/policies/,/policies/clinical/,/policies/clinical/uw-health-clinical/,/policies/clinical/uw-health-clinical/gen-care/,/policies/clinical/uw-health-clinical/gen-care/blood-products/,

/policies/clinical/uw-health-clinical/gen-care/blood-products/224.policy

20160384

page

100

UWHC,UWMF,

Policies,Clinical,UW Health Clinical,General Care and Procedures,Blood Products

Donation of Autologous/Directed Blood Products (2.2.4)

Donation of Autologous/Directed Blood Products (2.2.4) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Blood Products

2.2.4


UW HEALTH CLINICAL POLICY 1
Policy Title: Donation of Autologous/Directed Blood Products
Policy Number: 2.2.4
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: January 21, 2016

I. PURPOSE

To establish procedures for the collection of autologous (patient donating for self) and directed (family
member or friend donating for patient) donor blood products.

II. POLICY ELEMENTS

A. Autologous donation may not be the best approach for transfusion needs of patients. Historically, more than
half of autologous units have not been transfused at UWHC. Pre-operative iron therapy should be
considered.
i. When a patient requires blood products, a physician or designee w ill evaluate their medical
condition. If determined appropriate then a discussion occurs w ith patient about
autologous/directed donation. The order (American Red Cross (ARC) Special Collection Order -
Autologous & Directed form) must include the follow ing: number of units requested, the proposed
date of use, and an order for iron supplement, if appropriate. Do not request greater than 3
autologous units unless you have discussed w ith the Blood Donation Center medical director. A
healthcare w orker w ill provide the patient w ith educational material for autologous or directed
donation (Health Facts for you... "Autologous Blood Donation Making an Informed Choice" HFFY
ID# 5057 or "What is a Directed Donation?" HFFY ID# 5058).
ii. Autologous Donor Preassessment:
a. Suitable autologous donors are those individuals w ho have a hematocrit of no less than
33%, are not being treated for bacteremia and w hose medical condition is not adversely
affected by donating blood.
b. There is no age limit on autologous donation. Minors may donate w ith parental/guardian
consent.
c. A patient w ith a know n viral infectious agent is eligible to donate autologous blood.
B. If a donor is less than 17 years of age, a parent or guardian must accompany him/her to sign the consent
form at the American Red Cross (ARC).
C. A physician or designee completes the American Red Cross (ARC) Special Collection Order - Autologous &
Directed form. Section C of the form requires the ordering physician's signature.
D. A registered nurse checks the order for completeness then faxes or mails ARC Special Collection Order
form to the location w here donation is going to take place.
E. Autologous Donor w ith Positive Infectious Disease Test Results:
i. UWHC Transfusion Service w ill accept autologous units w ith positive infectious disease test
results.
ii. Standards require the Blood Donation Center to notify the Transfusion Service w hen an autologous
unit is to be shipped and unit tests positive for any marker of transfusion-transmitted disease. The
Transfusion Service w ill notify ordering physician of positive infectious disease result.
iii. The Red Cross w ill require permission from the patient's physician and Transfusion Service to
release autologous units w ith a positive test result for anti-HIV, nucleic acid amplif ication test (NAT)
for HIV, or hepatitis B surface antigen (HBsAg).
F. Directed Donor Preassessment:
i. The health history questionnaire is no different for directed donors than it is for the general public.
ii. If directed donors are excluded by health history questions a unit of blood w ill not be draw n.
G. Directed Donor units w ith Positive Infectious Disease Test Results w ill be discarded.

III. PROCEDURE

A. Nurse checks the order (American Red Cross (ARC) Special Collection Order - Autologous &
Directed form) for completeness.
B. Nurse instructs patient to do the follow ing:
i. Read and review the Health Facts for You information sheet w ith him/her.
ii. Review instructions for taking iron supplement.
iii. Be certain that the patient understands the need to contact the Blood Donation Center to arrange



