Reward for a highly specialist role
A critical care nurse who devised patient retrieval protocols, pathways, multidisciplinary training and family liaison for a highly specialist, high-risk ECMO service has won a national award.
Jo-anne Fowles led the Teva Innovations in Respiratory category of the Nursing Standard Nurse Awards for her achievements in improving patient care as Extracorporeal Membrane Oxygenation (ECMO) lead nurse at Papworth Hospital NHS Foundation Trust.
Jo-anne was part of the team that put together the successful Papworth Hospital tender to be one of five centres nationally that provide ECMO.
ECMO involves draining venous blood from the patient, removing carbon dioxide from the blood and adding oxygen, and then returning the blood to the patient. It is used to support patients with acute respiratory distress syndrome.
‘Setting up the ECMO service was a huge learning curve,’ says Jo-anne, who was previously a sister on critical care. ‘I had to look at service provision, the referral and retrieval of patients, the ambulance support service and the education of the multidisciplinary team.’
As part of this role, she also devised robust referral pathways and worked on ensuring safe repatriation of patients back to a hospital nearer their home when appropriate.
Clinically, Jo-anne is lead practitioner on the team, demonstrating a high level of expertise in ECMO practice. This includes trouble-shooting the circuit, and managing patient care including when weaning off ECMO and post-ECMO support.
It is clear to see that Jo-anne is passionate about education and training. The Papworth team retrieves patients from its allocated catchment area – Cambridgeshire, Norfolk, Suffolk, Hertfordshire, Bedfordshire, Essex and North East London. As a national centre, Papworth accepts patients from further afield if others are at capacity. The Papworth retrieval nurses and medics therefore have been trained specifically to transport patients supported with ECMO.
Jo-anne has set up the training programme for the entire multidisciplinary team at Papworth, including practical sessions and assessments, training in the clinical area, study days and medical inductions.
‘I feel very strongly that nurses should be well represented in the new service, and have enhanced roles in a previously medically led service,’ says Jo-anne.
She is especially proud to have developed the role of the ECMO nurse specialist at Papworth with a programme of study days, annually assessed reflective essays and clinical assessments. ‘It has improved patient care and cost effectiveness – and the course is very over-subscribed,’ she adds.
‘Nurses at the bedside attend study days looking at different types of ECMO, as well as observations and surveillance so they can recognise any deterioration. Now they work quite independently. They follow the patient journey all the way through.’
As a result, patient care is less fragmented and when nurses are supporting relatives they have the knowledge and experience to answer their questions.
Establishing the service
The ECMO unit was a complex service to set up, as Jo-anne explains. She had to raise awareness of it – and who could and could not benefit from ECMO support – both within the trust and with others within Papworth’s region.
Communication has been crucial. Jo-anne launched the trust’s ECMO website and set up a single contact number at Papworth. Flyers and emails were sent to consultants at other trusts, followed up by personal visits, education and training.
There are protocols for keeping in touch with the referring unit while the patient is at Papworth and following their repatriation, and letters are sent to the patient’s GP.
Another challenge has been staffing and rotas. One appropriately trained nurse and doctor are always on call and have to be available to go on retrieval while maintaining the necessary skill mix on critical care.
Setting up the retrieval service itself required a tender and contract process for an ambulance company. This was to ensure the 24/7 availability of a ‘fast car’ to get to the referring hospital quickly and then a specially equipped ambulance to bring the patient and team back safely.
Once a patient’s treatment is complete, they are repatriated to their local hospital. Papworth’s involvement doesn’t end there, however, as they support the patient’s local team with ongoing telephone follow up.
‘After six months we invite the patient back to our clinic where we do a quality of life assessment using a modified questionnaire from Canada, asking how they feel that day,’ says Jo-anne. ‘We also take ex-patients and their families to the ICU and show them an ECMO circuit. It is a very important part of the patient’s recovery – and amazing to see their response.’
The follow-up clinics help patients and their families come to terms with their experience. Patients report that they have helped fill in some memory gaps and improved psychological recovery.
Feedback gained from patient satisfaction questionnaires are very positive, as is the feedback from the relatives’ experience questionnaires. Patient/carer information has been made available so relatives can be more informed about the treatment. The nurses that travel with the retrieval team are also trained in family liaison and give families a written leaflet.
Jo-anne feels very privileged in her role and says she has enjoyed amazing support. ‘I am proud of what I have achieved for patients and nurses.’
Looking to improve
But the team is constantly striving to improve. The monthly multidisciplinary meeting includes discussion of untoward incidents and the lessons that can be learnt from them. This approach ensures patient care is constantly improving.
They discuss all referrals, including the appropriateness of the decision to accept or not accept patients for ECMO and the outcome for those patients not accepted as well as all patients accepted.
‘We look at the whole patient experience – from referral to follow up in clinic. We continually assess patient stories and we use family satisfaction surveys to assess patient experience,’ adds Jo-anne. ‘We are always looking at what could have been done better – this is very much a work in progress.’
Chief nurse Josie Rudman says: ‘Before this service was developed patients had to travel miles for ECMO, often overseas. This meant that at this critically ill phase they were often separated from their loved ones.
‘With Jo-anne’s specialised role there has been a focus on improved patient outcome, and indeed many more people are now benefiting from the service, with improved survival rates.’