On this episode of Scrubbing In, a podcast powered by SpecialtyCare, our guest is Al Stammers. Al Stammers is the vice president of clinical quality and outcomes research SpecialtyCare. In this conversation, Al and I talk about his start in research, his shift into the perfusion industry, and how the expansive research and data his team develops is making surgery safer.
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So, today I’m joined by Al Stammers, our vice president of clinical quality and outcomes research here at SpecialtyCare, and I wanted to talk to you today a little bit about your history throughout the perfusion sort of industry, ’cause you’re well versed in it, but also some of the changes that have happened over the years and sort of where you see it going in the future. If you don’t mind, I’d like to start out briefly just asking you how you got into perfusion as a job.
Al Stammers: Sure, Todd. That’s great. And thank you so much for having me today.
Todd Schlosser: Absolutely.
Al Stammers: I do appreciate it. After I graduated with my undergraduate degree, I stayed on and worked as a research technician at Cornell University and my primary function, believe it or not, was studying bovine growth hormone injection into dairy cows. It actually increased milk production by 30%.
Todd Schlosser: Oh, wow.
Al Stammers: But more importantly, I really enjoyed doing research and then I went on and worked at a Upstate Medical Center for a pediatric cardiac surgeon, and before I got into perfusion, we were working on how to better preserve children’s hearts undergoing cardiac surgery. We spent a couple of years doing work on cardioplegia or myocardia protection before I entered perfusion school. So, I’ve always been involved in research for a number of years before I became-
Todd Schlosser: Yeah, even before you-
Al Stammers: Exactly. Before I became a perfusionist.
Todd Schlosser: Absolutely.
Al Stammers: When I went to perfusion school, which was an Upstate Medical Center in Syracuse, I was doing research while I was in school. We wrote a number of papers during that time period, but then I went and continued in academics for about 15 years or so working at University of Michigan hospitals, working at the Medical University of South Carolina, then at the University of Nebraska Medical Center where we had a graduate level perfusion program, and with all the students that were working with us, these were graduate theses driven programs, we were requiring them to conduct research. So, we continued to do a fair amount of research and prospective, both clinical and in the laboratory.
So, that was my background how when I came to SpecialtyCare and the position I took, which is not only quality, which is clearly analytics, but dealing with research, how we can bridge knowledge gaps with what we know in cardiovascular perfusion, cardiac surgery, and cardiovascular anesthesia with what is developed. And of course, we use the scope, the SpecialtyCare operative procedural registry as the primary area where we glean that information and develop our hypothesis for research.
Todd Schlosser: I do know that because of the amount of data that we collect at SpecialtyCare, we produce a lot of research papers and a lot of them get recognized as like best papers and things of that nature. Is that something that, I’d imagine that you have quite a bit of your hands in?
Al Stammers: Yeah. That’s a good point. Yes, we do. We have all institutional review board approved studies, both in perfusion and in the neuro monitoring service lines. And you’re right, in the past two years, we have written and published over 15 papers in the perfusion service line, and these are all studies that involve the medical department, all part of the medical department. Our team consists of Eric Tesdale, Andy Sasco, Linda Mongero, Dr. Tarny [inaudible 00:03:59] is our director, and others. There’s quite a few that are in our realm.
But I oversee all of the perfusion research, so any research that is being conducted with the scope database, that’s what I oversee, and help with generating hypotheses and seeing the studies through to fruition.
Todd Schlosser: So, with your title of clinical quality, is that where that quality piece comes in? Is that what that title is in reference to?
Al Stammers: Yeah, that’s exactly right. For the quality, all of quality is based on data and since we have such a strong robust system for collecting data and analyzing it, we do leverage that to improve the knowledge in regards to what our associates are doing and providing exemplary care, but also to answer questions that are unknown. We do a lot of work on blood management. Basic perfusionists are fluid dynamic individuals. They deal with fluid dynamics for every procedure that they are performing. So, we use that information to assist us in hopefully reducing blood product utilization, which is both expensive, costly, and does lead to increased complications when patients do receive it. So, that’s one of the areas that we focus intently on.
Todd Schlosser: I was reading about how transfusions can be unwarranted or just very expensive for hospitals, and that’s something that we sort of can assist with. Can you speak to that at all, or how that … how they can be deemed unwarranted?
