A standardized ECPR activation protocol and resuscitation efficiency, patient outcomes, and nursing cognitive load: a retrospective multicenter study

Objective To evaluate changes in resuscitation efficiency, patient outcomes, and nursing cognitive load associated with implementation of a standardized extracorporeal cardiopulmonary resuscitation (ECPR) activation protocol. Methods This retrospective multicenter observational study included 103 consecutive patients with in-hospital cardiac arrest who underwent ECPR at three tertiary hospitals in Guangdong Province, China. The control group included 30 patients treated from September 2019 to December 2023, and the post-implementation group included 73 patients treated from January 2024 to December 2025. Outcomes included resuscitation-process measures, clinical outcomes, and perceived nursing workload assessed using the NASA Task Load Index (NASA-TLX), a multidimensional measure of perceived workload. Results Compared with the control group, the post-implementation group had shorter ECPR preparation time (2.87 ± 2.32 vs. 8.60 ± 1.34 min), ECMO priming time (14.83 ± 2.88 vs. 19.07 ± 1.18 min), and ECMO initiation time (35.01 ± 2.36 vs. 54.12 ± 3.55 min), and a higher one-time readiness rate of disposable supplies (100% vs. 50.0%; all P < 0.001). The total NASA-TLX score was lower after implementation (415 ± 26 vs. 452 ± 25, P < 0.001). Thirty-day survival was numerically higher in the post-implementation group but did not differ statistically (42.5% vs. 23.3%; crude OR 2.43, 95% CI 0.92–6.37; P = 0.069). Favorable neurological outcome at discharge was more frequent after implementation (30.1% vs. 10.0%; crude OR 3.88, 95% CI 1.07–14.15; P = 0.036), and the association persisted after adjustment for SAVE score and time-to-ECPR-decision (adjusted OR 3.79, 95% CI 1.02–14.08; P = 0.047). Conclusion Implementation of the standardized ECPR activation protocol was associated with shorter ECPR preparation, priming, and initiation times, lower perceived nursing workload, and higher odds of favorable neurological outcome at discharge. Thirty-day survival was numerically higher but did not differ statistically. Given the retrospective pre-post design, these findings should be interpreted as associations rather than causal effects.