Huntington Memorial Hospital
Delineation Of Privileges Perfusionist
Provider Name:
Privilege Requested Deferred Approved
Job Description: The Perfusionist is responsible to the chair fo the Department of Cardiothoracic Surgery under the direct supervision of the supervising physician. The Perfusionist is responsible for the surgical patient while under the auspices of his/her specialty. The responsibility encompasses the knowledgeable operation of various therapeutic and operational modalities with the application of the appropriate physiological principles of such modalities.
Qualifications: An appllicant must have graduated from an approved training program in perfusion technology and evidence of completion of entire ABCP (both written and oral) exam; this means that the perfusion candidate must be eligible to use either the title Perfusionist or Graduate Perfusionist as defined by the Perfusionist Titling Act (AB569) which became law under the Business and Professions Code (Chapter 5.67, Division 2) on January 1, 1993. This law also requires the perfusionist to maintain certification by the ABCP, or documentation proving that continuing education equivalent to that required by the ABCP has been achieved. Maintenance of current basic certification by the AHA or AHA approved equivalent.
1. Extracopeal circulation/cardioplumonary support. ______
2. Counterpulsation ______
3. Circulatory support/ventricular assistance ______
4. Extracorporeal membrane oxygenation (ECMO) ______
5. Blood conservation techniques/autotransfusion ______
6. Myocardial preservation ______
7. Anticoafulation and hemotalogic monitoring/analysis ______
8. Physiological monitoring/analysis ______
9. Blood gas and blood chemistry monitoring/analysis ______
10. Induction of hypothermia/hypothermia with reversal ______
11. Hemodilution ______
Page 1 Printed on Friday, October 12, 2012
Huntington Memorial Hospital
Delineation Of Privileges Perfusionist
Provider Name:
Privilege Requested Deferred Approved
12. Hemofiltration ______
13. Administration of medications, blood components, and anesthetic agents via the ______extracorporeal circuit
14. Documentation associated with described duties ______
15. Isolated limb/organ perfusion ______
16. Electrophysiologic analysis ______
17. Organ preservation ______
ACKNOWLEDGEMENT OF THE ALLIED HEALTH PROFESSIONAL:
I have requested only those privileges for which I am qualified to perform, based upon my education, training, current experience and demonstrated performance. I understand that in exercising my practice privielges granted, I am constrained by hospital and medical staff policies and rules, including those outlined in the Allied Health Professional Rules and Regulations.
Signature of AHP: ______Date: ______
Signature of Supervising Physician:______Date: ______
INTERDISCIPLINARY PRACTICE COMMITTEE RECOMMENDATION:
I have reviewed the requested practice privileges and supportive documentation for the above names applicant and recommend action on the privileges as noted above.
Applicant may perform practice privileges as indicated: ______YES ______NO
Exceptions/Limitations (Please Specify): ______
______
Page 2 Printed on Friday, October 12, 2012
Huntington Memorial Hospital
Delineation Of Privileges Perfusionist
Provider Name:
Privilege Requested Deferred Approved
APPROVALS
Interdisciplinary Practice Committee: ______Date: ______
Medical Executive Committee Date: ______
Board of Directors Date: ______
Page 3 Printed on Friday, October 12, 2012