A blood donor center physician has been struggling with how best to deal with 'orders' from surgeons to collect units of autologous blood from patients scheduled for surgery. The inquiring member laments that at her institution, a surgeon can 'order' an autologous unit to be drawn, and once that order is received by the donor center, it is up to the donor center staff (including the donor center medical director) to find out the patient's pertinent medical (especially cardiac) history, and to tract down a cardiologist or internist who may have seen the patient to evaluate the patient's risk for donation. The inquiring member asked the e-network how others handle orders for autologous blood donations. The inquiring member is upset over her institution's policy as the current approach for autologous blood collection takes a large amount of time to gather all the necessary information, and even when the information is obtained, the inquiring member does not feel that the patient has been thoroughly assessed. The inquiring member commented that she has considered requiring the surgeon to fill out a form and to obtain consent from the patient with risks explained before the patient is sent to the donor center for processing. If such a remedy is implemented, the inquiring member feels that there would be a better assessment of risk, and if the surgeon is willing to share in the responsibility for a safe donation, perhaps fewer high risk patients would be sent for donation.

The following replies have been submitted in response to the above:

1. Please review an earlier e-Network discussion that is germane to the inquiring member's predicament (Procedure for Documenting Physician Orders for Autologous Donation; April 1, 2001).

2. A donor center medical director in Southern California wrote that at his institution (a community donor center) the responsibility for obtaining medical and/or cardiac clearance rests with the ordering physician (through the patient). The responding medical director's staff will cooperate with the ordering physician and the autologous donor to help expedite the process. This help is in the form of calling the ordering physician's office to inform him/her of needed documentation, accepting faxed documents, etc., but autologous blood will not be collected unless all requisite documentation is available. The donor center medical director mentioned that his center's policy will permit him or his associate medical directors to take full responsibility and sign off on the patient's medical condition, but the need to do this is an uncommon occurrence, now that the community physicians have been "trained."

3. Another donor center physician wrote that at her blood center they believe that the responsibility for determining autologous donor suitability is a shared one between the ordering physician, the patient, and the donor center medical staff. They expect the ordering physician to have evaluated the patient well enough to identify cardiac or other medical conditions that could affect the safety of the patient. If they are in doubt of the prospective donor's health status, they require the patient to get additional clearance from either an internist, their own primary care doctor, or if the patient appears to have significant cardiac issues (evidence of CAD, pacemaker, history of significant arrhythmia, etc.), a cardiologist. The ultimate responsibility for the decision does rest with the blood center physician, and if the responding member is in doubt even after the above actions are taken, the decision is made to decline to draw the blood. Rarely a surgeon will challenge a decision to decline to draw an autologous donation, but if such a challenge occurs, it provides an opportunity to dialog directly with that doctor and a scenario that provides an opportunity for education (bi-directional), and direct communication. This usually is a fruitful process, and provides both parties with a chance to better understand the other. If it appears that the patient should not be donating, they always reinforce the message about the safety of community blood, and also suggest that they consider directed donations. These options seem to reassure the patients and doctors and appear to be perceived as suitable alternatives to an autologous donation. The responding member suggested that the inquiring member should require surgeons to fill out a brief medical form. Such a form would probably be better received if there was a check off list and an "other" column. Getting the surgeon to list medications could also be helpful.

4. A blood banker in Houston strongly recommends that the surgeon be informed that no autologous donations can be obtained without the patient's personal physician providing pertinent medical information and that the information be submitted at the time the request for autologous collection is made.

ADDENDUM Sept. 5, 2001

5. A blood banker in the great Northwest writes that their process starts with their Autologous Blood Storage Order Form (BCS Form F0457) which is completed by the ordering physician. Section 16 states "Please indicate if your patient has any of the following conditions: ... Significant cardiovascular or cerebrovascular disease, Aortic/Subaortic stenosis, Osteomyelitis". Next in BCS-0410 it states "Review the Autologous Blood Storage Order Form. If the ordering MD indicated donor has a high risk condition, inform the donor he/she will have to get a written authorization from his/her physician and bring it to the first donation. If the donor does not bring the authorization, he/she may not be able to donate." Then finally during the screening process in BCS-0606 it states "Review pertinent health history and determine if a MD authorization is needed."

ADDENDUM Sept. 13, 2001

6. A blood bank physician commented that at her facility they require that evaluation of the autologous donor's medical history be done by the ordering surgeon or patient's appropriate clinical specialist. Her staff do NOT take the responsibility for obtaining the information. If Ihe responding physician does not feel comfortable with the information given, they will not draw the donor.

Please submit comments to the e-Network Forum.

Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator