteristics, includ-
ing those by Kolb and Fleming.
In Kolb’s model of experiential learning, (discussed in
previous section) ideal learning sessions will incorporate
each “mode” [concrete experience (CE), reflective observation
(RO), abstract conceptualization (AC), and active experimen-
tation (AE)] in a cyclic process. Individuals prefer different
learning modalities depending on their learning style. Kolb
describes four learning styles based on individual predilec-
tions for the 4 modes: accommodators (CE þ AE), convergers
(AC þ AE), divergers (CE þ RO), and assimilators (AC þ RO).15
Accommodators gravitate toward “hands on” learning and
practical activities. Convergers prefer active application of
theories. Divergers learn best by applying their imagination
and engaging in discussion with others. Finally, assimilators
favor activities incorporating inductive reasoning and crea-
tion of theories.
Another model of learning style, Neil Flemming’s VAK/
VARK model, addresses individual preferences for learning
 SEM I N A R S I N
Table 2 – Comparison between adult learning theories and application to ECMO education.
Purpose of learning
Humanist Become self-actualized
Behaviorist Desirable behaviors encouraged
through positive reinforcement;
undesirable actions extinguished
with negative reinforcement
Cognitivist • Develop capacity and skills to learn Structuring learning content in
more efficiently
• Knowledge understood through
underlying concepts and relationships
Constructivist To construct meaning about a topic
though participation in relevant
experiences
Social To gain knowledge of new roles and
cognitive behaviors
through one of four sensory modalities, including visual,
auditory, reading/written, and kinesthetic.16 Visual learners
take in information best by seeing, and prefer visual aids like
graphs, charts, and diagrams. Auditory learners prefer to take
in information by listening, incorporating lectures, discus-
sions, or podcasts. Some learners most effectively process
information language as written words, while kinesthetic
learners most effectively interact with material by “doing.”
These learners prefer having experiences, and gravitate
toward project based work, experiments, and simulations.
Flemming felt that this model could be utilized to help
learners identify their preferred style, and to enhance learn-
ing by focusing on the methods that best supported their
preferences.
The recognition that all individuals learn differently sup-
ports the utilization of a variety of different educational
methods in designing an institution’s ECMO educational
program.
Curriculum design for ECMO education
Rigorous curriculum development is a critical step in the
development of an institutional program for ECMO education,
and using an established framework is beneficial. The
approach outlined by Kern can easily be applied in medical
education.17 Key steps in this process include problem
P E R I N A T O L O G Y ] (2018) ]]]–]]] 3
Role of the instructor Examples of application in ECMO
education
• Facilitate learner’s Completing voluntary ECMO training to be
development as a person able to provide better care for patients
• Long-term mentoring
relationships
Provide specific, timely feedback Procedural/technical skills training, such
to optimize performance as coming off of bypass emergently,
psychomotor steps in cannulation,
changing out a circuit or a circuit
component
Initial understanding of anatomy of the
an organized, logical manner circuit through diagrams, hands on
practice with a water-filled circuit, and
explaining the relationship between
circuit components and troubleshooting
complications during clinical care
Assisting learner in making Development of educational sessions, like
connections, clarifying case-based discussions or simulations,
questions, identifying novel or reviewing relevant clinical cases to
applications for material permit understanding of a construct
To model and guide new roles Novice providers observe (either clinically
and behaviors or during simulation, and in real-time or
recorded) experienced individuals,
whether low-frequency, high-risk
emergency on ECMO, making
management decisions, or effectively
communicating and leading the medical
team
identification, conducting general and targeted needs assess-
ments, development of goals and objectives, choosing educa-
tional methods, piloting, implementation, and assessing the
effectiveness of the curriculum at achieving the desired
outcomes. Reviewing the framework in its entirety is outside
the scope of this review, but several elements will be
considered in turn.
Goals and objectives
The needs assessment will guide the creation of the goals and
objectives. Goals detail the broad tasks that a learner should
be able to accomplish at the end of the session, while
objectives describe specific cognitive, psychomotor, and
affective points to be addressed. Learning objectives should
describe the following: (1) the intended learner, (2) what will
be accomplished, (3) how much/how well it should be
