INTRODUCTION
It is crucial that all staff involved in requesting, processing and administering blood transfusions are appropriately trained and aware of the importance of their individual contribution to ensuring patient safety. The first key decision is whether a transfusion is clinically indicated and if the benefits for that patient outweigh the potential risks. Once a decision has been made to transfuse blood or blood components it is essential to ensure that “the right patient gets the right blood, at the right time”.
This document, endorsed by the Hospital Transfusion Committee, is based on the current national guidelines (British Committee for Standards in Haematology, 1999) produced by the Blood Transfusion Taskforce of BCSH in collaboration with the Royal College of Nursing and Royal College of Surgeons of England (see Appendix). It outlines the procedures used in the Trust to ensure transfusion safety and all individual clinical area protocols must be based on these principles. It is a dynamic document which will be reviewed regularly to take account of clinical and technological developments.
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COLLECTION OF TRANSFUSION SAMPLES
Positive patient identification and absolute care in labelling sample tubes and request forms is the vital first step in ensuring safe transfusion.
BLOOD SAMPLING
Blood samples for transfusion can be taken by a registered medical practitioner, or by a healthcare worker, nurse or midwife trained and accredited in accordance with Trust Policies.
BLOOD TUBE AND PATIENT IDENTIFICATION
Inadequate patient identification or sample labelling may lead to fatal ABO incompatible transfusions.
All inpatients must have an ID wristband at the time of sample collection and this must not be removed before transfusion. Extra care must be taken to positively identify Outpatient and Day-case patients at the time of sampling. The patient must be asked to give their first name and last names and date of birth. All patients having Day-case transfusion must have an ID wristband in place at the time of transfusion.
The label on the sample tube must be clearly hand-written by the blood collector at the bedside immediately after collecting the blood. Research shows that mislabelled samples are 40 times more likely to contain the wrong patient’s blood. Never pre-label transfusion sample tubes.
Details from Patient (handwritten)
Check against wristband.
The sample tube must be carefully labelled with the patient's full forename and surname and date of birth, as given verbally by the patient wherever possible (see below). In the case of infants, always check with the parents or ward staff. The tube must be labelled at the bedside immediately after collecting the blood. These details must be checked with those on the ID wristband.
It should be remembered that the name on the bed head-board may be the patient's preferred name, which may be different from their proper name, or may even be the name of the patient who was previously in the bed.
In addition the tube should be labelled with the hospital number (or unique A&E number for unidentified emergency admissions) obtained from the wristband and signed clearly by the authorised blood collector together with the date of collection. In the case of samples taken in Outpatients or Pre-admission Clinics, the hospital number must be put on the label if the case-notes are available and the patient has been positively identified.
If patients are unconscious, confused or have linguistic difficulties, the details written on the blood tube must be taken from the wrist identification band (which is subsequently used for positive identification of the patient when blood is transfused). Wherever possible ask a member of the ward staff to confirm the identity of the patient. Positive identification is crucial in the case of infants or children – check with the parents or ward staff.
During all subsequent laboratory procedures it is the details on the sample tube and not the request form which will be used as the prime source of identification and information so great care is required with tube labelling. The Blood Bank staff have instructions to reject any tube which is not fully labelled as above. Unlabelled sample tubes cannot be accepted under any circumstances.
UNKNOWN PATIENT IDENTIFICATION SYSTEM (A&E DEPARTMENT)
This system of unique transfusion ID numbers has been introduced in the A&E Department for those occasions when the patient is not identified but requires an urgent transfusion. Staff must ensure they are familiar with the system used in their department and that this is only used in appropriate circumstances.
COMPLETING THE BLOOD TRANSFUSION REQUEST FORM
The special request form must be fully completed by a registered medical practitioner (or, where specially authorised by the medical consultant, a nurse, midwife or Operating Department Practitioner). It is the clinician’s responsibility to ensure that any special requirements, e.g. CMV negative or irradiated products, are communicated to the Blood Bank. Wherever possible, the clinical indication for transfusion should be written in the patient’s case-notes.
