TRANSFUSION POLICY (ADULT)

Version / 10
Name of responsible (ratifying) committee / Hospital Transfusion Committee
Date ratified / 06 July 2018
Document Manager (job title) / Transfusion Practitioner
Date issued / 02 August 2018
Review date / 05 July 2021
Electronic location / Clinical Policies
Related Procedural Documents / Patient Identification Policy; Consent to Examination and Treatment Policy; Management of Adverse Events and Near Misses; Management of Serious Incidents Requiring Investigations; Massive Transfusion (Haemorrhage) Guideline; Policy for the Care of Patients Who Wish to Decline Transfusions
Key Words (to aid with searching) / Blood; Platelets; Red Cells; Adverse Transfusion Reactions; Administration; Observations; Blood Components; Administration Sets; Plasma; Blood Transfusion; Consent; Blood Warmers; Jehovah’s Witnesses; Religious Beliefs; Training;

Version Tracking

Version / Date Ratified / Brief Summary of Changes / Author
10 / 06/07/2018 / ‘Blood’ removed from title; Indication codes updated; Platelets and frozen components now included (adapted from guidelines on pharmacy pages);Consent sticker now mandatory; “Should” changed to “Must” throughout / K Heron / Sue Chambers
9 / 22/04/2016 / Title. Minor adjustments throughout. Indication Codes; Special Requirements; Consent Sticker; Written Instruction and Observation Sheet; Flyer Information; Reaction Flow Chart. / K Heron/ Sue Chambers
8 / 26/10/2012 / - / J Hickey

CONTENTS

QUICK REFERENCE GUIDE

1.INTRODUCTION

2.PURPOSE

3.SCOPE

4.DEFINITIONS

5.DUTIES AND RESPONSIBILITIES

6.PROCESS

7.MANAGEMENT OF ADVERSE TRANSFUSION REACTIONS

8.RAPID INFUSIONS AND BLOOD WARMERS

9.STORAGE

10.USE OF PLATELETS

11.USE OF FRESH FROZEN PLASMA (FFP) AND CRYOPRECIPITATE

12.TRAINING REQUIREMENTS

13.REFERENCES AND ASSOCIATED DOCUMENTATION

14.EQUALITY IMPACT STATEMENT

15.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

APPENDIX 1: Indication Codes for Transfusion

APPENDIX 2: Blood Transfusion, Size Matters!

APPENDIX 3: Consent for Transfusion

APPENDIX 4: Written Instruction

APPENDIX 5: Blood Component Specific Requirements

APPENDIX 6: Emergency Blood Issue

APPENDIX 7: Acute Transfusion Reactions (ATR)

APPENDIX 8: Common Complications Associated with Transfusion of a Blood Component

APPENDIX 9: Modified WHO Bleeding Score

EQUALITY IMPACT SCREENING TOOL

QUICK REFERENCE GUIDE

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.

