Four Reasons ECMO Programs Stall

For many tertiary care hospitals, not offering extracorporeal membrane oxygenation (ECMO) is increasingly difficult to justify. Choosing not to offer ECMO means patients who could survive are instead transferred, delayed, or simply lost. As outcomes continue to improve and implementation becomes more accessible, the case for inaction grows weaker by the year.

For many hospitals, fear of the unknown keeps them on the sidelines. There are stories of ECMO programs that stall, struggle to break even, or quietly fade after the first year, not because of bad intentions or lack of clinical skill, but because of the specific, predictable ways that highly specialized programs falter when they’re built without the institutional infrastructure to sustain them. 

The same pitfalls emerge across institutions of every size and geography. Here are the four most common and what it takes to overcome them.

1. The “who do you call?” problem

When a new program trains its own staff from the ground up, everyone in that program is a beginner at the same time. That may be manageable in some services, but ECMO patients are among the sickest in the hospital. Solid ICU staff can be trained to do ECMO, but they need an expert resource available at 2 a.m. when a complication arises. 

In established programs with years of institutional experience, there is always someone who has seen it before: a grizzled specialist, a medical director with thousands of ECMO hours. But in a program built entirely from scratch, that person does not exist.

This is a structural reality of starting from zero in a high-stakes specialty. Without experienced backup, specialists feel isolated and thus quietly abandon ECMO for more familiar therapies. As a result, the ECMO program fails to grow and expand, leading to a cycle of low volume, eroding skill, and diminishing confidence.

Programs that succeed almost always have access to experienced clinicians, whether through outside hires or external partnerships, who can serve as a lifeline during those critical first 6-12 months.

2. The feast-or-famine staffing trap

ECMO volume is uniquely unpredictable. A hospital may go four to six weeks without a single case, then face three patients simultaneously. 

The famine side of the equation is well understood: ECMO is a perishable skill. Specialists who are not regularly running ECMO cases are not staying sharp. Even ELSO suggests retraining when there has been a long gap in bedside care, recognizing that time away from the bedside has clinical consequences. 

Low volume breeds skill decay, and skill decay breeds avoidance. In addition, even when there are ECMO cases, all of the ECMO-trained staff may not have an opportunity to care for that patient.

The feast side is just as damaging, although less discussed. When census spikes, you need people and you need them now. You cannot float an RN from the medical floor to manage an ECMO circuit. If a specialist is on maternity leave or vacation, there is no coverage option that does not involve serious risk. Ongoing, uninterrupted coverage of a single ECMO bed around the clock requires at least seven trained specialists when using a three 12-hour-shifts-a-week model and accounting for vacations. Very few community hospitals can realistically maintain that many trained staff, and fewer still can flex up when there are two or three ECMO patients.

This is the staffing paradox that quietly kills ECMO programs. Low volume means skill decay, high volume means you don’t have enough people. Neither problem has a clean in-house solution at most hospitals. 

Programs can address skill decay by providing ECMO training and simulation to bridge gaps between cases and by engaging preceptors to support less experienced specialists. To manage census surges or sudden staffing gaps, hospitals can supplement their teams with external specialists who can provide on-demand coverage. Because traveling ECMO specialists routinely manage ECMO patients, they bring both competency and additional capacity when it’s needed.

3. Getting the billing wrong

There is a widespread myth that ECMO is a money-losing program. While it is resource-intensive, ECMO carries one of the highest DRG reimbursements in all of healthcare. Medicare, Medicaid, and commercial payers all reimburse at rates that make a well-run program not just clinically valuable but financially impactful. The opportunity is real and well-documented.

The most common mistake is failing to capture that revenue accurately and appropriately. Critical steps to capturing that reimbursement correctly include coding precision and clinical documentation discipline around codes and procedures that most hospital billing teams have simply never encountered. ECMO-specific charge capture, DRG and AP-DRG assignment, CPT code selection, and physician billing integration are not standard competencies in most revenue cycle departments, especially when the hospital has not done ECMO before. Errors and omissions are common, and because they’re invisible at the point of care, they often go uncorrected for years.

An ECMO program that is losing money is doing so because the revenue cycle infrastructure cannot accurately capture the revenue from the care being delivered, not because ECMO isn’t financially viable. 

This shortcoming can be addressed by working with clinicians and revenue cycle teams who have done ECMO-specific coding and billing, understand appropriate setting of charges, and are facile with outlier payments. In addition, assigning one dedicated person to manage the revenue cycle for all ECMO patients has been very impactful. When coded, charged, and billed correctly, ECMO programs can typically achieve profitability with just a handful of cases per year.

4. Underestimating the program infrastructure

Hospitals that build ECMO programs independently tend to focus heavily on the clinical side, but ECMO programs are not just clinical. They require a strong underlying administrative infrastructure, such as policies, procedures, credentialing guidelines, patient selection guidelines, clinical order sets, quality metrics, and steering committees. None of these are insurmountable individually, but when every decision is being made for the first time by a team with no prior frame of reference, the cumulative weight of it stalls programs that were clinically ready to succeed. The physician champion cannot install this administrative framework alone and needs significant institutional support to build a strong ECMO chassis.

The hospitals that navigate this well almost always have access to a network of peers and experts who have solved these problems before, whether that’s template med staff documents, an EHR configuration that actually works, or a quality framework that satisfies ELSO standards without reinventing the wheel. That kind of institutional knowledge only comes from having done this across many programs, many times.

The common thread

None of these failure modes reflects a lack of commitment from hospital leadership or clinical staff. They reflect something more fundamental: ECMO is specialized enough that the learning curve carries real clinical and financial consequences, and there is no shortcut to the institutional knowledge that takes years to accumulate.

The programs that succeed tend to be the ones that recognized this reality early. They built their programs with the humility to seek out expertise they did not yet possess, and the strategic clarity to understand that learning from others is the fastest and most reliable path to a program that delivers great outcomes for patients. Programs that recognize these challenges early and build accordingly tend to reach stability faster and with fewer setbacks.

Image: Magicmine, Getty Images

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