The Real Cost of Perfusion and ECMO Instability: Why Hospitals Need a Workforce Hedge

Cancelled Cases, Burnout, Revenue Loss, and the Risk of Operating Without a Plan

By Matt Ehman, Business Development Manager at Epic Cardiovascular Services 

There is a moment every cardiovascular program wants to avoid. 

The patient is ready. So is the surgeon. The room is blocked. An ICU bed has been planned. The team has prepared for a high-acuity case that matters clinically, operationally, and financially. 

Then a staffing gap appears. 

Maybe a perfusionist is out unexpectedly. Maybe the call team is stretched too thin. Maybe an ECMO patient is running in the ICU while the OR schedule is already full. Maybe one more late case, one more activation, or one more weekend of being on call becomes the tipping point. 

From the outside, it may look like a simple staffing issue. 

It is not. 

Perfusion and ECMO instability are not just about whether a shift is covered. It is about whether the cardiovascular service line has enough resilience to absorb predictable and unpredictable stress without disrupting cases, overextending clinicians, limiting surgical capacity, or weakening long-term program growth. 

That is the real cost.

Perfusion Is a Small Workforce Attached to a Large Revenue Engine 

Perfusionists represent a relatively small clinical workforce, but they sit in the middle of some of the highest-acuity and highest-value areas of the hospital: cardiac surgery, ECMO, ventricular assist device support, transplant, complex vascular procedures, HIPEC, and other advanced cardiovascular services. 

That is what makes this issue so important. 

If a general staffing gap occurs in a large department, the hospital may have multiple ways to flex. In perfusion, the margin for error is much smaller. The work requires specific training, certification, judgment, and readiness. A hospital cannot simply float someone from another unit into the pump room. 

The same is true in ECMO. ELSO describes the ECMO team as multidisciplinary and identifies roles that may include physicians, surgeons, perfusionists, ECMO coordinators, ECMO specialists, ICU nurses, respiratory therapists, and other critical team members. ELSO also describes perfusionists as individuals with specialized training and certification in running the heart-lung machine in the operating room and ECMO at the bedside, and ECMO specialists as personnel with specialized training in operating the ECMO circuit and managing its effect on the patient.¹⁰ 

That means perfusion and ECMO coverage should not be viewed as a basic labor line item. It should be viewed as critical service line infrastructure. 

A hospital can have surgeons, anesthesia, nursing, equipment, OR time, and patient demand. Without stable perfusion and ECMO support, however, the program can quickly lose capacity, delay patient care, and limit its ability to grow.

The Visible Cost: Canceled Cases and Lost Capacity 

The most obvious cost of instability is the case that does not happen. 

A canceled or delayed cardiac case is not a small event. It can affect OR utilization, surgeon productivity, anesthesia time, nursing resources, ICU planning, patient experience, referral confidence, and contribution margin. 

The exact financial impact varies by hospital, procedure type, payer mix, and timing. That distinction matters. What is consistent, however, is that published surgical cancellation literature shows delays and cancellations carry measurable financial implications. A 2021 systematic review in the International Journal for Quality in Health Care noted that U.S. hospitals may lose approximately $1,430 to $1,700 per hour for same-day surgery disruption, depending on timing and duration. The same review found that hospital-related causes, including unavailable OR time, scheduling issues, lack of beds, and unavailable staff, were leading contributors to cancellation across the literature reviewed.⁹ 

This does not mean every cancellation is caused by perfusion. It does mean that when perfusion coverage becomes unstable, the operational and financial downside can be significant. 

A missed case does not simply disappear from the schedule. It leaves behind unused capacity, frustrated clinicians, delayed patient care, and financial waste that may never be fully recovered. For cardiovascular service lines focused on growth, even occasional disruptions can erode efficiency, physician confidence, and long-term program performance. 

The Hidden Cost: Burnout Before Turnover 

The more dangerous cost is often hidden for months. 

Perfusion instability usually does not start with a resignation. More often, it begins with call burden. PTO becomes harder to approve. One or two people quietly carry more than they should. Late cases, weekend pressure, emergency activations, and the feeling that there is no relief valve gradually become the norm. 

Then the cycle begins. 

