Better Blood Transfusion Programme Continuing

Better Blood Transfusion Programme – Continuing

Education Programme

Module 1 - Safe Transfusion Practice

Administration of Blood & Blood Components and Management of the Transfused Patient

Better Blood Transfusion

Scottish National Blood Transfusion Service

Ellen’s Glen Road

Edinburgh

EH17 7QT

0131 536 5962

Version 2009

Introduction

This handout has been designed to help you understand the issues surrounding:

The hazards of transfusion
The legal requirements that relate to transfusion of blood components
Basic ABO serology
The decision to transfuse
Taking of a blood sample for pre- transfusion testing
Identification of the correct storage conditions for blood components
Correct procedures for collecting blood components
Correct procedures for administration of blood components
Correct procedures for monitoring the transfused patient
Equipment required when setting up a transfusion

The handout consists of a short introductory paper and a recommended reading section, you should refer to your hospital Blood Transfusion Policy as you work through this handout. Should you require assistance you should approach your local co-ordinator.

Glossary of Terms

Blood Administration SetInfusion set incorporating a mesh filter 170-200

micron pore size), for infusion of blood component

CompatibleNot possessing an antigen or antibody which may

induce a haemolytic reaction in the recipient (may not

be blood group identical)

Traceability labelTie on label bearing patient's details and unique

number of component which is applied to the

component by the hospital transfusion laboratory

prior to issue

CryoprecipitateFibrinogen-rich component formed by collecting the

precipitate which forms in FFP on thawing at 4oC

Fresh Frozen PlasmaPlasma removed from whole blood donation and

(FFP)frozen within 8 hours of donation

LeucodepletionRemoval of white cells by filtration to achieve <5 x 106

per unit

Platelets - pooledPlatelets collected from 4 or more blood donations

and pooled in one bag to give an adequate adult dose

Red Blood Cells (RBCs)Any one of a number of blood component whose

principal constituent is red cells

Request formStandard form bearing details of patient, test/product

required which accompanies blood sample to

laboratory

TraceabilitySystem used to identify and record the specific blood

component received by an individual patient

Safe Transfusion Practice - An Overview

Introduction

The Serious Hazards of Transfusion (SHOT) Scheme was launched in November 1996. It is a voluntary scheme covering both private and NHS hospitals in the United Kingdom and Northern Ireland. The aim is to collect data on the serious sequelae of transfusion of blood and blood components in order improve safety of the transfusion process, (in both the Transfusion Service laboratories and clinical areas) and to develop standards and guidelines for the use of blood and blood components.

Typical errors during the administration of blood products can result in:

The blood sample for pre-transfusion testing being drawn from the wrong patient

Patient details being recorded incorrectly on the blood sample tube label or the blood request form

The incorrect blood component being collected from the blood refrigerator The formal final identity check at the patient’s bedside being omitted or performed incorrectly at the time of administration

Since the UK Serious Hazard of Transfusion (SHOT) scheme was launched in 1996, largest number of serious adverse events reported to SHOT were in the category of ‘Incorrect Blood Component Transfused’. The majority of these episodes involved the administration of a unit of blood intended for another patient and generally involved more than one error in the transfusion process. The majority of these errors occurred during the collection or administration part of the transfusion process resulting in the death of 24 patients. A further 107 patients suffering major morbidity, for example requiring admission to intensive care or dialysis due to renal failure.

The transfusion process involves a number of steps that may appear to be simple. SHOT have summed up the correct outcome of this process in a simple slogan:

‘RIGHT BLOOD, RIGHT PATIENT, RIGHT TIME’

Our aim is to ensure that you understand the transfusion process and that the above slogan works every time!

In addition to the voluntary SHOT reporting scheme, since 2005, the transfusion of blood components has been covered by UK legislation under the Blood Safety and Quality Regulations (2005). The regulations apply particularly to the laboratory aspects of the transfusion process but also involve clinical areas because they cover storage, distribution and traceability of all components. It is also a legal requirement to report adverse reactions and events to the identified competent authority, check with local protocols for method of reporting.

Basic ABO Serology

ABO groups are named after the antigens present on the red cell surface. In the ABO groups, individuals produce antibodies (immunoglobulins) against the antigens that are not present on their own red cells. Thus group O individuals have, in their plasma, antibodies to both group A and group B while group AB individuals do not have either of these antibodies.

If red cells carrying A or B antigens are transfused to someone who has antibodies to these then a severe immune reaction can occur which may be fatal. The red cells are not compatible with the recipient. The transfusion of only a few mls of the wrong (incompatible) ABO group can trigger a massive immune response leading to shock and disseminated intravascular coagulation. Individuals may die from circulatory collapse, severe bleeding or renal failure, often within minutes or hours.

