Establishing a successful autologous transfusion program Essay

Autologous blood transfusion is an idea whose time has come. The
number of institutions offering these programs increased 16-fold from
1970 to 1981, according to an American Association of Blood Banks (AABB)
survey. Our own 460-bed community hospital introduced such a program in
the spring of 1983 for those types of elective surgery where a blood
need is anticipated. Acceptance by clinicians and patients has grown
steadily since then.



Although autologous blood is indisputably safer than homologous blood, the concept has not yet gained widespread acceptance. One reason
for this relates to questions about cost-effectiveness. At our
institutio, we believe the two kinds of transfusion have comparable
direct costs. Autologous blood transfusion may even prove to be the
more economical alternative in the future as further tests are developed
to screen homologous blood.



When the AABB polled its institutional members nearly three years
ago, it found that 49 per cent or 861 out of the 1,774 responding
hospitals had at least one type of autologous transfusion program–primarily predeposit phlebotomy (blood drawn from the patient
before surgery, as in our hospital) or intraoperative salvage (blood
displaced during surgery and recycled back into the patient). Programs
were more prevalent among hospitals with over 400 beds than among
smaller hospitals.



Unfortunaely, the study did not address the volume of autologous
transfusions; some of the responding institutions might have only
transfused one patient with his or her own blood per year. The AABB
study also predated the AIDS epidemic. A follow-up study is in progress
and might indicate whether AIDS has spurred greater use of autologous
blood.


The best available information indicates that our hospital has the
largest predeposit autologous blood program in Minnesota. How we
analyzed the feasibility of an autologous blood transfusion program,
what we did to set it up, and our experience to date may be instructive
for other community hospitals contemplating a similar program.



A team of laboratory administrative, medical, and technical
personnel began by asking whether sufficient scientific knowledge
existed to justify establishment of the program. Many publications,
including the AABB Technical Manual, regard autologous blood as the
safest possible option. True, homologous blood transfusion carries low
known risk of clinically significant complications resulting from
serologic incompatibilities (to erythrocytes, leukocytes, and
platelets), disease transmission, and other immune and allergic
reactions. But with autologous transfusion, the risk is eliminated
entirely.



The next question was whether we had a large enough potential
patient base for an autologous blood transfusion program. In 1982,
approximately 50 per cent of our blood transfusions were administered to
patients undergoing elective surgery. Furthermore, a significant amount
of blood use in elective surgery was accounted for by major orthopedic
procedures–total hip and total knee replacements–and plastic
reconstructive or cosmetic surgery, including cosmetic surgery,
including cosmetic reduction mammoplasty. These are ideally suited to a
predeposit phlebotomy program.



Other hospitals, of course, might perform other types of major
elective surgical procedures shown to routinely require blood, and use
autologous blood in those cases. Doctors at Cedars Sinai Hospital in
Los Angeles have also demonstrated the safety of predeposit phlebotomy
for certain high-risk individuals, among them patients undergoing major
elective cardiovascular surgery, patients over 70 years old, and a small
group of pregnant women.



At our hospital, a previously developed maximum surgical blood
audit schedule enables us to predict fairly accurately how many units of
blood will be needed for each kind of elective procedure. It defines
types of elective surgery, such as gallbladder removal, not ordinarily
suited to a predeposit phlebotomy program since they are unlikely to
require transfusion. Such guidance minimizes waste of autologous
blood–units drawn but not used. This is of particular importance for
us. Because we are licensed as a transfusion service, not as a blood
bank, we cannot routinely process unused autologous units for homologous
transfusions.


If a hospital has not accumulated its own data, many available
references indicate how many units of blood should be crossmatched for
different elective procedures. The figures can be used as guidelines
for a predeposit phlebotomy program.



Administrators are interested primarily in whether the cost of this
service is competitive with that of the established homologous blood
transfusion program. We believe it is, although the direct and indirect
costs of such a service are complex, still evolving, and hard to fully
define. Staffing patterns and the calculation of overhead can vary
significantly from one institution to the next, leading to markedly
disparate results.



There are other factors we must consider in assessing the real cost
of autologous blood transfusion. For example, unlike 5 to 10 per cent
of homologous blood recipients, patients in an autologous program do not
have post-transfusion complications, nor do they require routine
crossmatching prior to surgery. There is no mandatory syphilis or
hepatitis testing, for no disease marker will disqualify an autologous
donor. When an AIDS test is available, that also will not be necessary
for autologous blood. All these tests add to homologous blood costs.