performed, (4) over what time frame the task should be
completed, and (5) how the outcome will be assessed.17 The
importance of writing clear and specific goals and objectives
cannot be underscored, as these will drive the selection of the
educational methods.
Taxonomies, or classifications, exist for cognitive learning
objectives (factual information that learners should know),
psychomotor learning objectives (actions that learners should
perform, including skills and behaviors), and affective
4 SE M I N A R S I N P E R I N A T O L O G Y
learning objectives (what learners should value or believe,
including role expectations).17 The most frequently reported
is Bloom’s modified taxonomy, which is used for cognitive
objectives, and describes a hierarchy of mental skills.18 These
range from the simple recall or remembering of facts to
activities like appraising, critiquing, or creating new materi-
als. This framework was further revised by Marzano and
Kendall to incorporate four levels, including retrieving knowl-
edge, comprehension, analysis, and utilization of knowl-
edge.19 Targeting higher levels of thinking in educational
sessions is desirable, as it requires a deeper understanding
of the material, making it more likely that the concepts will
be retained in long-term memory and transferred to real-life
situations.20
Educational strategies: traditional to innovative
Using the Kern’s method, educators should maintain con-
gruence between the type of objective (i.e., cognitive, psycho-
motor, and affective) and the educational methods chosen.
Table 3 lists a number of traditional and novel educational
methods, as well as potential applications to ECMO education
programs. There are very few studies reporting specific
strategies to teach ECMO skills and even fewer that involve
randomization. However, there is mounting evidence in the
educational literature to support specific strategies that could
be extrapolated to ECMO. In addition to traditional educa-
tional methods, there are newer approaches that show
promise in meeting the needs of adult learner’s as well as
appealing to individuals with varied learning styles. These
strategies are different depending on the learning domains:
cognitive, psychomotor, and affective.
Cognitive domain
Traditionally, lectures and reading have been used for cogni-
tive skill acquisition. Lectures can be useful for learners who
can understand concepts through restating or paraphrasing
material during note-taking and rehearsing the material
during review of notes after the session.20 However, most
adults will lose focus and have a decrease in their ability to
retain new information after about 20 min. Thus in-class
traditional lectures are being reformatted or disappearing
entirely from many learning institutions in favor of other
methods. In addition, to target higher-order thinking, it is
preferable to include learner-centered activities, such as
opportunities for problem solving in small groups or case-
based discussions, rather than focusing on instructor-driven
formats such as lectures.
Many programs and schools are adopting a format called
the “flipped classroom,” where the content of interest is
reviewed prior to class. This permits in-class time to focus
on interactive activities such as case-based discussions or
working through questions and answers (activities that were
traditionally assigned as homework after the class) to target
higher-order thinking. Flipping the classroom also supports
different learning styles, as material can be delivered in
various ways: reading, watching a video explaining the
material, and/or other computer-based activities. Learners
] (2018) ]]]–]]]
rate the flipped classroom model as preferred to traditional
lectures and there is some data suggesting improved knowl-
edge retention.21,22 One could easily imagine how the flipped
classroom could be incorporated successfully into an ECMO
course, and might allow the 24–36 h currently suggested for
the didactic portion of the ECMO course to be shortened
substantially, especially on the part of the instructor. The
ECMO Red Book and ECMO specialist book developed by ELSO
are great resources that already cover much of the relevant
content.2,5 Thus if learners read assigned chapters in
advance, the in-class session could be devoted to problem
solving, case discussion as well as conversation about specific
institutional practices.
Other strategies that can be used to target higher-order
thinking and application of knowledge are computer-based
interactive programs and “ serious games.” Serious games are
computer-based games that have been designed for a pur-
pose other than entertainment, and have been utilized in
numerous industries.23,24 Learner satisfaction, learner knowl-
edge, improved psychomotor performance and even trans-
lation to improved patient outcomes have been shown with
serious games.25 Several computer-based programs have
been developed for ECMO training that may be useful for
novice and experienced providers.26 However, it is important
