NHS Blood and Transplant (NHSBT) Therapeutic Apheresis Services (TAS) provide treatment for both adults and children across a range of clinical specialties. Using technology called an apheresis machine, our nurses perform a comprehensive portfolio of procedures, to save and improve patients' lives.
In addition to patient treatment procedures, which are described below, TAS nurses also collect cells from related and unrelated donors, for patients who need a stem cell transplant from another person. For unrelated donors, we do these collections on behalf of the bone marrow and stem cell registries that operate in the UK—Anthony Nolan, the British Bone Marrow Registry (BBMR) and DKMS.
TAS launched in 2007 and since then the apheresis nurses have completed over 50 000 procedures for more than 9000 patients and donors. Our services are delivered from eight TAS units based across England, which are embedded within acute hospital trusts.
The TAS workforce consists of more than 90 frontline staff, made up of lead nurses, nurse practitioners and unit assistants. TAS unit staff are supported by consultants, the senior management team, education and quality leads and administrators.
What is apheresis?
Apheresis is the overall term used for the range of procedures that can be undertaken using an apheresis machine. An apheresis machine is used to remove, exchange, collect or treat a specific component from the blood.
A person having one of these procedures will require two intravenous lines. One is the access line, which is used to draw blood into the machine, the other is used to return blood and fluids to the patient. Two peripheral cannulas may be used, or a central line that is suitable for apheresis.
Therapeutic apheresis enables a range of diseases to be treated. Examples of apheresis procedures include the following:
Peripheral blood stem cell and donor lymphocyte collections
Apheresis is used to collect a patient's or donor's cells for peripheral blood stem cell transplants. These transplants may use the patient's own cells (autologous transplant) or a donor's cells (allogeneic transplant). Stem cell transplants are used to treat a range of diseases, acute leukaemia being just one example.
Sometimes a patient will also need donor lymphocytes after a transplant from a donor and these donor lymphocytes are also collected as required. The clinical use of peripheral blood stem cells is likely to grow further, as indications for using this form of treatment expand.
Therapeutic plasma exchange
A patient's plasma may be removed and replaced by donated plasma, or another replacement fluid, as part of the treatment for a range of conditions. For example, in a rare disorder called thrombotic thrombocytopenia purpura (TTP), the patient has low platelet counts, there is destruction of red blood cells and small blood clots form in blood vessels throughout the body (Scully et al, 2012). Daily plasma exchange will be required as soon as possible following diagnosis and will continue daily until the patient responds and their platelet count is stable.
Automated red cell exchange
In sickle cell disease, automated red cell exchange is used to remove the abnormal HbS sickle cells and replace them with donated red cells. This procedure may be done in an emergency to treat symptoms, for example if the person with sickle cell has an acute stroke or chest crisis. It may also be done before surgery or as part of a programme to prevent further complications in some patients, such as those who have recurrent painful crises or had a previous stroke.
Extracorporeal photopheresis
Extracorporeal photopheresis (ECP) procedures are generally undertaken in patients who have had a stem cell or bone marrow transplant from a donor and have then gone on to develop a complication called graft versus host disease (GvHD). ECP uses a closed system to collect the patient's white blood cells. A drug is then added to these cells that makes them sensitive to ultraviolet (UV) light. The cells are then exposed to UV light, before being returned to the patient. Successful treatment with ECP can significantly improve a patient's quality of life, in addition to reducing the symptoms of GvHD.
White cell depletion
Some patients with leukaemia have very high white cell counts when they are diagnosed. Before treatment with chemotherapy can begin, it may be necessary to remove some of these abnormal white cells. This is often performed as an emergency procedure.
CAR-T cell collections
Working in partnership with hospital clinical teams, pharmaceutical companies and research groups, in several of our units TAS nurses undertake apheresis procedures for patients who will receive chimeric antigen receptor T-cell (CAR-T) therapy. CAR-T is a new and rapidly evolving type of immunotherapy, which involves collecting and using the patients' own immune cells to treat their condition. A patient's lymphocytes are collected and sent to a laboratory where they are manipulated or ‘trained’ to fight the patient's cancer cells. The CAR-T blood is then transported back to the hospital to be administered back to the patient to treat their condition.
| Birmingham | Collection and exchange apheresis services |
| Bristol* | Collection and exchange apheresis services |
| Cardiff* | Extracorporeal photopheresis |
| Leeds | Collection and exchange apheresis services |
| Liverpool | Collection and exchange apheresis services |
| London | Collection and exchange apheresis services |
| Manchester | Collection and exchange apheresis services |
| Oxford | Collection and exchange apheresis services |
| Plymouth* | Extracorporeal photopheresis |
| Sheffield | Collection and exchange apheresis services |
Working for NHSBT Therapeutic Apheresis Services
Nursing within NHSBT may not be one of the first options that come to mind for nurses considering a change of direction in their nursing career. Many nurses across the UK are blood donors and may be aware that nurses work in blood donation, but the role of nurses within TAS is not as widely known.
Many of the apheresis procedures undertaken by our nurses are elective and done on an outpatient basis in the TAS unit where that nurse is based. Children and adult inpatients who are too unwell to be moved to the TAS unit are treated at their hospital. The TAS equipment is transported to the patient's hospital, where the TAS nurse who is performing the procedure will work alongside that patient's clinical team to deliver their care. Thus TAS nurses work both in their TAS unit and also travel to other hospitals in their region to provide both routine and emergency procedures.
