Laboratory QA Decreasing Preoperative Autologous Blood Donation: Collaboration Between a Hospital and a Blood Center to Prompt Change in Physician Ordering Behavior

Preoperative autologous blood donation (PABD) was encouraged as a means to reduce allogeneic blood transfusion during a time when the community blood supply posed significant infectious risks to patients. However, increasing safety of the allogeneic blood supply and technological advances in the operating field has decreased the advantages of PABD. Although PABD has a role in certain clinical scenarios, such as when serologic compatibility issues complicate the use of blood from community donors, current evidence on PABD raises a number of concerns regarding its unrestricted use in the perioperative setting. Several studies 1-3 have demonstrated a greater incidence of preoperative and postoperative anemia in patients who undergo PABD before surgical procedures. Also, iatrogenic anemia due to PABD has been shown 4-6 to delay surgical procedures and to increase the likelihood of transfusion. Some healthcare providers who order PABD believe that transfusion of autologous blood products is safer than allogenic transfusions, and fail to recognize the potential risk for bacterial contamination, fluid overload, and receipt of the wrong blood unit due to clerical error. The cost effectiveness of PABD as a medical intervention is an additional concern. PABD products have a higher processing cost and a higher percentage of them are wasted compared with community blood products. 1-3,6 Although some blood management programs continue to use PABD as a means of reducing allogeneic exposure, many recognize that safer and more cost effective alternatives exist. In 2004 Mayo Clinic in Phoenix, Arizona had the largest number of PABD orders in its geographic region, but ABSTRACT Objective: To describe the collaborative efforts of a large healthcare institution and its local blood center in reducing preoperative autologous blood donation (PABD). Methods: Through an educational letter-based campaign, we contacted physicians who historically had ordered PABD units. Follow-up educational efforts occurred at departmental and individual meetings. Results: Our educational campaign to reduce PABD achieved complete elimination of PABD orders and the resultant waste of PABD units within 3 years of the start of the program. These changes were sustained for at least 2 subsequent years without the need for additional educational efforts. Conclusion: Targeted educational efforts directed at practitioners of PABD were successful in significantly decreasing the use and waste of PABD at the health care institution we studied and may yield the same results in comparable institutions.

Preoperative autologous blood donation (PABD) was encouraged as a means to reduce allogeneic blood transfusion during a time when the community blood supply posed significant infectious risks to patients. However, increasing safety of the allogeneic blood supply and technological advances in the operating field has decreased the advantages of PABD. Although PABD has a role in certain clinical scenarios, such as when serologic compatibility issues complicate the use of blood from community donors, current evidence on PABD raises a number of concerns regarding its unrestricted use in the perioperative setting. Several studies 1-3 have demonstrated a greater incidence of preoperative and postoperative anemia in patients who undergo PABD before surgical procedures. Also, iatrogenic anemia due to PABD has been shown [4][5][6] to delay surgical procedures and to increase the likelihood of transfusion. Some healthcare providers who order PABD believe that transfusion of autologous blood products is safer than allogenic transfusions, and fail to recognize the potential risk for bacterial contamination, fluid overload, and receipt of the wrong blood unit due to clerical error. The cost effectiveness of PABD as a medical intervention is an additional concern. PABD products have a higher processing cost and a higher percentage of them are wasted compared with community blood products. [1][2][3]6 Although some blood management programs continue to use PABD as a means of reducing allogeneic exposure, many recognize that safer and more cost effective alternatives exist.
In 2004 Mayo Clinic in Phoenix, Arizona had the largest number of PABD orders in its geographic region, but 75 Laboratory QA by 2012 had eliminated all PABD orders. The success of this intervention was based on educating physicians using evidence-based information and practice data. The approach was multitiered and applied to physicians from diverse specialties at numerous time points. The hospital never instituted a policy change to restrict usage. Overall, in this brief report, we highlight the successful efforts by a large hospital and its local blood center to align practice behavior with the emerging standard of care for PABD.

