BACKGROUND:Simulation-based education (SBE) is increasingly used in training students in allied healthcare, yet data on its role in United States (U.S.) perfusion programs are limited. This study surveyed perfusion programs with the purpose of assessing simulation use, curricular integration, challenges, and future directions. METHODS:A 22-question validated survey was distributed via REDCap to all 23 perfusion program directors in the U.S. between March and April 2025. Questions addressed demographics, simulation infrastructure, curricular integration, challenges, and future directions. RESULTS:The response rate was 100%. All programs use at least one simulation modality, and 82.6% use high-fidelity simulation. Most programs (69.6%) fully embed simulation into credit-bearing courses, and 73.9% grade student performance. 60.9% of programs report that they have a dedicated simulation space. 56.5% report a lack of a dedicated budget. Common challenges identified were time constraints (73.9%) and limited faculty manpower (65.2%). While all programs teach adult CPB using simulation, the incorporation of pediatric CPB, ECMO, and IABP simulation is less common. CONCLUSION:SBE is widely adopted in perfusion programs across the U.S., but standardization, faculty training, and curricular integration are necessary to optimize its impact.

Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used in cardiac arrest (CA) resuscitation, yet its effects on biventricular mechanics remain poorly defined. Given that early on-ECMO hemodynamics associate with survival, we used a swine model with real-time pressure-volume (PV) loop analysis to assess ventricular-arterial coupling and mechano-energetics during graded ECMO flow after CA. Methods: In a ventricular fibrillation swine model, high-fidelity conductance catheterization was performed to measure real-time PV loops in left ventricle (LV) and right ventricle (RV). Baseline (pre-arrest) data were acquired, followed by 20 minutes of CA and VA-ECMO initiation. PV data were obtained across multiple ECMO flow rates (Q [cc/kg/min]). Ventricular elastance (Ees), arterial elastance (Ea), Ees/Ea coupling ratio, stroke work (SW), potential energy (PE), pressure-volume area (PVA), and mechanical energy efficiency (MEE = SW/PVA) were quantified. Results: Both ventricles demonstrated acute post-arrest dysfunction; however, the trajectories diverged thereafter. RV Findings: Ees/Ea declined from 1.7 (baseline) to <0.4 across ECMO flows, reflecting uncoupling. This was driven by disproportionate increases in Ea and declines in stroke volume, despite modest changes in contractility (Ees). RV volumes (EDV/ESV) remained elevated, indicating sustained dilation. SW remained flat while PE and PVA increased, resulting in a drop in MEE from >80% to ~40%. LV Findings: The LV exhibited partial recovery in Ees with ECMO ramping. Despite increased Ea (likely from retrograde flow and reduced ejection), Ees/Ea remained stable (~0.7). SW and PVA both declined, consistent with unloading, yet MEE was preserved. PV loop morphology showed progressive LV volume reduction with preserved loop geometry, while RV loops demonstrated early dilation, impaired ejection, and rising energetic burden. Conclusions: This model shows that following CA and VA-ECMO initiation, the RV and LV display distinct mechano-energetic and coupling patterns. The RV demonstrated persistent uncoupling and inefficiency, potentially due to post-arrest pulmonary changes, while the LV showed partial recovery and preserved efficiency. These results support the need for individualized biventricular assessment during ECMO-supported resuscitation.

Background Traditionally, novice perfusionists learn and practice clinical skills, during live surgical procedures. The profession’s accrediting body is directing schools to implement simulated cardiopulmonary bypass (CPB) into the curriculum. Unfortunately, no CPB simulation models have been validated. Here we describe the design and application of a CPB simulation model. Methods A CPB patient simulator was integrated into a representative operative theater and interfaced with a simple manikin, a heart-lung machine (HLM), clinical perfusion circuitry, and equipment. Participants completed a simulation scenario designed to represent a typical CPB procedure before completing an exit survey to assess the fidelity and validity of the experience. Questions were scored using a 5-point Likert scale. Results Participants ( n = 81) contributed 953 opinions on 40 questions. The participants reported that the model of simulated CPB (1) realistically presented both the physiologic and technical parameters seen during CPB ( n = 347, mean 4.37, SD 0.86), (2) accurately represented the psychological constructs and cognitive mechanisms of the clinical CPB ( n = 139, mean 4.24, SD 1.08), (3) requires real clinical skills and reproduces realistic surgical case progression ( n = 167, mean 4.38, SD 0.86), and (4) would be effective for teaching, practicing, and assessing the fundamental skills of CPB ( n = 300, mean 4.54, SD 0.9). Participants agreed that their performance in the simulation scenario accurately predicted their performance in a real clinical setting ( n = 43, mean 4.07, SD 1.03) Conclusion This novel simulation model of CPB reproduces the salient aspects of clinical CPB and may be useful for teaching, practicing, and assessing fundamental skills.

The utilization of simulators for training is increasing in the professions associated with cardiac surgery. Before applying these simulators to high-stakes assessment, the simulator's output data must be validated. The aim of this study is to validate a Cardiopulmonary Bypass (CPB) simulator by comparing the simulated hemodynamic and technical outputs to published clinical norms. Three Orpheus™ CPB simulators were studied and compared to a published reference of physiologic and technical metrics that are managed during clinical CPB procedures. The limits of the simulators user modifiable variables were interrogated across their full range and the results were plotted against the published clinical norms. The data generated with the simulator conforms to validated clinical parameters for patients between 50 and 110 kg. For the pre- and post-CPB periods, the independent variables of central venous pressure (CVP), heart rate (HR), contractility, and systemic vascular resistance (SVR) must be operated between the limits of 7 and 12 mmHg, 65 and 110 beats/min, 28% and 65%, and 6 and 32 units respectively. During full CPB the arterial pump flows should be maintained between 3.5 and 5.5 LPM and SVR between 18 and 38 units. Validated technical parameters during cardioplegia delivery are expected at solution flow rates between 250 and 400 mL/min and 100 and 225 mL/min for antegrade and retrograde delivery routes, respectively. We have identified the limits for user-modifiable settings that produce data conforming to the physiologic and technical parameter limits reported in the peer reviewed literature. These results can inform the development of simulation scenarios used for high stakes assessments of personnel, equipment, and technical protocols.