Al Stammers: Yeah. That’s a great question. The basic way to think about this is we have circulating counts of blood elements within our body. The most obvious ones are red blood cells. Everybody who’s cut themselves understands that you want to keep that blood inside your vascular system and not let it get on the outside. Cardiac surgery is one of the main operative procedures that use a tremendous amount of blood products, and that’s for a number of reasons. Not only is the surgery very invasive by itself, but most of the people who come to surgery are on some blood altering medications. Guys like me who are taking an aspirin a day and people who are taking more potent type of medications to reduce platelet function, and also anemia. What happens with heart disease and congestive heart failure is individuals no longer can generate the amount of red blood cells or platelets, or other elements in blood, say blood proteins to allow them to coagulate normally and to maintain adequate red blood cell concentrations.
So, when you combine all those factors together, we’re at a very strong likelihood of receiving a red blood cell or other transfusion during cardiac surgery. In fact, 50% of all open heart procedures that are performed nationally will receive one or more units of blood and dependent upon how low your blood counts are, you can receive multiple units. And we all know that the more blood you receive, the higher the likelihood, it’s basically exponential, the more blood you receive, the more likely that you will develop a outcome that is associated with the red blood cells. Not the reason for receiving a red blood cell, but getting the blood itself.
So, getting back to your second part of your question in regards to cost, when … these are extremely costly units of blood to administer to patients, just because it takes a tremendous concerted effort to get this organ, basically blood is an organ, to get it and to maintain it, whether it’s American Red Cross or other blood facilities. And then when you administer the blood, there’s a tremendous amount of cost associated with laboratory analyses that are assessing what type of unit should be given and your compatibility. So, it’s not unusual to have costs for one unit of red blood cell, not including outcomes that are associated receiving that, but just getting the blood to a patient can cost a hospital anywhere from $1500 to $2000 to administer that.
Todd Schlosser: Per unit?
Al Stammers: Per unit of red blood cells, exactly.
Todd Schlosser: Wow.
Al Stammers: So, it’s very expensive. It’s a limited resource. We all listen to the radio and hear, “Please-”
Todd Schlosser: I get calls from the Red Cross every three months, yeah. They know my number.
Al Stammers: So, we’re always being asked to go ahead and donate blood. And there’s always critical shortages. So, not only can it negatively influence a patient if it’s done inappropriately … An example of an inappropriate transfusion would be somebody who has no hemodynamic signals that they are requiring a unit of blood, but say historically the surgeon or anesthesiologist, or even perfusionist who’s in charge of administering the blood says, “I really feel that we should be at some level without any demonstrable signals being sent to that individual from the patient that they should receive blood.”
Obviously a bleeding patient should be transfused, especially if it’s a critical factor, such as coagulation factors or platelets. But if someone has an hematocrit level, the national average for all of our data is 25%. So, if somebody is above 25%, 26%, there’s really no reason to transfuse that individual without signals that they are suffering from either anemia or hemodynamic collapse. And we know that a fair number of patients are transfused up to 30% while being in that mid 20 range would be more than adequate.
Todd Schlosser: Clearly. I only ask it this way because it’s rare that I get to talk to somebody who has worked both in the ORs as a perfusionist but also on the collegiate side, and also the research side, which you started out in.
Al Stammers: Correct.
Todd Schlosser: So, what I wanted to ask is if you could go back and tell the younger version of yourself as you were entering perfusion some words of wisdom, what would those words of wisdom be to the young Al Stammers?
Al Stammers: Yeah. That’s another very good point.
Todd Schlosser: No necessarily from the old Al Stammers.
Al Stammers: Well, it could be.
Todd Schlosser: But just the Al Stammers you are now.
Al Stammers: Having children, we do fall into that, “Let me give you my advice whether you want it or not.” Well, first of all, it’s an extremely exciting time to get into the field. This is really a great opportunity. When many of us got in the field decades ago, it was just when open heart surgery was really taking off in the ’70s and early ’80s, and a lot of the operations we were doing were on relatively, by today’s standard, healthy individuals. 50 year old men coming in with coronary disease. There was a lot of smoking, a lot of obesity, a lot of poor lifestyle changes. Our lifestyle choices that people were making that ended up increasing their risk for heart disease, nowadays, ti’s very rare to find somebody who’s smoking or living off of a high lipid diet, or a hypertensive. There’s so many medications that we have to control high blood pressure and diabetes is something that can be controlled through a number of steps such as diet, exercise, and staying away from high sugar foods.
