Currently in health care, several wide-ranging and significant changes in practice culture are afoot. Clearly, evidence- based medicine, non-surgical approaches to cardiovascular disease, and cardiac surgery without the support of extracorporeal circulation require immediate attention by perfusionists. Just as cardiopulmonary bypass has been an integral part of cardiac surgery over the past fifty years, the profession of cardiovascular perfusion today must fully integrate itself with the health care concerns of 2004 and the next fifty years. In May of 2003, a vision was set upon by several individuals to link perfusion practice to improved patient outcomes by developing evidence-based, literature supported, consensus oriented guidelines of practice. The collaborative approach of multidisciplinary teams establishing standards of care has been shown to improve outcomes, improve efficiency, reduce clinical error and reduce cost. The Best Practice Perfusion group consists of a variety of clinicians with a common goal; to promote the highest standards of perfusion practice to our peers, perfusionists, surgeons and anesthesiologists.
With a direct effect on perfusion, cardiac surgery over the past five years has struggled to maintain its identity as a front line definitive therapy for cardiovascular disease. Reimbursement for procedures has been dramatically reduced, patients are medically managed for as long as possible in the misdirected hope of avoiding surgery. Percutaneous coronary interventions in the cath lab have sky rocketed, off pump CABG continues as a raging debate, and the patients we do see in the operating room are sicker than ever. Yet, in the face of decreasing total number of open-heart procedures, new surgical programs are opening all over the country to provide communities with current standard therapy of acute coronary syndromes; emergency room, catheterization lab and surgery. Perfusion technique and technology are rapidly changing and perfusion training programs are rapidly closing. The net effect of all this for perfusionists is significant stress, and a high level of burnout. In the 2003 American Board of Cardiovascular Perfusion Annual Report, the perfusion program directors council reported that “prospective applicants were still getting negative information about the profession”. From David Bishop, President of the ABCP, the approach to take in these stormy times as a profession is to “remain vigilant to maintain valuable skills to meet the ever changing work environment.” We couldn’t agree more. Therefore, the Best Practice Group has set a course to engage the perfusion community and provide the guidance necessary to assist perfusionists clinically and professionally as an integral member of the cardiac surgical team.
The Best Practice Perfusion Group consists of surgeons, anesthesiologists, epidemiologists, neuropsychologists and perfusionists. We are an inclusive group with no limits on involvement. We look forward to an ever-expanding group of concerned and proactive individuals willing to effect positive change clinically and professionally. The group is in its infancy, and the first attempt at gaining consensus supported practice guidelines has been to focus on relatively simple relatively non-controversial evidence supported guidelines. These guidelines are intended to set current minimum standards to assist perfusion teams in their respective programs and act as a working document to be utilized with other members of the cardiac surgical team.
Evidence
based medicine - As stated earlier, evidence based guidelines of practice have
become common place. The goal of such
guidelines is to enhance patient care and improve the quality of patient
outcomes. Dr. John W. Goethe recently
wrote on the topic of evidence based medicine in the Journal Connecticut
Medicine: Evidence Based Medicine: What’s New – What’s Not – What’s Needed. In his article, Dr. Goethe writes, “The
charge for physicians can be expressed no more clearly. We are asked not only to improve the
condition of those we treat, but also improve the quality of the art and
science that are the basis for our clinical decisions.” Therefore “the ultimate goal of EBM is the
delivery of information in a manner that addresses the so called “”gap””
between recommended and actual practice.”
This gap is readily apparent in perfusion practice. A concern of this working group continues to
be the phenomenon of perfusionists attending high quality clinical meetings,
gaining important clinical knowledge, yet making no changes in their management
of patients on bypass. At a recent one
day symposium on best practice perfusion, a survey was held to gain insight
into standard practices by perfusionists.
Despite the recurrent emphasis at meetings over the last several years
regarding prime volume, biocompatible surface coatings, field suction and
overall neurologic protection, the following profile presented: 1) 45%
responded to still have a prime volume
of 1.5 to 2 liters, 2) 48% responded glucose is not treated until >200mg/dl,
3) 99% responded field blood is returned to the perfusion circuit, 4) 56%
responded they feel their program transfuses PRBC too often, 5) 48% responded
to no use of a biocompatible technology.
This survey model will continue as our group presents at different
venues in the future. As such, the
evidence based practice follows a two pronged approach; the scientific
literature is appraised and validated, then the analysis of the literature or
evidence is disseminated. To this end,
the Best Practice Perfusion Group has begun this journey. We fully recognize that it is not our intent
to force blind adherence to a set of guidelines. Rather we seek to provide the tools necessary to facilitate an
assurance of seeking best practice for every patient and enhancing overall outcomes.
Professional
Practice - It is entirely fruitless for a perfusionist to embark on changing
their practice or techniques and technology in a vacuum. No net effect in outcome improvement will
come by decreasing a prime volume, utilizing a reduced surface area circuit
with some form of biocompatibility and avoiding transfusion in the operating
room if the anesthesia team you are working with routinely administers 3000ml
of crystalloid pre-bypass, the surgeon you are working with demands to send all
field blood the circuit, and the ICU has no formal transfusion algorithm to
follow. Therefore, it is the
reason we seek to engage our peers to initiate a higher level of professional
practice. To effect such change,
perfusionists must be involved clinically and institutionally more than ever
before. It is critical for perfusion
departments to support staff involvement in surgical morbidity and mortality
conferences, transfusion committees, quality assurance committees, JCAHO
compliance and the like. To not be
involved as allied health professionals will result in the failure to seed a
secure future as an allied health professional. Through critical analysis and thoughtful interaction with
anesthesiologists, surgeons and administrators, the path to effecting change
will become attainable. A focus must be
placed on the education of future perfusionists, not merely in clinical practice, but in professional
practice. Students must enter the
surgical arena with a desire to move forward professionally. Emphasis should be placed on basic perfusion
research, attaining licensure, developing improved technology and techniques
with value being associated publicly to our profession. Only from this point will we be able to
effectively turn back the tide of extracorporeal circulation being associated
as having such a negative impact on patients.
In the majority of the literature debating which approach of coronary
revascularization is better, on or off bypass, cardiopulmonary bypass is only
referred to as “standard CPB” or “conventional CPB”. The playing field is not level in this debate. The Best Practice Perfusion Group is thus
advocating that standard CPB in effect means current best practice in both
technique and technology, thereby creating a platform to support the safety and
efficacy of extracorporeal circulation.
As
stated, this is just the beginning. We
look forward to increasing numbers of involved individuals contributing to this
process. We are planning to publish
consensus guidelines in clinical journals, present at meetings, hospitals and
training programs. The topics will also
continue to evolve and we look forward to providing the current evidence on
whatever topic we are asked to or deem relevant at the time. We eagerly await phone calls to assist
individual perfusionists and or perfusion teams in effecting positive change
and move towards greater professional involvement. Please do not hesitate in contacting us.