  1. Obtaining consent for all transfusions is a Department of Health requirement and is the responsibility of the Clinician or Non-Medical Authoriser making the decision to transfuse. Do not forget the rights of the competent patient to refuse a transfusion or request an alternative treatment, if available. Transfusion Patient Information Leaflets are available and must be offered
  1. Transfusion written instruction (prescription) must include four patient specific identifiers: surname, first name, date of birth and NHS number. If patient has no NHS number write on request form “NHS number not available” and use Casenote/Hospital/PAS number. For “unknown” patients (primarily ED) use ED number, unknown and gender. Type of blood component, specific requirements (e.g. CMV negative, irradiated etc.), quantity to be given, duration and rate of infusion, name and signature of Clinician or Non-Medical Authoriser
  1. Only suitably trained registered practitioners can request blood and blood components. Request forms must contain the four markers of patient identification (PID) as above, together with the reason for transfusion (Indication Code, appendix i, page 24), date and time required, name and signature of requesting Clinician or Non-Medical Authoriser, and the location
  1. Only suitably trained staff may take samples for group and screen and cross-matching. The sample must be taken into an EDTA (pink top) tube. These must be correctly labelled by hand, beside the patient, from the PID band (inpatients), with the four points of ID and they must be dated, timed and signed. All samples must be labelled by the staff member who took the sample
  2. When a cross-match is requested and the patient does not have a historical group recorded on the Apex (LIMS) computer system, the Transfusion Laboratory staff will request a second sample. This will NOT cause a delay in obtaining blood for the patient when blood is required urgently. The patient will receive group ‘O’ until the group has been verified. Whilst there is no time specification between the two samples, they MUST NOT be taken at the same time. Ideally taken by a different practitioner and must be sent with a separate request form
  3. A consent sticker (appendix iii, page 29)must be used to document, that the process of gaining informed consent has taken place
  4. All staff collecting blood and blood components must have initial training then annual revalidation. All staff are responsible for ensuring their training needs have been met.
  5. Before collecting the blood or blood component, ensure the patient is ready to receive the transfusion and has the correct PID band in situ.
  6. When collecting blood or blood components, staff must check the four specific points of PID (as above) they have brought with them against the component label before scanning it out of the issue fridge or signing for it from within the Transfusion Laboratory (any discrepancies must be reported to a member of the Transfusion Laboratory staff immediately)
  7. Blood and blood components must be commenced, or returned to the Transfusion Laboratory within 30 minutes from collection
  8. Before administration the specific four points of PID (as above) must be checked against the component label and the PID band at the side of the patient. Do not connect any components unless you have checked all the details are correct yourself (any discrepancies DO NOT GO AHEAD, report to Transfusion Laboratory staff immediately)
  1. Transfusions must be given in clinical areas, where frequent visual and verbal contact with the patient may be maintained
  2. As a minimum per unit, the conscious patients’ temperature, pulse, respiratory rate (TPR), blood pressure (BP) and oxygen saturations (O2 Sats) must be checked before the start of the transfusion, 15 minutes following the start of the transfusion and again at the end of the unit. The unconscious patient requires, as a minimum per unit, TPR, BP and O2 Sats before the unit is started, every 15 minutes for the first hour and hourly thereafter
  3. Blood and blood component labels must be fully completed. As indicated, one must be returned to the Transfusion Laboratory and one fixed to the patients’ transfusion written instruction/notes
  4. Patients must be encouraged to inform a member of staff if at any time during the transfusion they feel unwell (day case patient information leaflets to be given on discharge, available to order from Medical Illustration ref: 14/5879)
  5. A giving set used for a blood transfusion must NOT be subsequently used for administering fluids or different blood components
  6. Accurate documentation of the transfusion must be maintained
  7. Any suspected adverse reaction(s) or events should be communicated to the Transfusion Laboratory staff and/or to the Transfusion Practitioner (TP) and Transfusion Practice Educator (TPE) and a Datix report completed
  8. Blood and blood components must NOT be stored in a ward domestic or drug fridge UNDER ANY CIRCUMSTANCE
  9. Routine transfusions may be administered overnight, providing the environment is conducive to safe practice enabling close visual monitoring of and verbal communication with the patient and all observations to be carried out and recorded as per this policy. However, if the transfusion could safely wait until the day time then this would be preferable.

TRANSFUSIONS MUST TAKE PLACE OVERNIGHT IF THE PATIENT IS BLEEDING OR SYMPTOMATIC

Use of Platelets, page: 19

Use of FFP and Cryoprecipitate, page: 21

1.INTRODUCTION

Appropriate transfusion is an essential support to many medical treatments and can be lifesaving. There are many risks to the patient, including acute haemolytic reactions and transfusion transmitted infections. Incidents affecting the safety of transfusion are highlighted through the Serious Hazards of Transfusion (SHOT) haemovigilance scheme. This scheme has shown that avoidable, serious hazards of transfusion continue to occur in Trusts throughout the UK, the most frequent factor being human error. Out of 3091 total reported incidents, 87% were caused by human error (often multiple errors). There has been little progress in the last decade (Annual SHOT Report 2016, July 2017).

