ELSO Award for Excellence in Life Support
Center of Excellence Application
2015
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 Gold and Platinum Level Awards will be designated amongst the applications that are
established and have invested time. 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
3 year Award Period
Must be a member of ELSO 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.




$2,000 fee USD
3 year Award Period
Must be a member of ELSO
Must complete sections 1, 2, 3 and 4
Primary Application Contact Information
ELSO Center Name:Click here to enter text.
Primary Contact Name:Click here to enter text.
Address: Click here to enter text.
Address: Click here to enter text.
City: Click here to enter text. State: Click here to enter text. Zip: Click here to enter text.
Country: Click here to enter text.
Telephone: Click here to enter text. Fax: Click here to enter text.
E-mail Address: Click here to enter text.
ELSO Award Application
© 2015 Extracorporeal Life Support Organization
ELSO Award for Excellence in Life Support
Center of Excellence Application
2015
Medical Director Contact Information
( ) Same as Primary Contact
Medical Director Contact Name: Click here to enter text.
Address: Click here to enter text.
Address: Click here to enter text.
City: Click here to enter text. State: Click here to enter text. Zip: Click here to enter text.
Country: Click here to enter text.
Telephone: Click here to enter text. Fax: Click here to enter text.
E-mail Address: Click here to enter text.
Your Initials and Signature Verify that you have:
____ Read and Verified all of the information entered herein.
____ Read and Acknowledge the policies and procedures of the ELSO Award for Excellence in
Life Support.
Electronic Signature: Click here to enter text.
ELSO Award Application
© 2015 Extracorporeal Life Support Organization
ELSO Award for Excellence in Life Support
Center of Excellence Application
2015
Instructions

To receive the Award at the fall ELSO meeting:
o Application period is through June 1. Applications received during this time period will be considered
for the Award of Excellence. The designation will be awarded at the fall 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 spring 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 and the policies and procedures 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.

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.

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.
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 scenario
o Recent annual written test
o Recent continuing education water drill checklist or scenario

Submit completed application and all required attachments electronically to prycus@umich.edu.