We do perform a type and screen as a preliminary measure in case
more blood is required during surgery than had been anticipated when the
autologous blood was drawn.



Nationally, the financial advantages of autologous blood
transfusion remain a controversial issue. Large regional blood
suppliers often believe that their programs, which are highly automated
and draw blood from thousands of donors, can be run in a far more
cost-effective manner than a single-donor porgram. Our laboratory
administrators concluded that the direct costs would be comparable,
however, particularly for transfusions of more than one unit of blood.



We already had adequate refrigerator storage space, and regardless
of the workload, two technologists are available to staff the
transfusion service at all times. We attempt to schedule autologous
donors when the transfusion service’s routine workload is at its
nadir.



As far as donor facilities go, all that’s really needed is a
donor chair in an area set apart from the main flow of laboratory
traffic. If space is at a premium, the lab might be able to schedule
donations elsewhere in the hospital–for example, the outpatient area.



Using the AABB Technical Manual as a guide, we developed a detailed
autologous blood transfusion procedure and incorporated it into the
blood bank’s procedure manual. The AABB manual covers such aspects
as donor criteria, donation and storage, consent, physician
responsibility, iron supplementation, and recruitment. It also goes
into serologic testing, record keeping, releasing unused blood, and
intraoperative blood salvage.



Before implementing the program, we launched an educational and
public relations campaign, directed at physicians and the public. A
four-page pamphlet, titled “Your Surgery, Your Blood,” was
distributed to physicians’ offices. Written from a patient’s
perspective, the pamphlet describes the program’s mechanics and
advantages. We also sent background information to local media and went
on radio and television to discuss what we planned to do.



Within the hospital, we advised the transfusion, medical staff, and
executive committees of our progress and prepared a comprehensive
educational program for the hospital staff. A number of in-services and
informal sessions were held.



It is also important to outline your autologous blood transfusion
program to health insurance providers implementation. We wanted to
insure prompt reimbursement by third-party payers, and, we wanted to
receive the endorsement of our homologous blood supplier. Our supplier
recognizes the benefits of autologous blood transfusion and has been
supportive.



Our program will mark its second anniversary in a few months. In
the beginning, most patients donated because they had seen the pamphlet
or heard about the program through the media and called it to their
doctors’ attention. Now doctors suggest it to their patients.



A statistical analysis of the first complete fiscal year–from July
1983 through June 1984–revealed that 72 patients deposited 139 units
for autologous blood transfusion. The 122 units ultimately transfused
represented 3 per cent of our total transfusion volume for this period.
Significantly, the number of units drawn has steadily increased to a
current collection level of about 30 units per month. Autologous blood
units are expected to account for 8 per cent of the total transfusion
volume for the 1984/85 fiscal year.



While most of the autologous donors during the last fiscal year
came from the immediate area, some traveled as far as 30 miles to give
blood. Donor ages ranged from 17 to 86 years, and 15 were at least 70
years old. Exactly half of the 72 participants were first-time donors.



Only three donors–one elderly woman and two teenagers–had a
reaction. The effects were minor, of the vasovagal type. In only one
case was it necessary to discontinue phlebotomy before collecting a unit
suitable for transfusion.



There hasn’t been a single recipient reaction. Autologous
blood is automatically compatible. Indeed, the only possibility of an
adverse reaction would be if a patient somehow received the wrong unit
of blood. As long as safeguards are in place to insure that donors get
back their own blood in the operating room, we don’t have to worry
about this potentially life-threatening problem.



The success of our autologous blood transfusion program has been
monitored in a number of ways. Clearly, the mounting use of this option
bespeaks its acceptance. Not only are donors almost universally pleased
with the service, but they also get positive feelings from involvement
in their own medical care. Physicians are also satisfied and continue
to recommend autologous donations. And lab personnel welcome the added
opportunity for direct patient contact and interaction.



Health insurance providers, perhaps the severest critics of any new
medical program, also seem to support our efforts. In the more than 20
months of autologous blood transfusion, none of our third-partypayers
has shown any reluctance to cover the cost of the procedure.



That’s probably due to our efforts to achieve maximum
utilization. During the study period, we discarded only 17 units of 139
collected. This underscores the importance of using surgical blood
audit data to determine how much predeposit blood will be needed.



We have a teo-tier fee system. Patients are charged a phlebotomy
fee for donations, but they don’t pay an administration fee unless
units are actually transfused.



At a conservative estimate, 25 per cent of all surgical admissions
qualify for autologous transfusion, and we expect to see most of these
patients in our program someday–just as we expect many more hospitals
to offer the autologous transfusion option.

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