ELSO Award for Excellence in Life Support
Application
2016
This page is confidential for ELSO Administrative use only. All
correspondence will be sent to both the Primary Contact and Medical
Director.
Please read the Instructions Completely
Please choose which Award you are applying for:
( ) Center of Excellence The Center of Excellence Award is for Centers that are established and have invested time in
developing their programs according to ELSO Guidelines. A minimum score must be achieved on the Excellence in Life Support
application in order to be designated as a Center of Excellence.






$3,500 fee USD (International ELSO Centers in specific countries may be eligible for a discounted fee)
3 year Award Period
Must be an ELSO member in good standing for at least 3 years
Must have supported an average of 5 patients per year for the past 5 years
Must have reported all patients to the ELSO registry
Must complete all sections of the ELSO Award Application
( ) Center on the Path to Excellence These programs are on the Path to Excellence, but have not yet demonstrated the
extraordinary achievement in all categories as required for the Center of Excellence Designation. These programs desire recognition
for their adherence to the ELSO Guidelines in providing ECLS patient care and are working towards the requirements for designation
as a Center of Excellence. A minimum score must be achieved on the application in order to be designated as a Center on
the Path to Excellence.





$2,000 fee USD (International ELSO Centers in specific countries may be eligible for a discounted fee)
3 year Award Period
Must be an ELSO member in good standing
Must have reported all patients to the ELSO registry
Only complete sections 1, 2, 3 and 4
Primary Application Contact Information
ELSO Center/Hospital Name: Insert here
Primary Contact Name: Insert here
Address: Insert here
Address: Insert here
City: Insert here
State: Insert here Zip: Insert here
Country: Insert here
E-mail Address: Insert here
_______________________________________________________________________________________________
ELSO Award Application
Page 1 of 17
© 2016 Extracorporeal Life Support Organization
ELSO Award for Excellence in Life Support
Application
2016
All inquiries regarding fees and submission direct to prycus@elso.org
Medical Director Contact Information
( ) Same as Primary Contact
Medical Director Contact Name: Insert here
Address: Insert here
Address: Insert here
City: Insert here
State: Insert here Zip: Insert here
Country: Insert here
E-mail Address: Insert here
Your Initials and Signature Verify that you have:
____ Read and Verify all of the information entered herein is correct and true.
____ Read and Acknowledge the policies and procedures of the ELSO Award for Excellence in
Life Support.
Electronic Signature: Insert here
All inquiries regarding fees and application submission direct to prycus@elso.org
All inquiries regarding the Award for Center of Excellence in Life Support or the Path to Excellence
in Life Support direct to award@elso.org
ELSO Award Application
Page 2 of 17
© 2016 Extracorporeal Life Support Organization
ELSO Award for Excellence in Life Support
Application
2016
Instructions

To receive the Award at the USA ELSO meeting:
o Application period is through May 1. Applications received during this time period will be considered for the
Award of Excellence. The designation will be awarded at the USA ELSO conference, and will continue for a
period of 3 years.

To receive the Award at EURO ELSO:
o Application period is through March 1. Applications received during this time period will be considered for
the Award of Excellence. The designation will be awarded at the EURO ELSO conference, and will continue for
a period of 3 years.

Save the application form on your computer as a new word document, using the title:
YourCenterELSOApplication.docx
(Example: MillionDollarBabiesHospitalELSOApplication.docx)

Please read the entire application before beginning the application. The application questions are designed to allow
each center to describe in detail the important aspects of their ECMO program. It is not necessary to provide additional
elements in answers that do not request additional information.

Please read the policies and procedures before beginning the application. It is a requirement that the Center read and
acknowledges that they are aware of the policies and procedures prior to submission of the application.

When examples of projects, processes, or initiatives are requested, specific examples should only be used once. For
instance, the same example may not be used for both a quality initiative and a best practice journey. If examples are
repeated, only one question will be given credit. The other will automatically be scored as a “does not meet”.

Use spell check and grammar check. It may be helpful to compose answers in a word processing program and
copy/paste into the document.

