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.