Some of the details requested on the form are important and could have medico-legal implications. In contrast to the cross-match blood tube, the patient identity on the request form is best given by using an addressograph label. The request form must contain the surname, first name, date of birth, gender and patient identification number. It is important that the name (in block capitals) and bleep number of a team doctor are given so that any problems that arise with crossmatching can be discussed with the medical team. The person taking the blood sample must also sign the appropriate box on the request form.
Always feel free to request advice from the Blood Bank or Clinical Haematologist in the use of specific blood products or the availability of special products such as “Paedipacks” for neonatal use.
The details required include:-
- Ward/location (for transfusion) and Consultant in charge
- Diagnosis and reason for transfusion (remember to indicate if “High Risk” for infection)
- Transfusion history: check case-notes front for warning sticker
- Previous pregnancies (may provoke antibodies)
- Number and type of blood components, including any special requirements
- Date and time required (indicate am or pm for routine samples)*
- Signature of person authorising the request
- Legible name (in capitals) and bleep number of MO
- Signature of person taking the blood sample
* Urgent samples must be discussed directly by phoning the laboratory and the form should then be labelled "URGENT". Please avoid the term "ASAP" as this does not help the laboratory staff to determine priorities.
The maximum allowable time interval between collecting blood for cross-matching and subsequent transfusion is 3 months. This is particularly useful for pre-admission surgical clinics. If the patient is pregnant or has been transfused during the previous three months with a blood product there is an increased likelihood of red cell antibody formation occurring after the sample is collected therefore a shorter time interval applies (contact Blood Bank for details).
TELEPHONE REQUESTS FOR BLOOD AND BLOOD PRODUCTS
Excellent communication is vital for patient safety. If the Blood Bank holds an appropriate sample on the patient (see below) you will be asked to provide the following information:
- Your name and position
- Patient's surname, first name, patient identification number and/or date of birth
- Number and type of blood products required
- The reason for the request
- The time and date required
- Location of the patient
NB. Telephone requests should only be made by registered practitioners.
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SCREENING AND CROSSMATCHING PROCEDURES
Routine full screening and crossmatching is the safest method for the patient and should be used whenever possible. This section describes the methods by which blood is made available and how you must indicate the degree of urgency. Once again, excellent communication between clinician and Blood Bank is vital for patient safety.
PLANNED POSSIBLE TRANSFUSION:- GROUP AND ANTIBODY SCREEN
This is the normal procedure for a patient who might need blood in the near future or for whom surgery is being planned ahead. It gives forewarning of any problems with crossmatching or the procurement of rare blood groups and avoids any unnecessary delays in providing safe blood when needed. This also ensures the patient’s details are on the Blood Bank computer to check against any future samples received.
PLANNED TRANSFUSION:- GROUP, SCREEN AND CROSSMATCH
This is the normal procedure when patients are known to require blood or are undergoing surgery very likely to require blood. For routine surgical procedures please refer to the Maximum Surgical Blood Ordering Schedule (MSBOS) agreed with your team. Wherever possible samples should be sent to the laboratory 24 hours before surgery to prevent unavoidable delays in obtaining compatible blood. You will be asked to justify requests which deviate from this schedule. If operations are cancelled, please inform the laboratory so the blood can be reallocated to other patients.
URGENT:- EMERGENCY CROSSMATCH
Accurate identification and labelling is essential in urgent and stressful situations.
The procedure for an emergency cross-match may be completed in a minimum of 30 to 40 minutes from receipt of the sample if there are no problems with testing or special product requirements.
Always telephone the Blood Bank with urgent requests.
VERY URGENT:- GROUPED BUT UN-CROSSMATCHED BLOOD
If blood is required very urgently, un-crossmatched blood of a compatible ABO group can be provided within 5 to 10 minutes of receiving a sample and a warning telephone call. Where the clinical situation allows, it is safer to use group compatible blood rather than the emergency "flying squad" blood.
EXTREME URGENCY (IMMEDIATE TRANSFUSION):- GROUP 0 Rh NEGATIVE BLOOD
For life-threatening situations only, a limited stock of haemolysin-free O Rhesus negative red cells ("flying squad blood") is available in key clinical areas.
