President's Message

When is Practicing What is Best, Not What is Best Practicing? Part I

By Al Stammers, MSA, CCP
AmSECT President

Everyone who earnestly practices perfusion is acting with the full belief that what they are doing is in the best interest of their patients. Of this, there can be no doubt. However, practicing what is best may not be what is best practicing. This may seem somewhat contradictory because the decisions we make on how to treat our patients are surely based upon what we, as clinicians, feel best. However, the influential factors that affect our decisions are diverse and may not be based upon the best available information. Furthermore, interpretation of these results can vary from person to person and hence, be subject to an ‘eye of the beholder’ phenomena.

Over the past ten years, there has been a growing interest in an effort to assure that clinical decisions were made using the best available evidence. Such a movement grew out of the appli­cation of quality improvement methods, historically developed in the industrial sector, and infiltrated the field of medicine throughout the nineties. What really accelerated these efforts was a 1999 Insti­tute of Medicine’s publication titled, To Err is Human, which made the public aware of the degree to which healthcare workers were making mistakes, many of which resulted in patient harm. The juxtaposition of the need to link evidenced-based health care decision making with quality improvement, fertilized what has come to be known as the field of evidenced-based medicine, which has been universally embraced. It is in this spirit that AmSECT has engaged in efforts to improve the overall quality of perfusion worldwide.

There are certain tenets which are mandatory for the successful implementation of the ambitious un­dertaking of incorporating evidenced-based practice into the field of perfusion. To organize this process, AmSECT has convened a steering committee, made up of dedicated volunteers from diverse backgrounds, who are charged with coordinating these efforts. One of the first tasks was to establish a venue where known principles and techniques could be shared. The first meeting was held in Bellevue, Washington the first week of October 2006 and was called Best Practices in Perfusion. More than 140 individuals were in attendance to hear and discuss a variety of sub­jects that included theories of quality improve­ment, models for improving performance, the state of evidence in perfusion, future mandates and requirements, and the need for dedicated volunteers to see all the above to fruition. In this attendee’s perspective, the meeting was a re­sounding success. As a manager of a relatively large perfusion department, overseeing three hospitals and associated clinics, I am looking forward to upgrading our practice with many of the principles presented by an outstanding faculty in Bellevue.

It was recognized early on that an impor­tant and critical element for success would be the need for global perfusionist participation. Therefore, an International Consortium on Evidenced-Based Perfusion (ICEBP) has been created and is made up of member organiza­tions from around the globe, and is still actively recruiting additional societies to join*. At this first meeting, representatives from ten different perfusion societies were present confirming the importance that the entire profession is placing on improving the quality of care of perfusion.

One of the most critical aspects of this endeavor will be the production of guidelines for perfusion practice. Each of us uses some semblance of these to guide what we do. These are based on a combination of surgeon preferences and from departmental policies and procedures. In most situations, the utilization of these will follow an approach that combines past experience with gained knowledge. But what has been lacking has been the establishment of ’best’ evidence. The recent publication by Shann and colleagues was surely a step to reduce the gap. _ However, whether or not the best evidence exists, has been controversial. Victor Ferraris, in an editorial on publications on perfusion re­search _ stated “the fact that there are few RCT (randomized clinical trials) for CPB may reflect more the acceptance of a lack of heterogeneity of treatment effect between interventions, than a lack of scientific study.” I am not convinced many perfusionists would necessarily agree with such an observation, and surely the OPCAB literature is chock full of implications that sup­port continued improvements in the conduct and application of perfusion are warranted.

When the ICEBP releases their guidelines, they will have the effect of providing clinicians with the ability to critically evaluate the profes­sional societal recommendations as they apply in their own clinical setting. If indeed, they are applied, and if all the theories and concepts predicated on an evidenciary approach to care are indeed correct, then our life-long charge of seeking knowledge, and the truth will occur and our patients will benefit. That’s something we all would be proud to participate in.

 

* International Consortium on Evidenced-Based Perfusion – Invitation List

  1. American Academy of Cardiovascular Perfusion (AACP)
  2. American Society of ExtraCorporeal Technol­ogy (AmSECT)
  3. Australasian Society of Cardiovascular Perfusion (ASCVP)
  4. Canadian Society of Clinical Perfusion (CSCP)
  5. European Board of Cardiovascular Perfusion (EBCP)
  6. German Society of Cardiovascular Engineering (GSCVE)
  7. Indian Society of Extracorporeal Technology (ISECT)
  8. Japanese Society of Extracorporeal Technology (JSECT)
  9. Scandinavian Society for Extra-Corporeal Technology (SCANSECT)
  10. Chinese Society for Extracorporeal Circulation (CSECC)
  11. Nederlandse Sociëteit voor Extra Corporale Circulatie (NeSECC)
  12. Belgian Society of Extracorporeal Technology (BelSECT)
  13. La Asociación Española de Perfusionistas
  14. Italian Perfusion Society (ANPeC)
  15. Czech Society of Extracorporeal Circulation (CZSECT)
  16. Asociación Española de Perfusionistas
  17. Sociedade Brasileira de Circulação Extracorpórea
  18. Saudi Arabia Society of Extracorporeal Tech­nology
  19. Iranian Society of Extracorporeal Technology

References:

  1. Shann KG, Likosky DS, Murkin JM, Baker RA, Baribeau YR, DeFoe GR, Dickinson TA, Gardner TJ, Grocott HP, O’Connor GT, Rosinski DJ, Sellke FW, Willcox TW. An evidence-based review of the practice of cardiopulmonary bypass in adults: a focus on neurologic injury, glycemic control, hemodilution, and the inflam­matory response. J Thorac Cardiovasc Surg. 2006;132(2):283-90.
  2. Ferraris VA. J Heroes and evidence. J Thorac Cardiovasc Surg. 2002;124(1):11-3.