UW HEALTH CLINICAL POLICY 2
Policy Title: Donation of Autologous/Directed Blood Products
Policy Number: 2.2.4

an appointment for donation 1 to 4 w eeks prior to surgery.
iv. The patient should not schedule their donation more than 42 days prior to surgery w ithout physician
approval w hen ordering red blood cells. If ordering w hole blood, do not schedule their donation
more than 21 days prior to surgery. (See section Reference: Physician Guidelines.) If ordering a
directed donation for a pediatric patient, the collection should be scheduled no more than 10 days
from surgery.
C. The nurse w ill inform the patient that there w ill be a charge for providing autologous/directed donation
services that may not be covered by insurance. Unused autologous blood products w ill be billed to the
patient.
i. If necessary, the clinic w ill have patient complete a Medicare Advanced Beneficiary Notice (ABN)
form. Blank ABN forms can be obtained from Standard Register.
ii. Send the completed ABN form, for scanning, to: Fiscal - Document Imaging Department, mail drop
code 9230.
D. Before leaving the clinic, the patient w ill be given the follow ing:
i. Health Facts for You.
ii. Prescription for ferrous sulfate (if required).
E. The clinic personnel w ill complete the follow ing:
i. Complete the ARC Special Collection Order form, fax (309) 674-9642 to ARC Madison collection
facility prior to the patient's blood donation.
ii. For a list of collection facilities outside of Dane County have patient call the Madison location at
(800)-400-8098.
iii. Send the completed ARC Special Collection Order form, for scanning to: File Room (UWHC), mail
drop code 2427 or fax to (608) 203-4607.
F. When the patient presents on the day of surgery, the nurse w ill:
i. Identify the patient and make sure a patient identif ication band is applied as outlined in UW Health
clinical policy #3.2.1, Patient Identif ication.
ii. Release the signed and held Health Link order or complete UWH form #1280411 as follow s:
a. Request a Type & Screen.
b. Indicate the number of units desired.
c. Indicate that autologous and/or directed donor units are available.
d. Send blood specimen w ith form to Blood Bank.
iii. If surgery is canceled or postponed and the patient has autologous/directed blood products, then
requesting department w ill notify Blood Bank. The requesting department w ill contact Blood Bank to
see if autologous/directed units w ill or w ill not expire before rescheduled surgery.
G. Blood Specimen Requirements: Please refer to UWHC policy #8.12, Blood and Blood Component
Transfusion Requiring Pre-Transfusion Testing.
H. The Blood Bank w ill store the patient's blood until it expires. To obtain autologous/directed blood from the
Blood Bank and for guidelines on the administration of blood and blood components refer to UWHC policy
#8.12.
I. If blood is not used, the patient w ill still incur a service charge.

IV. FORMS

A. Forms:
i. UWHC Transfusion Request (UWH #1280411).
ii. Health Facts for You "Autologous Blood Donation Making an Informed Choice" HFFY ID# 5057.
iii. Health Facts for You "What is Directed Donation?" HFFY ID# 5058.
iv. American Red Cross "Special Collection Order" Autologous and Directed Form (14.4.frm9 v -1.0).
v. Physician Guidelines.
vi. Advanced Beneficiary Notice (ABN).
B. To obtain forms follow instructions below .
i. Copies of "Health Facts for You" can be found on U-Connect. Once on U-Connect go to Workroom,
Clinical Apps tab, then scroll dow n to Health Facts for You and click on link. Then use the search
option to f ind the document you are looking for. If you have any problems obtaining Health Facts for
You please call the Patient Learning Center at (608) 263-6496 or e-mail learn@uw health.org.
ii. The ARC Special Collection Order - Autologous & Directed form can be obtained from ARC by
calling (800) 400-8098 or from the UWHC Blood Bank.




UW HEALTH CLINICAL POLICY 3
Policy Title: Donation of Autologous/Directed Blood Products
Policy Number: 2.2.4

V. COORDINATION

Author: Director, Special Technical Services, Clinical Laboratories
Senior Management Sponsor: VP, Professional and Support Services
Review ers: Manager, Transfusion Services, Medical Director, Transfusion Services
Approval committees: Tissue and Blood Products Committee; UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: December 21, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Jeff Grossman, MD
UW Health CEO

Teresa Neely
SVP and CAAO

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

See "Physician Guidelines for Autologous/Directed Donor Collection" attached to this policy.
UW Health clinical policy #3.2.1, Patient Identif ication
UWHC policy #8.12, Blood and Blood Component Transfusion Requiring Pre-Transfusion Testing

VIII. REVIEW DETAILS
Version: Revision
Next Revision Due: January 21, 2019
Formerly Know n as: Hospital Administrative policy #8.37