The dramatic increase in the use of extracorporeal membrane oxygenation (ECMO) over the last decade with the concomitant need for ECMO competent perfusionists has raised questions of how well perfusion education programs are preparing entry-level perfusionists to participate in ECMO. While all perfusion schools teach ECMO principles, there is no standardized or systematic approach to the delivery of didactic knowledge and clinical skills in ECMO. Given this variability of ECMO education across and within perfusion schools, the CES-A exam may provide a metric for comparing curricular approaches. The purpose of this study is to examine three different curricular approaches to prepare new perfusion graduates to master the Adult ECMO Specialist Certification exam (CES-A). We examined three different curricular approaches to prepare new perfusion graduates to master the Adult ECMO Specialist Certification exam (CES-A). We hypothesized that there would be no difference in CES-A pass rate, exam score, Rasch measure, and item category scores between SUNY Cardiovascular Perfusion Program (CVP) graduates who completed SUNY's ECMO Capstone experience (Group III) and CVP graduates who did not select the ECMO Capstone experience (Group II). Further, we studied the performance of a third group of new graduates from an external program that does not offer formal ECMO courses or an ECMO Capstone experience (Group I). Every perfusion graduate in all groups passed the adult ECMO specialist exam. The graduates who as students completed an ECMO Capstone experience (Group III) scored higher on the exam and significantly higher on four exam categories: coagulation and hemostasis (p = .058), lab analysis point of care (p = .035), and monitor patient and circuit (p = .073), and the safety and failure modes (p = .017). Overall the median graduate Rasch measures ranked with Group III demonstrating the highest measure to Group I the lowest measures (not significant at p = .085). There is a positive educational effect due to CVP graduates completion of the ECMO Capstone experience compared to the program standard ECMO-related curricula in the two perfusion programs participating in this study. From this observation a structured ECMO simulation-based program appears to be equally effective as a traditional, typical lecture-only, clinical perfusion preceptorship, while demonstrating a more satisfactory experience with a higher reported case experience. In this study the standard perfusionist education curriculum prepared the new graduate to be successful on the CES-A exam. The three curricular approaches appear to prepare perfusionist graduates to be successful on the Adult ECMO Specialist exam.

Perfusion education programs use simulation to provide students with clinical skills prior to entering the operating room. To teach the psychomotor execution of skills in a simulation lab requires a list of validated skills and deconstructed sub-steps to fully optimize adult learning. A list of the fundamental skills of adult cardiopulmonary bypass (CPB) was recently published; however, no defined list exists regarding pediatric CPB skills. The purpose of this survey is to form a definitive list of skills fundamental to pediatric CPB. A survey of 23 proposed pediatric CPB clinical skills and 291 proposed skill sub-steps was developed. Proposed pediatric CPB skills were evaluated using an established frequency and harm index. If the skill is performed >50% of the time (frequency), and if >50% believe that if the skill is performed incorrectly patient harm is probable (risk), then the skill is accepted as fundamental. The survey content was validated by subject matter experts and then distributed to practicing perfusionists between September 2020 and December 2020. Of the 125 survey respondents, 57.9% had 10 or more years in the field. 35.2% of respondents are American Society of Extracorporeal Technology (AmSECT) Fellows of Pediatric Perfusion (FPP) and pediatric CPB represents >50% of the annual caseload for 69.7% of respondents. 22 of the 23 proposed skills were accepted as fundamental in the conduct of pediatric CPB and 258 of the 291 proposed sub-steps associated with CPB skills were accepted as integral to skill performance. By surveying practicing pediatric perfusionists, this study identifies 22 skills as fundamental to the safe execution of pediatric CPB. In addition, skill sub-elements were identified as necessary for skill execution. This knowledge will assist perfusion programs in developing a pediatric simulation curriculum that matches current clinical execution of pediatric skills.

BACKGROUND:Cardiopulmonary bypass is known to raise the risk of acute kidney injury (AKI). Previous studies have identified numerous risk factors of cardiopulmonary bypass including the possible impact of perioperative ultrafiltration. However, the association between ultrafiltration (UF) and AKI remains conflicting. Thus, we conducted a meta-analysis to further examine the relationship between UF and AKI.HYPOTHESIS:Ultrafiltration during cardiac surgery increases the risk of developping Acute kidney Injury.METHODS:We searched PubMed, Web of Science, EBSCO, and SCOPUS through July 2021. The RevMan (version 5.4) software was used to calculate the pooled risk ratios (RRs) and mean differences along with their associated confidence intervals (95% CI).RESULTS:We identified 12 studies with a total of 8005 patients. There was no statistically significant difference in the incidence of AKI between the group who underwent UF and the control group who did not (RR = 0.90, 95% CI = 0.64-1). Subgroup analysis on patients with previous renal insufficiency also yielded nonsignificant difference (RR = 0.84, 95% CI = 0.53 -1.33, p = .47). Subgroup analysis based on volume of ultrafiltrate removed (> or <2900 ml) was not significant and did not increase the AKI risk as predicted (RR = 0.82, 95% CI = 0.63 -1.07, p  = .15). We also did subgroup analysis according to the type of UF and again no significant difference in AKI incidence between UF groups and controls was observed in either the conventional ultrafiltration (CUF), modified ultrafiltration (MUF), zero-balanced ultrafiltration (ZBUF), or combined MUF and CUF subgroups.CONCLUSION:UF in cardiac surgery is not associated with increased AKI incidence and may be safely used even in baseline chronic injury patients.

Cardiopulmonary bypass (CPB) is a highly technical clinical discipline with a recognized variability in practice. Professional standards and guidelines documents help direct clinical practice and reduce variability, but these guidelines are necessarily vague and fall short of providing specific objective recommendations of clinical practice metrics. If clinical practice metrics were known, they would be informative when writing departmental policy manuals, structuring quality improvement initiatives, describing product R&D specifications, and designing educational assessment rubrics. Therefore, to address this gap, we conducted a national survey of clinical practice with the purpose of producing a benchmark of the typical variability of specific technical parameters that are commonly managed during adult CPB procedures. A pool of expert clinical perfusionists collaborated to compile a data set of normal ranges for 41 individual physiologic and technical parameters (pressures, flows, saturation, times, solutions, and temperatures) that are commonly managed during adult CPB procedures. Results were collected using an online survey application. Respondent demographics and measures of central tendency with descriptive quartile statistics and confidence intervals for each parameter are presented. Of the 335 people who participated in the survey, 315 met the inclusion criteria. The geographic demographics of the respondents were representative of the American Board of Cardiovascular Perfusion's distribution of certified clinical perfusionists. Of the 41 parameters investigated, there were 13 hemodynamic parameters, 13 normal flow rates and technical circuit parameters, 10 blood gasses and hematocrit parameters, and five parameters of patient temperatures. The data presented here are informative and provide a consensus-based objective assessment of the standard practice for adult CPB as reported by practicing clinical perfusionists. Based on these survey data, we have identified the typical clinical limits for the 41 parameters that are managed during adult CPB. This information may be incorporated into guiding documents to support the work of clinicians, researchers, and educators.

