The Autologous (Self) Donation Program of Versiti allows you (the patient) to donate your own blood to meet the anticipated transfusion needs for planned surgeries. The use of autologous blood has decreased dramatically over the years because donor screening protocols and very sensitive tests have been developed to reduce the risk of transmission of diseases like hepatitis and HIV amongst other pathogens. Therefore, collection of autologous units is no longer a clinical standard practice. It is important to note, availability of your autologous units on the day of your procedure cannot be guaranteed due to reasons listed below. Please review this form in it’s entirety before scheduling.

It is the responsibility of your physician and the medical staff at Versiti to determine whether your health will permit you to donate safely. For your safety, certain guidelines must be followed:

There are several contraindications to autologous donations:

• Any heart diseases or other condition which may cause an adverse reaction during blood donation.
• Unmanaged aortic stenosis.
• Heart Attack (myocardial infarction) within the past 6 months.
• Hemoglobin less than 12.5 g/dL for females and 13.0 g/dL for males.
• High blood pressure greater than 180/100 mm Hg.
• Active infection with or without ongoing antibiotic treatment.
• Seizures within the past 2 months.
• Weighing less than 110 pounds.

Note: In the event you are not able to understand the donation procedure or reliably answer the medical history questionnaire given before donation, your legal representative must be available to provide appropriate medical information and/or donation authorization in case of need.

On the day of donation, you will be given a mini-physical. A medical history, blood pressure, pulse, temperature, and a small sample of blood to test hemoglobin will be taken. If you pass this mini-physical and meet the eligibility criteria, a unit of blood will be drawn. This process will take approximately one hour.

You may donate in an interval of 3 days between donations prior to surgery, as long as the required allogeneic hemoglobin level is met. The donation must be made at least seven days prior to the date of surgery.

Although rare, you may experience an adverse reaction during blood collection or within a few hours after blood drawing. These reactions include, but are not limited to: discomfort, swelling and bruising at the needle site; loss of consciousness, nausea, vomiting, injury to blood vessels or nerves, and infection. Some reactions may preclude any further autologous donations. In this and other instances, blood from the community blood supply may be needed for your surgery. You are strongly encouraged to discuss your transfusion desires with your physician in the event your autologous units are not available or not sufficient for your medical needs.

To prevent donation reactions, it is recommended that you hydrate well and have a full, high protein meal within the two hours preceding the donation.

A special autologous label with information linking the unit to you is affixed to the blood bag. Upon meeting testing and processing requirements, the product is delivered to the hospital’s blood bank where the surgery is scheduled.

Reasons for which the blood may not be available for your surgery include, but are not limited to:

• Breakage of the plastic container
• Inadvertent contamination of the blood
• Need for repeat or additional testing
• Hospital blood bank refusal of autologous donor units which are positive for infectious disease markers

As the Autologous Donor Program requires the services of many trained professionals, special handling of the blood, and additional paperwork, the processing charges for each autologous unit are higher than for other donated blood. These charges are assessed even if the blood is never transfused. There are additional charges for shipping the units out of Versiti service areas. Health insurance (including Medicare) may not cover processing fees for autologous blood and/or for additional processing as needed.

Drawing of autologous units to be transferred to hospitals outside the service areas needs to be approved by Versiti Hospital Services. If your blood needs to be shipped to another blood center, you are responsible for making arrangements in advance with the center to assure they will accept these shipments. Important note: Autologous units testing reactive for infectious disease markers will be shipped depending on acceptance by the physician and transfusing facility. If not accepted, these units will be discarded.

As soon as possible after the decision for surgery is made, please review this information with your physician. To request autologous units for your use, your physician must call SPS at (414) 937-6188 or 1-800-525-1388. An Autologous Donation Prescription will be provided concerning how many units are needed and need by date. Your physician must also verify the hospital’s blood bank, who will provide the units the day of your procedure, is willing to receive and store autologous units.

Versiti offers a Directed Donation Program whereby donations may be directed to specific patients for planned surgeries or transfusions. The Directed Donation Program is intended to provide blood for patients with rare blood types when blood cannot be sourced from the general supply. Before choosing to participate in this program, you and your physician should discuss the risks associated with directed donation, as listed below, as well as the benefits of the community blood supply, which is exceptionally safe.

Ordering Physicians must contact SPS for a Directed Donation Order as needed.

Published studies demonstrate increased rates of infectious disease markers in directed donors when compared to allogeneic donors. This finding is attributed to the undue pressure on friends and family members to donate for their loved one. To gain perceived eligibility, it is believed donors may inaccurately complete the Donor History Questionnaire.

There is no FDA licensed test to evaluate if donors have had the COVID vaccine. Therefore, directed donors and their blood units cannot be evaluated for evidence of COVID vaccination.

Finally, there is no guarantee your transfusion needs will be met by using directed donations or that units collected will be available for your planned procedure or transfusion date due to the reasons listed below. We strongly recommend you and your physician discuss plans for blood transfusion if directed units are not available.

