During the past sev­eral years, the field of perfusion has undergone a radical change. Those of us who practiced through the 80’s can reminisce of times where the surgical treatment of coronary disease promulgated the explosion in perfusion services with a resultant manpower shortage and abundant employment opportunities. When I gradu­ated from perfusion school in 1987, I was offered employment at all of the institutions to which I ap­plied, only because surgeries were being cancelled and the supply of Perfusionists was nowhere near the demand. The field exploded and Perfusionists were forced to focus on cardiac surgery, giving many ancillary responsibilities to other allied health specialists.  Although percutaneous transcoronary angioplasties were also expanding, there was no shortage of cases for the more than 2,000 prac­ticing Perfusionists in America at the time. There were always predictions of a decline in the use of the heart-lung machine, but few believed it would actually happen. Perfusion education programs expanded, and in 1995, reached the pinnacle of 35 programs in America graduating approximately 300 new Perfusionists per year, with most taking employment at either their first or second choices. Today, it is no surprise that the total number of cardiac cases has dramatically declined, not as a result of a reduction in acquired heart disease, but due to the expansion of catheter-based interven­tions and a rise in off-pump surgical techniques. This is reflected in a decline in perfusion schools to approximately half of the number seen in 1995. Clearly, this has resulted in a reevaluation of the case mix of all practicing Perfusionists and a critical examination of future trends. There are still a few who have not experienced this declination, mainly as a result of being insulated from market trends or through acquisition of closing programs or referral groups. However, this isolated good fortune should not portend future events, for it would be imprudent to base strategic decisions on the future of the profession on a ‘wait and hope’ scenario.

Scope of Practice
INITIATIVE: 
Reevaluate the current Scope of Practice for its degree of inclusiveness in current and future Perfusionist responsibilities.

GOALS: 
Using both current and future growth areas establish a firm and inclusive Scope of Practice to protect perfusion responsibility areas.

STEPS
a.   Establish an ad hoc committee to reevaluate the Scope of Practice as now stated.
b.   Incorporate new technologies as related to extracorporeal circulation.
c.   Incorporate units of measure and evaluate primary vs. secondary functions.
d.   Utilize resources from the Joint Commission on Accreditation of Health Organizations.

AmSECT’s interest in the declining car­diac case number paralleled what the thoracic surgery societies had identified as a critical juncture in their field. The current Strategic Plan addressed this issue as a critical element that would affect Perfusionists, and hence, required immediate attention. The AmSECT Board of Directors (BOD) called for the establishment of a taskforce to conduct a formal review of perfu­sion practice patterns. A call for volunteers to serve on a special Scope of Practice Taskforce was made and Cody Trowbridge was appointed to chair this committee. During 2005 and much of 2006, the Task Force developed a mission and established goals. The Task Force then sought input from practicing Perfusionists, and those concerned with the field, on both the state of the profession and on potential opportunities. The Task Force convened on several occasions and developed a draft document that was sub­mitted to the BOD who critically evaluated the developing Scope of Practice and returned sug­gestions of change. The Task Force reworked the document and submitted it to the BOD which voted to approve the document (please see page 5) which stands as the society’s current Scope of Practice.

The AmSECT BOD is indebted to Task Force for their outstanding efforts to identify the key elements of perfusion practice that will undoubtedly shape the future of the profession. Several other aspects of AmSECT’s Strategic Plan have used the new Scope of Practice to navigate future directions for the profession and will be the focus of future editorials.

AmSECT Task Force  Members

Scope of Practice for the Clinical Perfusionist
AmSECT Task Force on the Expansion of Perfusion Scope of Practice

Purpose
The purpose of this document is to define the Scope of Practice for Clinical Perfusionist Professionals and to specify their role as mem­bers of the health care team, acting in the best interest of the patient. The Scope of Practice is a “living” document that will evolve as techniques and technology expand.

The Scope of Practice defined here and the areas specifically set forth, describe the breadth of professional practice offered within the profession. Levels of education, experience, skill, and proficiency, with respect to the activi­ties identified within this Scope of Practice, vary among individual providers; a Clinical Perfusion­ist does not typically practice in all areas of the field. As the American Society of ExtraCorporeal Technology Code of Ethics specifies, individuals may only practice in areas in which they are com­petent based on their education, training, and experience. However, Clinical Perfusionists may expand their current level of expertise. Certain situations may necessitate that the Clinical Per­fusionist pursue additional education or training to expand their personal Scope of Practice.

The Scope of Practice statement does not supersede existing state licensure laws or affect the interpretation or implementation of such laws. It may serve, however, as a model for the devel­opment or modification of licensure laws.

Clinical Perfusion is a dynamic and continu­ously evolving profession; listing specific areas within the Scope of Practice does not exclude emerging areas of practice. Although not spe­cifically identified in this document, in certain instances Clinical Perfusionists may be called on to perform services (e.g., “multiskilling” in a health care setting, collaborative service delivery in schools) for the well-being of the individual(s) they are serving. In such instances it is both ethi­cally and legally incumbent upon professionals to determine that they have the knowledge and skills necessary to conduct such tasks.
 
