5 Insights from the NHS

Homerton University Hospital NHS Foundation trust

The trust provides general and specialist hospital services and community health services in Hackney and the city of London. The hospital has almost 500 beds and employs over 3500 staff.

Automated red cell exchange with Spectra Optia is offered to adult patients with sickle cell disease during weekdays in the medical day unit. The unit has 1 machine used solely for this procedure and plans one per day. Forty six adults (11.4%) from a caseload of 350 patients currently receive this treatment.

Patients transition to the Homerton adult sickle cell service from the Royal London Hospital paediatric service which does not have automated red cell exchange.

Treatment indications are in line with the other sites (see patient selection). Generally patients have the procedure every 8 weeks. All patients have a personalised transfusion protocol which is printed on the unit prior to each procedure and used by the nurses to programme the machine. Printing from the hospital computer system ensures the most up to date protocol is used.

The steps involved in the procedure are the same as at Guys and St Thomas' and are explored within the care pathway mapping section, although at Homerton post‑procedure bloods are taken before the lines are removed to maintain venous access until blood results are returned.

The team have developed a data sheet for automated red cell exchange transfusion containing details of all patients on the programme which is updated by the lead consultant and discussed at the sickle cell and thalassaemia haematology multidisciplinary team meetings.

Before adopting Spectra Optia for automated red cell exchange, 22 patients had regular manual red cell exchange and a very small number had top‑up transfusions for certain indications.

Adoption was led by a consultant haematologist with special interest in sickle cell disease. The successful business case focused on reduction in inpatient bed days, use of iron chelation and better patient tolerability of treatment.

Adoption involved transferring the patients having manual exchange or top‑up transfusions to automated red cell exchange. After this, all subsequent patients who met the criteria for automated red cell exchange were entered directly into the programme. The numbers of patients being offered the procedure continues to increase.

Initially, most patients had the procedure through femoral line access. As the service has developed, most procedures are done through peripheral line access.

All 13 nurses working on the day unit are trained to use Spectra Optia for automated red cell exchange. The training generally takes 6 to 8 weeks.

The team have analysed data on serial iron loading measures from liver MRI scans (Ferrisans) for 20 patients having regular automated red cell exchange over 3 years. This showed how people starting on automated red cell exchange with high iron levels experienced a sustained reduction in their iron burden. Those starting with no iron overload or mild overload did not accumulate any iron in 3 years of regularly having treatment. The team also noted how each patient responded to treatment over different periods of time, and that most patients' admission rates continued to fall 3 years after starting treatment.

The team undertook an analysis of admission rates (emergency day case, inpatient and emergency department) in the year before and in the 4 years after 8 patients commenced regular automated red cell exchange for recurrent painful crisis. Once the team had taken into account the costs of offering automated red cell exchange they estimated a saving of £480,000 for these 8 patients over 4 years due to reduced admissions.

In addition, the department has a recorded rate of allo‑immunisation of 0.065 per 100 units of red cells.

Because demand is increasing, the team is developing a business case for an additional Spectra Optia machine and exploring the feasibility of offering an emergency 24‑hour service. This would involve an on‑all rota with the nursing team. If the case for a second Spectra Optia machine is successful, the team is planning to link with the East London and Essex haemoglobinopathy network to offer a network‑wide service.

Guys and St Thomas' NHS Foundation Trust

The trust has over 1000 inpatient beds and provides a range of services for residents in the London boroughs of Lambeth, Southwark, Lewisham, Bromley, Bexley and Greenwich, as well as specialist services for patients from a wider area.

An adult automated red cell exchange service using Spectra Optia was established over 10 years ago and is managed by a consultant haematologist with special interest in sickle cell disease with support provided by a team of sickle cell nurse specialists and an apheresis nurse specialist. The service is provided on weekdays in the haematology day‑case unit (emergency exchanges out of hours are done manually).

