Making home transfusions work.
Within a month last spring, three local home health care agencies called the blood bank in our 500-bed hospital to see if we could help them provide home transfusion therapy for patients with chronic anemia and other disorders. This was a clear message that the trend toward shifting as much care as possible out of acute-care hospitals would even encompass services like ours, which traditionally were not supposed to be tampered with.
The idea made sense. Traveling to the hospital for transfusions imposes a serious burden on some patients and may lead to medical complications. We firmly believed, however, that home transfusions would be best handled through a hospital, where blood banking is patient-oriented, rather than by a blood supplier, whose facilities are primarily donor-oriented. A blood center nursing staff is generally used to handling healthy donors. Most nurses there are not likely to have recent, up-to-date transfusion experience.
If our hospital blood bank took the lead, we could train home health agency nurses for home transfusions, and we could make sure the program met American Association of Blood Banks transfusion standards. Besides training the nurses, we would perform compatibility testing and provide the blood.
Creating the home transfusion program presented us with a challenge, though. The concept was so new that the literature offered little guidance on how to proceed.
After reading a reference book on home transfusion therapy released at the 1986 AABB meeting and one journal article,1,2 we began considering how to implement home transfusions as a routine service in our blood bank. We would start with the three agencies that initially sought our help, then eventually market the program to other home health agencies in the county.
Since one of the three agencies was based at the hospital, we had ready access to the nursing directors who could help us plan the program. I compiled a list of problems that had to be addressed, and at our first meeting, we converted the list into tasks. These tasks were assigned to the blood bank technical director and medical director, and the home health agency (Figure I).
As technical director of the blood bank, I was responsible for preparing procedures, forms, a cost analysis, and an in-service education program for agency nurses.
Our medical director outlined the types of patients who would qualify for the home transfusion program (Figure II). From that list, we were able to draft transfusion audit criteria--indicating acceptable hemoglobin levels, for example--and list the clinical and laboratory data necessary to review the chart for blood utilization according to recommendations of the Joint Commission on Accreditation of Healthcare Organizations.3
The medical director also adjusted our transfusion reaction protocol to the conditions of home transfusion and discussed the new program at medical staff meetings. He asked physicians to contact us if they had any patients who might require home transfusion service.
The home health agency had to establish billing procedures, investigate the third-party reimbursement available for this type of care, recruit qualified nurses, and market the plan to its physician clients.
I developed a 25-page manual detailing methods for wristbanding, specimen labeling and transport from the patient's home to the blood bank, documentation, transfusion reaction reporting, and transport of blood from our facility to the patient's home. It also covered the technical nuts and bolts of transfusions--how to prime the filter and attach the saline, how to set the drip rate, what gauge needles to use, and when to take the vital signs and how to document them.
Preparation of the manual required close study of AABB standards for blood transfusions.4 These standards must be met for a hospital to maintain AABB accreditation, but they must also be met for home transfusion, which can present problems.
For example, standard F1.000 requires a patient identification number on the request form, but home patients don't have wristbands. Substituting the patient's Social Security number and having the nurse affix a wristband when drawing the specimen for compatibility testing solved the identification problem.
Standard B7.200 specifies that the shipping container must maintain a blood temperature between 1 and 10 C. The answer here was to insert a small dial-face thermometer into a 250 ml bag of refrigerated saline and place the bag in the portable cooler used for blood transport. The agency nurse would document the temperature reading upon arrival at the patient's home and again upon departure to make sure the cooler maintained its 1 to 10 C temperature. Similarly specific procedures were written for each step to meet AABB standards.
To avoid complicating internal blood bank procedures, we decided to work with existing forms where possible, including a transfusion request form that had been in use before we computerized and a routine transfusion reaction investigation form. We did have to develop one new form to document the who, what, when, where, why, and how of every home transfusion. Shown in Figure III, this data sheet is comparable to an inpatient's chart.
Cost accounting indicated that the blood bank would only incur incremental direct costs for each home transfusion. There was no additional labor expense: Our current staff could absorb the additional types, screens, and cross-matches at the outset of the program without any need for overtime. Direct costs included test supplies, reagents, and the blood supplier's processing fee. Setting our charges with this in mind, we could make sure the home transfusion service paid its own way.
Who should bill whom and for what? The home health care agency determined that we needed two types of billing mechanisms--one for insured patients and self-payers, the other for Medicare patients. In the former category, the hospital bills the home health agency for performing the compatibility testing and supplying blood. The agency then bills the patient or the patient's insurance for both hospital and nursing services, and pays the hospital.
It gets more complicated for Medicare patients. The agency bills Medicare only for the nursing services because that's all the Federal Government allows. The hospital send bills to Medicare for the compatibility testing and to the patient for the blood.
True, it is somewhat risky to depend on patients for payment. We felt, however, that this sizable population of the patients most likely to need home transfusions could not be excluded from the program. Collection has not been a problem so far. Many Medicare patients have supplemental insurance policies.
After three months of planning, the program was set to begin on July 1. To help market it, our hospital's home health care agency set up a display in the physicians' lounge. The agency's staff passed out rolls and coffee along with patient criteria sheets and brochures. They asked each doctor whether he or she had a patient who might qualify. Many said yes, and a few wanted to start right away.