The American Society of Extracorporeal Technology Board of Directors, consistent with the American Society of Extracorporeal Technology's safe patient care improvement mission, charged the International Board of Blood Management to write a knowledge and skill certification examination for healthcare personnel employed as adult extracorporeal membrane oxygenation (ECMO) specialists. Nineteen nationally recognized ECMO subject-matter experts were selected to complete the examination development. A job analysis was performed, yielding a job description and examination plan focused on 16 job categories. Multiple-choice test items were created and validated. Qualified ECMO specialists were identified to complete a pilot examination and both pre- and post-examination surveys. The examination item difficulty and candidate performance were ranked and matched using Rasch methodology. Candidates' examination scores were compared with their profession, training, and experience as ECMO specialists. The 120-item pilot examination form ranked 76 ECMO specialist candidates consistent with their licensure, ECMO training, and clinical experience. Forty-three registered nurses, 28 registered respiratory therapists, four certified clinical perfusionists, and one physician assistant completed the pilot examination process. Rasch statistics revealed examination reliability coefficients of .83 for candidates and .88 for test items. Candidates ranked the appropriateness for examination items consistent with the item content, difficulty, and their personal examination score. The pilot examination pass rate was 80%. The completed examination product scheduled for enrollment in March 2020 includes 100 verified test items with an expected pass rate of 84% at a cut score of 67%. The online certification examination based on a verified job analysis provides an extramural assessment that ranks minimally prepared ECMO specialists' knowledge, skills, and abilities (KSA) consistent with safe ECMO patient care and circuit management. It is anticipated that ECMO facilities and ECMO service providers will incorporate the certification examination as part of their process improvement, safety, and quality assurance plans.

Introduction: Training students to become entry-level perfusionists requires evaluation and assessment of their clinical skills. While our professional organizations have compiled resources which identify the profession's knowledge base and categorical skills applied to clinical practice, these resources are lacking the necessary detail to develop validated clinical assessment rubrics. Therefore, the purpose of this project is to identify, through expert opinion, the detailed fundamental skills necessary to perform adult cardiopulmonary bypass (CPB). Methods: We define a fundamental skill based upon frequency of use and risk of harm. A skill that experts report is conducted in >50% of their CPB cases - and, if not properly conducted, can cause harm, is deemed a fundamental skill. To identify these skills, a 73-question survey was developed and posted on PerfList and PerfMail from May 2017 to July 2017. Results: The results from 261 respondents were analyzed. The demographics of the participants were representative of the workforce. Twenty skills were surveyed and all 20 met the criteria to be identified as a fundamental skill. Data regarding the actions, assessments and behaviors that may be associated with fundamental skills were also identified. Conclusions: Based upon this survey data, we have identified that there is consensus within our profession regarding the fundamental skills of adult CPB and a core body of actions, assessments and behaviors that experts perform when conducting these skills. This information may be incorporated into the entry-level educational process to inform curricula and design valid assessment rubrics.

Extracorporeal membrane oxygenation (ECMO) is often managed using minimal anticoagulation. This can make the circuitry susceptible to thrombosis. The ECMO cannula may be particularly vulnerable to thrombosis if flow is interrupted for an undetermined but prolonged period of time. Therefore, under conditions where cannula blood flow stasis may be prolonged and flashing, the cannulae is not an option (e.g., air in circuit) it is imperative to have an emergency plan available, which can be rapidly implemented that will provide a means of cannula patency preservation. The following outlines a system to preserve cannula patency in these instances.

This paper represents a significant puzzle piece in the advancement of our profession and was published at a critical time in the development of our profession’s educational process. On reading it, I was immediately struck by both the contemporary timeliness of this subject material and the spirit of collaboration and professional community which must have existed circa 1980 to produce an article which so pointedly addressed a question for our entire profession. At the time of this publication, the young American Board of Cardiovascular Perfusion (ABCP) (founded in 1975) was diligently reporting from their database of test taker demographics and test outcomes to establish that there was statistically significant evidence to support an increase in the standards for perfusion education programs; that test scores were higher from schools with longer curriculum. At the time, the movement afoot in our community focused on the discontinuation of on-the-job-training programs. This movement can be compared to a discussion occurring in our profession right now which is calling for the entry level degree for all perfusion programs to be set at the master’s degree level (2). Considering that 56% of the perfusion education programs in the United States award a bachelor’s or a post-baccalaureate degree, this would be a significant change and would undoubtedly result in the termination of several programs if they failed to secure the prerequisite university affiliation to offer a graduate degree. Needless to say the suggestion is not without its opponents (3). Although the overall goal of improved minimum educational standards is the same, the primary difference between the educational movement in the 1980s and the present day discussion is our access to outcome data. This classic paper by Richmond, Arnold, and Kurusz represents the full participation of the ABCP in the growth of our professional community through the open distribution of outcome data for educational programs. This stands in sharp contrast to the current state of the discussion regarding an entry level Master’s degree for perfusion, which is, so far, based on thoughtful yet biased rhetoric. The demographic and outcome data for every perfusionist entering and re-entering the field is collected as a matter of procedure for all national certification test takers. The potential implications of rigorous statistical analysis of these data are obvious. While each program is currently provided outcome data for their students, the results are de-identified making it impossible for a program to validate the performance of programassessment tools through comparison of their graduate’s performance on program assessments to the same student’s performance on the certification examinations. Furthermore, there is currently no greater analysis beyond each individual program. Generation and distribution of national benchmark performance profiles would help identify programs of excellence and facilitate goal setting for all perfusion education programs. There is rarely any opposition to improving education. The debate generally focuses on how that should be done. Great improvements in clinical outcomes have been realized with the use of information obtained from clinical registries and mandated state reporting. In the 1980s, in my home state of New York, there was a great deal of skepticism over reporting of provider outcomes. Some believed that providing these data would limit access to care for the elderly and cause a shift of high-risk cases out of New York (nobody would operate on really sick people as it would ruin their stats and reputation). In 1998, Petersen and colleagues sought to determine if the prediction of the skeptics came true and found that not only was there no out migration of patients, nor access issues, States like New York and the Northern New England States that Richmond M, Arnold B, Kurusz M. The relationship of duration of training to American Board of Cardiovascular Perfusion written certification examination scores. J Extra Corpor Technol. 1980;12:127–30.

