Autologous blood transfusion is an idea whose time has come. Thenumber of institutions offering these programs increased 16-fold from1970 to 1981, according to an American Association of Blood Banks (AABB)survey. Our own 460-bed community hospital introduced such a program inthe spring of 1983 for those types of elective surgery where a bloodneed is anticipated. Acceptance by clinicians and patients has grownsteadily since then. Although autologous blood is indisputably safer than homologous blood, the concept has not yet gained widespread acceptance. One reasonfor this relates to questions about cost-effectiveness. At ourinstitutio, we believe the two kinds of transfusion have comparabledirect costs.
Autologous blood transfusion may even prove to be themore economical alternative in the future as further tests are developedto screen homologous blood. When the AABB polled its institutional members nearly three yearsago, it found that 49 per cent or 861 out of the 1,774 respondinghospitals had at least one type of autologous transfusion program–primarily predeposit phlebotomy (blood drawn from the patientbefore surgery, as in our hospital) or intraoperative salvage (blooddisplaced during surgery and recycled back into the patient). Programswere more prevalent among hospitals with over 400 beds than amongsmaller hospitals.
Unfortunaely, the study did not address the volume of autologoustransfusions; some of the responding institutions might have onlytransfused one patient with his or her own blood per year. The AABBstudy also predated the AIDS epidemic. A follow-up study is in progressand might indicate whether AIDS has spurred greater use of autologousblood. The best available information indicates that our hospital has thelargest predeposit autologous blood program in Minnesota. How weanalyzed the feasibility of an autologous blood transfusion program,what we did to set it up, and our experience to date may be instructivefor other community hospitals contemplating a similar program.
A team of laboratory administrative, medical, and technicalpersonnel began by asking whether sufficient scientific knowledgeexisted to justify establishment of the program. Many publications,including the AABB Technical Manual, regard autologous blood as thesafest possible option. True, homologous blood transfusion carries lowknown risk of clinically significant complications resulting fromserologic incompatibilities (to erythrocytes, leukocytes, andplatelets), disease transmission, and other immune and allergicreactions.
But with autologous transfusion, the risk is eliminatedentirely. The next question was whether we had a large enough potentialpatient base for an autologous blood transfusion program. In 1982,approximately 50 per cent of our blood transfusions were administered topatients undergoing elective surgery. Furthermore, a significant amountof blood use in elective surgery was accounted for by major orthopedicprocedures–total hip and total knee replacements–and plasticreconstructive or cosmetic surgery, including cosmetic surgery,including cosmetic reduction mammoplasty. These are ideally suited to apredeposit phlebotomy program. Other hospitals, of course, might perform other types of majorelective surgical procedures shown to routinely require blood, and useautologous blood in those cases. Doctors at Cedars Sinai Hospital inLos Angeles have also demonstrated the safety of predeposit phlebotomyfor certain high-risk individuals, among them patients undergoing majorelective cardiovascular surgery, patients over 70 years old, and a smallgroup of pregnant women.
At our hospital, a previously developed maximum surgical bloodaudit schedule enables us to predict fairly accurately how many units ofblood will be needed for each kind of elective procedure. It definestypes of elective surgery, such as gallbladder removal, not ordinarilysuited to a predeposit phlebotomy program since they are unlikely torequire transfusion. Such guidance minimizes waste of autologousblood–units drawn but not used. This is of particular importance forus. Because we are licensed as a transfusion service, not as a bloodbank, we cannot routinely process unused autologous units for homologoustransfusions. If a hospital has not accumulated its own data, many availablereferences indicate how many units of blood should be crossmatched fordifferent elective procedures. The figures can be used as guidelinesfor a predeposit phlebotomy program. Administrators are interested primarily in whether the cost of thisservice is competitive with that of the established homologous bloodtransfusion program.
We believe it is, although the direct and indirectcosts of such a service are complex, still evolving, and hard to fullydefine. Staffing patterns and the calculation of overhead can varysignificantly from one institution to the next, leading to markedlydisparate results. There are other factors we must consider in assessing the real costof autologous blood transfusion. For example, unlike 5 to 10 per centof homologous blood recipients, patients in an autologous program do nothave post-transfusion complications, nor do they require routinecrossmatching prior to surgery. There is no mandatory syphilis orhepatitis testing, for no disease marker will disqualify an autologousdonor.
