Table 2 Results of thematic analysis themes and subthemes with illustrative quotes

Pre-hospital: TVAA critical care teams

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Educational programmes

Awareness of pathway

We anticipated that our teams might meet resistance to the concept of load and go from ambulance service staff, when for years they have been taught to stay at the scene until ROSC [return of spontaneous circulation] is established. Our anticipation of this challenge was correct as this has been the largest barrier, the situation has improved as the pathway becomes better established and additional briefings to our partner services have occurred. (R12)

You'll need a big education program for the local ambulance service explaining why select patients will be 'scooped and resuscitated en route' because with the expansion of critical care / HEMS [Helicopter Emergency Medicine Services] teams working prehospitally, the norm has become to 'stay and play' for cardiac arrest, moving only if ROSC achieved and once patient is stabilised. (R1)

27

12

Value of joint simulation and training

I have been involved with the ECPR training between TVAA & Harefield and have found this to have been invaluable when dealing with these cases (R4)

9

5

Collectiveness in effort and culture

Buy-in leading to a common goal

We were able to announce to the pre-hospital teams that we needed the patient on the ambulance in this time frame. This focussed efforts on a goal and the pre-hospital teams worked well together in order to achieve this. (R7)

Local SCAS [South Central Ambulance Service] paramedics were aware of […] offering ECPR to certain patient groups and were aligned with the need to prioritise leaving scene (as opposed to completing ALS interventions, as per most cardiac arrests attended). This was important, as without this immediate buy-in, we could easily have been delayed on scene. (R14)

17

11

Learning culture and feedback

Regular shared governance and review of all cases, our reviews included joint simulations. (R12)

16

8

Supportive clinical environment

There is also a warm, sincere 'welfare check' on the crews after which is appreciated, as it is often quite a 'tour de force' to get these patients to Harefield within the required time frame. (R1)

9

5

Teamwork

Clear, adaptive leadership and decision maker

Crews were happy for me to take the lead in decision making and followed instructions well. (R3)

11

7

Communication

Good communication when arrived at Harefield—receiving team listened to handover and then immediately commenced respective roles, which made this phase succinct. (R3)

8

8

Empower specialists and experience

Being empowered to do the minimum necessary intervention at scene and en route to hospital to minimise on scene time. (R7)

Various approaches have been taken regarding airway management including transfer to ECPR on an iGel, intubation on route and pausing transfer briefly to intubate. All these are reasonable approaches and allowing clinicians to exercise their judgement is reasonable. (R12)

9

5

Interagency communication

Specialist dispatch selection and coordination

Support from HEMS desk paramedic to calculate estimated timings (time since arrest, anticipated time to Harefield Hospital and hence time limitation on scene) (R14)

HEMS desks/control room dispatchers’ communication with attending crews that the patient maybe a candidate for ECPR […] This will serve the attending crews/teams a reminder of the potential for patient treatment plan (R8)

6

4

Simple pre-alert with direct escalation

The phone-call literally being a trigger to Switchboard rather than a clinical discussion- this is a huge strength of the Harefield pathway and a huge frustration in other pre-hospital (and in-hospital) pathways. (R7)

9

6

Efficient, structured handover

Good communication when arrived at Harefield—receiving team listened to handover and then immediately commenced respective roles, which made this phase succinct. (R3)

13

8

Concurrent activity

[Ambulance] Crews and team leader were on board with the process and had been moving the scene on—Getting the scoop stretcher/stretcher ready and had an extrication plan (R8)

Moving the case forwards and proceeding to ECMO until this decision to stop is made seems necessary to me if being timed out is a risk, as opposed to waiting until a definite yes before proceeding. (R9)

Using time on the way to scene to calculate the time frames to successfully get the patient to Harefield within 1 h of cardiac arrest (R7)

11

7

Clarity of procedures

The instructions on the TVAA guidelines are clear and easy to follow. (R10)

8

6

In hospital: Harefield

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Learning and marginal gains

Debrief after complex cases to be able to learn (R17)

We have conducted a major overhaul of the entire system from the bottom up and reviewed every element of the pathway looking to refine the technical elements of the procedure and improve speed, fluency and time. (R19)

14

5

Standardise, simplify and protocolise

Protocol algorithms

Having a standardized approach to every patient has been key within the ECPR service. (R21)

Following protocols and shock protocols as listed in the trolley (R16)

17

5

Equipment

Simplify equipment. We reduced multiple aspects of the procedure to the bare minimum (but still safe) number of steps. This included using less wires and less dilators, this reduced the time by over five minutes. Organise equipment—we packaged our equipment in a trolley that we can take anywhere in the hospital and open rapidly—minimising preparation time. […] we are currently commissioning a company to create an ECPR pack with our entire set of equipment contained within in it—saves time on opening and reduces errors. (R19)

16

4

Technical procedure

We trained to use surface ultrasound techniques so that the imaging could be performed by the cannulators during the procedure without having to move the patient to fluro or relying on someone else to do a TOE [transoesophageal echocardiogram]. (R19)

The nurses drill their steps to fit in with the natural longer parts of the procedure (so cannulators start prepping and draping, nurses prep sheaths needles and initial wires. During access they prep the stiff wires and dilators and try to start with the cannulae. While the cannulae are being inserted they prep the circuit so it's ready to be connected immediately—this saves many minutes from the procedure. (R19)

8

3

Eligibility criteria

Having clear inclusion/exclusion criteria for decision making (R17)

A major problem has been the paradigm shift in decision making. Hospital doctors like to make high quality, shared, well considered decisions involving data and an MDT [multidisciplinary team] of experts. The paradigm is right patient, right place, right time, right treatment by the right people. In ECPR this noble philosophy results in delay and either dead or brain damaged patients. Tick box screening and rapid / abbreviated ECMO cannulation appears to completely ignore this whole paradigm and makes clinicians extremely uncomfortable. (R19)

14

5

Training and simulation

All people present should have had ECPR training/simulation or be familiar with ECPR—to ensure shocks are stopped, compressions continued etc.… (R17)

Simulation as much as possible between prehospital and in hospital team. (R21)

14

5

Nurturing effective team

Leadership- decision making and clear instruction

gave clear and precise instructions (R16)

consultant led decision to progress with ECMO cannulation with clear guidance, helps reducing the risk of non-technical aspects affecting the procedure. (R21)

11

8

Establishing team roles

Ensuring that everyone in the team knows their role and limitations. (R15)

Different part of the teams dealt with different parts of the arrest, therefore that allowed minimal interruptions (R16)

16

8

Balance experience and staffing

When there is a group of experienced staff it’s very straightforward (R20)

Having a small team of cannulators, perfusion team and operators also helps to standardize the procedure and ensure the skills and confidence to perform ECPR. (R21)

13

6

Welfare

There is an emotional impact to staff, psychology support must be available as well as a private space to decompress after withdrawal of therapy before resuming duties in theatre (R22)

A hot debrief is valuable (R22)

7

3