NHS Professionals. NHS Professionals Blood Transfusion Guidelines represent the minimum standard expected in transfusion practice.

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1 CG4 - Blood Transfusion Guidelines NHS Professionals Introduction The transfusion of blood and blood products is an important, often lifesaving, part of the treatment of many patients. It is also a procedure that has an element of risk, with errors potentially leading to the death of or long term damage to a patient who receives the wrong blood. SHOT (Serious Hazards of Transfusion) data for 2009 have shown that a total of 14 ABO incompatible red cell transfusions were given, 10 of which resulted from bedside administration errors and 3 from errors with the cross matching blood sample. 3 patients died following reactions related to these ABO incompatible transfusions (SHOT 2009) Such potentially fatal errors are almost completely preventable through consistent good practice However audits of practice in transfusion have shown that simple preventative measures such as the patient having a correct wristband or observations being taken in the first 30 minutes of transfusion can be overlooked (Taylor 2005). Administering the wrong blood type is the most serious outcome of error during transfusions. Most of these incidents are due to the failure of the final identity checks carried out between the patient (at the patient s side) and the blood to be transfused (NPSA 2006). NHS Professionals flexible workers who are involved in administering a blood transfusion to a patient during their assignment have a responsibility to ensure that their practice is safe, particularly if the surroundings are unfamiliar. As part of your orientation to a Trust you should familiarise yourself with local Trust policies and procedures regarding blood transfusion as these will vary from Trust to Trust. NHS Professionals Blood Transfusion Guidelines represent the minimum standard expected in transfusion practice. Scope of guidance This guidance applies to flexible workers working for NHS Professionals in acute healthcare settings. It is essential that you confirm which parts of the blood and blood products administration process you may participate in as an NHS Professionals flexible worker under the policy of the hospital you are working in. Even when permitted to do so, you must only undertake those aspects of care in which you have been trained and are competent. 1

2 This guidance is intended to be used alongside, and not to replace, local Trust guidelines. You are required to familiarise yourself with and follow local Trust blood transfusion policies and procedures. Guidance 1. Prior To Transfusion. 1.1 Every in-patient who is having blood sampled for a transfusion must be wearing a correct identity wristband. If you are caring for a patient who is going to have a pretransfusion blood sample taken and who does not have a wristband, you must identify the patient using two separate identifiers (e.g. full name and date of birth, or full address) and provide the patient with an identification bracelet containing as a minimum their surname, first name, hospital number, gender and date of birth (BCSH 1999). This should preferably be placed on their dominant arm (NPSA 2005). 1.2 Ensure your patient is aware that they may be having a blood transfusion and that they understand why they will be having it, what this will involve and potential risks. Provide written information if available locally. If the patient requires further explanation, ensure this is given by an appropriately knowledgeable person before commencement of the transfusion. 1.3 The transfusion may only proceed where the patient has expressed informed consent (except in exceptional circumstances) in advance, and that consent is recorded in their records. 1.4 You may only take the pre-transfusion blood sample if you have been trained and assessed as competent to do so, and approved to undertake this procedure in the clinical area and hospital in which you are working. You must undertake this procedure in line with the Trust s local policies and procedures. 2. Collection of Blood and Blood Products. 2.1 If as part of your duties it is necessary for blood to be collected for your patient, or you are asked to do so by a health professional, make sure this is permissible within the policy of the Trust in which you are working and that you are competent in the procedure. 2.2 Units of blood and blood products must be collected immediately prior to the transfusion taking place. Transfusion of blood and blood products must be commenced 2