The unit has 4 Spectra Optia machines which are used for:

  • red cell exchange

  • plasma apheresis:

    • to treat thrombotic thrombocytopenic purpura (TTP)

    • for some neurological conditions

    • for some dermatological conditions.

The trust has a caseload of 828 adults with all types of sickle cell disease. Automated red cell exchange is provided to 86 people (including patients from other hospitals who only attend Guys and St Thomas' for their exchange). Treatment indications for patients currently on the programme are in line with the other sites (see patient selection). Automated exchange with Spectra Optia is offered on a case‑by‑case basis to young people with good venous access transitioning from the trust's paediatric sickle cell service.

Patients have a cross‑match blood test 24 to 48 hours before the automated exchange. The procedure itself takes 3 to 4 hours and the patient is discharged when post‑procedure blood results are acceptable. Five to 6 nurses provide cover until 16:30 and 2 nurses until 18:30 each day.

Before implementation of automated red cell exchange, patients were offered a mixture of top‑up transfusions and manual exchanges as needed. Adoption was driven by a lead consultant haematologist with support from colleagues who considered automated exchange to be quicker, easier, safer and more effective than manual exchange, with less need for iron chelation.

The service was established in 2000. After demand for the service increased by 25–30% in 2014–15, team members visited other sites offering automated exchange to explore different models of working. As a result, capacity was increased by:

  • Doubling the number of automated exchanges done on 1 machine per day from 1 to 2 (morning and afternoon).

  • Increasing the nursing ratio of 1 trained nurse for: 1 automated exchange to 1 nurse, supported by a healthcare assistant, for: 2 simultaneous exchanges (where clinically safe and where one procedure is using peripheral access and the other femoral access). The team report this has allowed them to increase capacity to 4 exchanges per day.

  • Aiming for predominantly peripheral access (located with ultrasound).

  • Purchasing an additional Spectra Optia machine (following a more recent business case which focused on the role of exchange transfusions in the teenage population).

Treatment is split fairly evenly between femoral access and peripheral access, although 14 patients have the procedure via portacaths (for which they have regular antiplatelet therapy).

The manufacturer initially provided training. Now there is well‑developed expertise in the unit, in‑house cascade training is offered to new members of staff (see education). There is a high turnover of nurses so training provision is ongoing. The team reports that it takes 3 months to become proficient in using Spectra Optia for automated exchange and to be able to practice independently.

8 day‑unit nurses and the sickle cell nurse specialists are trained in using the device. To reduce nursing time taken during set up, a number of healthcare assistants have been trained to load the necessary equipment into the machine.

Key details about all patients on the programme are stored in an Excel database which is managed and updated by the lead consultant haematologist after clinic appointments. This is used at the weekly patient progress meetings between the lead red cell exchange consultant and day‑unit lead nurse (see measuring success).

The team reports that many patients ask for automated exchange because they see how it benefits other patients. There are plans to increase the number of automated exchanges via peripheral access and discussions on developing a 7 day 24 hour emergency service.

Central Manchester University Hospitals NHS Foundation trust

Manchester Royal Infirmary (MRI) is the largest of the 6 hospitals which make up Central Manchester University Hospitals NHS Foundation trust. The trust provides general hospital services to central Manchester residents as well as being a leading provider of tertiary and specialist healthcare services in Manchester and Trafford treating more than a million people every year. MRI is a specialist regional centre for sickle cell disease.

The trust offers an automated exchange service with Spectra Optia to adult patients with sickle cell disease on weekdays in the haematology day‑case unit. If emergency treatment is needed out of hours, where possible the unit will stay open later or manual exchange will be done instead.

The service is led by a consultant haematologist with a special interest in sickle cell disease. Twenty‑three patients currently receive regular automated red cell exchange, representing around 10% of all sickle cell patients under their care. Cases are considered individually alongside hospital selection guidelines and treatment is offered in line with the other sites (see patient selection).