to note that specific processes, including peer review and
educational design, should to be used in the development of a
serious game to ensure its quality as a learning strategy.27
The existing ECMO serious games platforms have not been
rigorously evaluated and thus, until further information is
available, may not be a reliable as a sole source for teaching
the relevant material. However, a well-developed and vali-
dated ECMO serious game could address needs of individuals
with unique learning styles and could help fill the gap that
has developed with the disappearance of animal labs.
Psychomotor domain (technical skills)
The hands-on portion of an ECMO course is critical for ECMO
providers to practice and eventually demonstrate proficiency
in performing a number of critical technical skills in a timely
fashion. In addition, there are specific psychomotor skills that
other non-ECMO specialist ECMO providers should be able to
perform (or at minimum, have awareness of the steps to
effectively assist or supervise the ECMO specialist). ELSO does
not dictate any specific strategy for “running” the water drills
beyond recommending small groups to permit each learner
to have hands-on experience, and ensuring learners can
perform recommended skills in a reasonable time period for
emergency procedures and a pre-established period of time
for less complicated procedures.
Strategies that have been shown to be effective for helping
learners acquire requisite technical skills can be applied to
the design of water drill sessions. Deliberate practice in a
mastery learning model (DP/ML) is one such strategy that, by
nature of its design, ensures learner mastery of the specific
skill by the end of the session. In addition, several studies
have shown benefit at the patient level after learners partici-
pated in DP/ML sessions.28,29 In essence, DP/ML involves the
instructor coaching the learner through the steps of the
procedure sequentially. The process continues until each
Table 3 – Traditional and novel educational methods and their application to ECMO programs. Adapted from Kern.17
Educational method Description
Reading Targeted materials (textbooks,
articles) directed towards
learning objectives
Lectures Topic-based sessions,
oftentimes incorporating
audiovisual aids;
Can be enhanced by strategies
to engage learners, such as
problem-solving exercises or
case discussions
Discussion Instructors utilize specific
techniques (questioning,
generalizing, summarizing)
to allow individuals or
groups of learners to explore
an issue or topic
Programmed learning/ Materials (such as textbooks,
Serious games computer programs)
developed to be presented in
a sequential fashion
Simulation “a person, device, or set of
conditions which attempts
to present problems
authentically.” Learners
respond as they would in the
clinical environment
• May involve a range of equipment,
including low-technology task
trainers to high-technology
patient simulators
Benefits Barriers Matching Examples
with
objectives
• Low cost • Passive Cognitive Learners scheduled for initial ECMO training are
• Minimal instructor preparation • Requires sufficient learner asked to read specific chapters of a textbook
time motivation & time covering basic ECMO physiology and
management
• Low cost • Passive Cognitive Novice ECMO providers attend a lecture on
• Structured • Instructor centered anticoagulation, which discusses physiology,
• Large learner: instructor ratio • Variable quality goals, and complications
SEM
I N A R S I N
• Active • Requires learners to have Cognitive/ ECMO providers participate in a small group
PE R I N A T O L O G Y
• Learners must apply knowledge existing knowledge/ affective discussion about a patient with development
to solve problems and make of a new large intracranial hemorrhage while
experience
on ECMO, incorporating potential
decisions • Group depends
management strategies and ultimate goals of
• Exposes various perspectives • Facilitator dependent
care
• • Cost of Cognitive Novice ECMO learners are required to complete a
] (2018) ]]]–]]]
Active
• Psychological safety development may be web-based module that reviews the basics of
• Learners able to self-pace circuit structure and function
prohibitive, if not
• Learners can apply new knowl- commercially available
edge
• Immediate feedback provided
• Safe learning environment • Equipment expensive Psychomotor Interprofessional ECMO teams participate in a
• No risk of patient injury with • Requirement for (skills/ high-technology simulation session on a
learners practicing new skills faculty development behavioral) patient with decreased venous drainage,
secondary to pericardial tamponade
• Useful for high-risk, low-frequency • Low learner:
events instructor ratio
• Provides standardization in ex- • Difficulty replicating some
posures for all learners clinical conditions
• Can include all members of the effectively
interprofessional team, allowing
for optimization of
communication and team
behaviors
5
6 SE M I N A R S I N P E R I N A T O L O G Y ] (2018) ]]]–]]]