Group O blood can be safely given to all groups of patients in a life threatening situation as there are no A or B antigens to react with the recipient’s antibodies.

COMPATIBLE DONOR RED CELLS
Patient's / A / B / AB / O
Blood Group
A / b / r / r / b
B / r / b / r / b
AB / b / b / b / b
O / r / r / r / b

85% of the population are RhD Positive and 15% RhD Negative. RhD Negative blood is often in short supply so it may be necessary to use RhD Positive blood for the transfusion of RhD Negative patients. Although giving RhD Positive blood to an Rh Negative patient will sometimes induce formation of Anti-D this does not cause any acute problem. The immune anti-D will be picked up by the hospital; transfusion laboratory the next time a group and screen is performed on the patient. RhD-negative blood would then be issued if a blood transfusion was required.

Immune Anti-D made by an RhD Negative mother exposed to an RhD Positive blood, can cause haemolytic disease of the newborn or severe fetal anaemia and heart-failure (hydrops fetalis) in RhD Negative females of child-bearing potential.

Decision to Transfuse

Signed consent for transfusion is not a legal requirement in the UK however the patient should be informed in a timely manner of why they might need or require a transfusion. The discussion should include information on the risks and benefits of transfusion and the patient or their relative should be given the opportunity to raise any concerns they might have and to talk about the possibility of alternative therapies such as autologous transfusion or iron therapy. Patient information leaflets are available from your local hospital or Blood Transfusion Service.

Before commencing the transfusion the nurse should check the decision to transfuse is recorded in the patient’s case notes prior to administration in order to ensure that they are aware of the patients’ current assessment and planned programme of care, (NMC,

Standards for Medicines Management, 2008).

Good Practice Advice

Use the patient information leaflets that are available from your local hospital or Blood Transfusion Service.

Requesting Procedure

The person making the request is responsible for checking the patient’s case notes for any previous transfusion history. Any special requirements, such as irradiated or CMV negative blood, should be clearly stated on the request form or electronic system (if applicable).

Taking the Pre-transfusion Sample

Complete the request form or the order com/ electronic system, making sure you include all the relevant information e.g., previous transfusion history or any special requirements. You should clearly state when the blood is required. Most request forms will be completed by a doctor or clinical nurse specialist however, the sample may be taken by another staff member i.e., phlebotomist. The person filling in the form is responsible for identifying if the patient has special transfusion requirements.

The current BCSH guideline (BCSH, 1999) recommends that you do not use addressograph labels for sample labelling, as this practice is more likely to result in an error of patient identification. Never pre-label the compatibility tube (i.e., do not write the details on the sample label in advance of drawing the blood). Pre-labelling of sample tubes has been identified as a major cause of patient identification errors that can lead to fatal transfusion reactions.

When a pre-transfusion test is requested, it is important to bleed only one patient at a time in order to reduce the risks of a patient identification error occurring. You should follow the procedure detailed below.

Step 1:

Step 2:

You must positively identify the patient BEFORE drawing the sample. This can best be achieved by asking the patient to tell you their:

♦ First name

♦Last name ♦Date of Birth

Check this information against the patient’s identification band for accuracy.

If you are taking a sample for pre-transfusion testing from a patient in the out patient setting where they may not be wearing an identification band, refer to your local hospital policy for advice.

In the unconscious patient (or in paediatric practice) it is imperative to verify the patient identification details with a second member of staff. In unidentified patients in the A/E department the unique identification number should be used at all times during the transfusion process.

The details on the patient’s identification band must then be checked against documentation e.g., patient case notes, to ensure that they are accurate.

Collect 5 ml (minimum 1 mL for neonates or very young patients) of blood into the appropriate sample tube. Hand-write the sample tube clearly and accurately (it is essential to spell the patient’s name correctly and consistently) with the following information beside the patient after you have drawn the blood sample:

♦First name ♦Last name ♦Date of birth

♦Hospital number ♦Hospital ward ♦Date

♦ Signature of person drawing the sample.

Samples should be sent to the hospital transfusion laboratory the most appropriate way for the clinical situation, routine samples should be sent by the identified method for your hospital. For urgent samples, you should notify the HTL by telephone and send the sample and request from by most rapid method or the identified method for your hospital i.e., local major haemorrhage protocol.

Good Practice Advice

Spell the patient’s name correctly and consistently when you label the sample tube and complete the request form.

Avoid taking the blood sample from the arm that is the infusion site because this may result in a diluted sample being sent for analysis, or a spurious laboratory result being obtained.

