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Everybody wins with this autologous donor program.

Everybody wins with this autologous donor program

Beset by DRGs, reduced staffing, cost containment, and increased competition, health care managers dream of elusive win-win decisions that will benefit all concerned. The success of a predeposit autologous transfusion program at our 339-bed community hospital is just such a dream come true.

We are part of a rising trend across the nation. An American Association of Blood Banks survey of institutional members found 745 autologous transfusion programs in 1985, a 35 per cent increase over the 550 tallied two years earlier.

One reason for the growth in autologous transfusion programs is concern about transfusion-associated AIDS. Though it is well out of proportion to actual risk, this concern has spurred public demand for a safe blood supply-- and it is widely accepted that autologous blood is the safest blood available.

Increased autologous transfusion activity in connection with elective surgery could not have come at a more opportune time for our hospital. For one thing, it has helped the transfusion service avert a reduction in staff due to downward trends in workload.

Beginning with the introduction of a surgical blood ordering schedule in 1979,1 I had seen the transfusion service's average productivity fall by more than 12 per cent despite a continual rise in the number of patients and blood components transfused annually. Figure I lists several voluntary changes that contributed to the drop in workload and productivity, mainly through reductions in testing. The surgical blood ordering schedule alone cut crossmatches by 59 per cent (last year's transfusion-to-crossmatch ratio was 76 per cent).

Although the hospital had made predeposit of autologous blood available on request for many years, not until 1982 did we have sufficient space, in an expanded laboratory facility, for autologous blood drawing on a routine basis.

During 1982, we set up policies and procedures for the autologous program, including standards for donor acceptance, and medical staff and laboratory responsibilities. This enabled us to establish a homologous donor program as well, although most of that supply still comes from the area blood bank and the Red Cross.

The autologous program was announced to surgeons in early 1983. One element of the announcement was a physician information sheet (Figure II) describing the basic donor/patient requirements and outlining how to place patients in the program.

We also displayed a leaflet for patients--"Is Surgery in Your Future?'--in public areas of the hospital and distributed it to hospital employees and physicians' offices. It answered such questions as: What are the risks of blood transfusion? What is an autologous transfusion program? How can I be an autologous donor /patient? Do all patients having surgery need blood? What happens to my blood if I don't need it during surgery?

All participants in the program are interviewed about their medical history. This enables us to identify patients for whom blood collection is not safe. Bacteremia or treatment in progress for it is the only absolute cause of rejection, but other possible causes include severe anemia or coronary artery disease, which are subject to evaluation by the transfusion service's medical director.

Since blood units that are eventually not needed for autologous transfusion could be used for other patients, the interview also seeks to determine whether the donor/patient meets Food and Drug Administration criteria for homologous blood donors. If, for example, we know that a donor has had hepatitis, then the blood cannot be used for homologous transfusion, and we can save ourselves the trouble of performing the required tests for hepatitis B surface antigen, hepatitis B core antibody, HIV antibody, RPR, ALT, and atypical antibodies.

Only 17 autologous units were collected in 1983, from 11 patients. Eleven of the units were transfused to seven of these patients, and two units were put into our general inventory when they were not needed by the donors.

The surgical staff's lukewarm attitude toward the new program disheartened us. However, physician support did surface in the hospital's transfusion and quality assurance committees, which had a few surgeon members. These committees began to bring the importance of autologous transfusions into focus.

With widening physician and public awareness, 1984 participation rose modestly to 33 patients, who deposited 63 units. Seventeen patients eventually received autologous transfusions of 33 units, and 13 units were put into general inventory.

Autologous transfusions became a hot topic in 1985. Nearly every hospital committee discussed them, the local newspaper carried a feature story about our program, and I received invitations to address professional and civic organizations on the subject. By June, patient participation surpassed the level for all of 1984, and we answered telephone inquiries from prospective autologous donors almost daily.

To cope with these repetitive inquiries, I wrote copy for a 2 1/2-minute audio tape that went into the hospital's Tel-Med library of more than 240 telephone health messages. Calls from inpatients and community residents rapidly made it one of the most frequently requested messages.

All that interest helped boost participation to 116 patients who deposited 176 units in 1985. Forty-two of the patients received autologous transfusions of 74 units, 61 units were released to the general inventory, and five units were sent to another hospital for autologous use.

Now the financial advantages of autologous transfusion became readily apparent. The program had $6,020 in material and labor expenses for 1985. In addition to the 140 units of red blood cells, 99 units of fresh frozen plasma were provided to patients--the cost for all components would have been $8,275 if we had obtained them from our blood suppliers. Thus we realized direct savings of $2,255.

Hospitals in our state are on all-payer Diagnosis Related Groups. The DRG rates are, of course, comprehensive predetermined payments for patient care. So when we save on blood supply expenditures, it's money in the bank for our institution.

Additional savings are realized through abbreviation of the standard compatibility test. Even though autologous donors are transfused with their own blood, we do an immediate spin cross-match on their blood to be absolutely sure of ABO compatibility and to make certain the right units are going to the right person.

We also save money, and patients benefit, through a reduction in adverse reactions, including fewer cases of disease transmission. Finally, in some of the more complex surgical procedures, autologous fresh frozen plasma has now replaced the more expensive use of albumin, and intraoperative blood recovery has further reduced the need for bank blood.

Participation in the program keeps growing. In 1986, 176 patients predeposited 300 units, and we saved $4,993 through autologous transfusions. The pace accelerated in the first five months of 1987, when 115 patients predeposited 177 units. Autologous transfusions now account for more than 40 per cent of all the blood transfused for elective surgery at our hospital.

Besides the obvious medical and financial advantages, the program offers a number of other benefits. For one thing, the transfusion service did not have to cut its staff after a long decline in pre-transfusion testing. The department's productivity index is currently at its highest since 1979.

The new donor activities--collecting blood, processing it, turning it into components--not only built up our workload but also gave employees new skills, making them more marketable. Two staff members who learned to draw blood for the autologous program are moonlighting as phlebotomists for a local blood collection agency.

The transfusion service staff stresses to all patients that while one's own blood is the safest, today's blood supply has probably never been safer. Some patients nevertheless have concerns about safety but are not good candidates for autologous transfusion. For them, we recently began offering directed donations.

In summing up 1985, administration cited the autologous program as one of the year's five significant accomplishments. Press coverage of the program, my speaking engagements, the Tel-Med audio tape, and word of mouth from patients all drew area attention to our hospital. As a result of this publicity, several patients elected to have surgery at our hospital instead of institutions closer to their homes.

For many of the program's participants, predepositing blood is the first contact they have with the hospital, and we strive to demonstrate efficient, professional, and caring service. When patients take part in their own care and have a positive experience in the hospital prior to admission for surgery, it contributes substantially to their sense of well-being.

1. Schoenleber, D.G. A blood ordering system that works for us. MLO 12(11):67-74, November 1980.

Table: Figure I Changes lowering transfusion service workload

Table: Figure II Autologous transfusion information for physicians
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Title Annotation:formal program to encourage autologous transfusions
Author:Schoenleber, David G.
Publication:Medical Laboratory Observer
Date:Aug 1, 1987
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