individual step is performed correctly in sequence without

feedback from a clinical mentor after they are

and blood gases and to troubleshoot problems
Participants learn to interpret circuit pressures

while managing a pig who is cannulated for

the need of further formative feedback. The DP/ML model has

A novice ECMO provider receives formative

been applied successfully for learning discrete procedures

observed leading an ECMO cannulation

such as central line placement30 as well as more
complex situations such as cardiac arrest.31 This model could
be applied to ECMO water drills and technical skills. To
ensure standardization of this process, it would be important
to ensure that instructors had received specific training to
optimize their coaching skills, development of checklists with
multiple sources of validity evidence to detail the correct
steps and sequence of the procedures, and the determination
of a performance threshold that would indicate mastery of
Examples

the skill.32
ECMO

To address the needs of the surgical team placing ECMO

cannulae, cannulation task trainers have been developed and
refined so that learners can learn and practice these skills in
the simulation laboratory. Allan et al.33 report on one such
behavioral)
Psychomotor

Psychomotor

trainer. Following one simulated cannulation using the task

objectives
Matching

(skills/

trainer followed by expert debriefing, significant decreases in

with

time to cannulation on the trainer were noted with subse-

quent attempts. This improvement was sustained at 3
months.
of

Other devices have been developed that can integrate with

• Limited availability

be experienced with

ECMO circuits and can assist in the simulation of ECMO

providing feedback
• Observer needs to

emergencies such as air entrainment and changes in circuit

• Moral/ ethical

pressure.34,35 The more advanced technology allowed with

these devices can enhance the fidelity of the water drills and
• Expensive

concerns
animals

simulations allowing for more learner engagement.

Barriers

Psychomotor domain (behavioral skills)

Simulation is a widely accepted learning strategy for learners

actual clinical experiences
physiology of humans on

Promotes learning through

at all levels to practice being able to apply knowledge and

Ability to replicate clinical

perform technical skills in an environment that mimics

actual patient situations, allowing learners to have an oppor-
tunity for critical thinking and performing behaviors under
stress. Managing patients on ECMO requires the coordination
and communication of multiple interprofessional providers
ECMO

(i.e., nurses, physicians, respiratory therapists, pharmacists,

Benefits

and specialists/perfusionists) in both emergent and non-

emergent situations. Interprofessional education (IPE) is when
two or more professionals learn together. The goal of IPE is to
simulate human physiology
A living animal (such as a pig

actual clinical environment

increase the cohesiveness and functioning of the team

Learners receive feedback on
their performance in the

through interprofessional collaboration, thereby decreasing

or sheep) is utilized to

medical errors and improving patient and family care. There

are four main competencies that have been described as the
and responses

foundation for IPE: values/ethics, roles/responsibilities, inter-

professional communication, and teams and teamwork.36
Description

Simulation is an ideal methodology to incorporate interpro-

fessional communication and teamwork, as specific objec-
tives to trigger these behaviors can be incorporated into the
scenario design.37,38 An interprofessional team of providers
participating in ECMO simulation is shown in Figure 1.
Table 3 (continued) )

Real-life experiences
Educational method

Several studies have reported on the use ECMO simulation

for education and have shown improvements in learner
knowledge39 and confidence,40,41 time to cannulation in
Animal lab

