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An autologous transfusion program helped this small rural hospital.

An autologous transfusion program helped this small rural hospital

The advent of AIDS has rewritten blood transfusion policies and practices throughout the country. Concern about the safety of the blood supply has made many patients think twice about having surgery performed. This reluctance disturbed the physicians at our small rural facility. The medical staff kept asking the transfusion committee to "do something."

Autologous donation seemed a good solution. We asked the administrators of a large hospital 55 miles away whether their staff could process our autologous donors; they agreed. Even this step wasn't enough, however: Prospective donors balked at the long drive and worried that their blood might not make it back to our hospital in time for their operations. We clearly had to find a way to provide the service closer to home. Thirteen weeks and much planning later, we did just that.

General Hospital of Saranac Lake is not a typical rural hospital. True, we're small--just 91 beds--but we offer a full range of big-city services, including intrauterine insemination. We serve as a trauma triage center and have helicopter service.

The hospital employs 35 staff physicians and 15 consulting physicians. Our facility, located in the midst of New York's Adirondack Mountains, serves an area extending for 80 miles to the Saint Lawrence Seaway. Our status as a resort community and our proximity to Lake Placid, site of the 1980 Winter Olympics and home of a year-round sports facility, bring in patients from all over the world.

The laboratory employs 26.5 FETs. Two technologists cover blood bank and serology from 8 a.m. to 4:30 p.m. The three staff members who work the evening shift rotate throughout the laboratory. We provide a full range of tests and send out very little labwork. Since a licensed blood banker is available at all times, we can do a crossmatch at any time of the day or night.

* Reaching out. Several aspects of the project were in our favor. The blood bank was duly accredited and licensed; the staff was experienced and flexible. Brainstorming with the director of nursing set the wheels of interdepartmental cooperation in motion. The ambulatory surgery and physical therapy departments were offered as possible donor sites. The nursing department agreed to help monitor each donor after laboratorians had started each draw. Therefore, we would need no additional staff members to draw blood from the donors and no additional space for a donor room.

* Meeting requirements. The laboratory was licensed to draw blood in emergencies. The blood bank was AABB accredited and licensed by New York State. To find out what else might be required, I called the State Department of Health to review the current regulations for an autologous donor program. The health department merely asked to read and approve our standard operating procedure. The FDA's response, however, was to send us yet another license form to complete.

The paperwork turned out to be relatively painless. Within three weeks, we had our official license. In the meantime, the blood bank's charge technologist was busily devising donation and transfusion procedures. The hospital's transfusion committee subsequently approved our simple transfusion request and information form, which included contra-indications (anemia, bacteremia, and heart, kidney, or liver disease), special precautions (physician is to be present during phlebotomy of pregnant patient; if candidate is a child, must have good veins, understand procedure, and be cooperative), and important data (patient's temperature, pulse, blood pressure, volume taken, and any adverse reactions). The consent form was more complicated but received the necessary approvals as well.

The charge technologist then went to work on the patient history forms--a simplified version of the blood bank's standard donor medical history card. We also had to order blood packs and autologous donor tags and to train more laboratorians--and nurses from the ambulatory surgery department--in the art of phlebotomy.

* Problems. The hospital's massive renovation project posed our most formidable challenge. Space restrictions aside, we wanted to do the draws outside the lab at a site where a physician would be available in case of emergency. Although the ambulatory surgery unit graciously volunteered, they were in the midst of relocating and couldn't help for a while. The solution lay in networking with other departments to formulate a contingency plan. When the physical therapy department offered to lend us backup space, we agreed to schedule donors around their activities.

Projecting monthly donor participation was yet another challenge. The American Red Cross provided us with a list of other area hospitals that performed autologous transfusions. I reworked the figures to calculate corresponding participation according to the size of our hospital. My computations indicated that we could expect six to 10 donors per month--somewhat fewer than we had hoped. Even so, we had made a commitment to our community and wanted to get the program up and running as soon as possible.