Educational Approach
The project began with conversations between the local blood center and the hospital laboratory. Both entities recognized the significant waste and cost associated with PABD and agreed to collaborate on an effort to change practices for ordering PABD. Physicians at the local blood center requested one-on-one meetings with local surgeons. The 5 surgeons who ordered the greatest number of PABD products from the blood center (all of whom were from Orthopedic Surgery) were asked to meet so we could better understand their rationale for using PABD in their patients. From those conversations emerged a letter-based campaign in 2008 targeted to all local surgeons who had ordered PABD from the blood center within the previous 2 years. Most of those PABD orders had come from Orthopedic Surgery (>90%), with the remaining orders coming from Neurosurgery, Oncology, and Obstetrics and Gynecology. The letter included a list of considerations that summarized the literature and recommended changes in practice ( Figure  1). Also, the letter contained pertinent references about PABD 6,10-12 from various medical publications. After the letter-based campaign, additional educational efforts specific to Mayo Clinic in Arizona were initiated. In 2009, hospital pathologists with expertise in laboratory medicine and blood banking/transfusion medicine directed educational efforts toward the surgical departments that request PABD. Meetings were also scheduled by the same group of pathologists to provide one-on-one information to individual surgeons who had been absent from the general meetings or whom they perceived to be resistant to the information when it was first delivered. Other than the administrative support of mailing letters and scheduling meetings and appointments, most of the time invested (at the height of the intervention) came from the pathologists, who devoted 2 to 3 hours per week to conduct the educational activities.
The educational program focused on several key points. First, precedent had been set at other, similarly complex institutions that successfully eliminated PABD. Second, we shared evidence-based literature on PABD usefulness and patient safety. Third, emphasis was placed on the safety of the community blood supply and how it has significantly changed, highlighting the significant reduction in infectious risks that were associated with transfusions more than 20 years ago. Fourth, we presented data specific to the departments at the Mayo Clinic in Arizona showing use, waste, and unnecessary transfusions associated with PABD. The inappropriate reflex action of transfusing an autologous unit after it

Figure 1. Issues to Consider When Offering Preoperative Autologous Blood Donation (PABD) to Patients
Older patients often have suboptimal vascular access, which leads to difficult draws at the donation center and slow blood flow into the collection bag. This increases the chance that the unit will contain clots, rendering the product unavailable for transfusion. Most patients tolerate blood collection well. However, it has been observed that older patients with complicated cardiovascular/pulmonary medical problems have a higher incidence of adverse reactions related to blood donation. Studies have demonstrated a greater incidence of preoperative and postoperative anemia in patients who undergo PABD before surgery. Some studies show that PABD may reduce the need for allogeneic blood transfusions. However, autologous blood donors are still more likely to receive transfusions intra-and postoperatively. Much of this can be attributed to the inappropriate practice of transfusing autologous blood in certain situations because it is available, despite that this option is not clinically indicated. Autologous blood still poses risks to the patient, such as bacterial contamination, fluid overload, and mistransfusion due to possible clerical error. The decision to transfuse an autologous unit should be the same as the decision to transfuse a unit from the community blood supply. Autologous blood has not been shown to convey significantly greater health benefits than allogeneic blood and is not a cost-effective medical intervention. Reports indicate that as much as 30% to 55% of autologous blood is wasted. Other alternatives to consider that may be appropriate for your patient include intra-/postoperative blood salvage and acute normovolemic hemodilution. The community blood supply is very safe today. The risk for transfusiontransmission of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) is so low that mathematical models now estimate the residual risk at approximately 1 in every 1 to 2 million units of blood transfused.
Laboratory QA was collected simply because it was available, and not because of a clinical need for increased oxygen delivery, was stressed. Finally, we distributed the "Patient's Guide to Blood Transfusion," a document written for patients and containing information on blood options, and asked physicians to use it in counseling their patients before ordering PABD. The document, provided by the local blood center, describes the safety of the allogeneic blood supply, along with alternatives to PABD. We reminded physicians that they should make medical exceptions only when the patient possesses a rare antigen type and/ or multiple red cell antibodies that would make finding a compatible blood product difficult.

Collection of PABD Data
We collected data under 2 different settings. The first data collection occurred at the blood center. Second, we performed a search for all PABD orders collected at the blood center within the previous 2 years. The intent of these collections of data was to identify the physicians who had placed the highest number of PABD orders in the local community. We asked those physicians to participate in additional discussion about PABD practice. The second data collection occurred at Mayo Clinic in Arizona. We collected and analyzed autologous transfusion data from 2004 through 2012 under routine usage review of transfusion practices at the institution. The information captured for each year included the total units of PABD ordered and the number of units transfused.