Remove all identifiers in the application. The city, institution, staff names, or other identifiers should not be used in
answering questions. All attachments should have center-specific headings & information removed or blacked out.
Applications will be returned if they are not de-identified.

International centers should assure fluency of English. Centers may choose to complete the application in their native
language. Google Translator or a similar application may be used once the application is complete to translate to English.

The following supporting documentation is required to be attached at the time of application submission. Missing
supporting documentation will result in not meeting the standards of those questions. Attachments should be de-identified
with center-specific headings and content blacked out or removed. Additional documentation may be included within the
body of the application.
o Download ELSO Excellence in Life Support Documents
o ELSO Award for Excellence in Life Support Equipment and Resource Questionnaire
o Agenda for the most recent ECMO Training Course
o Initial water drill checklist or simulation scenario
o Recent annual written test
o Recent continuing education water drill checklist or simulation scenario

Submit completed application and all required attachments electronically to prycus@elso.org

Submit check or credit card payment. See payment form for details. (download ELSO Excellence in Life Support
Documents. All inquiries regarding fees and application submission direct to prycus@elso.org

Direct all inquiries regarding the Award for Center of Excellence in Life Support or the Path to Excellence in Life
Support to award@elso.org
ELSO Award Application
Page 3 of 17
© 2016 Extracorporeal Life Support Organization
ELSO Award for Excellence in Life Support
Application
2016
Center Application Number: (To be filled in by ELSO)
1.
Systems Focus
Provide generalized background information about your institution.
1.1
Has your center been a member of the Extracorporeal Life Support Organization (ELSO) for
at least 3years? How many patients have been supported with ECLS at your center per year
in the last 5 years? Count each patient once. (List patients/year and any variances)
For Path of Excellence Applications, please note if you have had patients and in which
populations, or mark as Not Applicable.
2011
2012
2013
2014
2015
Neonate
Pediatric
Adult
Total ECMO
Patients
Insert additional information here.
1.2
Are there any patients in your institution on extracorporeal life support (specifically a pump
with an oxygenator) that are not reported to the registry and why?
Insert answer here.
1.3
Check all of your specialty services available on a 24-hour/day on-call basis? (Describe
plan for any services not available)
☐ Cardiology
☐ Cardiovascular surgery
☐ Anesthesiology
☐ Interventional Radiology
☐ Biomedical Engineering
☐ Neurology
☐ Critical Care Specialist
☐ Hospitalist
☐ Infectious Disease
☐ Other:
ELSO Award Application
☐ General surgery
☐ Neonatology
☐ Neurosurgery
☐ Genetics
☐ Social Work
☐ Nephrology
☐ Pulmonology
☐ Hematology/Oncology
☐ Gastroenterology
Page 4 of 17
© 2016 Extracorporeal Life Support Organization
ELSO Award for Excellence in Life Support
Application
2016
Insert additional information here.
1.4
Check available support services and/or consultants that are available (Describe plan for any
services and/or consultants not available)
☐ Blood gas laboratory
☐ Blood Bank
☐ Cardiovascular operating room with
cardiopulmonary bypass capabilities
☐ Occupational and/or Physical Therapy
☐ Nutritionist
☐ Interpreter services
☐ Chemistry and hematology laboratory
☐ Pharmacy
☐ Radiology including cranial ultrasound and
CAT scan
☐ Developmental/rehabilitation Specialist
☐ Pastoral Care
Insert additional information here.
1.5
Outline available inter-hospital transport services for patients on ECLS. If you do not
provide ECLS transport services, please detail your plan for transporting patients on ECLS
to or from your center in case of emergent need.
Insert answer here.
1.6
Describe the ECLS Medical Director position responsible for the overall operation of the
Center.
Provide medical specialty:
Insert answer here.
Outline specifics of the scope of Directors responsibilities:
Insert answer here.
1.7
Describe the ECLS Coordinator position responsibilities in your institution.
Provide description of specialty:
Insert answer here.
Outline specifics of the scope of Coordinators responsibilities:
Insert answer here.
ELSO Award Application
Page 5 of 17
© 2016 Extracorporeal Life Support Organization
