ECMO on Your Roadmap: Why Is Staffing the Bottleneck? 

By Matt Ehman, Business Development Manager at Epic Cardiovascular Services 

Saying ECMO staffing is “the bottleneck” can oversimplify one of the most operational and clinically complex ecosystems in modern healthcare.  

That would be a little like reducing extracorporeal science down to:  

“Blood comes out and goes back in.”  

Technically true.  

But dangerously incomplete.  

There are many variables to consider in this highly complex patient population. Staffing itself is only one small piece of the equation. The harder part is everything that comes with the decision to initiate ECMO. In summation, it starts with a decision, then the coordination of teams cannulate. Then comes the ability of multiple disciplines to create a plan of care together to provide the best chance for an extremely critical patient.  

In reflection, the real challenge lies in the system surrounding the patient. It lives in patient selection, escalation pathways, bedside expertise, perfusion strategy, emergency preparedness, physician alignment, ICU readiness, and the strength of the family to be part of the complex decision-making. Welcome to an overview of the support structure in the most complex therapy in modern critical care.  

For cardiovascular leaders, those operational pressures directly affect program scalability, clinician sustainability, and long-term service-line growth through both non-productive time with the amount of initial and ongoing education, as well as incentives to retain these highly trained healthcare professionals.   

When ECMO Growth Outpaces Program Infrastructure 

This distinction matters greatly due to the rapid expansion of ECMO use in both pediatrics and adults.  

Many hospitals are no longer treating ECMO as salvage therapy or as a distant future capability. They are actively researching, evaluating, and collaborating with ECMO programs, cardiogenic shock pathways, ECPR capabilities, mobile ECMO teams, and advanced mechanical circulatory support services as part of broader service-line growth.  

As this growth continues to accelerate, staffing naturally becomes one of the most visible pressure points. However, visibility and root cause are not always the same thing.  

In many cases, what looks like a staffing problem is really what happens when ECMO growth moves faster than the program built to support it. ECMO becomes more than a recruiting challenge or staffing model issue.  

With ECMO’s intense resource needs and balance within all departments, it could be deemed a clinical ecosystem, and ecosystems are rarely stabilized by solving only one variable at a time. 

ECMO Programs Are Not Built the Same 

Considerations when looking to start or expand an ECMO program are assuming every program is trying to build the same thing. They are not.  

Some hospitals operate heavily perfusion-driven ECMO models. Others build hybrid structures involving perfusionists, nurses, respiratory therapists, and dedicated ECMO specialists. Some high-volume centers operate with highly specialized bedside ECMO teams capable of independently managing large portions of the workflow. 

None of these models is inherently “right” or “wrong.”  A center’s structure of an ECMO program evolves over time based on goals and capabilities. Staffing ratios, physician coverage, perfusion vs ECMO Specialist vs Nurse-All-In-One Model availability, transport capability, anticipated patient volume, institutional culture, and long-term service-line goals all shape what the eventual model becomes. 

As the saying goes, “Rome wasn’t built in a day”. So, it is safe to say many successful ECMO programs evolve best in phases. That idea shows repeatedly throughout ELSO guidelines, Center Certification, and ECMO literature. ECMO centers are consistently described not just as technology platforms, but as organized systems requiring structured training, simulation, multidisciplinary coordination, protocols, and continuous development. ¹ 

Sustainable ECMO Growth Requires Operational Alignment 

The strongest programs also recognize that sustainable ECMO growth depends on operational alignment between administration, clinical leadership, perfusion coverage strategy, ICU readiness, and long-term workforce planning. 

In a  2022 study published in Healthcare, the study described the development of an ICU-based ECMO referral center that was built progressively over multiple years by simulation education, protocol development, transport planning, structured training, referral infrastructure, and phased activation of services.² The authors described a deliberate progression from initialization to training, preparation, and activation: a useful reminder that ECMO program development is rarely just a matter of buying the equipment or hiring staff. 

That phased approach matters because cardiovascular leaders are increasingly being asked to scale high-acuity capabilities while maintaining quality metrics, protecting staff retention, and ensuring consistent patient outcomes. This is an important point because it reinforces something many ECMO teams already know firsthand: 

You are not just building the ability to place a patient on ECMO. 

You are building the infrastructure required to safely support everything that happens afterward. 

ECMO is Different Than Almost Everything Else in Healthcare 

Advocation, innovation, and a strong foundation are key when committing to start or expand an ECMO program. It has to be clearly understood by all stakeholders that an ECMO patient is not simply another ICU patient. ECMO is not simply another device. And it certainly is not another interchangeable staffing category.  

ECMO programs spend enormous amounts of time preparing for emergent moments they hope happen rarely: oxygenator failure, sudden loss of flow, air entrainment, accidental decannulation, and ECPR activation under pressure.  

