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Specialty that boosts survival

Jo-anne Fowles, extracorporeal membrane oxygenation lead nurse at Papworth Hospital NHS Foundation Trust, has been recognised for her achievements in improving care for patients with acute respiratory distress syndrome. She won the Innovations in Respiratory category of this year’s Nursing Standard Nurse Awards.

A critical care nurse has devised patient retrieval protocols, pathways, multidisciplinary training and family liaison for a highly specialist, high-risk service to oxygenate blood, and developed the roles of her nursing team.

Survival rates have improved since the service was developed

Picture credit: Tim George

Jo-anne Fowles, pictured, won the Innovations in Respiratory category of the Nursing Standard Nurse Awards 2015, sponsored by Teva, for her achievements in improving patient care as extracorporeal membrane oxygenation (ECMO) lead nurse at Papworth Hospital NHS Foundation Trust.

She was part of the team that put together the successful Papworth Hospital tender to be one of five centres nationally that provide ECMO. The process, which involves the drainage of venous blood, adding oxygen and removing carbon dioxide before returning it to the patient, is used to support people with acute respiratory distress syndrome (see Box 1).

Extracorporeal membrane oxygenation

Papworth Hospital provides extracorporeal membrane oxygenation (ECMO) to patients with acute respiratory distress syndrome, a life-threatening condition with high mortality. A specialist retrieval team is available 24 hours a day for referred patients.

ECMO is a technique that oxygenates blood outside the body. It can be used in potentially reversible severe respiratory failure when conventional ventilation is unable to oxygenate the blood adequately. The blood is removed from the patient, taking steps to avoid clots forming. Oxygen is then added before it is pumped artificially to support the lungs.

The aim is to allow the injured lung to recover while avoiding complications of conventional ventilation. As it is high-risk, it is only used as a last resort in difficult cases.

‘Setting up the service was a huge learning curve,’ says Ms Fowles, who was previously a sister in critical care. ‘I had to look at service provision, the referral and retrieval of patients, the ambulance support service and the education of the team.’

She is responsible for devising the robust referral pathways and ensuring safe return of patients to a hospital nearer their home when appropriate. Clinically, she is the lead practitioner on the team, demonstrating a high level of expertise in ECMO practice and managing patient care, including when weaning off ECMO and post-ECMO support.

Ms Fowles is passionate about education and training, which has been tailored for different parts of the multidisciplinary team. All programmes include practical sessions and assessments, training in the clinical area and study days.

The Papworth team retrieves patients from its catchment area – Cambridgeshire, Norfolk, Suffolk, Hertfordshire, Bedfordshire, Essex and north east London – and accepts patients from further afield if other centres are at capacity. The retrieval nurses and medics therefore have a training package specific to transporting patients supported with ECMO.

Ms Fowles felt that nurses should have enhanced roles in the previously medically-led service so she is proud to have developed the ECMO nurse specialist role, 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 over-subscribed,’ says Ms Fowles.

‘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 and now work quite independently. They follow the patient journey.’

As a result, patients’ care is less fragmented and when nurses are supporting relatives they have the knowledge and experience to answer their questions.

As well as being a complex service to set up, Ms Fowles had to raise awareness of who could benefit from ECMO support, both in her trust and its catchment area. Communication has been crucial. She set up a single contact number at Papworth Hospital and launched the trust’s ECMO website. 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 after they leave. Letters are also 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 in critical care.

Setting up the retrieval service itself required a tender and contract process for an ambulance company 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 the patient is ready, they are returned to their hospital but Papworth supports the local team with telephone follow-up.

‘After six months we invite all patients to our clinic where we do a quality of life assessment using a modified questionnaire from Canada on how they feel that day,’ says Ms Fowles.

‘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.’ Follow-up clinics help patients and families come to terms with their experience. Patients report the clinics have helped fill in some memory gaps and improved psychological recovery.

Patient satisfaction questionnaires are also positive, as are relative experience questionnaires. Patient/carer information has been made available, and the nurses travelling with the retrieval team are trained in family liaison.

Alain Vuylsteke, consultant in cardiothoracic anaesthesia and critical care, says Ms Fowles has been key in the success of the ECMO service at Papworth.

‘She has been instrumental in bringing together a large team in delivering excellent care, and ensuring priorities from all groups are met,’ says Mr Vuylsteke, one of the five lead clinicians of the National Respiratory ECMO service. ‘She has gained respect from all clinicians and none will challenge her ECMO knowledge.

