Original Title: Utilisation de l’oxygénation extracorporelle par membrane (ECMO) chez l’adulte au Québec

Authors' objectives: In 2019, INESSS published a first report highlighting disparities in Québec’s ECMO programs and issued 18 recommendations to standardize and enhance practices [INESSS, 2019]. To further improve care quality and optimize resources, the Ministère de la Santé et des Services sociaux (MSSS) has asked INESSS to review how these recommendations have been implemented and to assess trends in ECMO utilization across Québec.

Authors' results and conclusions: RESULTS (#1 AN IMPROVEMENT IN THE ORGANIZATION OF ECMO SERVICES IN QUEBEC WAS OBSERVED, BUT A FEW ISSUES REMAIN): Several of the recommendations in the 2019 report have been implemented: protocols for ECMO maintenance, monitoring, discontinuation, and weaning have been formalized; availability of ECMO equipment has increased; and close to half of the ECMO centers have expanded their clinical teams and specialist roles. (#2 ECMO UTILIZATION AND ACCESSIBILITY HAS INCREASED ACROSS QUEBEC): • Annual ECMO cases stabilized at approximately 140 to 150 cases a year. • Overall, 43.4% of the patients were put on ECMO for cardiac support, 32.3% for respiratory support, and 24.3% for cardiopulmonary resuscitation support. • There were marked disparities in intervention volumes across centers, with some performing fewer than 10 ECMO cases annually, while others managed over 40 cases per year. (#3 CHANGES IN PATIENT DEMOGRAPHICS: AN OLDER PATIENT POPULATION): Patient comorbidities varied by ECMO modality: cardiac comorbidities were most common in VA-ECMO patients, whereas diabetes, acute renal failure, and pulmonary or infectious comorbidities were more prevalent among those receiving VV-ECMO. • The most common treatment goal in using VA-ECMO was a bridge to recovery, primarily in cases of cardiogenic shock and failure to wean from cardiopulmonary bypass (CPB) following cardiac surgery. The median time from cardiogenic shock to VA-ECMO was 3.4 hours, well below the recommended maximum threshold of 6 hours. (#4 IMPROVEMENTS NOTED IN CERTAIN ECMO-RELATED PROCESSES: SHORTER ECMO DURATIONS): • Weaning was initiated in 36.4% of VA-ECMO patients, 47.6% of VV-ECMO patients and 27.9% of ECPR patients. Weaning was not initiated in patients who were transitioned to a permanent circulatory support device, those for whom ECMO was discontinued to provide palliative care, and those who died while on ECMO. • For analytical purposes, the advisory committee suggested defining successful weaning as a weaning attempt followed by hospital discharge and survival at 30 days post-ECMO. Based on this definition, close to two-thirds (65.2%) of patients in whom ECMO weaning was initiated (n = 319) were successfully weaned, across all modalities and periods. (#5 PERSISTENT CLINICAL BURDEN DESPITE PROCESS IMPROVEMENTS: HIGH AND INCREASING COMPLICATIONS RATES, LONGER LENGTHS OF STAY, AND STABLE, BUT HIGH MORTALITY RATE): • Median hospital and ICU lengths of stay were longer than those reported in the previous evaluation in all three ECMO modalities. Compared to data from the ELSO registry, median hospital length of stay was longer for VA-ECMO and VVECMO, but shorter for ECPR. • ECPR patients often died shortly after ECMO initiation: 31.4% of those who received ECPR in Québec died within the first 24 hours, 42.2% within 48 hours and 48.0% within 72 hours. • Across all ECMO modalities, in-hospital mortality rate remained around 56.9% to 58.4% throughout the evaluation period. When aggregated across all periods, inhospital mortality was 54.8% for VA-ECMO, 49.4% for VV-ECMO and 77.0% for ECPR. (#6 INCREASED USE OF HEALTHCARE SERVICES AFTER ECMO TREATMENT): One year after ECMO, the total number of hospitalization days (from 1127 to 2204) and of ICU days (from 271 to 549) nearly doubled compared to the year preceding ECMO, across all ECMO modalities. CONCLUSION: Overall, the organization of ECMO care and services in Québec has been gradually improving, but the clinical outcomes remain mixed. Case volumes have continued to rise throughout the evaluation period, stabilizing at approximately 140 to 150 cases annually across the province. All ECMO centers in Québec now meet the minimum annual case volume of six (across all ECMO modalities), as recommended in the previous evaluation. However, substantial case load disparities between centers persist. Treatment protocols are now better formalized, and several recommendations made in 2019 have been implemented. Nevertheless, variability in clinical practices remains, particularly with regard to patient selection. Establishing a formal indication review process would help ensure greater consistency in practice and in patient selection criteria.

Authors' methods: Descriptive statistics were used to characterize patient profiles, treatment modalities, complication rates and clinical outcomes. Data-matching with medical administrative databases supplemented hospital records where necessary. For methodological purposes, each patient was counted only once, even if they were transferred between hospitals or placed on ECMO multiple times during the same hospitalization. An advisory committee including representatives from ECMO centers was consulted throughout the project to provide insights on the organization of ECMO services, the interpretation of findings, and the contextualization of data.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/utilisation-de-loxygenation-extracorporelle-par-membrane-ecmo-chez-ladulte-au-quebec.html

Year Published: 2025

URL for published report: https://www.inesss.qc.ca/fileadmin/doc/INESSS/Rapports/Soins_critiques/ECMO_EP_INESSS.pdf

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)