So anyway, years ago when we started, patients were relatively healthy. Today the patient population we have is 15 years older. We don’t have the 50 and early 60 year old men coming. A lot of times, people show up for their heart surgery in their seventh or eighth decade of life. And not only are they much older, but they have a higher degree of comorbidities, and the more risk factors, the more comorbid conditions that they have, the more likely that they’re going to have a bad outcome with their surgery. We risk stratify our patients and that tells us what the risk of them having a bad event would be, or an event that was above and beyond the surgery itself.
So, that high degree of comorbidic conditions changes how individuals who are entering the field now are gonna be treating their patients. They have to be smarter than we were 20 and 30 years ago. They have to be more attuned to this advanced population. They have to be more able to interpret the data, the publications, the information that’s out there so that they can better fine tune how they would intervene on their patient’s behalf, and that’s something that’s very challenging. And on top of that, with the large shortage that we have of perfusionists, the perfusionists are being asked to do more. And so they’re required to be more knowledgeable, to be more in tune of what the recent data in publications are, and they’re required to do that by working even longer hours today than they have.
Luckily, with the shortage comes increased remuneration. The salaries for perfusionists are up over 20% in the last three years to begin with, so it’s not that people are necessarily being abused without some … not retribution, but without some-
Todd Schlosser: Compensation.
Al Stammers: Compensation, thank you. Without some compensation. So, that’s one good thing. That’s not the only reason that people should enter the field, is compensation. If you do, you change very quickly, because you become frustrated. But it’s exciting what can be done not only with treating elderly patients, but also newborns. 8.8% of all children who are born today will have some sort of congenital heart defect, so there’s over 150 hospitals that perform pediatric cardiac surgery. That’s an exciting time to get in and help children.
The use of extra corporal membrane oxygenation long term bypass has exploded due to the recent findings that it actually can help patients, specifically adults with disease processes such as ARDS or respiratory distress syndrome. So, it’s just a wonderful time to get in the field, to really find that you’re helping individuals and at the same time, we’re just on the precipice of all this new information knowledge coming out that is just gonna change how perfusion is being done.
Todd Schlosser: You mentioned a few things and I want to touch on a few things that you mentioned, the first of which being the shortage of perfusionists. Has that always been the case? Ever since you entered the field, has there always been a shortage of perfusionists, not enough to meet demand?
Al Stammers: No.
Todd Schlosser: Or is that relatively recent?
Al Stammers: That’s relatively recent. It all began in the last four or five years, and primarily-
Todd Schlosser: Really [crosstalk 00:14:27]?
Al Stammers: … why it occurred was once the CMS and other Health and Human Services and good research studies had shown that ECMO could be a good benefit to a larger group of patients, that type of procedure that is now done routinely in many hospitals tax perfusionists, so that they were the ones who were doing this extra corporeal type of procedure and they were the knowledgeable ones in hospitals for the most part. So, when that exploded, starting in 2009 and 2010, mainly due to viruses such as H1N1, that caused an increased demand.
It’s not that open heart surgery numbers are going up. In fact, they’re not. It’s been relatively flat and declining over the last decade and mainly what we discussed earlier with risk factor reduction. So, it’s not that there’s a great need for perfusionists to do more open heart procedures that were there when I got in, but it’s these other ancillary type of procedures that require perfusionists such as ECMO, ventricular resist device insertion, even blood management such as auto transfusion and the use of platelet rich plasma as a extensive healing process that accelerates individuals who are undergoing orthopedic procedures or skin lesions.
So, there’s just a great diversity in procedures that perfusionists are performing right now that are not focused primarily on cardiac surgery.
Todd Schlosser: As industries grow, like perfusion has grown because of these factors that you’ve just mentioned, normally so do the collegiate institutions to train those new perfusionists or whatever that industry is. Have the schools kept pace with that? Are there now more schools than there were when you were coming up in the perfusionist field?