3 within 30 minutes of arrival in the clinical area. Blood and blood products must not be stored in drug fridges or any other clinical area. 2.3 Check that the details on the blood collection form, or equivalent document, match the details on the patient s wristband 2.4 The blood collection form or equivalent documentation containing full patient identification must be taken to the blood bank by the person collecting the blood. 2.5 If you are the person collecting the blood or blood product, you must check the patient s identity, including the patient s full surname, forename, hospital number and their date of birth, on the blood collection form, or equivalent documentation, against the unit of blood or blood products you are collecting, and document the removal of the unit in the blood fridge register or electronic release system. 2.6 You must return immediately to the clinical area with the blood products. Care must be taken if transporting different blood products that are stored at different temperatures. You must follow local Trust policy for the storage and transportation of blood and blood products. 2.7 If you have collected the blood or blood product at the request of another health professional you must inform them that it has arrived in the clinical area. 2.8 If the blood is not required following collection, it may be possible to return it to the blood-bank if it is within 30 minutes of its documented removal. Check with the local policy or blood-bank on how to return blood in these circumstances. Blood that has been out of temperature control for more than 30 minutes must never be returned to the blood fridge and the blood-bank should be approached for instructions on how to dispose of the blood. 3. Prior to Administration of Blood and Blood Products. 3.1 You may only administer blood and blood products as an NHS Professionals flexible worker if you are permitted to do so under the policies of the Trust in which you are 3

4 working. 3.2 Ensure the patient is located where they can be easily observed, or if this is not possible that staff are available to regularly monitor the patient. Routine transfusions should not be administered overnight unless clinically indicated. 3.3 Gather all necessary equipment to administer the blood or blood products, ensuring that: The patient has patent venous access The giving set is suitable for the administration of the blood or blood product. If this unit of blood or blood products is commencing on completion of the infusion of a different fluid, commence the transfusion using a new administration set. The first unit commences with a fresh administration set. If it is a subsequent unit of blood (or blood products) and the existing giving set will have been in use for more than 12 hours on completion of the transfusion of this unit then a fresh giving set is used. Where small volume transfusions are being drawn into a syringe for neonatal or paediatric patients, an appropriate filter is used and that the blood pack is left attached to the syringe or giving set. If an infusion pump is to be used it must be certified for use with blood components by the manufacturer, the correct administration set must be used and you must be competent in the use of the device. If the blood is to be warmed it must only be done so with an approved blood warmer and you must be competent to use it. 3.4 Do not inject any drug or additives into the blood or blood products. Any drugs to be administered with the transfusion must be given as specified in the local transfusion or drug administration policy. 3.5 Explain the procedure of blood administration to the patient and confirm they understand why they are to receive the transfusion and have had the opportunity to ask any questions about the process. 3.6 Take the patient s baseline observations of temperature, pulse, and blood pressure (and respirations if Trust policy), and record these on the transfusion chart or equivalent document in use locally. 4

5 3.7 Check the expiry date of the blood or blood product, inspect the container for damage or leaks and check the contents for discoloration or any other abnormality. The expiry time is midnight on the expiry date. 3.8 Check that the prescription for the blood or blood products has been completed correctly, including the signature of the prescriber, and that all instructions with regard to the type of product, any drugs to be administered at the same time and the prescribed rate of administration are correct. 3.9 Wash your hands and undertake any additional infection control measures appropriate for the patient s condition in line with Trust policies Assemble all equipment necessary for the transfusion Take the unit of blood or blood products to the patient and undertake the final identity check with another healthcare professional (in line with local policy) in the patient s presence: Ask the patient to tell you their full name and date of birth. If the patient is unable to identify themselves, then ask another member of staff, relative or carer to verify the patient s identity. Confirm these details with the patient s wristband, If the patient does not have a wristband, then the blood must not be administered until the full procedure for checking the patients identity has been completed (see section 1.1) and an identity wristband applied Check these details against the details of the patient on the transfusion prescription. Verify that the blood group and donation number on the compatibility label and those on the blood or blood product are identical to the details on the blood issue/collection form. NB The final identity check must be done next to the patient by matching the blood pack with the patient s wristband. Sign the prescription to confirm that the patient identification checks have been carried out at the bedside If the checking is interrupted at any point, it must be commenced again from the beginning. 5