Results
The

Discussion
Hospital blood banks face the challenge of how to manage the lag between local ordering practices and current evidence-based standards of practice. We recognized that use of PABD was continuing despite mounting evidence that it was not useful. This persistent activity in PABD ordering led to the interventions described in this report. Prior to our interventions, the number of PABD orders was declining, consistent with national trends. 7 Overall, awareness of the limitations of PABD was already reaching healthcare professionals. However, we reviewed ordering practices for PABD from other hospital users, as supplied by the local blood center, and noted similar declines that eventually stalled in the absence of follow-up education. This observation suggests that the educational interventions described in this report were a key component in eventually eliminating all PABD requests. The effectiveness of our educational efforts is unsurprising, given what we learned about the perception of PABD among our targeted physicians after meeting with surgeons regarding PABD practice. Many of the physicians we interviewed were not aware of the implications on patient safety and the underlying costs associated with PABD. A common rationale for ordering PABD was based on the patient's concern about the safety of the community blood supply, and a desire by the surgeon, primarily to satisfy patients, to make the option available. Once we made physicians aware of the data showing that PABD was not in the best interest of The year in which department meetings and one-on-one conversations took place.
Laboratory QA every patient, they were not resistant to changing their practices. The feedback we received from physician offices was that patients who asked about PABD were satisfied with not donating an autologous unit once they were informed of the risks. An active educational plan with a measureable outcome and a defined goal was critical in the success of our educational program.
We changed PABD-ordering practices due to concerns about PABD and patient safety. Several unintended consequences associated with PABD have been reported, such as development of preoperative and postoperative anemia in patients. A retrospective study 8 of 70 patients who had undergone primary unilateral total knee arthroplasty between 2000 and 2002 reported that when a unit of autologous blood was collected a mean (SD) of 13 (3.3) days before an operation, the mean hemoglobin level of the patient declined from 14.1 g/dL to 12.8 g/dL. In a similar study by Cushner and colleagues, 9 74% of their study group had had hemoglobin levels of greater than 13 g/dL before autologous blood donation. When this group was tested 4 weeks later, before they had undergone surgery, 55% had hemoglobin levels between 10 g/dL and 13 g/dL; this observation suggests that, for some patients, a period of 4 weeks after PABD donation does not allow sufficient time for the hemoglobin level to return to normal.
Unintended effects of iatrogenic anemia due to autologous blood donation can be problematic. One concern is the delay it may cause for operations or other procedures. A study of 1073 patients who had donated multiple autologous units showed that the normal care was interrupted and delayed due to donation-associated anemia in 7.4% of patients. 4 PABD also increases the likelihood for transfusion. The results of a study 5 of 265 patients undergoing elective hysterectomy demonstrated that only 1 of 124 patients who did not donate autologous units required transfusion, whereas 25 of 141 patients who had donated an autologous unit were transfused. Bern and colleagues 6 investigated autologous blood donation and subsequent blood use in patients undergoing total knee arthroplasty; they found that patients who had undergone PABD were approximately 4-fold more likely to receive transfusions.
Ordering of PABD products results in financial repercussions. Autologous blood products are more expensive than allogeneic blood products due to the need for special handling of autologous donors and  [10][11] Substitution of autologous blood for allogeneic blood confers a minimal health benefit (0.0002 to 0.00044 quality-adjusted year of life saved) and significant additional cost (as high as $4783/U of blood). 12 The cost-effectiveness of autologous blood donation has been reported to range from $235,000 to higher than $23 million per quality-adjusted year of life saved. 11 With the increasing safety of the allogeneic blood supply and the excessive waste of autologous units, PABD is not a costeffective medical intervention.
Aligning medical practice with evidence-based medicine can be implemented in many ways. One approach is to forbid storage of autologous units in the blood bank. This approach clearly eliminates PABD; however it is less collegial and risks alienating physicians who disagree with the policy. Another approach is to establish specific guidelines for autologous blood use that are approved by the medical executive committee; this strategy can be very effective in changing physician behavior. However, as with any standardized practice that is codified as policy, it restricts physician autonomy and requires monitoring of compliance. Standardized practice guidelines may be useful for common medical practices, but in the case of PABD ordering, we believe that ongoing, physician-focused education was a more effective approach. Our approach was modeled after the concept of "academic detailing." 13 We believe this was the best option because the number of PABD requests was relatively low, educational efforts could be specifically targeted to the group of physicians who ordered PABD products, and the evidence base for cessation of this practice was compelling. We learned from our interviews with physicians that the persistent practice of PABD stemmed mostly from their unawareness of the negative patient and economic consequences of PABD. Hence, we Laboratory QA were confident that educational efforts, by themselves, could be successful and that the multitiered delivery of information would reach all physicians and provide a forum for discussion for any physicians resistant to this information. As our data show, this approach was successful in eliminating all PABD orders by 2012.
The success of any educational strategy designed to change physician practices relies on the hospital pathologists to get out of the laboratory-centric mindset and engage in multidisciplinary dialogue. We were confident in the education-only strategy based on preexisting relationships with the clinical-service physicians. Building and maintaining active relationships with clinicalservices over the years optimized our ability to effectively deliver the intended educational materials. Discussions are more productive and more likely to yield change when healthcare professionals trust the information they are receiving; having active relationships with our clinical colleagues helped establish that trust.
In summary, there is abundant evidence that healthcare professionals should not order PABD on a routine basis but should reserve it for patients with a true medical indication for autologous donation. The use of PABD is fraught with patient-safety concerns, waste, and poor cost-effectiveness compared with alternatives. Education delivered through various modalities and reinforced at a later time point proved effective at eliminating PABD orders at the Mayo Clinic in Arizona. LM