These units must only be used if the doctor feels that a delay of only 5 to 10 minutes (needed for grouped blood) would endanger the patient's life.
A correctly labelled sample must always be taken before infusion of emergency blood, and be dispatched to the Blood Transfusion Department without delay for subsequent grouping and crossmatching of these and further units. The Blood Bank must always be informed when the emergency supply is used so that stocks can be replenished for other patients.
The responsibility for administering un-crossmatched blood lies with the requesting clinician. Although the risk of a transfusion reaction is low, all units will be retrospectively crossmatched with the patient to identify potential problems.
Only blood provided and tested by the National Blood Service is acceptable for transfusion under any circumstances.
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STORAGE OF BLOOD AND BLOOD COMPONENTS
RED CELLS
Blood is an excellent culture medium for bacterial growth, therefore it is stored in approved refrigerators at 4oC, where it has a shelf life of 35 days from donation. There are legal requirements for temperature regulation and alarm systems for storage of blood. The hospitals have several approved Blood Bank refrigerators at strategic sites. Blood should never be stored in domestic or other refrigerators. It should be removed, one unit at a time, from the Blood Bank refrigerator only when a transfusion is due to commence within 30 minutes. Transfusion must be completed within 5 hours of removing the pack from the Blood Bank refrigerator to avoid the risk of bacterial growth.
Bacterial contamination of blood products may be the single largest cause of death from transfusion accidents. If a unit of blood has been out of the refrigerator for more than 30 minutes and there is no prospect of its imminent transfusion, the Blood Bank must be informed that it has been un-refrigerated for more than 30 minutes, the unit marked as "Unsafe to Transfuse", returned to the Blood Bank and handed to a member of staff for disposal.
Collection of the wrong blood from storage locations is one of the most common causes of serious transfusion accidents. Staff responsible for removing blood from approved Blood Bank refrigerators must carefully check the patient's identification details against appropriate documentation.
FRESH FROZEN PLASMA (FFP) AND CRYOPRECIPITATE
Fresh frozen plasma and cryoprecipitate are stored in approved freezers at less than -30oC. They are thawed just before use (a process which takes up to 40 minutes) and, once thawed, must be infused within 4 hours.
PLATELETS
Stocks of platelets are not kept in the hospital Blood Bank but ordered from the Transfusion Centre for specific patients as required. They are kept in the Blood Bank under special storage conditions which preserve their clinical effectiveness and have a shelf-life of only 5 days from donation because of the risk of bacterial contamination. Platelets must not be refrigerated. They are issued as an adult or paediatric "therapeutic dose" and must be transfused immediately after collection from the Blood Bank. Only Group A and O platelets are routinely prepared. Rhesus Negative premenopausal women should receive Rh Neg platelets whenever available.
HUMAN ALBUMIN SOLUTION (HAS)
Available as 4.5% or 20% solutions. 4.5% HAS is normally stored at room temperature and in the dark (check individual product specifications). It must not be left on window sills or in direct sunlight. 20% albumin is stored in a refrigerator at 4oC. Each transfusion must be completed within 3 hours.
Where stocks of HAS are held in clinical areas the patient's details and date and time of transfusion must be entered on the form kept with each batch. It is essential that all blood products can be traced to the patient receiving them - failure to complete documentation can have severe medico-legal consequences in the event of viral transmission or other adverse reactions.
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TRANSPORT OF BLOOD PRODUCTS BETWEEN HOSPITALS
Occasionally, blood is transferred between hospitals, particularly with patients requiring emergency specialist treatment. There are now statutory regulations relating to transportation of blood which include the completion of a 'Blood in Transit' document and the use of an approved insulated carrier box with cold pack insert. If the requirements have not been fulfilled the blood must be considered hazardous and must under no circumstances be transfused.
If blood is received from another hospital it must be sent without delay to the Blood Transfusion Department with any accompanying documentation. If the blood has been transported satisfactorily it will be re-issued and held in an approved Blood Bank refrigerator until required.
