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Institute Form

Institute Form (2019-2022)

Name and Address of the Institution (Including PIN Code, Website, Email Address, Phone & Fax Number)
Year Established
Year of Recognition by ESOI
Total Number of Beds in the Hospital
Status of the Hospital please mark (/): Govt.[1] /Pvt.[2] /Corporate[3]
Is the Hospital Recognized by MCI/DNB/ISCCM/ Equivalent Board for
Internship For House Job PG/Post Doctoral Courses DCCM/IFCCM/Post MBBS
Any Additional Information
Total Number of Beds in the Critical Care Units

Category wise Bed Strength

Total ICU Beds
Total ICCU Beds
Total PICU Beds
Total NICU Beds
Total MICU Beds
Total HDU Beds
Total Neuro ICU Beds
Miscellaneous

Case distribution record in the ICUs during last 3 years

Cardiology (2016/2017/2018)
Trauma (2016/2017/2018)
Surgery (2016/2017/2018)
OBG (2016/2017/2018)
Spesis (2016/2017/2018)
Toxicology (2016/2017/2018)
Respiratory (2016/2017/2018)
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 Diesease General Surgery Neonatology Neurosurgery Genetics Social Work Nephrology Pulmonology Hematology / Oncology
Gastroenterology
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 Theraphy
Nutritionist Chemistry & Hematology laboratory Pharmacy Radiology Includingcranial Ultrasound & CAT Scan Developmental / Rehabilitation Specialist
ECMO program initiated in Institute
Is your Center Member of ESOI
Is your Center a Member of the Extracorporeal Life Support Organization (ELSO)
How many patients have been supported with ECLS at your center per year in the last 5 years
Neonate (2014,2015,2016,2017,2018)
Paediatric (2014,2015,2016,2017,2018)
Adult (2014,2015,2016,2017,2018)
Do your center maintain ECMO registry? DO you submit your data to ESOI or ELSO registry? If not why?
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
Describe in detail all units/areas in the institution where ECLS is provided. (Include each patient population cared for)
Describe the general availability of your back-up equipment and components, and their location in relation to your ECLS patient.
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).
Amount of Stipend being / to be paid to ESOI Fellows per month
Security deposit being charged from the ESOI Fellows. If any

ECMO Team and Organisation

Describe the teaching staff/Consultants in your ICU include Name, Qualification, MCI Reg. No. , Experience & post Research Publication
Name of ICU Director/Head/Incharge
Consultant having at least 8 years experience after Training in Critical care Medicine
Consultants having at least 5 years experience after Training in Critical care Medicine

Describe the ECLS Medical Director position responsible for the overall operation of the Center.

Provide Medical Specialty
Outline specifics of the scope of Directors responsibilities
Name of the Director with Contact Details

Describe the ECLS Coordinator Position responsibilities in your Institution

Provide Description of Specialty
Outline specifics of the scope of Coordinator’s responsibilities
Name of the Coordinator with contact details
Describe the pre-requisites required to apply to be an ECLS Specialist. (Must include Specialty/discipline. Include past experience, skills assessments, certifications, etc.)
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)
Who provides primary medical management of the ECLS patient?
Who performs ECLS priming and how do you provide 24/7 coverage for priming?

Training Program and Facility

Please mention the number of seminar rooms/conference room with their seating capacity
Mention the name of various audiovisual aids available in the auditorium/seminar/conference rooms.
Projectors Laptops Mics Sound System
Does the Hospital have availability of Residential rooms for residents/ Fellows on duty?
Does your hospital have the facility of a Library? Kindly mention the details of the Library

  • Single common Library or Departmental Library
  • No. of Reading Rooms
  • No. of staff in the Library with their qualifications
  • Teleconferencing reception equipment available/not available
  • Please indicate the number of hours per day for which the library facilities will be available for the trainees On working days & On holidays
  • Please ensure that library facilities are available for at least two hours after working hours
  • Annual budget for the Library for three preceding years

Mention the details of the facilities available in Library

  • Text books available in Critical Care Medicine (Mention the edition, date of publication and name of the Authors).
  • Kindly provide the list of Journals : (National/International) subscribed [Paper or Digital]
  • Photocopy facility
  • Online library & Internet facility
  • Printer facilities

What is your continuing education and competency program for the ECLS Specialist, ECMO Physician & ECMO nurse?
Describe all Formal Team Meetings: (must include agenda details, frequency, education, attendance records and attendance requirements)
Describe Annual Examination process, must include minimum passing requirements (attach recent annual exam paper)
Describe annual pump time requirements
What ECMO specific initial priming education and water drill training are required by your Center to be a primer? Include Center-specific courses, water drills/simulations, minimum patient requirements, proctoring, policies etc.

Quality Assurance

How does your center maintain knowledge of current ECLS practice? How do you incorporate that new knowledge into your Centers’ clinical practice?
Describe how you stay current with the latest advances/research/techniques
How do you communicate this knowledge with your team?
Give a specific example demonstrating how your center implemented a recent advance/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.
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, include Data
List all ELSO and Collaborative conferences attended by one or more of your team within the last three years. (ELSO, ESOI, Keystone, SEECMO, EURO ELSO, etc.)
Describe the team members who attend each of the above conferences
List any meetings that individuals from your institution presented ECMO related posters or oral presentations
No. of research publications (abstracts/papers/presentations) made by the department staff during last three years in recognized journals only (submit list and copies of Reprints)
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
Give a specific example of a recent patient that was presented at an M&M within the last 2 years

Patient & Family Management

Specify your process for monitoring ECLS patient anticoagulation.
Describe the testing structure, protocol, tools or algorithms used for patient anticoagulation management
Insert your protocols available 24/7 to the ECLS Specialists for ECLS pump and patient management troubleshooting?
Give a detailed explanation of the educational materials you provide to the family of the ECLS patient.
Describe how your center updates & incorporates the family/caregiver into the daily care of the patient on ECLS.
How do you provide follow-up for your patients to see what their outcomes are? Describe your medical follow-up plans for every ECLS patient population

Additional Details (For Renewal Only)

How many fellows admitted in your institute both regular & alternate route in last 3 years?
Whether students maintain Log Book as per approved by ESOI sample.
How many Fellows passed in last 3 years & their results
Whether there was any issues or complaints from fellows or regarding fellows in last 3 years

Undertaking:

  • Each Teacher/Consultant will spent at least 8-10 hrs / week for teaching of ESOI fellows & certificate candidates as per the curriculum so as to complete the curriculum.
  • Hospital / Institute will provide facilities and time for research work as well as to attend ESOI organized conferences/Workshops to fellowship/Certificate candidates.
  • In case a Teacher leaves they will continue to provide training to the trainee.
  • Hospital will inform the ESOI within one week of leaving/joining of faculty.

Note:

  • Institute accreditation fees and form should be sent to the ESOI Secretariat office, Mumbai.
  • Fees are Rs.10,000/- ( Ten Thousand Only). Demand Draft should be drawn in favour of "ECMO Society of INDIA" payable at Mumbai. OR Online Payment through NEFT/ RTGS.
  • Institutes are requested to send the soft & Hard copy of the complete set of their Institute form and all certificates/documents to ESOI office.

By Clicking Submit, you Agree to the above terms and conditions.

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Institute Criteria Eligibility of Fellowship Course

ECMO Society of India (ESOI) established in September 2010. The head office of the society is in Mumbai. Society conducts Biannual training course & conferences in various parts of India since the time of Inception.

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