Despite the widespread use of vacuum-assisted venous drainage (VAVD) and case reports describing catastrophic incidents related to VAVD, there is a lack of data cataloging specific safety measures that individuals and institutions have incorporated into their VAVD practices for the prevention of these incidents. Therefore, the purpose of this study is to survey the perfusion community to gather data on VAVD practices, and to compare these current practices with literature recommendations and the American Society of ExtraCorporeal Technology (AmSECT) Standards and Guidelines. In September 2014, a survey was distributed via PerfList and PerfMail, and by direct e-mail to members of the New York State Society of Perfusionists, targeting certified clinical perfusionists in New York State. Survey topics pertaining to VAVD practice included 1) equipment, 2) pressure monitoring and alarms, 3) protocols, checklists, and documentation, and 4) VAVD-related incidents. Of ∼200 certified clinical perfusionists who live and/or work in New York State (NYS), 88 responded (42%). Most respondents (90.1%) report they use VAVD. Of these, 87.3% report that they monitor VAVD pressure, with 51.6% having audible and visual alarms for both positive and excessive negative pressures. At the institutional level, 61.2% of respondents reported that there is a protocol in place at for their team limiting negative pressure in the reservoir, 28.4% document VAVD pressure in the pump record, and AmSECT's three recommended VAVD checklist items are met with 53.7%, 55.1%, and 33.8% compliance. In conclusion, the results of this study reveal that the use of VAVD has increased and has become nearly universal in 2014. There is high compliance to some of the literature recommendations and AmSECT Standards and Guidelines, however, there are still some gaps between current practices and these recommendations. Continued improvement, both at the individual and institutional levels, will help to improve patient safety by preventing untoward events from occurring while using VAVD.

During a recent stroll through the perfusion literature I happened upon the classic paper which is the subject of this article. The Relationship of Duration of Training to American Board of Cardiovascular Perfusion Written Certification Examination (1) This paper represents a significant puzzle piece in the advancement of our profession and was published at a critical time in the development of our profession’s educational process. On reading it, I was immediately struck by both the contemporary timeliness of this subject material and the spirit of collaboration and professional community which must have existed circa 1980 to produce an article which so pointedly addressed a question for our entire profession. At the time of this publication, the young American Board of Cardiovascular Perfusion (ABCP) (founded in 1975) was diligently reporting from their database of test taker demographics and test outcomes to establish that there was statistically significant evidence to support an increase in the standards for perfusion education programs; that test scores were higher from schools with longer curriculum. At the time, the movement afoot in our community focused on the discontinuation of on-the-job-training programs. This movement can be compared to a discussion occurring in our profession right now which is calling for the entry level degree for all perfusion programs to be set at the master’s degree level (2). Considering that 56% of the perfusion education programs in the United States award a bachelor’s or a post-baccalaureate degree, this would be a significant change and would undoubtedly result in the termination of several programs if they failed to secure the prerequisite university affiliation to offer a graduate degree. Needless to say the suggestion is not without its opponents (3). Although the overall goal of improved minimum educational standards is the same, the primary difference between the educational movement in the 1980s and the present day discussion is our access to outcome data. This classic paper by Richmond, Arnold, and Kurusz represents the full participation of the ABCP in the growth of our professional community through the open distribution of outcome data for educational programs. This stands in sharp contrast to the current state of the discussion regarding an entry level Master’s degree for perfusion, which is, so far, based on thoughtful yet biased rhetoric. The demographic and outcome data for every perfusionist entering and re-entering the field is collected as a matter of procedure for all national certification test takers. The potential implications of rigorous statistical analysis of these data are obvious. While each program is currently provided outcome data for their students, the results are de-identified making it impossible for a program to validate the performance of program-assessment tools through comparison of their graduate’s performance on program assessments to the same student’s performance on the certification examinations. Furthermore, there is currently no greater analysis beyond each individual program. Generation and distribution of national benchmark performance profiles would help identify programs of excellence and facilitate goal setting for all perfusion education programs. There is rarely any opposition to improving education. The debate generally focuses on how that should be done. Great improvements in clinical outcomes have been realized with the use of information obtained from clinical registries and mandated state reporting. In the 1980s, in my home state of New York, there was a great deal of skepticism over reporting of provider outcomes. Some believed that providing these data would limit access to care for the elderly and cause a shift of high-risk cases out of New York (nobody would operate on really sick people as it would ruin their stats and reputation). In 1998, Petersen and colleagues sought to determine if the prediction of the skeptics came true and found that not only was there no out migration of patients, nor access issues, States like New York and the Northern New England States that examined results had an accelerated rate of improvement in outcomes (4). As we teach in school, every quality improvement process calls for careful analysis of data to identify the opportunity for improvement as well as continued data analysis to evaluate actions taken to effect the improvement. Maybe it is just time that we take the blinders off in perfusion education. Perhaps we could identify some best practices in education and realize improvements in student performance similar to the improvements in patient outcomes realized in New England. Furthermore, would it be farfetched to assume that better prepared clinician graduates may have a positive effect on a patient’s outcome? The current discussion regarding a master’s degree for all perfusion programs is still very new. There is still time for a full analysis of the ABCP outcome data to be provided to the ACPE.* I’m sure this information will be informative and help lead our educational programs in the most productive direction.

Pressure data acquired from multiple sites of extracorporeal circuits can be an important parameter to monitor for the safe conduct of cardiopulmonary bypass (CPB). Although previous surveys demonstrate that CPB circuit pressure monitoring is widely used, there are very little data cataloging specific applications of this practice. Therefore, the purpose of this study is to survey the perfusion community to catalog 1) primary CPB circuit site pressure monitoring locations; 2) type of manometers used; 3) pressure monitoring interface and servoregulation with pump console; and 4) the rationale and documentation associated with pressure monitoring during CPB. In June 2013, a validated 27-question online survey was sent directly through an e-mail link to the chief perfusionists in the northeast United States. Completed surveys were received from 75 of 117 surveys deployed yielding a 64% response rate. Arterial line pressure monitoring during CPB is reported by 99% with six distinct circuit site locations identified. Cardioplegia system pressure was monitored by 95% of the centers. For vacuum-assisted venous drainage (VAVD) users, the venous pressure was measured by 72% of the responding centers. Arterial line pressure servoregulation of the arterial pump was indicated by 61% of respondents and 75% of centers record arterial line pressure in their perfusion record. Most centers (77%) report the use of a transducer that is integrated into the pump console providing a digital pressure display, whereas 20% combine an aneroid gauge manometer with the integrated digital transducer. This study demonstrates that the practice of arterial line pressure monitoring during CPB is nearly universal. However, the selection of the pressure monitoring site on the circuit, modes of monitoring pressure, and their applications are highly variable across the perfusion community.