Thin coverage leads to more calls. More call leads to fatigue. Fatigue leads to burnout. Burnout increases the risk of turnover. Turnover makes the staffing model even thinner. 

This is not theoretical. 

A U.S. perfusion workforce survey reported a 12.3% vacancy rate and a 14.7% turnover rate among perfusion groups.⁵ Perfusion-specific burnout research has also shown that job demand variables, including stress level, conflict, call duties, hours worked, and case load, were related to burnout among perfusionists, with stress and conflict showing the strongest associations in that study.⁶ A national study of perfusionists also examined the relationship between job satisfaction, burnout, and intention to leave their job or profession.⁷ 

Burnout Has a Financial Cost 

That matters because the cost of turnover is far greater than recruiting a replacement. It includes recruiting, onboarding, lost continuity, overtime, temporary coverage, team disruption, physician frustration, and the clinical risk created while the program is understaffed. 

Hospitals already understand this in nursing. The 2026 NSI National Health Care Retention & RN Staffing Report estimated the average cost of turnover for one bedside RN at $60,090. It is also estimated that the average hospital loses between $4.2 million and $6.2 million annually from RN turnover, and that each 1% change in RN turnover costs or saves the average hospital approximately $295,000 per year.¹ 

Perfusionists are not bedside RNs, and the economics are different. Even so, that RN turnover number provides a conservative benchmark. If replacing one bedside RN costs roughly $60,000, then the replacement risk for a highly specialized perfusionist tied directly to cardiac surgery and ECMO capacity should be evaluated with the same strategic discipline. 

There is also broader evidence that clinician burnout has measurable financial consequences. A peer-reviewed study in Annals of Internal Medicine estimated that physician burnout-related turnover and reduced clinical hours account for approximately $4.6 billion in annual costs in the United States.⁸ That study is physician-specific, not perfusion-specific, but it reinforces the larger point: burnout is not only a wellness issue. It is also an operational, workforce, and financial risk that can directly affect a cardiovascular program’s ability to maintain capacity, retain specialized talent, and support long-term growth. 

The Pandemic Was the Drawdown Example 

The pandemic gave health systems a painful lesson in what happens when labor risk is not mapped early enough. 

Hospitals did not simply face a staffing shortage. They faced a drawdown event. Demand rose. Internal teams became exhausted. Supply tightened. Contractor relationships became transactional. Labor was purchased in crisis, often at the worst time, under the worst conditions, and at the highest price. 

The American Hospital Association reported that hospital contract labor expenses surged 258% from 2019 to 2022. Contract labor full-time equivalents increased 139%, and the median wage rate paid to contract staffing firms rose 57%.² Kaufman Hall separately reported that hospital labor expenses increased by more than one-third from pre-pandemic levels and that contract labor as a percentage of total labor expense increased more than five times the pre-pandemic rate.¹¹ 

Even after the most intense pandemic labor pressures moderated, labor remained a major financial strain. In its 2024 Costs of Caring report, the AHA reported that hospital labor costs increased by more than $42.5 billion between 2021 and 2023, reaching $839 billion, or nearly 60% of the average hospital’s expenses. Hospitals also spent approximately $51.1 billion on contracted staff in 2023.³ 

That is what unmanaged labor risk looks like when the market turns. 

The takeaway is not that contract labor is inherently expensive. It is that reactive contract labor often is. When contractors are treated only as last-minute commodities, health systems lose leverage, predictability, and strategic control. 

Organizations that plan ahead can use specialized workforce partners differently. Rather than reacting to staffing crises, they build flexibility into their workforce strategy before disruptions affect patient care, clinician well-being, or service line performance.

The Workforce Portfolio Model 

A savvy investor would never evaluate risk from one dimension. 

They would not look only at the price of one asset. They would look at concentration risk, liquidity, volatility, downside exposure, insurance, replacement cost, and what happens if the market moves against them. 

Hospitals should look at perfusion and ECMO workforce planning the same way. 

The internal employed team is the core holding. The PRN bench is liquidity. Education and competency are risk reduction. Leadership development is retention. Data tracking is the dashboard. A specialized service partner acts as a hedge, providing additional resilience when demand changes unexpectedly. 

The mistake is evaluating a service provider only by the daily rate. That is like judging an insurance policy only by the premium while ignoring the loss it protects against. 

