Six tips for assessing perfusion services in pursuit of greater clinical and financial performance

Healthcare organizations (HCOs) may overlook perfusion services when seeking ways to improve performance in cardiovascular, transplant, surgery and critical care services. Developing a deeper understanding of this vital service line may help HCOs improve performance and quality of care.

Looking at the not-so-distant past of heart surgery

The era of heart surgery was born out of pioneers who were determined to push back against the standards of the day. A now ironically famous quote summarizes the common perception in the late 1800's in 1896.¹

"Surgery of the heart has probably reached the limits set by nature to all surgery. No method, no new discovery, can overcome the natural difficulties that attend a wound of the heart," said English surgeon Stephen Paget.

Thanks to the determination of a community of scientists and physicians, research persisted in the face of adversity.

In 1953, Dr. John H Gibbon Jr. (with the help of IBM engineers and funding) invented the first heart-lung machine and put it to use on May 6 of that year, where he successfully performed the first intracardiac surgery on a human to close a septal defect. The nine-hour operation was a success and the patient was discharged home 13 days later.^2,3

Today, the heart-lung machine, also known as a bypass machine or cardiopulmonary bypass (CPB) machine, is used around the world every day. While the early machines took multiple operators to monitor and control, now they're typically under the purview of one person, the perfusionist.

Defining the components and clinical roles in perfusion

During heart surgery, perfusionists use the heart-lung machine to keep blood flowing to the body's tissues. They also control levels of oxygen and carbon dioxide in the blood and control temperature. Perfusionists are also responsible for measuring select laboratory values, including clotting tests (activated clotting time, heparin concentration, thromboelastography) and routine labs such as hemoglobin and hematocrit and electrolytes.

CPB machines provide a bloodless, motionless field for cardiac surgery, incorporating an extracorporeal circuit to provide physiological support. Venous blood is drained into a reservoir, filtered, oxygenated and sent back to the body using a centrifugal pump. Other applications of perfusion services include extracorporeal membrane oxygenation and auto-transfusion, known as cell saver.

Components of perfusion

• Extracorporeal membrane oxygenation (ECMO)
• During ECMO, blood is pumped outside the body to a heart-lung machine that removes carbon dioxide and sends oxygen-filled blood back to tissues in the body. ECMO is used to support life in multiple critical care situations
• Cell saver, also known as autotransfusion or intraoperative blood salvage, is a device used during surgery to collect and prepare the patient’s blood for reinfusion during or after the procedure.

Importance of roles and relationships

During procedures requiring CPB, the perfusionist, the surgeon and the anesthesia provider work in concert, demonstrating an elevated level of trust and precise communication that helps to ensure high quality care and outcomes for the patient.

Perfusion supplies: extensive options and procurement channels

Cardiac surgery encompasses many specific procedures including coronary artery bypass grafting, valve repair and/ or replacement, aortic aneurysm repair and congenital defect repair. Due to the variation of operations, the supplies required to assist the surgical team are quite extensive.

Perfusion supplies may enter an HCO through the supply chain, the operating room, the intensive care unit, or through a third-party contractor or perfusion services company. Performing an assessment to understand the supplies on hand, where the supplies originated, how supplies entered the HCO and the financial trail is key to identifying opportunities for savings and efficiency improvements.

The below list encompasses supplies often seen in perfusion packs and additional commonly used perfusion products.

Commonly used perfusion supplies

• Oxygenator
• Venous reservoir
• Centrifugal pump and probe
• Arterial filter
• Pre-bypass filter
• Retrograde one-way valve
• Sat/HCT cell
• Tubing subpacks (pump and table)
• Gas filter
• Purge line
• Vacuum relief valve
• Pressure separators (displays)
• Rapid prime line

Additional supplies

• Aortic Root Vent
• Left ventricular (LV) vent
• Cardioplegia delivery:
  • Antegrade
  • Retrograde
  • Ostial
  • Handheld
• Multi-perfusion Set
• Y Adapter
• Cardioplegia Line
• Tubing Connectors
• Suction:
  • Drop In
  • Rigid
  • Coronary
• Cannulas: arterial and venous

The extensive list of supplies is further compounded by individual product variations. For example, cannulas alone, the disposable piece that attaches to the bypass circuit, can represent over twenty different varieties. In fact, some perfusion-related product manuals reach over one hundred pages.