simulation33 and clinical eCPR initiation,42 and sytems based

practices with better adherence and use of an ECMO initiation
checklist.43 While current ELSO guidelines do not specify the
use of simulation for behavioral skills, it is likely that updated
 SEM I N A R S I N P E R I N A T O L O G Y
Fig. 1 – Interprofessional group of providers participating in
ECMO simulation session.
guidelines will include recommendations for team training
with simulation. Even without specific guidelines, many
ECMO centers have incorporated simulation into their ECMO
educational programs. Weems et al.44 surveyed US ECMO
centers affiliated with ELSO in 2012 to evaluate their use of
simulation for ECMO staff. At the time of the survey, about
half of the centers had active simulation programs in place,
and another quarter were in the process of developing ECMO
simulation programs. In these centers, only 7% still had an
animal laboratory as part of an ECMO course. Interestingly,
centers with higher volume were more likely to have an
active simulation program.
Simulation is increasingly being utilized to replace the animal
laboratory experience recommended by ELSO as the use of
animals for medical training is vanishing due to ethical and
cost considerations. Brazzi et al.45 described the Italian experi-
ence with a simulation-based training course during the H1N1
epidemic. Though the centers had some experience with using
ECMO, over half of the centers had not used ECMO as a therapy
for severe respiratory failure associated with H1N1. Thus with
advances in ECMO simulation technology and techniques and
the requirement for supervised clinical practice, the animal
laboratory should be able to phased out entirely.
Affective domain
Incorporating educational sessions that concentrate on the
affective domain are also important given the difficult sit-
uations that may arise with patients on ECMO. Interprofes-
sional education has values/ethics and roles/responsibilities
as two of the core competencies. Relevant areas in the
affective domain include appreciation for the role of each
team member, patient- and family-centered care, and shared
decision-making. These issues may be explored through
case-based discussions, standardized patients, simulations,
or reflection on clinical experiences.17
Learning beyond the initial course:
Successful completion of the individual components of an
ECMO course does not assure competence at the bedside of
] (2018) ]]]–]]] 7
an actual patient on ECMO. Thus learners should be super-
vised until the assigned preceptor has assessed that the
learner is ready for independent practice. In addition, as with
all skills, infrequent use, lack of reflection/feedback and
inability to keep up with the frequently changing technology
and practice can lead to inadequacy of providers. Thus a
well-defined and designed continued education curriculum
should be in place to prevent or mitigate the skill decay. Key
to the process of ensuring readiness for independent practice
as well as maintenance of skill level for practice is defining
the requirements for initial and re-credentialing. At this
time, ELSO does not specify the credentialing process for
ECMO staff beyond specialists. In 2015, Muratore et al.46
published results of a survey that revealed that only
2/3 of ECMO centers that responded required ECMO physi-
cians to be credentialed and only 16% required yearly certif-
ication. As simulation practice continues to evolve, the
potential to use simulation as one part of re-credentialing
providers may be possible. Simulation has been used as an
option for maintenance of certification for anesthesia pro-
viders to fulfill the practice performance and improvement
requirements. Anesthesia providers who participated in this
course had a high rate of implementing identified practice
changes.47
Supervised clinical practice
A commitment of 16–32 h of additional supervised
clinical practice accompanied by an experienced ECMO Spe-
cialist is recommended for all novice ECMO specialists. It is
acknowledged that teaching styles and clinical expertise are
variable, as are ECMO patient volume and acuity. Therefore, it
is desirable for novice providers to be exposed to a number of
different preceptors who can provide a variety of perspec-
tives.48 Thorough documentation of experiences on a com-
prehensive ECMO training checklist is essential given the
variability of bedside experiences. Exposure and performance
gaps can be identified and on-going simulation training and
educational sessions can be tailored to fill these gaps. ELSO
recommends customizing educational programs based on
each individual institution’s patient population, equipment,
and assigned responsibilities of team members to accommo-
date for ECMO program diversity.5
Continuing education
ECMO is a relatively infrequently used therapy. Even in
institutions with high ECMO volume, individual provider
exposure to patients on ECMO might be low. In addition,
many ECMO runs are without incident; thus, it is unlikely
that all team members will be able to practice and maintain
skill in responding to all types of ECMO emergencies by virtue
of their clinical experience alone.
Chan et al.49 describe an ECMO course that was developed
for new ECMO providers. ELSO recommendations were fol-
lowed, and several simulation scenarios were incorporated.
Participants were noted to have improved scores in knowl-
edge, confidence and ability after the course, but these scores
decreased to almost baseline levels upon retesting at a
6-month interval. Therefore, institutional ECMO curricula
8 SE M I N A R S I N P E R I N A T O L O G Y
should include continuing education for providers to allow
for skill maintenance in all domains. ELSO guidelines recom-
mend yearly knowledge assessments as well as semi-annual
water drills to assist in the prevention of skill decay. In
addition, many institutions use simulation sessions, morbid-
ity and mortality conferences and case reviews to continue
exposure of team members to ECMO principles and manage-
ment and interprofessional team training.
In addition to scheduled continuing education sessions,
another strategy that may be useful in ensuring optimal
performance when needed is just-in-time training. Just-in-
time training involves learners practicing a skill that is
anticipated or identified to be necessary in the near future.
In a systematic review, just-in-time training has been
demonstrated to have beneficial effects on provider
performance.50 This strategy could be adopted for the ECMO
setting. For example, an ECMO specialist could practice an
emergency component change in the simulation lab prior to
their shift or the team could practice an ECMO cannulation
when anticipating a patient with the potential need for
ECMO.
Conclusion
Development of ECMO curricula should be based upon knowl-
edge of relevant adult learning theory, learning styles and
clearly identified goals and learning objectives. ECMO educa-
tion should be based on evidence-based learning strategies,
and should incorporate novel techniques as evidence to
support these strategies continues to mount. ECMO education
does not end after the initial training; continuing educational
sessions are necessary even for experienced ECMO providers
especially with regards to management of ECMO emergencies
and effective interprofessional teamwork and communica-
tion. Further work to discern the optimal frequency, content
and delivery of ECMO educational sessions is needed.
Requirements for the assessment and credentialing of ECMO
providers continue to be institution specific. In the future,
however, the desire to ensure competency of providers may
lead to the requirement for summative evaluation to deter-
mine appropriateness to start or continue clinical ECMO
practice. Simulation sessions, observed clinical practice, and
cognitive assessments will likely be incorporated in this
process. Individuals with expertise in adult education and
assessment will be essential in the development of these
standards.
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