Submit check or credit card payment. See payment form for details.
Download ELSO Excellence in Life Support Award Documents
ELSO Award Application
© 2015 Extracorporeal Life Support Organization
ELSO Award for Excellence in Life Support
Center of Excellence Application
2015
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.
2010
2011
2012
2013
2014
Neonate
Pediatric
Adult
Total ECMO
Patients
Click here to enter text.
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?
Click here to enter text.
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
Click here to enter text.
ELSO Award Application
General surgery
Neonatology
Neurosurgery
Genetics
Social Work
Nephrology
Pulmonology
Hematology/Oncology
Gastroenterology
© 2015 Extracorporeal Life Support Organization
ELSO Award for Excellence in Life Support
Center of Excellence Application
2015
1.4
Check available support services and/or consultants that are available (Describe plan for any
services and/or consultantsnot 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
Click here to enter text.
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.
Click here to enter text.
1.6
Describe the ECLS Medical Director position responsible for the overall operation of the
Center.
Provide medical specialty:
Click here to enter text.
Outline specifics of the scope of Directors responsibilities:
Click here to enter text.
1.7
Describe the ECLS Coordinator position responsibilities in your institution.
Provide description of specialty:
Click here to enter text.
Outline specifics of the scope of Coordinators responsibilities:
Click here to enter text.
ELSO Award Application
© 2015 Extracorporeal Life Support Organization
2.
ELSO Award for Excellence in Life Support
Center of Excellence Application
2015
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)
Click here to enter text.
2.2
Describe the general availability of your back-up equipment and components, and their
location in relation to your ECLS patient.
Click here to enter text.
2.3
Discuss your plans for equipment and staff utilization in cases of increased ECLS census.
Click here to enter text.
ELSO Award Application
© 2015 Extracorporeal Life Support Organization
ELSO Award for Excellence in Life Support
Center of Excellence Application
2015
3.
Workforce Focus
For this application, “ECLS Specialist” refers to the individual your center designates to
care for the ECLS circuit.
3.1
Who do you designate as an ECLS Specialist?
Describe specialty(s):
Click here to enter text.
Describe the pre-requisites required prior to applying to be an ECLS Specialist. Include past
experience, skills assessments, certifications, etc.
Click here to enter text.
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)
Click here to enter text.
3.3
Who provides primary medical management of the ECLS patient?(Include all individual
ECLS populations described in 1.1)
Click here to enter text.
3.4
What resources and clinical expertise are available 24/7 to the ECLS Specialists for ECLS
pump and patient management troubleshooting?
Click here to enter text.
ELSO Award Application
© 2015 Extracorporeal Life Support Organization
ELSO Award for Excellence in Life Support
Center of Excellence Application
2015
3.5
Who performs ECLS priming and how do you provide 24/7 coverage for priming?
Click here to enter text.
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.
Click here to enter text.
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?
Click here to enter text.
ELSO Award Application
© 2015 Extracorporeal Life Support Organization
4.
ELSO Award for Excellence in Life Support
Center of Excellence Application
2015
Knowledge Management
ProvideECLS 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.
Click here to enter text.
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.
Click here to enter text.
4.3
What specific ECLS training is required for advanced practice nurses or physician assistants
who manage ECLS patients? Include initial and continuing education.
Click here to enter text.
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):
Click here to enter text.
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):
Click here to enter text.
c. Describe 16 – 32 hours of Bedside Training Sessions:
Click here to enter text.
ELSO Award Application
© 2015 Extracorporeal Life Support Organization
ELSO Award for Excellence in Life Support
Center of Excellence Application
2015
d. Describe Final Exam and process:
Click here to enter text.
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 Formal Team Meetings: (include agenda details, frequency of education and record keeping):
Click here to enter text.
b. Describe your Water Drill and/or Simulation sessions used to assess competency (attach a water drill
checklist or scenario)
.
Click here to enter text.
c. Describe Annual Examination process (attach recent annual exam):
Click here to enter text.
d. Describe annual pump time requirements:
Click here to enter text.
4.6
Describe your policy regarding an ECLS Specialist who does not meet continuing education
requirements.
Click here to enter text.
4.7
Describe your educational program for bedside nurses to care for an ECLS patient.
Click here to enter text.
ELSO Award Application
© 2015 Extracorporeal Life Support Organization
ELSO Award for Excellence in Life Support
Center of Excellence Application
2015
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.
Click here to enter text.
4.9
Explain your annual continuing education and competency required for ECLS primers.
Include courses, water drills/simulations, minimum patient requirements etc.
Click here to enter text.
Application for the Silver Level (Path to Excellence), Stop Here
ELSO Award Application
© 2015 Extracorporeal Life Support Organization
ELSO Award for Excellence in Life Support
Center of Excellence Application
2015
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:
Click here to enter text.
b. How do you communicate this knowledge with your team?
Click here to enter text.
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.
Click here to enter text.
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 managementwas 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.
Click here to enter text.
ELSO Award Application
© 2015 Extracorporeal Life Support Organization
ELSO Award for Excellence in Life Support
Center of Excellence Application
2015
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
careorimproving 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.
Click here to enter text.
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:
Click here to enter text.
Additionally, list any ELSO committees that individuals from your institution actively participate
on:
Click here to enter text.
ELSO Award Application
© 2015 Extracorporeal Life Support Organization
ELSO Award for Excellence in Life Support
Center of Excellence Application
2015
6.
Process Optimization
Provide outcome reviews and developmentally focused care.
6.1
Illustrateyour 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:
Click here to enter text.
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:
Click here to enter text.
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 theELSO Registry data reports in your centers’
practice.
Describe your process for reviewing and comparing your ELSO center specific patient data,
including outcomes and complications:
Click here to enter text.
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.
Click here to enter text.
ELSO Award Application
© 2015 Extracorporeal Life Support Organization
ELSO Award for Excellence in Life Support
Center of Excellence Application
2015
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 increasean aspect of performance
within your Program?
Detail your benchmarking process:
Click here to enter text.
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:
Click here to enter text.
6.4
Specify your process for monitoring ECLS patient anticoagulation.
Describe the testing structure, protocol, tools or algorithms used for patient anticoagulation
management:
Click here to enter text.
ELSO Award Application
© 2015 Extracorporeal Life Support Organization
ELSO Award for Excellence in Life Support
Center of Excellence Application
2015
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.
Click here to enter text.
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?
Click here to enter text.
How do you provide appropriate activity/developmental care for each ECLS patient population
listed in question 1.1? For those awake andresponsive patients, how do you include them in self-care
activities?
Click here to enter text.
7.3
ECLSpatients 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?
Click here to enter text.
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.
Click here to enter text.
END OF APPLICATION
ELSO Award Application
© 2015 Extracorporeal Life Support Organization