ELSO Award for Excellence in Life Support
Application
2016
2.
Environmental Focus
Provide information about your facility and equipment available for ECLS. Please assure
that you have completed the ELSO Equipment and Disposable Resource questionnaire.
2.1
Describe in detail all units/areas in the institution where ECLS is provided. (Include each
patient population cared for)
Insert answer here.
2.2
Describe the general availability of your back-up equipment and components, and their
location in relation to your ECLS patient.
Insert answer here.
2.3
Discuss your plans for equipment and staff utilization in the event that your center exceeds
your normal and usual number of ECLS beds/pumps (increased census).
Insert answer here.
ELSO Award Application
Page 6 of 17
© 2016 Extracorporeal Life Support Organization
ELSO Award for Excellence in Life Support
Application
2016
3.
Workforce Focus
For this application, “ECLS Specialist” refers to the individual your center designates to
care for the ECLS circuit.
3.1
Describe the pre-requisites required to apply to be an ECLS Specialist. (Must include
Specialty/discipline. Include past experience, skills assessments, certifications, etc.)
Insert answer here.
3.2
What is your staffing model for your ECMO patients? (Check all that apply)
1 Specialist per pump, patient has a dedicated nurse 1:1
1 Specialist per pump, patient’s nurse may have 1 or more other patients
1 Specialist for 2 pumps, patients have a dedicated nurse 1:1
1 Specialist for 2 pumps, patient’s nurse may have 1 or more patients
Single caregiver model (ECLS specialist is also the patient’s nurse)
Other (describe below)
Insert answer here.
3.3
Who provides primary medical management of the ECLS patient? (Include all individual
ECLS populations described in 1.1)
Insert answer here.
3.4
What written and electronic materials and clinical expertise are available 24/7 to the ECLS
Specialists for ECLS pump and patient management troubleshooting?
Insert answer here.
3.5
Who performs ECLS priming and how do you provide 24/7 coverage for priming?
Insert answer here.
ELSO Award Application
Page 7 of 17
© 2016 Extracorporeal Life Support Organization
ELSO Award for Excellence in Life Support
Application
2016
3.6
Highly stressful events are common during an ECMO run. These events may overwhelm
individual staff members and their ability to cope. Staff debriefing processes are defined as
programs available for staff where they are able to discuss events or situations, receive
support, and learn coping skills. Describe your staff debriefing process that occurs after
critical stressful incidents.
Insert answer here.
3.7
Moral distress is the physical or emotional suffering that is experienced when an individual
staff member knows the right thing to do, but constraints make it nearly impossible to
pursue the right course of action. How do you provide interventions for individuals in these
situations? How do you prevent or mitigate the moral distress that staff may experience
when caring for critically ill patients on ECLS?
Insert answer here.
ELSO Award Application
Page 8 of 17
© 2016 Extracorporeal Life Support Organization
ELSO Award for Excellence in Life Support
Application
2016
4.
Knowledge Management
Provide ECLS Team training and competencies.
4.1
Detail your institution’s initial physician credentialing process for ECLS. Include all
attendings, fellows, and residents who care for ECLS patients. Include courses, mentoring,
minimum patient requirements etc.
Insert answer here.
4.2
What annual continuing education and training is required for physicians, including
attendings, fellows and residents, to maintain credentials to care for an ECLS patient?
Include courses, water drills/simulations, minimum patient requirements etc.
Insert answer here.
4.3
What specific ECLS training is required for advanced practice nurses or physician assistants
who manage ECLS patients? Include initial and continuing education.
Insert answer here.
4.4
Explain your centers’ initial training program for future ECLS Specialists. Specifically,
how do you meet these ELSO Guidelines? Address all four questions regarding guidelines
for credit.
a. Describe 24 – 36 hours Didactic Sessions (attach class agenda):
Insert answer here
b. Describe your Water Drill and/or Simulation sessions used to teach basic circuit and emergency
management skills (attach a water drill checklist or scenario):
Insert answer here
Question continued on next page:
ELSO Award Application
Page 9 of 17
© 2016 Extracorporeal Life Support Organization
ELSO Award for Excellence in Life Support