Al Stammers: Yeah, that’s another very good point. In 1995, we peaked with the highest level of education programs, perfusion schools in our history. We peaked at 35. 10 years before that, we had 15. Right now, there are 16 accredited perfusion education programs.
Todd Schlosser: So, it’s gone down?
Al Stammers: We’ve gone down, we’ve lost, exactly.
Todd Schlosser: From 35 to 16 in 10 years?
Al Stammers: Exactly. It’s declined. But the programs that are in existence have all doubled or tripled their enrollment.
Todd Schlosser: To keep it-
Al Stammers: So, programs that when I was the director at the University of Nebraska, we took four students per year and that was 10 years, 15 years ago. Now they’re taking 20 in that one institution, or upwards of 20. Some of the schools are at 40 while just a few years ago, they might’ve only been taking 10 or 15. So, it’s not just the decline in schools. It’s how the schools that are existing have changed their enrollment to meet the demand of perfusionists.
Todd Schlosser: So, coming from your background, which is quite varied, but you do have a background in the collegiate space, I’d imagine having a class size of four and a class size of forty makes a very big difference into how well that information is received. So, are we seeing a less qualified perfusionist coming out of school now? Or is it … ‘Cause I know that we have at SpecialtyCare our own training programs to, once you graduate, we also assist getting you OR ready. And I know our training and development side really does a great job with that and we’re very proud of those results, but is that something that we’re having to do because of those bigger class sizes?
Al Stammers: That’s a great observation, Todd. All education programs that are accredited are accredited through the accreditation committee on perfusion education, which is part of what’s called CHAP, and that’s basically charged with assuring that all programs are at least providing a minimal educational experience for perfusionists. But with the shortage, and with accepting more individuals into the programs, the criteria for these new students coming in may or may not be as high as it was when we entered say 20 or 30 years ago. When I took four students, or when I graduated, we had four students in my class, but we had 150 applicants. Today you may have 30 students in a class and you still may have 100 or 150 applicants.
So, the quality, it would be interesting to see by asking program directors if they feel that the quality has changed. I think a lot of it, though, is so dependent upon the individual. How do you assess whether or not somebody is gonna go out and make a good perfusionist? Most of it is just self driven, as in basically any career. Having a work ethic that, as we just spoke about, days are no longer six or seven or eight hours and you’re home. Days could easily be 10, 12 hours in the operating room, and then perhaps even an evening shift performing ECMO. So, to instill the motivation in an individual to go ahead and excel in that very challenging environment is difficult.
And that’s why I’m sure you’re well aware the burnout rate for perfusionists, and surgeons, and nurses is extremely high, because people enter this and it wasn’t quite what they expected it to be, and although the money tends to be good, lifestyle is affected so much that people just can’t continue on in that rate.
Todd Schlosser: And quality of life is very important to really any industry you go into. That’s one of the big concerns. Pay has to be where it needs to be, but also quality of life has to be where it needs to be or you just really have to love what you’re doing.
Al Stammers: True.
Todd Schlosser: I’ve talked to a lot of perfusion, in fact we go to every new hire that we have here and we talk to perfusionist and IONM people who are just out of school and maybe taking our training programs, and they’re always very excited and it’s clear that they want to be doing what they’re doing, that’s fun to see. We also see some people who have been doing it for 11 years who have just moved and started working for SpecialtyCare who come to our new hire and they talk about how they love it and stuff, too.
Al Stammers: You’re exactly right. Not to get off of our stream of questions here, but the nice thing about SpecialtyCare, we have 500 perfusionists who work with us. And that’s, if you’ve met one perfusionist, you’ve met one perfusionist. Everybody is so unique and different.
Todd Schlosser: Absolutely.
Al Stammers: But when you have that group, that’s the largest group of perfusionists anywhere in the world working for a single organization, you tend to have a greater resource space. Right now we’re talking about knowledge and quality, and just academics, but from the standpoint of what we can provide as an organization, as an outsource provider, as a company of perfusionists, nobody can do what we do because of the resources that we have at our fingertips. So, perfusionists who do come on board who are experiencing quality of life issues or working extremely long hours, our leadership in the field who are overseeing operations, they’re very quick to intercede and make sure that our individuals are taken care of.