Collecting Blood Components

The procedure for collecting blood components is the same regardless of whether you are collecting blood from the hospital transfusion laboratory (HTL) or from a satellite refrigerator in the clinical area. The following procedure should be undertaken for each blood component required. Before completing the Blood Collection Form or phoning the portering service to ask for a blood component to be collected, it is vital that you positively identify the patient and ensure they have patent IV access.

Step 1: When collecting all blood components the following information is required:

♦ First name

♦Last name ♦Date of Birth

♦Hospital Number ♦Gender

You should complete the Blood Collection Form or follow your local hospital procedure. The details on the Blood Collection Form or document containing the patient's identification details must match the information on the patient's identification band.

If you are giving the patient’s identification details over the telephone, ask for the information to be read back to you to ensure that it is correct. In unidentified patients in the A/E department the unique identification number should be used at all times during the transfusion process.

Step 2:

Step 3:

On collection of the blood component the patient ID details must be checked against the traceability label attached to the blood component to ensure that they match.

All components must be documented on collection either electronically or manually.

As a minimum, the following information should be recorded:

♦Donation number of the component ♦Date and time of removal

♦ Signature

The components should be delivered promptly to the clinical area and a trained member of staff should check and sign that the correct blood component has been delivered.

If returning an unused component to the HTL or the blood refridgerator you must document the date/time of return in the appropriate register as this is a requirement under the Blood Safety and Quality Regulations. Red cells that have been out of refrigeration and have not been transfused within four hours must be returned must to the blood bank. Once out of the cold chain, the pack will slowly warm to ambient temperature, increasing the risk bacterial proliferation and red cell metabolism. Blood bank quality procedures must ensure that al red cell unit available for transfusion have remained under approved storage conditions.

Good Practice Advice

Inform the person who requested the blood that it has arrived as soon as it is delivered to the clinical area.

The Administration Procedure

Only designated staff should perform the final bedside check (check your local policy for authorised staff groups). The following process should be repeated for each component to be administered. You should ensure that the blood component has been prescribed (and confirm if any concomitant medication has been prescribed, e.g., a diuretic). You should also check if the patient has any special requirements, e.g., irradiated blood components. You must undertake baseline observations of temperature, pulse and blood pressure and visually inspect the unit for discoloration or clumping before commencing the transfusion. The expiry date/time of the component must also be checked.

If you are interrupted at any stage during the checking procedure you should start again.

Step 1: It is vital that you positively identify the patient. This can best be achieved byasking the patient to tell you their:

♦ First name

♦Last name ♦Date of Birth

Check this information against the patient’s identification band for accuracy.

Step 2: Check the patient’s first name, last name, date of birth, hospital number andgender details on the traceability label attached to the blood bag against the patient’s ID identification band.

Step 3: You should check that the blood group and the donation number on thetraceability label are identical to the blood group and donation number on the blood component.

A different but suitable blood group, which is compatible with the patient, may have been issued. If you are unsure about the suitability of the component check with the HTL before transfusing.

NB: If there are any discrepancies at any point, you should not proceed with the transfusion of blood components until they have been resolved. This process should be repeated for each component administered.

The Documentation Procedure

The UK Blood Safety & Quality Regulations (2005) introduces a legal requirement to ensure unmistakable traceability of every blood component from donor to patient or final fate if not transfused. The related evidence is to be retained and accessible for 30 years. You should refer to your local traceability policy.

Documentation must be completed for each component transfused. The donor unit number, the date and time of transfusion and the signature of person(s) undertaking the checking procedure must be recorded on the traceability and hospital transfusion documentation (e.g., compatibility form/ prescription sheet or transfusion record). The completed form must be filed in the patient case notes and kept as a record of transfusion.

Monitoring of the Transfused Patient

You should observe the patient during the transfusion of blood components to detect any adverse event as early as possible so that potentially life-saving action may be taken if necessary. Monitoring is required for all patients during the transfusion event as adverse reactions may occur with any blood component. The majority of severe reactions present during the first 15 minutes of a transfusion and you should observe your patient most closely during this period.

♦Prior to commencing the infusion briefly explain the procedure to your patient and advise them to notify staff immediately if they become aware of any reaction such as shivering, flushing, pain or shortness of breath.

♦Wherever possible you should administer transfusions in areas where the patient can be readily observed by the clinical staff.

♦Prior to commencing the transfusion of each unit, you should record the patient’s temperature, pulse and blood pressure on the appropriate chart (baseline recording). The patient’s temperature and pulse must be recorded 15 minutes after commencement of each unit. At the end of each blood component the patient’s temperature pulse and blood pressure must be recorded.

♦Additional recordings are at the discretion of each clinical area however, it is essential to continue observing your patient if they are unstable or if they appear to be experiencing an adverse reaction. Unconscious patients require routine observation to continue during transfusion.