HomeCirculationVol. 128, No. 10Patient Safety in the Cardiac Operating Room: Human Factors and Teamwork Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBPatient Safety in the Cardiac Operating Room: Human Factors and TeamworkA Scientific Statement From the American Heart Association Joyce A. Wahr, MD, FAHA, Co-Chair, Richard L. Prager, MD, FAHA, J.H. AbernathyIII, MD, Elizabeth A. Martinez, MD, Eduardo Salas, PhD, Patricia C. Seifert, MSN, Robert C. Groom, CCP, Bruce D. Spiess, MD, FAHA, Bruce E. Searles, MS, CCP, Thoralf M. SundtIII, MD, Juan A. Sanchez, MD, Scott A. Shappell, PhD, Michael H. Culig, MD, Elizabeth H. Lazzara, PhD, David C. Fitzgerald, CCP, FAHA, Vinod H. Thourani, MD, Pirooz Eghtesady, MD, PhD, FAHA, John S. Ikonomidis, MD, PhD, FAHA, Michael R. England, MD, Frank W. Sellke, MD, FAHA and Nancy A. Nussmeier, MD, FAHA, Co-Chairon behalf of the American Heart Association Council on Cardiovascular Surgery and Anesthesia, Council on Cardiovascular and Stroke Nursing, and Council on Quality of Care and Outcomes Research Joyce A. WahrJoyce A. Wahr Search for more papers by this author , Richard L. PragerRichard L. Prager Search for more papers by this author , J.H. AbernathyIIIJ.H. AbernathyIII Search for more papers by this author , Elizabeth A. MartinezElizabeth A. Martinez Search for more papers by this author , Eduardo SalasEduardo Salas Search for more papers by this author , Patricia C. SeifertPatricia C. Seifert Search for more papers by this author , Robert C. GroomRobert C. Groom Search for more papers by this author , Bruce D. SpiessBruce D. Spiess Search for more papers by this author , Bruce E. SearlesBruce E. Searles Search for more papers by this author , Thoralf M. SundtIIIThoralf M. SundtIII Search for more papers by this author , Juan A. SanchezJuan A. Sanchez Search for more papers by this author , Scott A. ShappellScott A. Shappell Search for more papers by this author , Michael H. CuligMichael H. Culig Search for more papers by this author , Elizabeth H. LazzaraElizabeth H. Lazzara Search for more papers by this author , David C. FitzgeraldDavid C. Fitzgerald Search for more papers by this author , Vinod H. ThouraniVinod H. Thourani Search for more papers by this author , Pirooz EghtesadyPirooz Eghtesady Search for more papers by this author , John S. IkonomidisJohn S. Ikonomidis Search for more papers by this author , Michael R. EnglandMichael R. England Search for more papers by this author , Frank W. SellkeFrank W. Sellke Search for more papers by this author and Nancy A. NussmeierNancy A. Nussmeier Search for more papers by this author and on behalf of the American Heart Association Council on Cardiovascular Surgery and Anesthesia, Council on Cardiovascular and Stroke Nursing, and Council on Quality of Care and Outcomes Research Originally published5 Aug 2013https://doi.org/10.1161/CIR.0b013e3182a38efaCirculation. 2013;128:1139–1169Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2013: Previous Version 1 IntroductionThe cardiac surgical operating room (OR) is a complex environment in which highly trained subspecialists interact with each other using sophisticated equipment to care for patients with severe cardiac disease and significant comorbidities. Thousands of patient lives have been saved or significantly improved with the advent of modern cardiac surgery. Indeed, both mortality and morbidity for coronary artery bypass surgery have decreased during the past decade (Figure 1).1 Nonetheless, the highly skilled and dedicated personnel in cardiac ORs are human and will make errors. In 1991, Leape and colleagues2,3 estimated that among the 2 million patients hospitalized in New York in 1984, there were 27 179 adverse events that involved negligence; other evidence suggests that up to 16% of hospital inpatients are harmed.4 Gawande and associates5 found that the incidence of surgical adverse events was 12% among cardiac surgery patients versus 3% in other surgical patients; 54% of the adverse events were considered preventable. Of the roughly 350 000 to 500 000 patients who undergo cardiac surgery each year, 28 000 will have an adverse event, and one third of deaths associated with coronary artery bypass graft (CABG) operations may be preventable.6Download figureDownload PowerPointFigure 1. Change in mortality and stroke rates in patients undergoing isolated coronary artery bypass graft (CABG) surgery, 2000 to 2009. There was a 24.4% and 26.4% reduction in the unadjusted observed operative mortality (2.4% vs 1.9%) and stroke rates (1.6% vs 1.2%), respectively, during the course of the study period. Reprinted from ElBardissi et al1 with permission from Elsevier. Copyright © 2012, The American Association for Thoracic Surgery.Refined techniques, advanced technologies, and enhanced coordination of care have led to significant improvements in cardiac surgery outcomes. However, more than 10 years after the Institute of Medicine report,7 there is little evidence that much progress has been achieved in reducing or preventing errors.8 The tools to measure potential risks and interventions to improve patient safety are still in the early stages of development and testing,9 and funding for patient safety studies remains inadequate. Published studies provide only limited evidence of improved outcomes.8,9 Furthermore, much of the existing research is, by necessity, qualitative and descriptive and thus does not lend itself to traditional quantitative statistical analysis. Therefore, many clinicians are not conversant with such research.Preventable errors are often not related to failure of technical skill, training, or knowledge but represent cognitive, system, or teamwork failures (Figure 2).10–14 Nontechnical skills such as communication, cooperation, coordination, and leadership are critical components of teamwork, but limited interpersonal skills often underlie adverse events and errors.15–17 In a review of litigated surgical outcomes, communication failures accounted for 87% of the system failures that led to an indemnity payment.18 The communication failures occurred primarily between caregivers, rather than between caregiver and patient.Download figureDownload PowerPointFigure 2. Accident model. Active and latent failures in healthcare organizations, hospital management, and individual human error can all contribute to adverse events during high-risk procedures. Reprinted from Carthey et al13 with permission from Elsevier. Copyright © 2001, The Society of Thoracic Surgeons.Breakdowns in teamwork that lead to surgical flow or operative disruptions are exceedingly common, having been noted at a rate of 17.4 per hour in one cardiac surgery study19 and at 11 per case in another.20 Importantly, such disruptions add up, leading to technical errors and adverse patient outcomes.21–23 The majority of flow disruptions are related to teamwork failures, and these disruptions have been shown to be strongly predictive of surgical errors.20Even minor events in cardiac surgical procedures, that is, those not expected to affect outcome, reduce the team’s ability to recover from major events and appear significantly associated with both death and near misses.22 In one study, for every 3 minor problems above the mean of 9.9 per case, intraoperative performance was measurably reduced and operative duration increased.23 The accumulation of minor disruptions and events apparently reduced the ability of the cardiac team to compensate for major errors24; in short, “little things matter.”17,25Surgical team members vary in their awareness of their own and their colleagues’ teamwork skills. In multiple studies, self-assessment of communication and teamwork skills by surgeons and anesthesiologists is disturbingly discordant with the opinions of their associated nursing and perfusion staff.26,27 Surgeons rated the teamwork of other surgeons as high/very high 85% of the time, but nurses rated their collaboration with surgeons as high/very high only 48% of the time.28 Objective assessment of teamwork skill reveals differences between skill level of team members and can indicate opportunity for education and training.29The present scientific statement includes data regarding many teamwork skills but focuses on communication. Communication failures were the leading root cause of 65% of sentinel events reported by The Joint Commission between 2004 and 2012 and were a leading contributor to errors in medications, wrong-site procedures, and operative and postoperative events.30 In one cardiac surgery study, teamwork failures occurred frequently (5.4 per case with familiar teams and 15.4 per case with unfamiliar teams); communication issues were the primary cause of these teamwork failures (89%).21The American Heart Association commissioned this scientific statement to summarize the evidence regarding risks to patient safety and clarify interventions to reduce perioperative risks and human error in cardiac surgery. A comprehensive review of all potential risks to patient safety and tested interventions would be voluminous and could include wide-ranging topics such as surgical techniques (mammary arteries in CABG surgery), various cardiopulmonary bypass (CPB) strategies, or techniques to reduce infection or retained objects. We have chosen to focus primarily on those human, environmental, and cultural factors that affect teamwork, particularly how cardiac surgery teams communicate within the OR and with other unit teams. The statement is organized to describe current knowledge about communication within and between teams, the physical work environment and how it influences teamwork (space, equipment, and ergonomics), and the organizational culture (safety climate and quality improvement [QI]) of the cardiac OR.Our process was to focus on studies in the cardiac surgical