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 under the direct supervision of the supervising . 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 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 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): ______

______

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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: ______

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