When an AIDS test is available, that also will not be necessaryfor autologous blood. All these tests add to homologous blood costs. We do perform a type and screen as a preliminary measure in casemore blood is required during surgery than had been anticipated when theautologous blood was drawn. Nationally, the financial advantages of autologous bloodtransfusion remain a controversial issue. Large regional bloodsuppliers often believe that their programs, which are highly automatedand draw blood from thousands of donors, can be run in a far morecost-effective manner than a single-donor porgram.
Our laboratoryadministrators 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 regardlessof the workload, two technologists are available to staff thetransfusion service at all times. We attempt to schedule autologousdonors when the transfusion service’s routine workload is at itsnadir. As far as donor facilities go, all that’s really needed is adonor chair in an area set apart from the main flow of laboratorytraffic. If space is at a premium, the lab might be able to scheduledonations elsewhere in the hospital–for example, the outpatient area. Using the AABB Technical Manual as a guide, we developed a detailedautologous blood transfusion procedure and incorporated it into theblood bank’s procedure manual.
The AABB manual covers such aspectsas donor criteria, donation and storage, consent, physicianresponsibility, iron supplementation, and recruitment. It also goesinto serologic testing, record keeping, releasing unused blood, andintraoperative blood salvage. Before implementing the program, we launched an educational andpublic relations campaign, directed at physicians and the public. Afour-page pamphlet, titled “Your Surgery, Your Blood,” wasdistributed to physicians’ offices.
Written from a patient’sperspective, the pamphlet describes the program’s mechanics andadvantages. We also sent background information to local media and wenton radio and television to discuss what we planned to do. Within the hospital, we advised the transfusion, medical staff, andexecutive committees of our progress and prepared a comprehensiveeducational program for the hospital staff. A number of in-services andinformal sessions were held. It is also important to outline your autologous blood transfusionprogram to health insurance providers implementation. We wanted toinsure prompt reimbursement by third-party payers, and, we wanted toreceive the endorsement of our homologous blood supplier. Our supplierrecognizes the benefits of autologous blood transfusion and has beensupportive. Our program will mark its second anniversary in a few months.
Inthe beginning, most patients donated because they had seen the pamphletor heard about the program through the media and called it to theirdoctors’ attention. Now doctors suggest it to their patients. A statistical analysis of the first complete fiscal year–from July1983 through June 1984–revealed that 72 patients deposited 139 unitsfor autologous blood transfusion. The 122 units ultimately transfusedrepresented 3 per cent of our total transfusion volume for this period.
Significantly, the number of units drawn has steadily increased to acurrent collection level of about 30 units per month. Autologous bloodunits are expected to account for 8 per cent of the total transfusionvolume for the 1984/85 fiscal year. While most of the autologous donors during the last fiscal yearcame from the immediate area, some traveled as far as 30 miles to giveblood. Donor ages ranged from 17 to 86 years, and 15 were at least 70years old.
Exactly half of the 72 participants were first-time donors. Only three donors–one elderly woman and two teenagers–had areaction. The effects were minor, of the vasovagal type. In only onecase was it necessary to discontinue phlebotomy before collecting a unitsuitable for transfusion. There hasn’t been a single recipient reaction.
Autologousblood is automatically compatible. Indeed, the only possibility of anadverse reaction would be if a patient somehow received the wrong unitof blood. As long as safeguards are in place to insure that donors getback their own blood in the operating room, we don’t have to worryabout this potentially life-threatening problem. The success of our autologous blood transfusion program has beenmonitored in a number of ways. Clearly, the mounting use of this optionbespeaks its acceptance.
Not only are donors almost universally pleasedwith the service, but they also get positive feelings from involvementin their own medical care. Physicians are also satisfied and continueto recommend autologous donations. And lab personnel welcome the addedopportunity for direct patient contact and interaction. Health insurance providers, perhaps the severest critics of any newmedical program, also seem to support our efforts. In the more than 20months of autologous blood transfusion, none of our third-partypayershas shown any reluctance to cover the cost of the procedure. That’s probably due to our efforts to achieve maximumutilization. During the study period, we discarded only 17 units of 139collected. This underscores the importance of using surgical bloodaudit data to determine how much predeposit blood will be needed.
We have a teo-tier fee system. Patients are charged a phlebotomyfee for donations, but they don’t pay an administration fee unlessunits are actually transfused. At a conservative estimate, 25 per cent of all surgical admissionsqualify for autologous transfusion, and we expect to see most of thesepatients in our program someday–just as we expect many more hospitalsto offer the autologous transfusion option.