Hospital leaders should ask a broader question than simply, “What does coverage cost?” 

They should also ask, “What is the financial and operational impact if coverage fails?” 

That shift in perspective changes the conversation from staffing expenses to protecting surgical capacity, supporting clinicians, and preserving long-term program performance.

The Right Partner Protects the Internal Team 

This is the part that matters most. 

A service provider should not be positioned as a replacement for the hospital’s team. Instead, the right partner strengthens and supports the team already in place. 

That means helping reduce excessive call. It means creating room for PTO. It means stabilizing coverage during vacancies, resignations, illness, leave, and periods of program growth. That also means supporting ECMO education, simulation, and competency so teams can continue developing while maintaining reliable patient care. 

This is not just a feel-good statement. CDC research found that positive working conditions, including trust in management, supervisor support, enough time to complete work, and workplaces that support productivity, were associated with lower odds of burnout among health workers. CDC also reported that health worker burnout rose from 32% in 2018 to 46% in 2022, while turnover intention increased from 33% to 44% over the same period.⁴ 

That creates a circular ecosystem. 

When employees feel supported, they are less likely to burn out. As burnout decreases, turnover risk decreases. When turnover decreases, the hospital avoids replacement costs and operational instability. And when the program is stable, it can grow. That stability also gives clinicians greater confidence in the future of the program, making retention easier over time. 

That is the real value. 

The hospital is not just buying coverage. It is investing in a more stable workforce portfolio.

A Simple Pro Forma for the Risk Conversation 

Every hospital should use its own internal data. The model below is illustrative only and should not be treated as a guaranteed savings calculation. Its purpose is to help leaders organize the risk conversation in a disciplined way. 

Start with five categories: 

• Turnover exposure 

• Vacancy and temporary coverage exposure 

• Case disruption exposure 

• Burnout and overtime exposure 

• Emergency premium labor exposure 

A simplified model could look like this: 

Total Workforce Risk Exposure = Turnover Exposure + Vacancy Coverage Exposure + Case Disruption Exposure + Overtime/Burnout Exposure + Emergency Premium Labor Exposure 

Risk Category	Sample Conservative Estimate
Perfusion attrition exposure	$75,000
Vacancy / temporary coverage exposure	$75,000
Delayed or cancelled case exposure	$100,000
Overtime and call burden exposure	$75,000
Emergency premium labor exposure	$50,000
Estimated annual downside exposure	$375,000

Now compare that with a structured service partner investment. 

If a hospital invests $250,000 annually in a stabilization model, the partner does not need to “save” $250,000 in visible staffing costs alone. The investment only needs to reduce enough operational and financial risk to justify the cost. 

ROI = (Avoided Risk Cost − Partner Cost) / Partner Cost 

Using the sample above: 

• Avoided risk cost: $375,000  

• Partner cost: $250,000  

• ROI = ($375,000 − $250,000) / $250,000  

• ROI = 50%  

That is a simplified model, but it shows the point clearly. The value of a partner is not only measured in covered shifts. It is also measured in avoided disruptions, protected revenue, and greater operational stability. 

The same logic applies to break-even. 

A $250,000 annual workforce hedge may break even by helping prevent: 

• A small number of high-value case disruptions  

• One specialized clinician resignation  

• Several months of emergency premium coverage  

• Sustained overtime that pushes a team toward burnout  

• Loss of surgeon confidence or referral capture  

• Program slowdown during ECMO growth  

The exact numbers will vary by hospital. But the framework matters. It gives leaders a better way to evaluate risk than simply asking whether a per diem rate feels high. 

What Hospitals Should Measure 

If hospitals want to manage perfusion and ECMO risk more effectively, they need a better dashboard. 

At a minimum, they should track: 

• Perfusion vacancy rate  

• Turnover rate  

• Time to fill open roles  

• Call burden per clinician  

• Overtime hours  

• PTO denial or PTO compression  

• Delayed or canceled cases tied to coverage  

• ECMO activations that conflict with OR coverage  

• Emergency staffing use  

• Locum spend  

• Training and competency completion  

• Staff engagement and burnout indicators  

• Surgeon concerns related to coverage reliability  

These are not just HR metrics. They are operational and service line risk metrics. 