The haematology day unit has 4 Spectra Optia machines which are used for automated red cell exchange, therapeutic plasma exchange and peripheral blood stem cell collection (auto collection and off donor collection). In 2014, 248 apheresis procedures were done of which 105 were automated red cell exchange.

Eight day‑case unit nurses are trained in using the technology. Commonly, one patient is scheduled per day on the unit for the procedure to ensure staff have the capacity to safely manage treatment. The frequency of exchange varies for each patient but is generally every 4 to 8 weeks.

The consultant haematologist is responsible for assessing the effectiveness of the automated exchange procedure in each patient. Measures of effectiveness include prevention of clinical complications and reduction of hospital admissions. Response to treatment guides individual treatment regimens which are recorded and accessible to the day unit.

Before using the technology, MRI offered top‑up transfusions with manual exchange if needed. This method had poor efficacy, led to iron accumulation and was associated with many practical difficulties, so there was a high clinical need threshold for offering these procedures.

The case for change was driven by the sickle cell specialist nurse with the support of the whole team. Shared learning from London hospitals that already offered the service and support from the manufacturer of Spectra Optia drove the case for adoption.

The staff were already familiar with Spectra Optia and adapted existing governance protocols and procedures for automated red cell exchange.

Savings were anticipated in hospital admissions and iron chelation therapy but these do not impact the day‑case unit directly. Haematology took a whole service approach and balanced the losses by considering the gains from other areas of haematology work.

Approximately one third of patients receive red cell exchange via peripheral line and the remaining via femoral line. 

The day‑unit nurses trained in using Spectra Optia have a number of other roles and are not dedicated to the apheresis service. The unit provides a comprehensive ongoing training package for staff which takes around 3 months to complete and is consistent with training at the other sites.

The haematology department has seen significant benefits since the adoption of Spectra Optia for automated red cell exchange. There has been a reduction in readmission rates and patients' reported quality of life is improved.

The team have done an audit of 16 patients on the regular automated red cell exchange programme from 2006 – January 2015. The audit showed no significant iron accumulation in patients on the programme. In some cases patients with high levels of iron due to previous top‑up transfusions have been successfully able to reduce iron to acceptable levels with iron chelation treatment despite continuing to receive RCE. Where there was an apparent rise in some patients, this may have been attributed to sporadic top‑up transfusions.

Feedback on patient experience indicates that for many people automated red cell exchange has been life‑changing, enabling meaningful employment and study. Many people have reported that the treatment has made them feel like they don't have sickle cell disease.

St George's University Hospital NHS Foundation Trust

St George's Hospital in Tooting is the main site of the trust, and offers planned automated red cell exchange on the haematology day unit on weekdays. The service is led by 2 consultant haematologists. It has 4 Spectra Optia machines used by 4 trained apheresis nurses for:

  • red cell exchange (45 to 50 transfusions per month)

  • plasma exchange (plasmapheresis), both albumin and plasma

  • emergency leucopheresis

  • stem cell harvesting.

Automated red cell exchanges are scheduled for every weekday. Up to 2 patients can be scheduled on 1 machine per day (morning and afternoon), and 6 procedures (red cell exchanges or plasmapheresis) can be done per day depending on staffing levels. The apheresis nurses run an on call rota enabling emergency apheresis 24 hours a day.

Most patients have the procedure through a large peripheral line. All other steps in the procedure are the same as detailed by the other sites and included in the care pathway mapping section.

Around 56 patients have regular automated red cell exchange. This includes patients from other hospitals who only attend St George's for their apheresis. The service is offered to adult patients and some adolescents (on a case‑by‑case basis). Patients offered red cell exchange at St George's reflect the indications at the other sites (see patient selection). Patients on the programme have a 'procedure passport' which is used for each treatment.

The apheresis team meets monthly with the clinical haematology team to discuss all the patients on the programme and their transfusion parameters. Patient's procedure passports are updated accordingly.