In some clinical conditions, such as newly diagnosed TTP or acute stroke in sickle cell disease, emergency apheresis procedures may be necessary and can be life-saving. To reduce the risk of a patient dying, or being harmed because of a delay in starting treatment, our nurses are flexible and responsive, providing an out-of-hours on-call service, 24 hours a day, 365 days a year.
Because TAS is a national service, we are in the unique position of being able to draw on the extensive experience of the nurses across our whole team and our national training and education structure, to train, support and develop new nurses who join us. We have a national infrastructure and our senior nursing, quality and management team work across the country, to support our nurses working in each TAS unit. Apheresis is a highly specialised area of nursing and there is a growing demand for this clinical skill.
Our TAS nurses work closely alongside other specialist teams and units, supporting and collaborating in research and clinical trials across the country. TAS also identifies areas for research and undertake research projects initiated from within the team. Our work in this area supports advances in the treatment of patients and the development of new therapies.
NHSBT has a robust quality management structure and TAS has a culture that supports ongoing quality improvement, to ensure safe and clinically effective care is delivered to our patients and donors. Our units are inspected by the Human Tissue Authority (HTA), the Care Quality Commission (CQC) and JACIE, which stands for the Joint Accreditation Committee International Society Cell & Gene Therapy (ISCT) Europe and the European Society for Blood and Marrow Transplant (EBMT). Nurses joining our team benefit from gaining significant experience of quality systems and quality management.
Nursing roles in TAS
Two nurses, one a nurse practitioner and one a lead nurse, describe their roles below.
Claire Morris, nurse practitioner, Manchester TAS
I joined the TAS team as a nurse practitioner just over 1 year ago. Our team is based in a unit within The Christie NHS Foundation Trust, Manchester, and is made up of seven nurse practitioners, one lead nurse and one unit assistant. We cover the north-west of England.
I have been qualified for 20 years. Prior to my role in TAS, I had worked in trauma and orthopaedics, gastroenterology, haematology and emergency medicine, including management roles. Since joining TAS I have followed a training plan with our education lead, which ensures I am competent in our apheresis procedures and am able to perform them independently either during a planned or an emergency treatment.
The role requires us to be highly skilled in the delivery of our specialised service and we have a high level of autonomy because we work remotely away from our base, caring for patients who are unable to come to the TAS unit. All TAS nurse practitioners participate in the emergency on-call service and, as a result, we develop wide-ranging experience, through undertaking procedures for acutely unwell patients, across a range of different environments. We treat patients with a variety of conditions, varying from auto-immune diseases, renal diseases, blood disorders and cancers. Indications for treatment are guided by the American Society for Apheresis Guidelines (ASFA) (Padmanabhan, 2019) and Howell et al (2015).
Our treatment is valuable in the care of children as well as adults. When caring for children, the treatment is performed within a paediatric environment; however, it does require specific modifications and management of the treatments. We also adapt the monitoring we do if the patient is a child, so that it is appropriate for their age group. As a team we have all advanced our understanding of working with children and their families.
The job allows us to demonstrate our clinical and leadership skills every day, to ensure that our patients and donors receive safe and effective care. Our role requires a high level of communication skills and the ability to establish a rapport with the referring team and nurses, who work alongside us when visiting non-host trusts. We work closely with, and are well supported by, our lead nurses and our NHSBT consultants, who review all referrals to our service and write an individualised treatment plan for each person.
Alka Chauhan, lead nurse, Bristol
I have been a lead nurse for 10 years. My TAS unit is located within the United Hospital Trust in Bristol and comprises five beds. The team consists of eight nurses and our unit assistants, who assist us with administration. My role as a lead nurse is extremely varied, from management and leading my team, to providing clinical expertise, giving advice to nurses and referring teams. I teach and deliver training, attend and present at meetings, and, alongside all of that, I also treat patients.
I have a very busy unit and in one day we could be doing the whole range of procedures and treatments we provide. We have booked appointments, but emergencies can come at any time. No one day is the same and that's what makes my job so fantastic.
I also lead our satellite Plymouth unit. In 2017 we started providing ECP treatment at Derriford hospital in Plymouth, up until then the Plymouth patients had to travel all the way to Bristol for ECP treatment. Starting this satellite service has made a real difference for these patients and their families. Patients with acute GvHD are on weekly treatment, 2 days a week, and those with chronic GvHD start on fortnightly treatment 2 days a week and then treatment is tapered down as they respond. There is a UK consensus statement (Alfred et al, 2017) that is followed by clinicians, to guide ECP treatment. Between 2018 and 2019 the Bristol Unit I lead provided approximately 1000 ECP treatments for both adults and children.
Conclusion
Therapeutic apheresis and cell collection services have existed within NHSBT for many years and since the formation of TAS, our service has rapidly developed. Working in partnership with NHS trusts, we envisage our service will continue to expand, to support hospitals in meeting unmet demand.
Nurses working within NHSBT TAS develop highly specialised skills and work across a range of different hospital environments, which provides them with interesting and varied experience when at work. Our annual patient experience surveys consistently show a high level of satisfaction with the service.
TAS is committed to the education of our nurses and to supporting educational initiatives for nurses working in other organisations. We host a biannual apheresis conference and have recently worked in partnership with the Scottish Blood Transfusion service to deliver this event. Currently we are developing digital learning modules, which will be shared with others, and have plans in progress for further educational resources.
A great deal of work is going on within NHSBT TAS to improve and save more lives than ever, alongside our NHSBT colleagues working in other parts of the organisation and our NHS colleagues in the hospitals where we are based. Many nurses may not have thought that TAS was part of NHSBT before, but it is hoped that now they will have greater insight into what we do.