In the last issue of the Journal, the From The Editor section conveyed some of my thoughts on the future of our profession, and how perfusionists ultimately, but not inevitably, affect its direction. It would be overly simplistic, and terribly clicheish, to say that we control our destiny. Such would imply that we had some way of manipulating the various disease processes in which our skills are utilized: inherited or acquired cardiovascular disease. Of course from a personal level we could surely mollify some of the environmental risks associated with the development and progression of heart disease. However, one would probably not dare argue too vehemently that much of what we do to shape our future comes more from a reactive means, then from a controlling basis. If this sounds the least bit negative, or perhaps even fatalistic, it is surely not my intention. Instead I use it to reiterate on a recurring concept that has appeared in many of these editorials over the past five years, taken from the roots on which this publication was founded: the application of science in the quest for answers to direct our clinical actions.
One need only spend a few hours in ‘pump’ or operating rooms anywhere across the globe to observe how perfusionists practice extracorporeal circulation and related functions. In fact almost 30 years ago the debate raged amongst perfusionists on weather or not what we did was more ‘art’ than ‘science’. Today one might think this laughable yet with almost 1,000,000 yearly cardiac surgical procedures performed world wide, we still have “Centers of Excellence” and ‘go-to surgeons’ or ‘centers’ to whom we would choose for our own care or for the care of those to whom we are most intimate. Science, or at least the scientific method, is predicated on the principle of replication with predictable outcomes based upon some small degree of variability. Each year thousands of research studies in cardiovascular medicine are completed, with numerous more abandoned, that ultimately increase clinical knowledge. The results of these studies, combined with our own clinical judgment, serve as a base to influence our choice of interventions. And when the most relevant of this evidence is accumulated and systematically reviewed, the results can serve as the cornerstone by which ‘Best-Practice’ and ‘Standards-of-Care’ of perfusion can be determined.
Many perfusion organizations have attempted to determine indicators of quality, which could then be used to direct practitioners so secure a consistency in care. For instance, for years AmSECT has convened a group of perfusionists to function as a Perfusion Quality Committee who have been charged with a diversity of initiatives. The results of their work can be seen on the AmSECT website (www.amsect.org) under the heading Perfusion Standards, where links such as Scope of Practice, Guidelines, Pump Templates, and Pre-Bypass Checklist take the viewer to downloadable resources. What is unique about these publications is the fact that they have been generated by the largest organization of perfusionists in the world and that they have been endorsed by the membership of the Society. Surely a highly credible, and oft referenced, resource. However, none of these contain information on the application of techniques of perfusion, which could provide clinicians with a basis to direct their actions.
It is clear, at least to this perfusionist, that what is sadly missing in our profession is the publication of standards based on the review of scientific information, obtained through the mandates of evidenced-based medicine. Such publication would go far in establishing mandates for perfusion practice that would enhance safety and improve outcomes. Numerous professional organizations have embraced this concept with the Society of Thoracic Surgeons spearheading this initiative in cardiac surgery.
So what are the mandatory requirements if such an initiative was to be implemented? At a minimum they should include the following: 1. Directed by one or more professional societies of perfusionists, 2. Conducted as a systematic review using classification of evidence based upon rating various levels of published research, 3. Conducted by perfusionists or individuals intimately involved in the conduct of extracorporeal circulation, 4. Published as an ongoing project on all aspects of extracorporeal circulation and perioperative blood management, 5. Reviewed and amended on a regular basis, 6. International in scope and participation, and 7. Published in peer-reviewed and indexed journals such as Perfusion and JECT. The benefits of establishing ‘Best-Practices’ and ‘Standards-of-Care are immense and everlasting. It is through such activities that perfusionists promulgate the numerous attributes of extracorporeal circulation and begin the transformation from reactive to proactive in the control of our destiny.
Alfred H. Stammers, MSA, CCP
Editor