(1205) Assessment of ECMO Candidacy Decision-Making Among Pediatric Critical Care Fellows and Intensivists

Introduction: Pre-illness functional status is an important factor pediatric intensivists consider when assessing ECMO candidacy. However, it is unknown what factors pediatric critical care fellows consider when assessing ECMO candidacy. We hypothesized that worse patient admission functional status score (FSS) would be negatively associated with fellow assessment of ECMO candidacy for children with respiratory failure and that fellows and intensivists would have high concordance when assessing candidacy.

Methods: We conducted a secondary analysis of a single-center, prospective cross-sectional study of pediatric critical care clinician assessments of ECMO candidacy of actual pediatric patients with respiratory failure. FSS scores were separated into 3 categories: normal/mild dysfunction (6-12), moderate dysfunction (13-18), and severe dysfunction (>18). Non-parametric summary statistics and logistic regression clustered by fellow assessed associations between patient characteristics and ECMO candidacy; Cohen’s Kappa assessed concordance between fellows and intensivists.

Results: A total of 21 fellows (median experience level PGY6) evaluated 80 patients (75% normal/mild dysfunction, 12.5% moderate dysfunction, and 12.5% severe dysfunction). Fellows considered 81.3% (65/80) to be ECMO candidates. In multivariable logistic regression controlling for age, moderate (OR 0.10, 95% CI 0.02-0.66) and severe dysfunction (OR 0.13, 95% CI 0.03-0.58) had lower odds of being considered ECMO candidates compared to normal/mild dysfunction. Concordance between fellows and intensivists was moderate (κ = 0.56). In cases of disagreement, intensivists cited poor prognosis of a chronic illness and irreversibility of organ failure while fellows cited concern for reduced quality of life and abnormal baseline functional status as reasons for not being considered an ECMO candidate.

Conclusions: Worse admission functional status was associated with lower odds of being considered an ECMO candidate by pediatric critical care fellows. Fellows had moderate concordance with intensivist assessment and had different reasons for considering patients a non-candidate. Understanding the variability and changes in ECMO decision-making criteria between fellows and intensivists can inform standardization of patient candidacy assessments.