* Strategic action. Group involvement was the key to a smooth operation. That meant working closely with the charge technologist in the blood bank, the head nurse in ambulatory surgery, and the transfusion director, a pathologist. I prepared our action plan, which mapped out the critical path (Figure I) and served as a time management guide and forecasting tool.

Each step in the critical path had to be completed before we could tackle the next chore. Having the goals on paper helped to motivate everyone to complete assignments on schedule and won points with hospital administrators, who love a good flowchart.

* Implementing the plan. With the procedures and consent forms approved, the program was ready to roll. The charge tech forwarded copies of all forms to the medical staff and surgical offices and to the directors of nursing and the ambulatory surgery unit as well.

The next order of business was deciding how much to charge for our new service. I reviewed the CPT (current pathology terminology) text to find the appropriate code numbers to maximize our reimbursement imbursement rate. Then I met with the hospital comptroller, who explained that we could also add a charge for nursing services.

Since transfusion charges are reimbursable, we felt it would be self-defeating to fail to recoup some of the cost of labor, supplies, and testing. While it's true that the patient provides the product, we believe our fee of $75 per unit is reasonable. We do not charge for tech time or for "borrowing" a hospital bed.

After only 13 weeks of preparation, we were ready to begin the program. One of our nurses, who was about to undergo surgery, inaugurated the service in the summer of 1988--the hospital's 75th anniversary year. We weathered the upheaval of a move to new quarters and an asbestos abatement program while managing to draw an average of five autologous donors per month.

* How it works. The monthly totals range from three to nine donors, each stockpiling approximately two units of blood--one per visit. We have a 30 per cent transfusion rate. Surplus units are autoclaved and incinerated.

Prospective donors travel as far as 100 miles to participate in our program. Most are older--at least 60 years of age--and a few have celebrated their 90th birthdays. While AIDS is by far the main motivator for autologous donation, the hysteria seems to be subsiding somewhat.

At first, with five donors per month, the program consistently failed to meet my initial projection of six to 10 monthly donors. Recently, howeveR, the number of autologous donors has risen to a steady eight per month.

The entire staff shares the credit for the program's smooth sailing and easy acceptance. Physicians on our medical staff spread the word among their patients. The nurses have been equally enthusiastic; some have volunteered for phlebotomy duty. I have produced an instructional videotape, scheduled in-service programs, and documented the nurses' phlebotomy prowess. The program now has three official nurse-phlebotomists to assist the technologists whenever needed.

Cooperation from our ambulatory surgery and physical therapy departments exemplifies our hospital's team spirit. These colleagues supported our efforts despite having had little to gain but our appreciation. By respecting their routine, too, we're careful not to wear out our welcome. For example, autologous donors are scheduled only in the afternoon, well after ambulatory surgery patients have been discharged for the day. If the unit is still full after lunch, the physical therapy department lends a hand by allowing our patients to donate there.

Any hospital--large or small, rural or urban--can offer an autologous donor program. Planning time is minimal. We spent much of our 13 weeks waiting for paperwork to clear bureaucratic channels. Startup costs are neglible. Our chief expense was to purchase a case of blood bags.

The key is to work together and keep everyone informed. Talking openly and often to the medical staff, nurses, anesthesiologists, volunteers, community representatives, and, of course, technologists is crucial. Considering their suggestions and formulating a universally acceptable approach can help make such a program a reality. We have found that showing respect for other departments' concerns encourages them to oblige. This simple strategy has made all the difference.

Marie McBride is laboratory manager at General Hospital of Saranac Lake in Saranac Lake, N.Y. She wishes to thank Judy LaDuc; Michealann Pandolph, R.N.; C.F. Varga, M.D.; and Eileen Wojcik, R.N., for their contributions and cooperation in the preparation of this article.
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Author:McBride, Marie
Publication:Medical Laboratory Observer
Date:Oct 1, 1990
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