Working Conditions for Perfusionists
I am retired now, but when I was a chief I knew that morale was a key element in managing the perfusion staff. If morale is poor, staffers will hesitate to go the extra mile that is sometimes needed to get the job done. If morale is high, there is no hesitation to participate in stressful situations when they are needed. Two important factors greatly affect the morale; the call schedule and working conditions. I will leave the call schedule for a later discussion. For this article I would like to focus on working conditions.
I have never seen a set of perfusion structure standards (not even mine) that incorporated a policy and procedure for dealing with fatigue. But the Joint Commission thinks fatigue among health care workers is important enough to publish a sentinel event alert on the subject (1). We have all worked until we were bone-deep tired; maybe even dosing off behind the pump. I know that I loved pumping cases, but I hated working when I was fatigued or sleepy. I did not feel that I was at my best in taking care of the patient. In particular, perfusionists diagnosed with sleep apnea should consider medical treatment because they can be a hazard even when their work schedule is not excessive (2). Even if you don’t dose off behind the pump, the stress of sleep apnea can impair cognitive ability, reflexes and reaction time. There are many people wandering around with undiagnosed sleep apnea and that probably includes a significant number of perfusionists.
Working when ill was another downer for me. If I told the surgeon I was not well enough to work and his case needed to be canceled (I was working alone then), his response was often to question how sick I really was. And I should put the wellbeing of the patient before my own (the old guilt strategy). Who was sicker, the child needing heart surgery or a perfusionist with the flu? That was at a time when cardiac surgery programs all over the USA were influenced by the philosophy that cardiac surgery teams should be able to work under the most extreme conditions (fatigue, illness, hunger, full bladder, PTSD or what have you) and still perform safely and to a high standard. But they confused safety with luck and a high standard with a marginally acceptable outcome.
For safety reasons, governmental regulations limit the work hours for certain professions such as airline pilots, train engineers, Over-The-Road truck drivers and even physicians in training (but not nurses or perfusionists). At some programs it is not unusual for perfusionists to work an average of 60+ hours per week because they are expected to keep up with the surgeons.
I once worked for two surgeons. One operated on Mondays and Wednesdays, the other on Tuesdays and Thursdays. They traded call every other Friday and weekends. Usually they would only do one scheduled CPB case each day. But sometimes they did two or even three cases consecutively. On such a day I found myself completing one day’s work just in time to start the next day with a new surgeon. I was just expected to keep up. Under those conditions I was sure that my performance was impaired by my fatigue. You could say that the surgeons had a long day (and night) as well except for the fact that they always had the next day off. As years passed I finally got help. But I know there are still perfusionists who work under similar conditions.
The AmSECT Guideline 15.1 is not much help. It states: “The Perfusionist should receive a minimum of 8 hours of rest period for every 16-hour consecutive work period.” I believe it should be the other way around; a minimum of 16 hours rest for every 8-hour consecutive work period. Under the AmSECT Guideline a perfusionist could be regularly scheduled for five daily 12 hour work periods each week (12 hours X 5 days/week = 60 regular hours/week plus ‘on call time’) and still be compliant with professional standards.
Many perfusionists are exempt employees. An exempt employee has no rights at all under the Fair Labor Standards Act (FLSA) rules for overtime limitation. Nothing in the FLSA prohibits an employer from requiring exempt employees to work a difficult schedule. Nor does the FLSA limit the amount of work time an employer may require or expect from any employee on any schedule. Mandatory overtime is not limited by the FLSA for exempt perfusionists. In fact, besides posing a greater risk to patients, healthcare professionals who routinely work more than 45 hours per week may be sacrificing their own health and wellbeing down the road in future decades (3). So assessing working conditions would not only assess the patient’s risk, but the perfusionist’s future wellbeing.
Assessing working conditions is not a “high risk case” verses a “low risk case” calculation based on the patient’s condition. Rather, this is a perfusionist’s self-assessment completed just before or just after all cases based on the working conditions and the risks those conditions pose to the patient. It is based on a model of pilot self-assessment suggested by the FAA that describes the conditions under which the pilot makes a flight (or a perfusionist pumps a case). Based on this assessment, the risk for the pilot to make each flight can be quantified. The higher the risk, the more likely an incident will occur. It is not fool proof, but the FAA thinks it has some value in preventing accidents because it alerts the pilot to conditions that might be ripe for an incident to occur. The FAA questionnaire includes conditions related to the pilot’s general health, fatigue, weather, available assistance, day or night time, etc. The scores are added and the overall scores fall into a range from low to high risk for each separate flight (4).