Application
2016
c. Describe 16 – 32 hours of Bedside Training Sessions:
Insert answer here.
d. Describe Final Exam and process (must include minimum passing requirements):
Insert answer here.
4.5 What is your continuing education and competency program for the ECLS Specialist?
Specifically, how do you meet these ELSO Guidelines? Address all four questions regarding
guidelines for credit.
a. Describe all Formal Team Meetings: (must include agenda details, frequency, education, attendance
records and attendance requirements):
Insert answer here
b. Describe your Water Drill and/or Simulation sessions used to assess competency (attach a water drill
checklist or scenario)
.
Insert answer here
c. Describe Annual Examination process (attach recent annual exam):
Insert answer here.
d. Describe quarterly pump time requirements:
Insert answer here.
4.6
Describe your policy regarding an ECLS Specialist who does not meet continuing education
requirements. (must include all continuing education components as described above in
question 4.5)
Insert answer here.
ELSO Award Application
Page 10 of 17
Organization
© 2016 Extracorporeal Life Support
ELSO Award for Excellence in Life Support
Application
2016
4.7
Describe your educational program for bedside nurses to care for an ECLS patient.
Insert answer here.
4.8
What initial priming education and water drill training are required to be a primer? Include
courses, water drills/simulations, minimum patient requirements etc.
Insert answer here.
4.9
Explain your annual continuing education and competency required for ECLS primers.
Include courses, water drills/simulations, minimum patient requirements etc.
Insert answer here.
Application for the Silver Level (Path to Excellence), Stop Here
ELSO Award Application
Page 11 of 17
Organization
© 2016 Extracorporeal Life Support
ELSO Award for Excellence in Life Support
Application
2016
5.
Quality Focus
Provide continuous quality improvement activities.
5.1
How does your center maintain knowledge of current ECLS practice? How do you
incorporate that new knowledge into your Centers’ clinical practice? Answer all three
questions for credit.
a. Describe how you stay current with the latest advances/research/techniques:
Insert answer here.
b. How do you communicate this knowledge with your team?
Insert answer here.
c. Give a specific example demonstrating how your center implemented a recentadvance/research/technique
into policy OR procedure OR standards, OR best practice development and initiation. This example must
represent work conducted within the last 2 years.
Develop your answer with the advance/research/technique you wanted to implement, how you
incorporated it into your practice and contextually within your ECLS program. Include the
evidence that shows you successfully implemented the advance/research/technique into practice
and how it improved patient care or outcomes.
Insert answer here.
5.2
Workforce management includes topics such as initial education and training, or continuing
education. The term “Best Practice” refers to processes and policies that generally produce
exceptional results. Best practices may involve the innovative uses of resources, staff, and
technology. What new best practice related to workforce management was implemented in
your ECLS center in the last 2 years?
Relate a specific example related to the development and initiation of a process specific to
workforce management OR education OR training, OR continuing education within your ECLS
program in the last 2 years. Describe the need you identified for this new best practice and how it
was developed, initiated, and evaluated for effectiveness.
Insert answer here.
ELSO Award Application
Page 12 of 17
Organization
© 2016 Extracorporeal Life Support
ELSO Award for Excellence in Life Support
Application
2016
ELSO Award Application
Page 13 of 17
Organization
© 2016 Extracorporeal Life Support
ELSO Award for Excellence in Life Support
Application
2016
5.3
The value of care we give our patients can be improved by reducing costs, increasing work
efficiency, reducing waste, optimizing the use of resources, promoting family centered care
or improving patient outcomes. What initiative have you implemented in your ECLS
program to improve the value of the care you deliver to the patient or family?
Give a specific example related to a process that improved the value of care delivered to a patient or
family within the last 2 years. The example should be complete and relevant to increasing the value
of care.
Insert answer here.
5.4
List all ECLS related conferences attended by one or more of your team within the last two