If blood is to be sent to another hospital, the Blood Transfusion Department must be informed as soon as possible. The laboratory staff will package the blood, complete the required documentation for transit and, if necessary, arrange for transport to the Blood Bank of the hospital concerned.
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ADMINISTERING BLOOD AND BLOOD COMPONENTS
All identification checks should be carried out by two staff (at least one of whom is a doctor, Registered Nurse/Midwife or ODP trained in the administration of blood and blood products) before the transfusion commences.
PRE-TRANSFUSION CHECKS ON BLOOD/BLOOD PRODUCTS
All the following checks must be carried out at the bedside or otherwise adjacent to the patient being transfused. Checking away from the patient, e.g. at the Ward Office or desk, is a common and avoidable cause of transfusion accidents.
1. Inspect the blood or blood component for:
- Leakage
- Unusual colour e.g. black or purple (may indicate haemolysis)
- Unusual cloudiness or particulate matter
- Presence of large clots (If any of the above are present, the unit must not be used and should be returned to the Blood Bank.)
2. Read and take note of any special labels or instructions attached to the blood pack or printed on the accompanying report
3. Positively identify the patient before transfusion:
Ask his/her surname, first name and date of birth whenever possible and make sure this is the same as on the ID wristband. It is essential that any patient having a blood transfusion has an ID wristband.
The surname, first name, date of birth and patient identification number should be checked and found to be identical on:
- The patient's ID wristband
- The blood transfusion compatibility report form
- The compatibility label attached to the blood pack
- The IV prescription chart
- The medical notes
The blood group and donation number put by the National Blood Service on the blood component must be checked and found to be identical to that on the compatibility report form and the compatibility label attached to the blood pack
The blood group on the unit must be compatible with the blood group of the patient indicated on the compatibility label attached to the blood pack (if in doubt, ring the Blood Bank)
The unit of blood or blood component must be checked for compliance with any special requirements on the prescription sheet e.g. CMV Neg, gamma-irradiated
The unit must be checked to ensure it has not passed its expiry date or expiry time
The blood transfusion compatibility report form and/or the IV prescription sheet must be signed by the members of staff carrying out the identity check and the date and time of commencement of transfusion of each unit indicated in the appropriate space together with the donation number of the blood pack
If any discrepancies not covered by a comment on the blood transfusion compatibility report form are found during the bedside identity check, the unit must not be transfused and the Blood Bank must be contacted
DOCUMENTATION ON THE BLOOD/IV PRESCRIPTION SHEET
Blood and blood components should only be administered when the doctor who is clinically responsible for the patient has prescribed the product on the Blood/IV Prescription Sheet. This must contain the full patient identification details. It must identify the product, the quantity given, the duration of transfusion and any medication required before or during transfusion. Drugs or other additives must never be put in the blood bag.
The blood transfusion compatibility report form should, wherever possible, be readily available during the transfusion. When the transfusion is completed it must be fixed in the patient's medical folder as a permanent record of the transfusion.
TRANSFUSION AND OBSERVATION
Transfusions should be given in clinical areas where patients can be readily observed and monitored.
Each clinical area must have a clear written policy which incorporates the following principles:
All cellular blood products must be infused through an approved blood administration set which already incorporates an in-line filter (170u). It is recommended that administration sets be replaced every 12 hours to prevent bacterial growth.
Micro-aggregate filters and special white cell reduction filters are no longer required as all blood products are filtered at the Blood Transfusion Centre soon after collection from the donor using highly effective techniques.
Only sodium chloride 0.9% (normal saline) must be used for priming and flushing giving sets.
Clinical staff responsible for monitoring patients must be trained in accordance with Trust policy and knowledgeable of the symptoms and signs of adverse events and their management:
Temperature, pulse and blood pressure must be measured and recorded before the start of each unit of blood or component and at the end of each transfusion episode
Temperature and pulse must be measured 15 minutes after the start of each unit
More frequent observations are only needed if the patient becomes unwell, shows signs of a transfusion reaction or is receiving blood by "clinical trial" because of a possible incompatibility. Specific clinical units will have individual requirements for more frequent observations.