Definition of the Profession
The Clinical Perfusionist Professional is an individual qualified by professional creden­tialing and academic and clinical education to provide extracorporeal patient care services. The Scope of Practice of the Clinical Perfusion­ist Professional includes those procedures, acts and processes permitted by law, for which the individual has received education and clinical experience, and in which he/she has demon­strated competency.

Scope of Practice of the Profession
1.1.      Extracorporeal Support
1.1.1.   Cardiopulmonary bypass for Adult, Pediatric, and Neonatal Patients.
1.1.2.   Cardiopulmonary bypass for congenital and acquired cardiovascular disorders.
1.1.3.   Extracorporeal circulatory support for renal, neurological, hepatic and vascular surgery.
1.1.4.   Extracorporeal resuscitation.
1.1.5.   Extracorporeal circulation for long term support of failing respiratory and/or cardiac function.
1.2.      Associated Extracorporeal Support Functions
1.2.1.   Myocardial protection.
1.2.2.   Hemofiltration/hemodialysis.
1.2.3.   Anticoagulation and hemostasis monitoring, analysis, and intervention.
1.2.4.   Thermal regulation.
1.2.5.   Blood gas and blood chemistry monitoring, analysis, and intervention.
1.2.6.   Physiological monitoring, analysis, and intervention.
1.2.7.   Administration of blood components, phar­maceuticals, and anesthetic agents
2.1.      Heart Failure Therapy and Support
2.1.1.   Ventricular Assist Device management
2.1.2.   Intra-aortic Balloon Counterpulsation
2.1.3.   Temporary Pacemaker management
2.1.4.   External counterpulsation
2.1.5.   Transportation of Extracorporeal Supported Patients
2.1.6.   Hemofiltration (i.e. “Aquapheresis”)
2.1.7.   Periodic flow augmentation therapy
3.1.      Blood Management
3.1.1.   Autotransfusion
3.1.2.   Platelet Gel Production
3.1.3.   Non-Differentiated Progenitor Cell Harvest
3.1.4.   Acute Normovolemic Hemodilution
3.1.5.   Phlebotomy
3.1.6.   Hemostasis monitoring and analysis
4.1.      Other Clinical
4.1.1.   Isolated Limb/Organ perfusion
4.1.2.   Isolated limb/organ delivery of chemothera­peutics, progenitor cells, gene therapy vec­tors, etc.
4.1.3.   Organ Procurement
4.1.4.   Thermogenic lavage
4.1.5.   Organ Preservation
4.1.6.   Dialysis
4.1.7.   Surgical assistance
4.1.8.   Electrophysiological analysis
4.1.9.   Therapeutic Hyperthermia
4.1.10. Therapeutic Hypothermia
4.1.11. Intravascular membrane oxygenation
5.1.      Non-Clinical Responsibilities
5.1.1.   Documentation of duties via the official medi­cal record
5.1.2.   Education, including the establishment and management of educational programs for new and current clinical Perfusionists, other healthcare providers, and consumers.
5.1.6.   Administration, including managing all aspects — technical, fiscal, workflow, and human re­sources — of Clinical Perfusion operations.
5.1.7.   Quality Control and Assurance
5.1.8.   Regulatory Compliance
5.1.9.   Competency/Performance Evaluation
6.1.      Professional Performance
6.1.1.   Obtains and maintains appropriate profes­sional credentials .
6.1.2.   Works in partnership with other health care professionals to provide the best medical care possible for all patients.
6.1.3.   Adheres to the standards , policies , and procedures  adopted by the profession and regulated by law.
6.1.4.   Stays current with required continuing medi­cal education (CME) in order to stay abreast of changes in the field of extracorporeal technology and to maintain professional cre­dentials.
6.1.5.   Participates in continuing education activities through professional organizations, to en­hance knowledge, skills and performance. 
6.1.6.   Adheres to the accepted professional ethical standards as defined by the Code of Ethics.
6.1.7    Acts as a patient advocate supporting patient rights.
6.1.8.   Design, coordination, and implementation of original investigation.
6.1.9    Critical evaluation of published research.

References:

1. Professional Credentials: Competency based Perfusionist credentials as typified by the Certified Cardiovascular Perfusionist awarded by the American Board of Cardiovascular Perfusion.
2. Standards: Statements of the minimum be­havioral or performance levels that are accept­able. Something established by authority as a rule for the measure of quantity or quality.
3. Policies: Written statements indicating what actions are to be taken when specific criteria are encountered. A definite course or method of action selected from among alternatives and in light of givenconditions to guide and determine present and future decisions.
4. Procedures: Written guidelines that state how a task is to be accomplished, the specific steps to be taken, or how a policy is to be executed.
5. Code of Ethics: Document defining the ex­pected professional standard of conduct for Clinical Perfusion Professionals; published by the American Society of ExtraCorporeal Technology and included in the appendix.