These are the moments where systems stop looking theoretical and start revealing how well a program actually functions under stress, and if the education they start with needs refining. Because when a patient destabilizes while on ECMO at 2 a.m., the conversation changes immediately. Suddenly, staffing is no longer an abstract scheduling discussion. It becomes a real-time test involving communication, escalation pathways, physician engagement, perfusion support, bedside competency, and multidisciplinary trust.  

Erin August Weaver, ECMO Coordinator and ELSO Liaison, has seen this reality firsthand through her years supporting ECMO programs and clinicians.  

“To me, an ECMO clinician succeeds when they understand that time is imperative, details, no matter how small, are important, and repetition is key.”  

That is why ECMO readiness extends far beyond simply “having enough people.”  

The Joint Society of Critical Care Medicine–ELSO task force emphasized this directly in its position paper on ECMO management, describing ECMO programs as systems requiring coordinated operational and multidisciplinary integration — not isolated technical competency alone. ³  

The hardest part of ECMO is often not the machine; it is coordination. Coordinators are like the Swiss army knives of any program, and as hospitals are looking for cardiovascular staffing and operational partners that understand both the clinical realities and workforce pressures behind that coordination, we learn the value that a coordinator brings. 

Where Programs Usually Begin Feeling Strain 

In my experience, some of the earliest signs of strain in growing ECMO programs begin appearing around coverage and coordination. Not because people are failing, but because complex systems naturally reveal pressure points through growth. 

Example: A weekend becomes difficult to cover. A second ECMO patient stretches the team thinner than expected. A late-night ECPR activation suddenly exposes how dependent the program may be on a small number of highly experienced individuals. 

For some programs, perfusion initially carries much of the bedside ECMO monitoring and troubleshooting responsibility. As programs grow, that can create difficult questions. Do we recruit additional perfusionists? Do we bring outside support? Do we build a hybrid ECMO specialist model? How quickly can we scale without losing control of the system? Those are all reasonable questions. However, I think the deeper issue is this: 

Coverage gaps are rarely isolated scheduling problems. 

More often, they reflect broader questions that are still evolving underneath the surface. Who owns ECMO activation decisions? What happens when a patient begins deteriorating unexpectedly? Which disciplines are expected at bedside? How mature is the escalation structure when multiple high-acuity situations happen simultaneously? 

Even patient selection becomes deeply tied to program readiness. The decision to place a patient on ECMO isn’t simply a technical event. It reflects the coordination, judgment, and alignment of the entire care system surrounding that patient. This is especially true when medical leadership governance is still evolving. 

Patient selection, activation criteria, cannulation ownership, post-cannulation management, and weaning decisions all require clear clinical leadership. Without that alignment, staffing may appear to be the problem, when the deeper issue may be uncertainty around who owns which decision, when, and under what conditions. And as hospitals continue expanding into cardiogenic shock, ECPR, mobile ECMO, and advanced mechanical circulatory support pathways, the complexity compounds quickly. 

Why Calling Staffing “The Bottleneck” Can Be Misleading 

To be clear: staffing absolutely matters. 

But reducing ECMO expansion challenges entirely down to staffing can oversimplify the reality of what these programs are trying to build. 

Staffing becomes highly visible because it is often the first place where strain is physically felt. But sometimes the strain people feel around staffing is actually the byproduct of something larger. The workflows are still evolving. Escalation pathways are still being refined. The program is moving faster than the team model, call structure, and decision-making pathways can comfortably support. And eventually, the pressure becomes visible through staffing because staffing is where the system physically meets the bedside. 

That distinction is important because adding personnel alone does not automatically stabilize a program. ECMO growth is ultimately a positive development for healthcare. Expanded access to advanced mechanical circulatory support creates opportunities to save patients who previously may not have had access to these therapies at all. Hospitals across the country are investing enormous effort into building these capabilities responsibly. 

ECMO growth has to be matched by the systems that make that growth safe: clear roles, practiced response pathways, realistic coverage models, and leadership willing to build the program in phases. That process takes time.

Program Readiness Cannot Be Rushed 

The strongest ECMO programs are rarely built overnight; they mature gradually. 

Many ECMO leaders talk about building programs “brick by brick.” Workflows tighten; communication improves; simulation becomes routine. Teams develop shared instincts under pressure. Over time, this allows the system to become more resilient due to the people dedicated to it. 

The goal is not simply launching ECMO capability. The goal is building durable systems capable of supporting high-acuity care safely over time. Research has demonstrated associations between ECMO center experience, organized multidisciplinary teams, and improved patient outcomes.⁴⁻⁶ It is important to use the word “associations” here because ECMO outcomes are influenced by many variables, and program structure cannot be reduced to one cause-and-effect relationship. 

Interestingly, Gawda et al. observed that while multidisciplinary ECMO programs are often considered the “gold standard,” alternative ICU-based approaches may also function effectively depending on institutional structure and available resources.² In their study, the center was developed within an existing mixed ICU and ultimately treated 33 patients during the initial study period, reporting a 90-day survival rate of 60.6%.² 

That nuance matters – ECMO program structures vary significantly between institutions, and no single staffing model universally applies to every hospital or patient population.

