Adult ECMO (extracorporeal membrane oxygenation)

I was just wondering how many of you utilize adult ECMO at your facility? We've had quite a few of them recently... two major successes, and two, which I can only describe as likely to end up as "epic fails." We recently started doing a lot more heart transplants, and thus, our ECMO usage has increased.

I am also wondering about staffing ratios and if you have specific policy/procedures and/or order sets you utilize when someone is on ECMO. I really like taking care of these patients, and I'm interested in possibly getting some ideas to help set up some order sets for my unit. Our NICU does a lot of ECMO, but obviously a preemie on ECMO is a whole different ball game, and typically our adults need arterio-venous instead of just veno-venous assistance.

As it is now, we currently begin with a 2 nurse to 1 patient ratio when a patient is first put on ECMO. Once the patient has stabilized somewhat, we go to 1:1. A perfusionist is also present 24 hours. There are at least 4 doctors who currently do ECMO setups, and each one of them has a different idea of what the Hgb/Hct should be, as well as lab frequencies, so it's a huge pain when one is initially set up, since they typically don't think to write these types of orders until we call 5 times to ask.

For example, one doc wants Q2 hr ABGs and lactic acids, but didn't want to check the H+H/plt any more than Q8 hrs, until my patient's platelets kept coming back critically low, and I got him to change the frequency on those tests. I think it would be a good idea to have a set list of orders from which the surgeon can choose from after he sets up the ECMO. For example, where he wants the ACT to be (usually 180-200), the parameters for H+H/plt, CVP parameters, standing orders for blood, platelets, albumin, etc, and boxes to check with lab frequencies.

I'd like to get some ideas so I can approach our UBC and my manager about this, so that we can make it a little more streamlined in the future. Any input would be greatly appreciated (heck, if you have an order set, feel free to message me for my e-mail address, if you wouldn't mind sharing it).