It is NOT recommended that a female patient of childbearing age receive blood from a husband or male partner, as their blood may cause immunization of the patient and therefore compromise future pregnancies.

It is NOT recommended that a female donate blood to their biological child or biological father of her child, as antibodies that may have been produced during pregnancy could cause a reaction during transfusion.

It is NOT recommended to have directed units if you have red blood cell antibodies in your blood.

It is NOT recommended to have directed units if you have had or will have a transplant or stem cell transplant in the future.

Directed units must be ABO and Rh compatible with the recipient’s blood type and are subjected to the same tests as other donated blood. If, for any reason, the directed unit fails testing or is otherwise not suitable for transfusion, it is discarded.

Directed donors of unsuitable donations are informed of abnormal test results only when all tests including confirmatory testing, have been completed. This notification may be later than the recipient’s transfusion date.

It is important to note, to protect the confidentiality rights of the donor, neither recipient nor the ordering physician are notified of non-suitable units. Only information pertaining to the availability of suitable units will be released.

Once the compatible, suitable directed units matching the order have been collected, the units will be distributed to the appropriate transfusing hospital’s blood bank. The blood bank will cross-match the units with a sample of your blood. Only cross-match compatible units will be held and reserved for your surgery in the hospital blood bank.

Other reasons (outside of compatibility and positive testing) directed units may not be available for your surgery include, but are not limited to:

• Breakage of the plastic container
• Inadvertent contamination of the blood
• Need for repeat or additional testing
• Risk of error in processing, storage and administration of products which is greater than in routine allogeneic transfusions

For these and other reasons beyond its control, Versiti cannot guarantee that directed donor units will be available. In such circumstances, your physician may decide to supplement your transfusion with blood from the community blood supply. Again, we strongly recommend you and your physician discuss plans for blood transfusion if directed units are not available.

Due to special handling, a surcharge is added to the blood processing fee charged to the hospital for each unit sent. Health insurance (including Medicare) may not cover processing fees for directed units and/or additional processing as needed.

Also, to standardize directed units and improve safety of the blood (such as prevention of a rare transfusion complication known as graft-versus-host disease), all directed products from blood relatives will be irradiated. All products are leukoreduced for safety.

• To request directed donations for your use, your physician must call SPS at (414) 937-6188 or 1-800-525-1388 for an order form.
• Your physician must also verify the hospital’s blood bank, who will provide the units the day of your procedure, is willing to receive and store directed units.
• To allow ample time for collection, testing, processing, and delivery to the hospital blood bank, donors must donate at least 7, but not more than 14 working days, (excluding Sundays and holidays) before the date of the surgery.
• If more products are needed after the original surgery date, a new order must be completed by your physician.
• Prospective donors must submit documentation of their blood type prior to scheduling.

Once SPS has received your physician’s order for directed donation, prospective donors can submit documentation of their blood type and contact information by fax to (414) 937-6439 or email to SPSAlerts@versiti.org. If the prospective donor is compatible with the recipient, the SPS department will reach out for scheduling.

Donations may be collected at any of our donation centers. Refer to Donor Centers for specific center locations and hours of operations.

Patients with hereditary hemochromatosis (HH) or undergoing testosterone replacement therapy (TRT) may donate at Versiti Blood Center of Wisconsin without a prescription, so long as they meet all allogeneic donation criteria. This includes an Hgb of 12.5-20.0 g/dL for females and an Hgb of 13.0-20.0 g/dL for males who are prescribed whole blood draws no sooner than every eight weeks. All other diagnoses and timeframes require a prescription.

It is the ordering physician’s responsibility to evaluate whether the patient’s health will permit them to donate safely. Versiti Blood Center of Illinois and Versiti Blood Center of Wisconsin ask for a limited medical history and perform a mini physical, including blood pressure, pulse, temperature and hemoglobin. Patients with significant cardiac, pulmonary or other donor safety health history issues may not be able to donate.

All therapeutic patients may donate as often as ordered (no more than once a week) as long as their Hgb remains ≥ 11.0 g/dL and no new patient safety issues arise.

Prior to the first donation (and annually), a prescription is required for more frequent donations than every 56 days for whole blood. This prescription must include the patient’s name, date of birth, diagnosis, frequency of phlebotomy, and lowest allowable Hgb to perform the procedure. If the prescription is incomplete, the missing order information must be obtained prior to phlebotomy being performed.

Other than Hgb level, no testing will be performed on the donation unless the patient meets all allogeneic donation criteria (other than donation frequency). If all allogeneic criteria are met, routine donor panel testing will be performed. Arrangements for other blood tests, such as ferritin levels, need to be coordinated with the patient using another laboratory service.

Patients will be given a Therapeutic Blood Loss Tracker card for monitoring the dates and volumes of serial phlebotomies. Physicians should encourage patients to bring their card to their appointments so that copies can be added to their charts.

There is no charge for therapeutic phlebotomy procedures.