environment regarding teamwork, but we did draw on other literature as needed to present critical concepts that were specifically lacking in the cardiac surgical literature. Although many cardiac surgery studies identify communication as a significant source of error, discussion of the concepts that underlie effective or defective communication are found primarily in the cognitive psychology literature, and we have included these references in the “Communication and Teamwork” section. Similarly, although our focus is on cardiac surgery, we have included pertinent data from other surgical disciplines. We have attempted to identify the references specific to cardiac surgery, but the reader is encouraged to consult individual references for further information. Because of our focus, we excluded many dynamic areas of research that we hope will be summarized in other scientific statements or similar reviews. Finally, the present scientific statement aims to identify major knowledge gaps and potential areas for further research.The present statement was coauthored by a writing committee composed of members of the American Heart Association’s Council on Cardiovascular Surgery and Anesthesia, as well as collaborating members of the following nonprofit organizations: the Society of Cardiovascular Anesthesiologists and its FOCUS (Flawless Operative Cardiovascular Unified Systems) initiative (Society of Cardiovascular Anesthesiologists Foundation), the Society of Thoracic Surgeons, the Association of periOperative Registered Nurses, the Human Factors and Ergonomics Society, and the American Society of Extracorporeal Technology. We hope that these data and recommendations will motivate further research to address the challenges of reducing human error and improving patient safety in the cardiac OR. Such research should be widely applicable to all ORs, as well as to interventional cardiology and electrophysiology procedural settings. In particular, we hope that the present scientific statement will encourage similar reviews of patient safety in cardiology catheterization and electrophysiology laboratories, as well as in other interventional settings such as hybrid ORs designed for percutaneous management of valvular lesions, percutaneous assist devices, or stenting of aortic aneurysms.Assessing Patient SafetyTo understand how to improve patient safety, we must understand how researchers have assessed nontechnical skills and their impact. To begin with, we need a common vocabulary; terms for nontechnical skills must be defined to promote reliable comparison of studies and discussion. Second, the effect of specific nontechnical skills on the reduction of human error or on patient safety must be quantified. Third, interventions to improve individual and team nontechnical skills must be designed and tested for efficacy. Fourth, the effect of improved nontechnical skill(s) on error reduction and, hopefully, ultimately on patient outcomes must be studied to demonstrate progress.31Technical skills can be measured objectively (eg, knots tied per minute), but nontechnical skills assessment requires observational and often seemingly subjective assessment by experts. Observational research, although new to many clinicians, has already identified the number, type, and severity of adverse events that occur in the OR.13 Many team and individual behaviors that are precursors of adverse events, as well as the behaviors associated with surgical excellence, have been identified.12,32 Observational research, however, has limitations: Valid results require trained observers, and not all trainees will become expert.13,32,33 In one study, only 32% of all recorded events were captured by both observers, although events that were captured by both were rated equivalently.34Teaching nontechnical skills is particularly challenging given the difficulty in assessing performance and providing feedback. Appropriate attention is paid to assessing the quality of technical skills, but nontechnical skills also require assessment for competency and to identify opportunities for education. As noted, observational assessment of nontechnical skills requires trained and experienced observers; to date, use of trained observers has primarily been applied in research, not in training or certification of clinical competence. During surgical simulations, a strong correlation is found between the expert’s assessment and the resident surgeon’s self-assessment of technical skills, but the same is not true for nontechnical skills.35 Senior surgeons’ self-assessments of technical skills highly correlate with that of an observer, but both junior and senior physician surgical trainees (resident and fellows), as well as surgical faculty, all rated themselves higher on their nontechnical skill level than did the expert observers.36Objective observers are also necessary to accurately assess disruptions, errors, communication skills, and the impact of these factors on outcome. Unlike trained observers, OR personnel judged disruptions to affect their colleagues more than themselves; surgeons perceived fewer team disruptions than did other OR team members.37 Nontechnical skills may need to be explicitly taught, because senior surgeons may or may not demonstrate better teamwork skills than those more junior, particularly in simulated crisis scenarios.35,36,38Teamwork MeasuresMany nontechnical skill measurement tools have been used (Table 1), but there is no single accepted instrument. Many are designed to measure nontechnical skills within a specific subteam (nurses, surgeons, anesthesiologists).49 Behavior rating systems must be valid (measure what they purport to measure), reliable (have good intraobserver and interobserver correlation), sensitive (detect differences in behaviors when they exist), and feasible (be easy to implement and be cost-effective).Table 1. Teamwork Assessment ToolsTools to Assess Teamwork Skills Within TeamDefinitionOTAS29,33,39–44Procedural task checklist centered on patient, equipment, and communications tasks ratings• Communication• Cooperation• Coordination• Shared leadership• Shared monitoringNOTECHS15,45–48Adapted from the aviation NOTECHS scale used in Europe• Cooperation/teamwork• Leadership/management• Situational awareness• Problem solving/decision making• ± Communication/interactionNOTECHS indicates Oxford Non-Technical Skills; and OTAS, Observational Teamwork Assessment for Surgery.Five measurement tools, each with its own strengths and weaknesses, have been designed for surgical team and subteam skills49: the Observational Teamwork Assessment for Surgery (OTAS),29,33,39–44,49 the Oxford Non-technical Skills (NOTECHS),15,45–48 the Non-Technical Skills in Surgery (NOTSS),50–52 the Anesthesia Non-Technical Skills (ANTS),53,54 and the Scrub Practitioners’ Non-technical Skills (SPLINTS).54a,54b Of these 5, NOTSS, ANTS, and SPLINT are designed to assess the individual nontechnical skills of surgeons, anesthesiologists, and scrub practitioners respectively, whereas OTAS and NOTECHS are specifically designed to assess team behaviors and skills.55 The OTAS includes a task checklist and a team behaviors assessment. It has good construct validity (ie, it actually measures what it appears to measure) and strong reliability between expert observers but weak reliability between expert and novice observers, which indicates that training of observers is required.41 The surgical NOTECHS was directly adapted from an aviation NOTECHS scale45 and measures skills in 4 domains (cooperation/teamwork, leadership/management, situational awareness/vigilance, and problem solving/decision making); some research teams have added communication/team skills.48 The NOTECHS has good reliability between expert and novice observers, has been used to show improvement in nontechnical skills after training, and has been used to show a significant inverse correlation between technical errors and nontechnical score.15,47 There is good correlation between the NOTECHS and OTAS scores when used in parallel47; both the OTAS and the modified NOTECHS have been found to be construct valid.47,56Surgical flow disruptions are correlated with adverse events in several studies but are defined differently in each study.20,37,57 Two tools have been proposed, namely, the Surgical Flow Disruption Tool (SFDT)57 and the Disruptions in Surgery Index (DiSI).37 Both have strong interrater reliability but have not been tested by other researchers.Outcome MeasuresPoor teamwork and poor nontechnical skills have been shown to adversely affect patient outcomes. Morbidity and mortality are associated with system failures,18 failures of coordination and communication,58 reported levels of communication,59 poor teamwork behaviors,12 unfamiliarity among cardiac surgical team members,21,60 and the number of minor events (disruptions) per case.22 Other studies have linked teamwork quality and behaviors to surrogates such as increased length of operation,23 number of technical errors in an operation,46 number of major errors,61 and stress levels of team members.62The ultimate desired outcome for any safety intervention is reduction in morbidity and mortality. Mortality in cardiac surgery is quite rare; thus, studies have to be very large to achieve adequate power to discern improvement in this measure. Neily and colleagues63 demonstrated a significant reduction in mortality with teamwork training but included 189 000 procedures at 108 Veterans Affairs hospitals to reveal a treatment effect.Because the safety climate of an institution correlates with communication errors, several studies have used changes in attitude toward safety or changes in team “emotional climate” as a surrogate of outcome to measure impact; these studies show training in nontechnical skills to be