In-services for the home health care nurses were the last major step before we launched home transfusions. We required prior intravenous and blood transfusion experience, and 40 nurses who qualified on that score received training in two separate sessions. We brought them in for a tour of the blood bank, discussed our home transfusion policies and procedures, and gave them a copy of the home transfusion procedure manual, complete with filled-out examples of the various forms.
At the end of the session, each nurse demonstrated proper techniques in identifying patients, priming the administration set with saline, and so on. Then they received a certificate of attendance for the agency's files.
The home health care agencies received a supply box with wristbands, specimen tubes, patient information brochures, and multiple copies of forms. We also put together emergency drug kits for the nurses to use in the unlikely event of a transfusion reaction to washed red blood cells.
What about legal risks? With proper documentation and monitoring, hospital and home health agency liability for home transfusions should be no different from liability for component therapy performed in a hospital.
The critical elements necessary to minimize liability and pass accreditation inspections are 1) requiring a physician's written order for the blood transfusion; 2) obtaining written informed patient consent; 3) employing registered nurses trained in transfusion therapy; 4) strictly adhering to AABB standards and home care agency protocols; and 5) obtaining accurate and complete documentation of the transfusion and patient response for the clinical record.5
We meet these criteria in the following way:
The day before a scheduled transfusion, the nurse visits the patient's home, draws and labels a specimen for crossmatching, places a wristband on the patient, and fills out her part of the compatibility testing order forms. She then brings the specimen and the forms to the blood bank, which performs the crossmatch. The next morning, the nurse returns to the blood bank with her copy of the compatibility testing order form and signs out the blood, which is placed in a cooler that is equipped with a thermometer. The blood units also have special temperature stickers, which change color if the internal temperature of the blood bag rises above 10C. The nurse is therefore able to constantly monitor the blood's viability.
Back at the patient's home, she and the patient's transfusion partner --the program requires patients to provide a "responsible adult' for documentation purposes and to assist the nurse if necessary--check the paperwork and the blood unit against the patient's wristband. (They later also sign off as witnesses to the transfusion.)
The nurse then administers the transfusion. The maximum is two units of red blood cells; if a patient requires more than two, he or she probably belongs in the hospital. During the transfusion, the nurse monitors the patient's progress and clinical signs and catches up on paperwork. She remains with the patient for another half hour or so afterward.
The likelihood of a transfusion reaction is minimal with this type of program--indeed, we haven't had any. Careful screening eliminates much of the risk, and we have had to turn a few patients away from the home transfusion program. Using washed red blood cells further reduces the chance of a transfusion reaction.
If there is a reaction, the nurse is instructed to stop the transfusion immediately, start the saline, and call the patient's physician. One of the terms of the program is that the physician must be easily reachable by phone throughout the entire transfusion. The second adult's extra pair of hands becomes especially important in this type of situation.
The nurse would describe the patient's signs and symptoms to the physician, take his or her orders, and administer the necessary medication from the emergency kit. It is important to note that the doctor makes all clinical decisions, including whether or not to transport the patient to the hospital. Patient education is also important, since the reaction time can vary from immediately to as much as 10 days after transfusion. We tell patients what signs to watch for and what to do if the signs appear.
After five months, we have about a half-dozen patients receiving home transfusions every month or two. They welcome the convenience of receiving their transfusions in a familiar environment; the nurses perform the procedures with confidence; and the blood bank reports absolutely no problems concerning compliance with standards and protocols. On the financial side, the program covers expenses and even brings in some revenue to the hospital.
We could probably double or even triple our patient base with little effort, but we are content to let the program grow gradually. I recently sent out a mailing to the other home health care agencies in our county, and seven of these 20 agencies responded. Right now, I am in the process of meeting with the seven prospects and preparing a follow-up mailing to the others.
More and more hospitals are moving into this new market, and I think the blood bank should be taking the lead. This is just one more example of how much medical technology has diversified since DRGs.
1. Snyder, E.L., and Menitove, J.E., eds. "Home Transfusion Therapy.' Arlington, Va., American Association of Blood Banks, 1986.
2. Beck, M.L., and Grindon, A.J. Home transfusion therapy. Transfusion 26: 296-298, 1966.
3. Fromberg, R., ed. "Medical Staff Monitoring Functions: Blood Utilization Review.' Chicago, Joint Commission on Accreditation of Healthcare Organizations, 1987.
4. Holland, P.V., and Schmidt, P.J., eds. "Standards for Blood Banks and Transfusion Services,' 12th ed. Arlington, Va., AABB, 1987.
5. Miller, P.C. Home blood component therapy: An alternative. National Intravenous Therapy Assn. 9: 213-217, May/June 1986.
Table: Figure I Tasks required to set up home transfusion service
Table: Figure II Patient criteria for home transfusion
Table: Figure III A home transfusion data sheet
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|Author:||Bachert, Lucia Berte|
|Publication:||Medical Laboratory Observer|
|Date:||Dec 1, 1987|
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