The Conversation Has to Become Bigger Than Staffing Alone 

As ECMO continues expanding across healthcare systems, I think the conversation increasingly needs to move beyond staffing numbers alone. 

The bigger discussion involves workforce planning, physician engagement, perfusion strategy, simulation, competency maintenance, transport capability, escalation design, leadership alignment, and long-term program durability. 

Hospitals are not simply trying to “fill shifts.” Many are trying to build sustainable high-acuity service lines capable of supporting increasingly complex patient populations over time. That requires more than temporary coverage solutions alone. It requires continuity. It requires alignment. And increasingly, it requires partners capable of supporting programs across multiple phases of development. 

That is where the right clinical service partner can make a meaningful difference. Not by simply sending names to cover holes in a schedule, but by helping a program understand what those holes are revealing. That kind of partnership requires real cardiovascular expertise, not generic healthcare staffing support. 

Sometimes the need is short-term perfusion or ECMO specialist coverage. Sometimes it is a developing specialist model, call structure, simulation plan, transport process, or governance cadence. The answer is different in every hospital, which is exactly why ECMO support should be built around the program, not forced into a generic staffing template. 

The Question Leaders Should Be Asking 

If staffing feels like the bottleneck, it may be worth pausing before rushing straight to headcount alone. 

The better question may be: 

“What is the staffing strain trying to tell us about the program?” 

For hospitals building or expanding ECMO, the first question should not simply be, “How many people do we need?” 

It should ask: 

“What kind of ECMO program are we actually trying to build, and what support structure will allow that model to hold up under pressure?” 

That answer may involve perfusion coverage. It may involve ECMO specialist development, simulation, transport planning, physician governance, call structure, or all of the above. 

This is where an outside service partner can become a real advantage. 

Not because an outside partner replaces the internal team. They should not. The internal team owns the culture, the patients, the medical decision-making, and the long-term direction of the program. But the right partner can help a hospital see the whole system more clearly. They can help identify where the staffing pressure is actually coming from, where the current model is stretched too thin, and what type of support makes sense for the phase of growth the program is in. 

Sometimes the need is immediate coverage. Other times it is temporary perfusion support while the internal team builds capacity. Sometimes it is helping develop a hybrid ECMO specialist model, pressure-testing escalation pathways, supporting simulation, or creating enough breathing room for leadership to build the program intentionally instead of reactively. 

That is the difference between filling a hole in the schedule and strengthening the program behind the schedule. 

So yes, staffing may be where the strain becomes visible. 

But the real work has to begin with the system, not just the schedule. 

Because in ECMO, systems are eventually tested at the bedside. 

How Epic Cardiovascular Services Supports ECMO Program Growth 

Building a sustainable ECMO program requires more than simply filling coverage gaps. It requires experienced clinical partnership, operational insight, and support models built specifically for high-acuity cardiovascular environments. 

At Epic Cardiovascular Services, we work alongside hospitals, perfusion teams, and ECMO leaders to help strengthen the systems behind the bedside — whether that means short-term perfusion support, ECMO specialist coverage, program expansion planning, or long-term workforce strategy. 

Because in ECMO, the goal is not simply staffing the next shift. 

It is building a program capable of delivering consistent, high-level care under pressure. 

Connect with Epic Cardiovascular Services to discuss perfusion staffing, ECMO program support, or cardiovascular workforce strategy for your organization.

About the Author 

References 

1. Extracorporeal Life Support Organization. ELSO Guidelines for ECMO Centers. Extracorporeal Life Support Organization. Accessed May 13, 2026.  

2. Gawda R, Piwoda M, Marszalski M, et al. Establishing a new ECMO referral center using an ICU-based approach: a feasibility and safety study. Healthcare (Basel). 2022;10(3):414. doi:10.3390/healthcare10030414  

3. DellaVolpe J, Barbaro RP, Cannon JW, et al. Joint Society of Critical Care Medicine–Extracorporeal Life Support Organization Task Force position paper on the role of the intensivist in the initiation and management of extracorporeal membrane oxygenation. Crit Care Med. 2020;48(6):838-846.  

4. Barbaro RP, Odetola FO, Kidwell KM, et al. Association of hospital-level volume of extracorporeal membrane oxygenation cases and mortality: analysis of the Extracorporeal Life Support Organization registry. Am J Respir Crit Care Med. 2015;191(8):894-901. doi:10.1164/rccm.201409-1634OC  

5. Na SJ, Chung CR, Choi HJ, et al. The effect of multidisciplinary extracorporeal membrane oxygenation team on clinical outcomes in patients with severe acute respiratory failure. Ann Intensive Care. 2018;8(1):31.  

6. Abrams D, Garan AR, Abdelbary A, et al. Position paper for the organization of ECMO programs for cardiac failure in adults. Intensive Care Med. 2018;44(6):717-729.