The team recently replaced older machines, increased the number of machines and increased staffing to cope with increasing demands. The successful business case to increase the number of machines focused on the importance of ensuring a sustainable service.

Data from St George's indicate that automated red cell exchange is clinically efficacious in 80% of patients. Importantly, patient feedback consistently highlights how much the procedure has changed their life.

Birmingham Children's Hospital NHS Foundation Trust

Birmingham Children's Hospital has 361 beds and provides children's health services for young patients from Birmingham, the West Midlands and a wider area. The hospital has offered automated red cell exchange since 1998 and a service for regular procedures was set up in 2013. On weekdays in the day‑case bay of the haematology oncology inpatient ward, 1 Spectra Optia machine is used for red cell exchange, plasma exchanges, leucodepletion and peripheral blood stem cell (CD34) collection.

The service is led by a consultant paediatric haematologist. There is a caseload of 400 patients with sickle cell disease. Fifteen currently have regular transfusions and of these two have regular automated red cell exchange. The youngest patient to have received a planned automated red cell exchange at the hospital was 6 years old, and the youngest enrolled on a regular programme was 9 years old.

A programme of regular automated exchange is offered for primary and secondary stroke prevention, recurrent painful crisis or acute chest syndrome not responding to hydroxycarbamide and severe multifocal avascular necrosis.

One week before a planned procedure, patients attend clinic for blood tests (including cross match) which will guide the procedure settings. One automated red cell exchange is done per day with an apheresis sister allocated to the patient and a second nurse available to collect and check blood and help manage any adverse events. An apheresis care pathway is used, which details the checks and steps that must be done before a procedure is started. For paediatric patients, 4 to 8 units of blood are used. After the procedure, patients are discharged after at least a 30 minute rest and acceptable observations.

Each patient is monitored closely (see measuring success) and attends clinic at least every 6 months to review progress and complications.

Before the regular automated red cell exchange transfusion service was established in 2013, patients who needed routine transfusions had top‑up transfusions. The regular automated red cell exchange service was part of the overall apheresis business case which was partially funded to increase the nursing team and create an apheresis specialist nurse post. Although automated red cell exchange costs more than top‑up transfusion, adoption was supported because the department already had a Spectra Optia machine used for other procedures.

Peripheral lines are mainly used for access. When this cannot be achieved the procedure is cancelled and rebooked for a femoral line to be inserted in theatre under general or local anaesthetic (depending upon the patient's age and preference). Achieving vascular access with adequate flow is the main barrier to offering this service to more patients. In order to increase success and minimise distress, the same advanced nurse practitioner aims to insert a patient's peripheral line each time. In future the apheresis specialist nurse will also do this.

The main reason patients stop treatment with Spectra Optia is because they are not coping with vascular access problems. The team are currently exploring whether double lumen vortex ports could provide access for some patients. The flow rate capability and location of the port is important for suitability for this procedure.

Currently 6 nurses are trained to use Spectra Optia for automated red cell exchange. Establishment of a regular programme has provided a better opportunity for staff to maintain competence. The team anticipate that capacity can now been increased with the employment of an apheresis specialist nurse. To support the development of the service the apheresis sister visited a site in Bristol to look at its model of working.

Patients and their families often opt for top‑up transfusions over automated red cell exchange, because only one cannula is needed and the patient is not restricted to a machine for 4 hours. The team are reviewing the information provided to patients and their families to ensure the benefits of automated red cell exchange are fully understood. To give continuity, the same apheresis nurse and the advanced nurse practitioner aim to be present for all red cell exchange procedures. Patients and families who have been on a regular programme report an improvement in quality of life for the whole family.

Data from Birmingham about 3 patients having regular transfusion for multifocal avascular necrosis showed clinical improvement and stable ferritin levels in all patients. No patients needed iron chelation therapy. Frequency of treatment was every 6 to 8 weeks, lasting at least 1 year.

This page was last updated: 02 March 2016