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Establishing a successful autologous transfusion program.

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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Author:Yomtovian, Roslyn
Publication:Medical Laboratory Observer
Date:Jan 1, 1985
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