Perfusion services: staffing, contracting and management

Perfusion technologists, with specialized training and certification, critical care RNs (ECMO monitoring) and surgical nurses (autotransfusion) deliver or monitor perfusion. Staffing may be provided by the HCO or outsourced to a third-party perfusion services company. In some HCOs there's a combination of hospital staffing and perfusion services company staffing. To understand and provide consistent and safe staffing requires ongoing training and education, and technologists obtaining national certification upon hire or within six months of hire.

Outsourcing perfusion services

HCOs may partner with a perfusion services company to provide part or all of the organization’s perfusion needs. This may include full staffing, data management, supply purchasing and management, autotransfusion (ATS), ECMO monitoring, CPB and capital equipment. Perfusion services companies may provide neuromonitoring services, too.

Contracts with multiple amendments provide service parameters but add much complexity to an already intricate service. Different departments and leaders may manage pieces of this challenging service, but no one entity or team may understand the entire service. This leads to variation in management, contracting, staffing and supply chain — potentially opening the door for gaps in service and quality. Variation leads to additional costs as well.

Data sources and monitoring

To understand baseline performance, perfusion metrics should be reviewed at a minimum on a quarterly basis. Deciding how to corral perfusion data can be a major challenge. Start with how perfusion technologists document their work in procedures.

Do they use the electronic health record (EHR), or is documentation through the perfusion contractor’s proprietary system? How is the data reported? Perfusion supply data may go through the HCO’s supply chain system or through a contractor’s system; depending on how supplies are purchased, how they enter the HCO and where they are used. Often setting up a specific department code for perfusion assists HCO’s identify perfusion-related spend.

Perfusion companies may offer their own proprietary data management systems and provide them to HCOs at a cost. The data collected may or may not help the organization track important quality, efficiency, regulatory, supply and staffing costs over time.

Data monitoring may include:

• Key performance indicators
• Clinical quality indicators
• Staffing plans and costs
• Cardiovascular surgery data — number of cases, case times, time on and off pump, lab values, length of stay, returns to operating room and more as required by the HCO’s cardiovascular program.
• Research-specific data monitoring

In-house perfusion staffing

Perfusion services may be managed as a hospital department, including a manager, staff, supplies and equipment. Perfusion may be part of the department of surgery or cardiovascular services. The challenge here is primarily staffing. Recruiting highly qualified perfusion technologists for this crucial service is difficult. HCOs may turn to a third-party contractor for staffing services to ensure via the contract that the service is staffed.

HCOs hiring their own perfusionists will need to assess their prospective staffing market and determine an effective hiring pipeline. This may include hiring contract staff when necessary. Staffing costs for this in-demand position can top registered nurse salaries.

Quality and safety considerations

Cardiopulmonary bypass is a life-sustaining process and technology. However, the patient is at significant risk if proper procedures and monitoring are not followed from preparation until the patient is safely removed from bypass. Like other high-risk procedures in HCOs, there are key performance indicators, recommended processes and checks and balances to ensure the safest possible outcome. Perfusion professional associations provide helpful information on national perfusion standards, key performance indicators, staffing templates and articles.

Things to consider when assessing perfusion services

• Perfusion is about more than disposable supplies
• Cardiovascular (CV) and operating room workflows, including perfusion, scope and setup, are often neglected performance improvement opportunities
• Perfusion services companies have little incentive to negotiate better pricing for HCOs
• HCOs fear the unknown of perfusion services, which often influences decision-making
• An influential CV surgeon as the project champion is key to successful change management in perfusion
• Perfusion information management systems are proprietary and owned by perfusion companies. They track data, including private health information, for the benefit of the outsourced company.