‘As an ECMO specialist i enjoy making a difference’

Sister Rhea Durgahee qualified as a staff nurse eight years ago. She came to Papworth Hospital six years ago as a senior staff nurse before applying for the ECMO specialist course.

Previously, ECMO was a medically led service, but lead nurse Jo-anne Fowles has been promoting and developing the role of ECMO specialist nurses.

‘There is a lot of respect for us as it is a very developed role, with a lot of in-depth training,’ says Ms Durgahee.

The course runs over several weeks and includes training with Ms Fowles, as well as a practical simulation element using an ECMO circuit with a perfusionist.

‘We had teaching sessions from various members of the multidisciplinary team, including physiotherapists, dietitians, consultants, transplant specialists and cardiologists,’ says Ms Durgahee. ‘It was a holistic teaching approach followed by clinical exams.’

Ms Durgahee says she had to develop herself as a member of the team.

‘Learning how to communicate and having the confidence to communicate with different members of the team was personally challenging,’ she recalls. ‘When I was a band 5 staff nurse, I knew who to go to – the sister. With this role, it is very much you and the consultant. But we are taught how to do that.

‘You have to learn how to deal with the greater responsibility and become comfortable with that. I had not known that nurses could have this level of responsibility before I came to Papworth Hospital. But there is a good, well-established support system.’

Ms Durgahee enjoys making a difference in her role. ‘ECMO is not in every hospital and people come a long way. I am providing a life-saving treatment to patients and I enjoy providing excellence and helping other staff provide it.’

She adds that she never feels that her professional development is stalling. ‘I enjoy the challenge of continuous learning; I am always learning something different.’

But the real satisfaction comes from the way it helps her give the best, holistic nursing care to her patients and support to their families.

‘They benefit from nurses being trained for this ECMO specialist role. They see the specialist nurses more regularly than doctors. Intensive care is a scary place to walk into – but relatives have a familiar face looking after their loved one. It is a comfort and they can build a rapport with their nurse.

‘The nurse is a constant and can get to know them a bit better, which is integral to supporting the patient and family. They might be more comfortable asking nurses questions. We can answer them – we have the clinical knowledge to explain procedures if needed – or we escalate to the medical team if we feel they still need a chat with the doctors.’

The medical team also testifies to the benefits of the role. Alain Vuylsteke, consultant in cardiothoracic anaesthesia and critical care says: ‘One of Jo-anne’s great achievements has been to understand that the new technologies allowed the development of nurses’ competencies to encompass all aspects of ECMO management.

‘As a clinician, it is great to know that the nurse who is at the patient bedside has received this tailored training. And I like to show fellows that our nurses have a very acute and detailed understanding of ECMO.’

‘She drove the wider team to wake patients up, extubate them while on ECMO, mobilise patients and even get them to pedal – or eat hamburgers from McDonald’s.’ He adds Ms Fowles also ensures continuity and quality control: ‘All this while still engaging on a nearly daily basis in bedside patient care.’

Chief nurse Josie Rudman says: ‘Jo-anne provides highly specialised advice, clinical leadership and supervision to the ECMO team and assists with the strategic planning, organisation, management, evaluation and continuity of the ECMO service locally and nationally.’

She adds that before the Papworth 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,’ says Ms Rudman. ‘With Jo-anne’s specialised role there has been a focus on improved patient outcome, and many more people are now benefiting from the service, with improved survival rates.’

Jo-Anne is probably one reason why people come to us from all over the world to learn ECMO

Her drive to share the knowledge gained, and to improve outcomes drove Ms Fowles to help set up an international training programme and she is one of two course directors.

Mr Vuylsteke says: ‘Jo-anne is probably one of the reasons people from all over the world keep sending us their colleagues to learn the art of ECMOing.’

The team is always striving to improve. The monthly multidisciplinary meeting includes discussion of untoward incidents and lessons that can be learned. They discuss all referrals, including the appropriateness of the decision on whether or not to accept patients for ECMO, and the outcome for those patients not accepted as well as those accepted.

‘We look at the patient experience – from referral to follow-up. We continually assess and share patient stories and we use family satisfaction surveys to assess patient experience,’ adds Ms Fowles. ‘We are always looking at what could have been done better – this is a work in progress’.

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