effective.64–70SummaryThe nontechnical skills of individuals and teams affect patient safety.OTAS and NOTECHS have proven construct validity and reliability. Training of observers who use these instruments is strongly recommended for accurate results.Proposed interventions to improve nontechnical skills should be tested for their efficacy in improving skill before being implemented.Communication and TeamworkCommunication Within TeamsCommunicationCommunication is “the exchange of information between a sender and a receiver.”71 In the OR, multiple individuals communicate simultaneously. Unfortunately, communication skill has been measured as the worst of 5 aspects of teamwork behavior in the OR29; deficits in patient safety are frequently a product of breakdowns or delays in communication.72,73 Miscommunication can occur when the sender inaccurately encodes a message (eg, by using vague or incomplete language), when the receiver decodes the sent information incorrectly, or when the information is given at the wrong time or received by the wrong individual.72 Communication failures are common72,74,75 and were the most common cause of problems in a host of studies.16,21–23,58,76 Miscommunication has been implicated as the root cause of error and adverse outcomes in both general and cardiac surgery.13,18,20–22,59,77–80 It is worse when teams are unfamiliar with each other.21Communication failures in the OR are equally related to timing, content (erroneous or missing data), purpose, and audience (directed to or received by the wrong person).72 Effective communication is open, adaptable, accurate, and concise, and it is more likely to occur in supportive and safe climates.71 Open communication fosters seamless coordinated activities81; adaptable communication shows that team members are aware of and adapt to others’ workloads, and concise communication promotes efficiency.82The connection between effective communication and improved team performance/outcome has been shown in cockpit crews,83 navy teams,84 and surgical teams.81 A recent meta-analysis provided definitive evidence of the criticality of information sharing for effective team performance.85 Systematic literature reviews indicate that communication is a key feature of successful teams86 and is essential for high-quality patient care.87 Good communication enables and facilitates other fundamental team processes and states, such as coordination, cooperation, cognition, coaching, and conflict resolution.88CooperationCooperation is a critical element of teamwork as well and captures the feelings, attitudes, and beliefs that drive behavior. Attitudinal components began to be studied after several tragic aviation accidents were attributed to teamwork failures. Recognizing that the lack of teamwork skills (previously considered “nonessential”) created severe consequences, the aviation industry developed and implemented CRM (ie, cockpit or crew resource management) programs to improve teamwork.89Some of the most studied attitudes include collective efficacy (a collective sense of competence),90,91 team orientation (a preference for and belief in teamwork),92,93 cohesion (a commitment to the team, its task, or both),94,95 and mutual trust (a shared belief that all will contribute to and protect the team).96,97 Although data from cardiac surgical teams are lacking, other studies of dynamic, complex environments have shown that adaptive performance is critical. Psychological safety, team empowerment (the feeling that team members have the authority to control their work and environment), and safety climate are critical.98–101 Empirical research has shown that when teams have high levels of collective efficacy, members exert more effort and take more strategic risks, which leads to better performance and higher satisfaction.102,103 The level of trust within a team affects how much members monitor each other, how committed team members are to the organization, and performance.104–111CoordinationCommunication also enables the behavioral skills necessary for optimal coordination and team performance.112 Coordination requires effective communication and is essential for successful team performance. It is, essentially, “orchestrating the sequence and timing of interdependent actions.”113 Coordination can be established explicitly with synchronization and awareness or implicitly with covert sequencing and communication.71Implicit coordination entails a shared understanding of the task, the environment, and individual roles and responsibilities within the team. It allows members to anticipate each other’s actions and needs without explicit communication, which enhances efficiency.114–116A mutual team understanding allows team members to provide assistance, information, and feedback,71 which allows the team to modify structures and processes without detriment in performance.117 The ability to foresee is imperative for effective teamwork and performance, especially in high-stress situations.71 Without coordinated behaviors, team members cannot ensure that actions and tasks are performed in synchrony without wasted effort.112For decades, research in the military and aviation has demonstrated that a team’s mutual understanding facilitates coordination and performance.114,115,120,121 Other studies show that teams with and without external pressures exhibit better performance when they have effective and efficient coordinating behaviors.122,123 Within medical teams, explicitly stating the team’s needs and goals or using team familiarity can build coordination skills and allow team members to develop clear expectations and understanding.71 Training in coordination and adaptation, providing information updates, and distributing responsibilities improves coordinating behaviors.115CognitionCognition is a shared understanding that arises from team interactions,124 which improves with repeated interactions.125 Cognition refers to the team’s collective knowledge about the roles, responsibilities, and capabilities of each member.82 The ability to anticipate team members’ needs enhances coordination and communication.126 A common understanding among team members enhances shared awareness of the surroundings, critical for problem solving in dynamic situations.117 Teams lacking in shared understanding have reduced coordination, which leads to poor performance.125,127Studies of team cognition in aviation and the military, as well as in laboratory studies with students, have shown that experienced teams and teams familiar with one another have better team cognition (eg, shared mental model) and better outcomes than inexperienced teams.21,60,128–131 Shared knowledge affects team behaviors and performance (reviewed by Mathieu et al132). Shared cognition improves team communication,133–136 learning and self-regulation,126,137–140 and coordination.125–127Within the medical domain, reflexivity training (ie, guided reflection of strategies used by the team),131,140 cross-training (ie, training on the tasks and duties of other members),126,141 and simulation-based team training142,143 have been discussed as effective interventions to improve team cognition. Improving the understanding shared among team members enhances coordination and performance.ConflictCommunication is pivotal for conflict resolution. Conflict, defined as discrepancies or incompatibilities among team members,144 can center on tasks, relationships, or processes.145,146 Conflict has been found to occur during the treatment of 50% to 75% of hospitalized patients,147,148 and this may be even greater in the OR, where ostensibly equal physician teams share in the care of a single patient.Conflict can have positive or negative implications.149,150 Task-based conflict improves group performance in the evaluation of nonroutine problems and in group decision making,144 but conflict also results in lower team member satisfaction, commitment,151 cohesion, and effectiveness.145 Unlike task-based conflict, relationship conflict has a profound negative effect on both performance and satisfaction and decreases members’ willingness to remain part of the group.151–153In the OR, conflicts are often poorly managed through avoidance, yielding, or competition, when collaboration and compromise would yield a better outcome.154 Collaboration and compromise are particularly difficult when there is status asymmetry, whereby one member has greater power or seniority, such as physicians with nurses or an attending physician with residents.147,155 Among OR personnel, 73% opined that disagreements in the OR are resolved appropriately, but 29% stated they would have trouble speaking up if they perceived a problem with patient care, and 41% felt unable to express disagreement.156 Behaviors that physicians perceive as decisive and necessary to achieve task goals may be viewed as harsh and demeaning by subordinates.157 Difficulty in seeing one’s own behavior as others see it is pervasive throughout OR and intensive care unit (ICU) teams.158,159 When watching videos of conflict scenarios, surgeons, anesthesiologists, and nurses rated the tension levels similarly but rated their own profession as having relatively less responsibility for creating or resolving the tension.160,161There are well-known approaches to conflict resolution in the literature (eg, the 7-step model, principle-based conflict resolution, advocacy/inquiry).144,146,162,163 Teaching conflict management to OR teams is important and possible.157,163 Effective techniques for conflict resolution are an important component of most team-training methods.63,164CoachingTeam coaching, defined as “direct interaction with a team intended to help members make coordinated and task-appropriate use of their collective resources in accomplishing the team’s work,”165 can be used to