6 4. Administration of Blood and Blood Products. 4.1 Wash your hands again and undertake any additional infection control measures appropriate for the patient s condition in line with Trust policies. 4.2 Commence the transfusion, setting the rate and ensuring that the administration of a unit of blood is completed within 4 hours of removing the unit from controlled storage. (Handbook of Transfusion Medicine 2007). Units of platelets or fresh frozen plasma are usually transfused within 30 minutes (BCSH1999). 4.3 Ask the patient to inform you or another member of the healthcare team if they begin to feel flushed, develop shivering, shortness of breath, have any new pain or other symptoms that develop once the transfusion has commenced. Be aware of unconscious, compromised or paediatric patients who are not able to report symptoms. 4.4 Take the patient s vital signs of blood pressure, temperature, pulse and respirations (if hospital policy) 15 minutes after commencing every unit of the transfusion and repeat as per local Trust policy. Record these on the transfusion chart or equivalent document in use locally. 4.5 Return to the patient frequently to assess their condition, repeating the observations according to local policy, and the patient s condition. Record all observations with those already taken. Observation during and after transfusion is essential for the early detection of any adverse events or reactions. 4.6 If the patient show signs of any adverse reaction which may be due to the transfusion, for example: chills, pain/oozing at cannula site, burning along vein, chest pain, lumber or flank pain, bronchial spasm or respiratory distress, abdominal cramps, shock or loss of consciousness, stop the administration of the blood or blood product immediately and call for medical assistance immediately. Keep the IV site patent with an infusion of 0.9% saline and record a full set of observations including measuring urine output if possible. (Handbook of Transfusion Medicine 2007). 4.7 All reactions must be recorded in the patient s record, and as appropriate through the Trust s incident reporting arrangements. 6

7 4.8 The Blood Safety and Quality Regulations (2005) require all blood components to be positively traced from the donor to the recipient. All hospitals have a mechanism in place to ensure this traceability and it is essential that you are familiar and comply with local policy and practice with regard to this record keeping. 5. Following Administration of Blood and Blood Products. 5.1 On completion of each unit of blood or blood products, take the patient s vital signs temperature, pulse, blood pressure (and respirations if Trust policy), and record these, along with the time the transfusion was completed. 5.2 Retain or dispose of the empty blood pack according to local policy. 5.3 Complete the fluid balance and other charts relating to the transfusion, and record the completion of the administration of that unit of blood or blood products in the patient s records. 5.4 If the patient is to have intravenous fluids through the same venous entry point as they had the blood or blood products, the giving set must be replaced. 5.5 If the patient is to have a platelet transfusion following the administration of blood, a new platelet or blood administration set must be used. 6. References BCSH (1999) British Committee for Standards in Haematology Blood Transfusion Task Force Guidelines The Administration of Blood and Blood Components and the Management of Transfused Patients. Transfusion Medicine, Vol 9 pp Handbook of Transfusion Medicine (2007) 4 th Edition. UK Blood transfusion and tissue transplantation services. Available at Blood and Safety Quality Regulations (2005) HM Government. The Stationery Office Limited, London. 7

8 National Patient Safety Agency (2005) Safer Practice Notice 11: Wristbands for Hospital Inpatients Improves Safety. NPSA, London. National Patient Safety Agency (2006) Safer Practice Notice 14: Right Patient Right Blood NPSA, London. SHOT (2009) SHOT Annual Report 2009 available at Taylor, C et al (2005) Re-Audit of Bedside Transfusion Practice. National Comparative Audit of Blood Transfusion. Birmingham. CG4 VERSION HISTORY Version Date Status Author 1 June 2006 Document created 1 March June September 2010 September 2012 Approved by Clinical Governance Committee Document reviewed and updated Document reviewed and updated Review date Richard McMahon, Director of Karen Barraclough, Clinical Governance and Risk Manager Karen Barraclough, Senior Nurse 8