They know if we don’t adhere to what the requirements are for a good quality of life, we’re gonna lose people. So, they’re very quick to respond from an operations perspective to relieve people who are working long hours or extremely, in difficult situations.
Todd Schlosser: That actually ties into another question that I had, and that was, and you touched on it actually, that we are the largest employer of perfusionists sort of anywhere, and I’d imagine the quality of life accounts for that, but what else do you think SpecialtyCare does that draws in perfusionists? I mean, we have to have built up the largest workforce for some reason, so I was wondering what those reasons might be.
Al Stammers: Yeah. That’s a good observation. One nice thing about our company, there’s a lot, but we’re in over 200 hospitals throughout the United States and growing. So, if an individual … Like I grew up in New York, just outside of New York City, yet I worked in Omaha, Nebraska, in Michigan, and South Carolina. So, I gave my family an opportunity to go perhaps and see places of the country that they wouldn’t necessarily see. As a SpecialtyCare perfusion associate, you have that opportunity to go to a large number of hospitals. If one was not what you expected, say working in the northeast, you have the ability to go say south, or the south area you didn’t like, head west. We’re all over the country.
I think we’re in 43 states totally as an organization, so there’s just a tremendous amount of opportunity to travel, to go to these different facilities and work, but importantly, we also have advancement. Most profusion groups have very little opportunity for growth, so if you’re in a hospital say doing 300 hearts, there may be three perfusionists. There’s usually a chief and two staff perfusionists and it’s not until that chief retires or leaves does that spot open up for advancement. SpecialtyCare, we have multiple levels.
So, you start out fresh out of school as a perfusionist one and you can go up through a perfusionist four. Then you can become a chief perfusionist in area clinical management, a director of operations, or look at what I’m doing. I’m a perfusionist. You could go into quality and research. You could deal with aspects of what we call a swat team, a number of … We have 15 individuals who all they do are they’re our first line for going to problem areas, big account or even a small account that got very busy. We send this group of very talented individuals out and … First of all, they’re very knowledgeable and they’re able to go into any work environment and take over on a moment’s notice.
So there’s a lot of opportunity that way, while if you’re working for either a hospital or a small perfusion company, you don’t have that. The last thing is the resources I mentioned earlier, our policies and procedures are very, very well designed and based upon the best level of evidence. A number of our staff serve on guideline writing committees. I serve as a member of the FDA medical device board, so we-
Todd Schlosser: For the Food and Drug Administration?
Al Stammers: Yes.
Todd Schlosser: Oh, okay.
Al Stammers: So, we’re evaluation what the new devices and techniques and technologies that are coming out. And as I mentioned, a number of our associates serve in professional societies as leadership roles, as presidents of the societies, and so we have that. Reviewers on journals, I’m a past editor of the Journal of Extra Corporeal Technology, so we’re very familiar with what goes into not only writing a paper, but all of the important aspects of scientific methodology that should be followed. And as I mentioned earlier, we have Dr. Eric Tesdale who is our senior bio statistician who keeps us all on the straight and narrow, because what we may think is an opportunity to do data analytics that we feel would support a particular hypothesis, Eric is so regimented and structured in what analytical assessment should be from a statistical perspective that he directs us to make sure that our interpretations are correct.
Todd Schlosser: Awesome. I probably should have asked this earlier, but is it okay if I call you Al? No to quote Paul Simon.
Al Stammers: Oh, sure.
Todd Schlosser: Probably should have asked that earlier.
Al Stammers: You know, being an Al, that’s the first time anybody’s ever said that.
Todd Schlosser: There’s no way that’s possible.
Al Stammers: That is. That’s the first time, absolutely. That’s great.
Todd Schlosser: You need better friends. Well, I really do appreciate you coming in and joining us on the podcast, and hopefully we can have you again and discuss more issues with you.
Al Stammers: Be wonderful, Todd.
Todd Schlosser: Thank you so much.
Al Stammers: Thank you so much. I appreciate the opportunity.
Todd Schlosser: Thanks for listening to Scrubbing In. Please take a second to give us a rating on your podcast app and subscribe so you won’t miss out on what we have coming up. See you next time.