I propose doing the same thing for perfusionists. Individual perfusionists could use the self-assessment questionnaire below to determine their working conditions. If their average score over a month’s time is over 14, then they should probably seek help in whichever area the self-assessment identifies as being the problem. Is lack of sleep the problem? Is there a personal health issue? Is there psychological stress? Are there problems with case scheduling, vital information communication, back-up assistance, etc? There are numerous publications demonstrating the impact of working conditions of health care providers on patient outcomes (5). But none for perfusionists that I know. This questionnaire may answer that question.
I have prepared Excel score sheets that can be used to facilitate scoring. There is no charge or obligation. Just contact me at< firstname.lastname@example.org> and I will send them to you.
If the staff is willing, a chief perfusionist could use this same scoring system to identify the staff perfusionists who are stressed so that they can get help. That’s good for morale. Secondly it can quantitatively document the cumulative risk level under which all the perfusion staffers in a program are working. This can justify asking for additional help from the higher ups, if needed. Lastly, it is evidence that risk is being proactively assessed. Reducing risks proactively is much better than waiting for an incident to occur and then reacting to it. There may be other benefits that I have not thought of. There might also be some disadvantages that I have not thought of, as well. Nevertheless, this is how it would work. There would be a simple questionnaire to be completed just before or just after each case like the following:
Perfusionist Working Conditions Self-Assessment
- Fatigue due to lack of sleep:
Slept well last night = 1
Did not sleep well last night= 2
No sleep in last 24 hours = 3
- Physical wellbeing:
I feel well = 1
I am a bit off = 2
I am symptomatically ill (headache, upset stomach, back pain, etc.) = 3
- Psychological wellbeing:
Everything is going great = 1
I was late to work or I’m making errors or I’m feeling out of step = 2
I am feeling stressed out = 3
- Time of work:
Routine daytime/workday case = 1
After hours/weekend case = 2
Unscheduled case on a holiday = 3
- Patient familiarity:
Familiar with patient’s condition = 1
Unknown specifics about patient condition = 2
Emergent case of a known patient = 3
Emergent case with an unknown patient = 4
Routine setup; no rush to get case started = 1
Running behind, need to hurry = 2
Need to rush; emergent case = 3
- Available assistance:
Reliable back-up helper = 1
Back-up helper with unknown competency = 2
No back-up helper = 3
The chief perfusionist would collect the questionnaires and score each sheet.
7 = working under the best conditions
22 = working under the worst conditions
A Case Summary Assessment score is a good idea. It is not a part of the Working Conditions Self-assessment score. It is a separate score by itself; a summary of sorts. The Summary Question is very general so that the perfusionist can answer it without self-condemnation. For example;
Case Summary Assessment:
- Case went well.
- Case was average.
- Case was difficult.
This can then be correlated to the Working Conditions Self-assessment score.
Afterwards, the average scores from multiple questionnaires for each particular perfusionist could be calculated. When compared to other staff scores, this may tell the chief perfusionist which perfusionists are working under the most stress. (I realize that some people thrive on stressful situations and others hate to be stressed out. That’s a quandary for another time.)
The cumulative average scores from all the staff perfusionists could tell the chief perfusionist the level of stress that the entire group is working under. Example, if there were a lot of “3s” for #3 Psychological wellbeing or for #7 Available assistance, then risk reduction efforts could be focused on those areas. Or if a particular perfusionist had a lot of “2s” for #1 Fatigue due to lack of sleep, s/he might have undiagnosed sleep apnea which is not only a danger to the patient, but also very dangerous to the perfusionist. Scores averaging over 14 probably indicate that some interventional action needs to be taking before an incident occurs.
I have no idea what the working conditions are generally for perfusionists worldwide. I suspect that some working conditions are really bad and some are really good. But this is not about overworked perfusionists; this is about reducing risks to patients. Would you want yourself or a family member to be pumped by a perfusionist working under condition 22? Perhaps a group participation project (or coordinated student project) could be organized to determine what reasonable working conditions should be. For example, if 100 programs with 450 perfusionists all completed questionnaires on every case over a month’s time, the working conditions could be quantitatively calculated for the average perfusion program. This would establish a useful benchmark for evaluation.