Careful monitoring of clinical signs is especially important in unconscious patients.
Empty donor bags must be retained in the clinical area or Blood Bank for a period of 48 hours (according to local protocol) before disposal by incineration. Blue plastic plugs are provided to avoid residual blood escaping from the donor bags.
USE OF ELECTRONIC INFUSION PUMPS
Electronic infusion pumps may damage blood cells and must not be used for the administration of red cells unless they have been verified as safe to use for this purpose according to the manufacturer’s instructions.
USE OF BLOOD WARMERS
Warming of red cells or blood components should be limited to patients receiving massive transfusions (i.e. adults at rates > 50 ml/kg/hr, children at rates > 15 ml/kg/hr), exchange transfusion in infants or patients with clinically significant "cold" antibodies.
Only specially designed and regulated blood warmers with a visible thermometer and audible warning must be used. Blood must not be warmed by any other method, such as immersion in warm water, because of the risk of contamination through minute holes in the bag and lack of control of the temperature which may lead to dangerous haemolysis.
Keeping the patient warm is usually more important than use of a blood warmer.
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REACTIONS TO TRANSFUSIONS
MAJOR REACTIONS
Major transfusion reactions are usually a result of administering incompatible blood and the commonest causes are mistaken identity in blood sampling, collecting the wrong blood from the storage refrigerator or administering blood at the bedside or operating theatre. They can be lethal because of resulting immune reaction which can cause DIC and renal failure. Occasionally, severe reactions will be caused by the transfusion of bacterially infected blood. Correct handling, storage and inspection of blood is important in preventing this often lethal (and medico-legally serious) problem.
A major reaction is usually recognised by unexplained sharp pain in the drip vein or loins, by a rise in temperature, or by shock (low blood pressure and fast thready pulse) or breathing problems:
- if a major reaction to transfusion is noted, the transfusion must be stopped immediately and urgent medical advice sought
- the line should be kept open with sodium chloride 0.9% (normal saline)
- the patient's identity and details on the wristband must be checked against the compatibility label on the donor unit
- the patient must be monitored closely and urine colour and volume observed (the urine may become red or dark brown from free haemoglobin or production may stop if there is renal failure)
- the Blood Bank must be contacted without delay and made aware of the situation
- The donor unit, blood administration set and blood samples (as advised by the Blood Bank) must be sent to the Blood Transfusion Department as soon as possible
MINOR REACTIONS
Minor reactions are common and include unexplained small rises in temperature (to 37.5oC), urticaria, rashes and headaches. The transfusion rate should be slowed, the patient must be monitored more closely and the doctor in charge informed. Febrile reactions are now much less common following the introduction of filtered (leucodepleted) blood.
"Routine" prophylaxis, e.g. hydrocortisone and chlorpheniramine, is not good clinical practice. Patients who experience recurrent reactions with transfusions should be discussed with the clinical haematologist who will advise about appropriate prophylaxis or investigation.
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PRODUCT LIABILITY AND LEGAL REQUIREMENTS
Every individual involved in procedures leading to the transfusion of blood and blood products is bound by product liability legislation (Consumer Protection Act, 1987). This demands that clear links be established between each stage in the procedure from collection of the sample to infusion of the blood or blood products. It must be possible to trace each stage, the time at which it occurred, and the individuals who were involved.
It is the responsibility of all staff involved in the transfusion process to be aware of hospital transfusion policies and guidelines. Senior/managerial staff must ensure appropriate training and education occurs in their unit.
Since the vast majority of problems associated with blood transfusion are due to simple clerical errors or incorrect patient identification, it is vital that the guidelines are followed in both clinical and laboratory areas.
All transfusion accidents or errors (including "near miss" accidents) are reviewed by the Hospital Transfusion Committee with the objective of identifying problems with procedures or training which can be rectified for the safety of patients. There is now a national confidential reporting system for Serious Hazards of Transfusion (SHOT) to inform and improve clinical transfusion practice. All staff are encouraged to report potential problems in their area to the Blood Bank or Clinical Haematologist - prevention is better than cure.
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