A transfusion medicine colleague in Massachusetts reports that his institution is currently debating the pros and cons of centralization of their hospital's transfusion services (which includes a blood bank and donor apheresis program). He acknowledges that the whole issue of centralization is a complex labyrinth that is not readily analyzed in a simple, straightforward linear manner, because of many interacting and value-laden variables. He is hoping to get input from others who have transformed their service to a centralized, off-site model, to learn from their experience, and would also appreciate input from those who have considered transforming, but decided not to do so. The bottom line is he wants to know if a centralized, off-site service works as well (or better) than a traditional on-site blood bank? To that end, the following questions are posed:

• For transfusion services that are (or have moved) off-site from the hospital(s) served, what have been the costs and benefits of going off-site (separated by more than 100 yards out-of-doors)? Issue to consider include: turn-around-time, costs for delivery of requested blood products, $/sq ft of space, efficiencies of compressing several small, sporadically but not always busy work forces into one large, multi-tasking, always busy work force.
• How well have the client clinical services (OR, ER, other) been satisfied with the arrangement, and/or what have been the main complaints and problems?
• What are the key points (sine qua nons) to consider in designing such an off-site move, such as the feasibility of patient-centered transfusion medicine consultation?

ADDENDA Dec. 27, 2003

1. This question is intriguing to the e-Network Forum Editor & Moderator, who believes that a "virtual" transfusion service laboratory (Editorial, Transfusion, 1997) is a model that could facilitate centralization of hospital transfusion services, off-site. For example, as was pointed out in the the article entitled "Suitability of preadmission blood samples for pretransfusion testing in elective surgery" by Marosszeky and colleagues (Transfusion 1997;37:883-5), the results of ABO/Rh and antibody detection testing could be considered valid for at least one month for patients who have not been recently transfused or pregnant. In addition, Cox and colleagues (Transfusion 1997;37:960-4) demonstrated that a networked information system could be established to provide computer crossmatched blood both within an individual hospital and at sites remote from the hospital. Thus, the results of ABO/Rh and antibody detection testing can physically be "stored" in a centralized location electronically for later use, with the caveat that this information is only to be used in a manner that is in full compliance with ALL federal, state and local regulations. Thus, by using a compliant networked information system, many of the functions of traditional hospital transfusion services could potentially be extended beyond the walls of a laboratory and/or even beyond the hospital. The Webmaster believes that current and emerging technologies in testing methods, laboratory equipment, communications, electronics, and computers will make it increasingly feasible to implement automated blood bank testing, to improve control over patient and specimen identification, to improve accuracy of test results, and to assure that a blood product intended for transfusion is administered to the correct recipient. This would be possible regardless of whether the transfusion service were centralized in an off-site location or in the hospital. As we look to the future we might envision the routine use of computers (whether on-site or remote) to control each step in the process of acquiring and testing patient specimens and donor units, in the performance of pre-transfusion compatibility testing, and in the administration of blood components.

ADDENDA Jan. 3, 2003

2. A colleague from the Pacific Northwest states that her institution has been using a centralized blood bank (BB) for many years, and they are currently considering bringing these services back in-house. She offers the following points to carefully consider before finalizing the decision:

1. "Who will validate and pay for the joint or community accessible computer system? This is a cost your institution might incur.
2. Will your physicians be satisfied with turnaround time (TAT), especially in emergencies and bleeding traumas? 
   1. Meet with your Emergency Dept., OB and OR physicians BEFORE you decide; let them know the changes that will occur. 
   2. Remember there are 2 delivery stages for each sample sent:  one is to the centralized blood bank, and the second one is from the blood bank back to your facility. Make several runs in both directions to determine parking and traffic conditions especially during peak traffic times. 
   3. If you are in a busy metropolis, what are the parking options?  These 2 things can have a tremendous impact on TAT, possibly tripling it. Longer TAT for routines and pre-surgeries are insignificant. However, in an emergency, TAT makes a significant difference.
3. How will increased TATs affect patient care; do you have OB patients, are you a trauma center, do you perform surgeries?
4. Be aware of hidden costs.  If your blood center claims to have some of the lowest prices for blood and components, but you get charged for other items such as transportation costs, your budget will increase greatly.  When an antibody ID is performed, what are all the possible charges you might incur and can you pass those along to the patient?  Consider other hidden charges.
5. Who will determine how much emergency stock you will be allowed to keep on hand for emergencies?
   1. Inadequate emergency stock on hand during a bleeding trauma could result in pulling blood from other patients, and then having to pay for re-crossmatching replacement units.
   2. How will you negotiate if your facility determines that you need to keep additional stock?  And if you do this, make sure your "new" staff (especially if you are considering lowering the qualifications for these new staff members, since they will not be doing any “testing”) are qualified, trained and competent to do just that, pull units from other patients when necessary.
6. Will you do any testing, i.e. for ABO and Rh?
   1. If not, even for something as simple as thawing plasma, the TAT will now increase. You will need to send the sample, wait for it to arrive at the central BB, and then wait for the testing to be complete.  Will you be allowed to keep stock FFP and if so, how many of each type?
   2. Will you perform ABO and Rh for OB patients?
7. Who will be responsible for investigating transfusion reactions?
   1. Will in-house staff spin a tube of blood to inspect for hemolysis and send all other testing to the central BB?  Will the TAT be satisfactory?
   2. Who will be responsible for monitoring these statistics?  Who will be responsible to report Hemolytic or other clinically significant events?
8. How will this new system affect overall wastage?  Think cautiously about this.
9. Will you still be able to return in-date, unused FFP, cryo and platelets for credit?  Will the central BB thaw FFP and cryo and pool platelets? If so, this will greatly increase wastage.  If not, this is where the need to do ABO testing or having access to the central BB records will be necessary. 
10. Carefully consider what you are willing to give up and what you want to keep in-house.
    1. Could you re-organize your current staff and tasks to be more efficient:  You could consider doing basic BB in-house and sending "problems" (ABO discrepancies and positive screens) to a reference lab/central BB; after all, antigen testing/antibody panels are very expensive.
    2. Could you save money by not keeping all the panels and antigen typing sera (anti-c, anti-K, etc.) and just doing basic BB?  Many small hospitals do just that.
    3. If you are a large institution, could you re-organize to have MTs perform basic BB testing, use MLT or equivalent to do processing such as thawing and pooling, receiving and returning products, and send out complex testing?"

She concludes with the following:

• "This does not have to be an all-or-nothing proposition; you can pick and choose what to keep and what to give up.
• There are many issues to consider other than where the testing gets done. 
• Please, please brainstorm with different staff; do a Process Improvement process, make absolutely sure you know exactly what you are agreeing to do and not to do BEFORE you sign on the dotted line.  
• EVEN BETTER, VISIT A FACILITY THAT IS CURRENTLY USING A CENTRALIZED BLOOD BANK BEFORE YOU MAKE YOUR FINAL DECISION.  TALK PERSONALLY WITH THE PEOPLE AT HOSPITIALS WITH SIMILAR BED SIZE AND SIMILAR PATIENT MIX WHO CURRENTLY ARE USING CENTRALIZED BLOOD SERVICES.  On paper, things often look very different than what pans out in reality."

Please submit comments to the e-Network Forum.

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