Stringent procedures must be followed to ensure that the correct blood/blood component is always given and that any adverse reactions are dealt with promptly and efficiently.

Procedures for requesting, writing up and the administration of blood and blood components, as well as the management of any complications support this clinical policy on transfusion. Procedures for the documentation of transfusions in nursing, medical and laboratory records are also provided, including the procedure for the reporting of any adverse reactions or events occurring in relation to transfusions.

This clinical policy has been revised to clarify terminology, incorporating core standards in transfusion practice in adult patients.

Neonatal Intensive Care patients are one of the most transfused groups and because of their potential normal life expectancy they are more susceptible to the long-term effects of transfusion. Particular care and attention must be given to neonates and children to minimise blood component use. See local departmental PHT policy for neonatal and paediatric practice.

This policy reflects the Blood Safety and Quality Regulations (BSQR) 2005, current NICE guidelines and BSH recommendations.

2.PURPOSE

The purpose of this policy is to:

  • Provide a clear framework and guidance for safe transfusion practice, throughout Portsmouth Hospitals NHS Trust (the Trust)
  • Ensure a consistent approach to the requesting, writing up, handling and administration of blood and blood components throughout the Trust
  • Ensure that all members of staff involved at any stage of the process of transfusing blood and blood components are aware of their role and the legal aspects of this practice

3.SCOPE

This policy applies to all staff involved in the requesting, sampling, prescribing, storing, collecting, transporting and administering of human blood and blood components, including those who work in Primary Care Trusts supplied with blood/blood components from the Trust Transfusion Laboratory.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain on going patient and staff safety’

4.DEFINITIONS

Transfusion: blood or any of its components used to correct or treat a clinical abnormality

Blood component: red cells, platelet concentrate, fresh frozen plasma (FFP), OctaplasLG®, and cryoprecipitate

Blood Product: any drug which is manufactured using human blood components

Patient Blood Management (PBM): a standard of care that focuses on measures to reduce or avoid the need for transfusion if possible. If a transfusion is needed, the aim is to ensure that the patients are only given what they really need and that the transfusion is given safely

Cold chain: the legal requirements to monitor transport and storage conditions of blood components, from donor to recipient

Maximum Surgical Blood Ordering Schedule(MSBOS):the Trust’s agreed maximum number of cross-matched units or group and screen testing requirements for surgical procedures

Medicines and Healthcare Products Regulatory Agency (MHRA): An executive agency which aims to enhance and safeguard the health of the public by ensuring that medicines and medical devices work and are acceptably safe

Serious Adverse Blood Reactions and Events (SABRE): the MHRA reporting schemeto which serious adverse reactions and events related to blood components / products are reported

Serious Hazards of Transfusion (SHOT):the United Kingdom’s independent, professionally-led haemovigilance scheme, responsible for recording and monitoring all blood component adverse events and reactions

Serious Incidents Requiring Investigation (SIRI): Trust system for investigating Amber or Red incidents and events

5.DUTIES AND RESPONSIBILITIES

(A)The Hospital Transfusion Committee (HTC)

The HTC includes members of the Hospital Transfusion Team and representatives from all clinical areas where blood and blood components are administered.

Responsible for:

  • Overseeing all aspects of transfusion practice
  • Promoting good transfusion practice based on national guidelines through the provision of a robust framework to communicate information and advice
  • Arranging for audits of blood and blood component usage to be carried out, in line with local and national requirements and receiving and reviewing the reports of those audits
  • Making recommendations to address any issues highlighted by the reports and monitoring the implementation of the actions
  • Receiving quarterly reports from the Hospital Transfusion Team regarding the trends and themes from adverse incidents, including any variance from this policy and for recommending any actions to address the variance
  • Reviewing all SHOT submissions and ensure the root causes are identified and all necessary action taken to prevent a recurrence
  • Monitoring the implementation of actions arising from the investigation of SIRI
  • Receiving the results of all audits associated with the transfusion process and developing any required action plans to address the identified issues
  • Undertaking regular review of this policy and recommending any changes as highlighted by audits or adverse incidents
  • Ensuring any risks associated with the transfusion process are assessed and escalated to the Trust Risk Register
  • Acting as a forum to discuss advancements in transfusion practice, including PBM and reviewing and amending practices and policies in the light of those advancements
  • Providing, through the Chair, an annual report on all aspects of transfusion practice, to the Governance and Quality Committee