years. (ELSO, Keystone, SEECMO, EURO ELSO, etc.) Maintain anonymity by listing the
individuals by role (coordinator, director, etc.)
Describe the personnel who attend each of the above conferences:
Insert answer here.
Additionally, list any ELSO committees that individuals from your institution actively participate
on:
Insert answer here.
ELSO Award Application
Page 14 of 17
Organization
© 2016 Extracorporeal Life Support
ELSO Award for Excellence in Life Support
Application
2016
6.
Process Optimization
Provide outcome reviews and developmentally focused care.
6.1
Illustrate your Centers’ Morbidity and Mortality Review process. Describe a recent review
of a case that includes a major complication or death that was discussed with ECLS team
members.
Detail your M&M process, including how you incorporate all ECLS team members (physicians,
specialists, perfusion, etc.) into this process:
Insert answer here
Give a specific example of a recent patient that was presented at an M&M within the last 2 years.
Include personnel present, discussion, analysis, and conclusions that may have arisen from the
M&M:
Insert answer here
6.2
The ELSO Registry provides specific reports to each center to assist in comparing center
outcomes to the aggregate international outcomes. Discuss how you review the ELSO
Registry data reports and how you utilize the ELSO Registry data reports in your centers’
practice.
Describe your process for reviewing and comparing your ELSO center specific patient data,
including outcomes and complications:
Insert answer here.
Give a specific example of how the ELSO Registry data specifically has impacted patient care or
driven practice changes within the last two years. Describe the entire process -from identifying the
need for data through the change implementation.
Insert answer here.
ELSO Award Application
Page 15 of 17
Organization
© 2016 Extracorporeal Life Support
ELSO Award for Excellence in Life Support
Application
2016
6.3
Benchmarking is the process of measuring your own performance against the performance
of industry leaders. Utilizing information obtained through benchmarking to improve
processes, procedures, and treatment strategies shows a commitment to excellence and
improving patient care outcomes. Discuss your center’s benchmarking process. How has it
influenced your ECLS Program to adapt best practices to increase an aspect of performance
within your Program?
Detail your benchmarking process:
Insert answer here.
Give a specific example of the development or the revision of a process that can be directly related
to Benchmarking a process in the last 2 years. Describe the need you identified for this process
change and how benchmarking was used. Must include data to show the improvement in the
process:
Insert answer here.
6.4
Specify your process for monitoring ECLS patient anticoagulation.
Describe the testing structure, protocol, tools or algorithms used for patient anticoagulation
management:
Insert answer here.
ELSO Award Application
Page 16 of 17
Organization
© 2016 Extracorporeal Life Support
ELSO Award for Excellence in Life Support
Application
2016
7.
Patient &Family Focus
Provide family education and participation in care.
7.1
Give a detailed explanation of the educational materials you provide to the family of the
ECLS patient.
Insert answer here.
7.2
Family centered care recognizes the vital role families play in ensuring the health and wellbeing of infants, children, adolescents and family members of all ages. Describe how your
center incorporates the family/caregiver into the daily care of the patient on ECLS
How do you include family in the daily care of the patient?
Insert answer here.
How do you provide appropriate activity/developmental care for each ECLS patient population
listed in question 1.1? For those awake and responsive patients, how do you include them in selfcare activities?
Insert answer here.
7.3
ECLS patients are often awake and responsive, and may require long ECLS runs. Families
are presented with statistics, facts and unknown prognoses for their loved ones. How do you
address the potential distress and suffering that may occur in your families and/or patients
with the real probability of death or unpredictable outcomes on ECLS?
Insert answer here.
7.4
How do you follow-up your patients to see what their outcomes are? Describe your medical
follow-up plans for each of your ECLS patient population listed in question 1.1.
Insert answer here.
END OF APPLICATION
ELSO Award Application
Page 17 of 17
Organization
© 2016 Extracorporeal Life Support