Cell phone use in the U.S. has increased dramatically over the past decade and text messaging among adults is now mainstream. In professions such as perfusion, where clinical vigilance is essential to patient care, the potential distraction of cell phones may be especially problematic. However, the extent of this as an issue is currently unknown. Therefore, the purpose of this study was to (1) determine the frequency of cell phone use in the perfusion community, and (2) to identify concerns and opinions among perfusionists regarding cell phone use. In October 2010, a link to a 19-question survey (surveymonkey.com) was posted on the AmSECT (PerfList) and Perfusion.com (PerfMail) forums. There were 439 respondents. Demographic distribution is as follows; Chief Perfusionist (30.5%), Staff Perfusionist (62.0%), and Other (7.5%), with age ranges of 20-30 years (14.2%), 30-40 years (26.5%), 40-50 years (26.7%), 50-60 years (26.7%), >60 years (5.9%). The use of a cell phone during the performance of cardiopulmonary bypass (CPB) was reported by 55.6% of perfusionists. Sending text messages while performing CPB was acknowledged by 49.2%, with clear generational differences detected when cross-referenced with age groups. For smart phone features, perfusionists report having accessed e-mail (21%), used the internet (15.1%), or have checked/posted on social networking sites (3.1%) while performing CPB. Safety concerns were expressed by 78.3% who believe that cell phones can introduce a potentially significant safety risk to patients. Speaking on a cell phone and text messaging during CPB are regarded as "always an unsafe practice" by 42.3% and 51.7% of respondents, respectively. Personal distraction by cell phone use that negatively affected performance was admitted by 7.3%, whereas witnessing another perfusionist distracted with phone/text while on CPB was acknowledged by 33.7% of respondents. This survey suggests that the majority of perfusionists believe cell phones raise significant safety issues while operating the heart-lung machine. However, the majority also have used a cell phone while performing this activity. There are clear generational differences in opinions on the role and/or appropriateness of cell phones during bypass. There is a need to further study this issue and, perhaps, to establish consensus on the use of various communication modes within the perfusion community.

Novel COstatus system (Transonic Systems, Inc., NY), based on ultrasound dilution (UD), works off in situ arterial and central venous catheters in pediatric patients to measure cardiac output (CO). The purpose of the present study was to validate CO measurement by UD (COUD) with pulmonary artery (PA) thermodilution (COTD) in a prospective animal study. Ten anesthetized pigs (16–45 kg) were instrumented with pediatric PA, central venous, and peripheral artery catheters. For COUD measurements, normothermic saline (0.5–1.0 ml/kg body weight, up to a maximum of 30 ml) was injected into the venous limb of an arteriovenous loop that was connected between in situ catheters. For COTD measurements, 5–10 ml cold saline was injected into the PA catheter. Sixty-four averaged sets were obtained for comparison. COTD mean was 2.98 ± 1.21 l/min (range 1.33–6.29), and COUD mean was 2.68 ± 1.16 l/min (range 1.33–5.85). This study yielded a correlation r = 0.96, COUD = 0.91*(COTD) − 0.04 l/min; bias was 0.3 l/min with limits of agreement as −0.39 to 0.99 l/min; and the percentage error was 23.73% between the methods. CO measurements by UD agreed well with thermodilution measurements in the pediatric swine model.