(B)Hospital Transfusion Team (HTT)

The HTT includes the Clinical Lead for Transfusion, Transfusion Laboratory Manager (TLM), Transfusion Laboratory Seniors, Transfusion Practitioner (TP) and Transfusion Practice Educator (TPE).

Responsible for:

  • Meeting at least once a month to discuss current issues and incidents
  • Addressing and monitoring any outstanding corrective and preventative actions
  • Informing the decision-making process for new initiatives
  • Ensuring the HTC is informed of any required audits
  • Reporting quarterly to the HTC
  • The review and development of policies and guidelines

(C)Clinical Lead for Transfusion

Responsible for:

  • Acting as the main point of contact for medical staff, including GP’s, requiring information, advice and guidance on transfusion issues
  • Submission of clinical information to NHSBT to aid investigation of serious adverse transfusion reactions, in conjunction with TP and TPE

(D)TLM

Responsible for:

  • Ensuring the Transfusion Laboratory complies with the legislation as set down in the Blood and Safety Quality Regulations (BSQR 2005) and the statutory requirements of the Department of Health to ensure patient and staff safety
  • Submission of reports to SABRE and/or SHOT, in conjunction with the TP and TPE
  • The investigation of all adverse incidents and near misses associated with any aspect of transfusion, in conjunction with the TP, TPE and Laboratory Seniors

(E)TP and TPE

Responsible for:

  • Submission of reports to SHOT and/or SABRE, in conjunction with the TLM and Laboratory Seniors
  • The investigation of all adverse clinical incidents and near misses associated with any aspect of transfusion
  • Provide the HTC with quarterly reports on all aspects of transfusion practice, including adverse events
  • Facilitate education and training for all relevant clinical staff groups
  • Participate in local and national audits and feedback results to HTT and HTC
  • Maintain and update relevant clinical policies
  • Provide advice and support on transfusion matters to clinical staff

(F)Clinicians Including Non-Medical Authorisers

Responsible for:

  • The decision to transfuse in conjunction with NHSBT indication codes (appendix i, page 24)
  • For stable, non bleeding patients consideration must be made that each unit is a separate clinical decision in conjunction with the potential risk of Transfusion Associated Circulatory Overload (TACO), see appendix ii, page 27
  • The consent process, sticker (appendix iii, page 29) must be fully completed and placed into the patients’ notes. Patient written information leaflets must be offered, these are available from TP and TPE
  • Where practical, informing patients of alternatives to transfusion
  • Full completion of Transfusion Written Instruction (appendix iv, page 30)
  • Ensure any specific requirements are met (appendix v, page 32)

(G)All Ward and Line Managers

Responsible for:

  • Being aware of this policy and associated policies and guidelines
  • Releasing staff for training
  • Integrating compliance into the Knowledge and Skills Framework (KSF) and Annual Performance and Development Appraisals (APDR) for all their staff
  • Ensuring appropriate evidence of compliance is gained during the APDR process
  • Ensuring their staff are aware of and understand this policy and comply with its content
  • Communicating any concerns regarding staff compliance with this policy to the TP/TPE

(H)All Staff Involved in the Processes Associated with Transfusion

Responsible for:

  • Being aware of this policy and associated policies and guidelines
  • Comply with this policy at a level commensurate with their involvement
  • Attending training relevant to their role in the process
  • Report all adverse events and near misses on Datix to enable investigation/monitoring by TP/TPE

6.PROCESS

Note: whilst the same principles apply to all patients regardless of age, there are some very specific issues which relate to neonates and paediatrics, see local PHT departmental guidelines.