Retention is not just about compensation. It is also about creating a work environment where specialized clinicians can build sustainable careers while supporting consistent patient care.

From Commodity Vendor to Strategic Hedge 

Hospitals should still use contractors when needed. The difference is how those relationships are approached. 

A commoditized model asks, “Can you send someone to cover Tuesday?” 

A strategic partnership (hedge) asks: 

• What are our real coverage risks?  

• Where is our internal team overextended?  

• What level of external support protects our core team?  

• How do we reduce emergency labor dependence?  

• How do we support ECMO growth without burning people out?  

• How do we measure the ROI of workforce stability?  

That is a much better conversation. 

The right partner can help a hospital cover shifts, but the greatest value comes from helping strengthen the entire cardiovascular program. That may include core coverage support, PRN relief, surge capacity, ECMO education, competency support, program review, data tracking, and workforce planning. 

Partners with deep cardiovascular expertise can also provide guidance that reflects the realities of perfusion and ECMO programs, helping leaders make informed workforce decisions before staffing challenges affect patient care or program performance. 

In a high-risk area like perfusion and ECMO, stability is not a luxury. It is the foundation that allows the program to operate, grow, and deliver care safely.

What a Strategic Workforce Hedge Looks Like 

Throughout this article, the term workforce hedge has been intentional. 

In finance, a hedge is not an investment made because someone expects failure. It is a deliberate strategy designed to reduce downside risk, preserve stability, and protect long-term value when uncertainty inevitably occurs. 

Cardiovascular workforce planning deserves the same perspective. 

A strategic workforce partner should not exist simply to fill open shifts. Their value is realized long before a staffing crisis occurs. Like a financial hedge, the right partner helps reduce exposure to operational risk while allowing the hospital’s core assets – its employed clinicians, surgeons, and cardiovascular program – to perform at their highest level. 

A true workforce hedge helps protect against: 

• Unexpected vacancies and extended recruitment timelines 

• Burnout caused by excessive call burden and overtime 

• Canceled or delayed surgical cases due to coverage gaps 

• Emergency premium labor purchased during times of crisis 

• Disruptions that slow program growth or reduce referral confidence 

This shifts the conversation away from daily staffing rates and toward overall organizational resilience. 

When viewed through this lens, a strategic partnership is not simply another staffing expense. It becomes part of the hospital’s broader risk management strategy, providing flexibility when demand changes, preserving institutional knowledge, supporting clinician well-being, and helping maintain consistent surgical capacity. 

That is what a workforce hedge is designed to do. 

At Epic Cardiovascular Services, we believe the strongest partnerships are built around that philosophy. Our role is not to replace internal teams, but to strengthen them by providing specialized cardiovascular expertise, flexible clinical support, workforce planning, education, and program development that help hospitals remain stable through both expected and unexpected challenges. 

The goal is simple: protect the internal team, preserve the program’s capacity, and create a cardiovascular service line that is more resilient over the long term. 

A Better Way Forward 

Hospitals do not have to choose between investing in their internal team and partnering with an external workforce expert. 

The strongest cardiovascular programs recognize that these strategies are complementary, not competing. 

A dedicated internal team provides culture, continuity, institutional knowledge, and program leadership. A strategic workforce partner provides flexibility, specialized expertise, and additional capacity when circumstances change. Together, they create a more resilient cardiovascular service line. 

Ultimately, this is not a conversation about staffing. 

It is a conversation about risk. 

Programs that view perfusion and ECMO support solely as a labor expense will continue reacting to workforce disruptions as they occur. Programs that view workforce stability as strategic infrastructure are better positioned to retain specialized talent, protect surgical capacity, support clinician well-being, and sustain long-term growth. 

Every cardiovascular program will face workforce challenges. 

The difference is whether those challenges become operational crises or whether they were anticipated, planned for, and absorbed before patient care is affected. 

That is the difference between simply filling shifts and building a resilient cardiovascular program. 

Every cardiovascular program faces workforce challenges, but the strongest programs plan for them before they disrupt patient care. Connect with Epic Cardiovascular Services to learn how our specialized team can help you build a more resilient perfusion workforce through flexible staffing, workforce planning, and clinical expertise. 

About the Author 

References 

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