ECLS Pre-Program Assessment | Comprehensive Care Services

Basic Information

Tell us about yourself and your institution

Name (First, Last, Credentials) *

Phone Number *

Email *

Hospital Name & Location *

What is your role relative to the ECLS program? *

ECLS Program Director (First, Last, Credentials)

ECLS Program Coordinator (First, Last, Credentials)

Program Specifics

Details about your ECLS program

What stage is your ECLS Program in? *

Brand new - The program has no prior experience and is in the planning or initial setup phase.

Infancy - The program has recently started and is in the early stages of implementation, with limited experience.

Established - The program has been operational for a significant period, with protocols and processes firmly in place.

Mature - The program is long standing, well-experienced, and possibly a mentor or reference center for others.

What population of patients does your program place on ECLS? * (Select all that apply)

Neonates

Pediatric

Adult

How many patients does your program support each year? *

1-5 Patients

6-10 Patients

11-20 Patients

21-30 Patients

31-40 Patients

41-50 Patients

>51 Patients

What type of ECLS does your center perform? * (Check all that apply)

VAV

VVA

ECPR

ECCOR2

VAD

Other

What is the max capacity of ECLS patients your center can manage at any given time? *

Staffing & Personnel

Information about your ECLS team

Who performs ECLS cannulations at your center? * (Check all that apply)

Cardiothoracic Surgeons

Interventional Cardiologists

Vascular Surgeons

Critical Care Physicians

Anesthesiologists

Advanced Practice Providers (e.g. Nurse Practitioners, Physician Assistants)

Other

Who are the staff responsible for managing ECLS at the bedside in your program? * (Check all that apply)

Perfusion

Specialist (RN or RT)

Bedside nurse caring for patient

Contracted Group (Specialist)

Contracted Group (Perfusion)

Other

Areas of Interest & Improvement

Help us understand your goals

What areas within your ECLS Program do you feel need improvement? (Check all that apply)

Training and Competency Development

Documentation & Reporting Process

Staffing & Scheduling

Equipment & Disposables

Protocols & Procedures/Guidelines

Communication & Team Collaboration

Quality Assurance & Performance Metrics

Patient Safety & Care Standards

ECLS & Emergency Preparedness

Program Growth & Expansion

Other

What areas are you most interested in learning more about that CCS has to offer? (Check all that apply)

Training & Education Programs

Staffing Solutions & Support

Quality Assurance & Performance Improvement

Program Development & Expansion Strategies

Documentation & Reporting Tools

Equipment & Disposables

Policy & Procedure/Guideline Optimization

Physician Consulting & Supportive Services

Joint Commission Preparedness

Center of Excellence Guidance

Complete ECLS Program Review

Other

Please share more about your ECLS program, including overall goals you wish to see for growth and improvement.

Additional Details

A few more questions to complete your assessment

Does your Program currently complete Interfacility transports? *

Yes

We do, and welcome additional information on what is offered

We do not, but would like to start

What ECLS system(s) is your program currently utilizing? * (Check all that apply)

Centrimag

Pedimag

Cardiohelp

Vital Flow

Novalung

SCPC

NA; looking for systems to purchase that would best suit our program and budget

Looking to expand upon our existing ECLS systems

Other

How did you hear about CCS? *

Conference attendance

Word of mouth

Google search

Other

Thank you for taking the time to complete this survey. One of our team members will be in touch with you shortly.