Blood Transfusion Policy V4.3 Sept 2012

Blood Transfusion Policy
V4.3
Sept 2012
BLOOD SAFETY AND QUALITY REGULATIONS
IT IS ESSENTIAL THAT ALL PATIENT COMPATIBILITY PAPERWORK
ISSUED FOR BLOOD PRODUCT TRANSFUSIONS IS RETURNED TO THE
BLOOD TRANSFUSION LABORATORY WITHIN 24 HOURS OF
COMPLETING THE TRANSFUSION EPISODE.
THIS IS A LEGAL REQUIREMENT COVERING RCHT, ALL PCH AND
INDEPENDANT HOSPITALS.
FORMS MUST BE RETURNED WHETHER THE PRODUCT WAS
TRANSFUSED OR NOT.
Table of Contents
1. Introduction ................................................................................................................... 4 2. Purpose of this Policy ................................................................................................... 4 3. Scope ........................................................................................................................... 4 4. Definitions / Glossary .................................................................................................... 4 5. Ownership and Responsibilities .................................................................................... 4 5.2. Role of the Head of Transfusion ............................................................................ 4 5.3. Role of the Hospital Transfusion Committee ......................................................... 5 5.4. Role of the Hospital Transfusion Team: ................................................................ 5 5.5. Role of the Managers ............................................................................................ 6 5.6. Role of Individual Staff ........................................................................................... 6 6. Standards and Practice ................................................................................................ 6 6.1. Safety .................................................................................................................... 6 6.2. Key Points of Good Transfusion Practice .............................................................. 6 6.3. Overnight Transfusion ........................................................................................... 7 6.4. Contacting the Transfusion Department ................................................................ 7 6.5. Education and training ........................................................................................... 7 6.6. Errors and near miss events .................................................................................. 8 6.7. Specimen Collection .............................................................................................. 8 6.8. Red Cell Transfusion Requirements ...................................................................... 9 6.9. Massive Haemorrhage Packs .............................................................................. 11 6.10. Massive Transfusion ........................................................................................ 11 6.11. Special requirements ....................................................................................... 12 6.12. Autologous pre-deposit blood .......................................................................... 13 6.13. Release, Collection and Storage of Red Cells ................................................. 13 6.14. Transporting Blood in Temperature Controlled Boxes ..................................... 14 6.15. Blood arriving with patients from other hospitals .............................................. 14 6.16. Administration of the Blood Transfusion .......................................................... 15 6.17. Patient Observations during Transfusion ......................................................... 16 6.18. On Completion of the Transfusion ................................................................... 16 6.19. Blood Transfusion Reactions ........................................................................... 17 6.20. Blood Components and Products other than Packed Red Cells ...................... 18 6.21. Blood Administration Sets, Rates and Equipment............................................ 21 7. Dissemination and Implementation ............................................................................. 21 8. Monitoring compliance and effectiveness ................................................................... 22 9. Updating and Review.................................................................................................. 23 10. Equality and Diversity.............................................................................................. 23 Blood Transfusion Policy
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10.2. Equality Impact Assessment ............................................................................ 23 Appendix 1. Blood Transfusion Policy - Blood Transfusion Competencies Pack ............... 24 Appendix 2. Blood Transfusion Policy - Blood Products Guide.......................................... 25 Appendix 3. Governance Information ................................................................................ 30 Appendix 4.Initial Equality Impact Assessment Screening Form ....................................... 34 Blood Transfusion Policy
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1. Introduction
1.1. Transfusions are a routine part of patient treatment but carry a significant risk if
not performed according to national guidelines. The purpose of this policy is to
ensure staff have access to the most up to date guidance regarding the transfusion
procedure, ensuring receiving blood and blood products is as safe as possible for
patients.
1.2. This version supersedes any previous versions of this document.
2. Purpose of this Policy
This policy has been produced to state standards, manage risk and improve the quality of
care to patients in relation to the transfusion of blood and blood products.
3. Scope
This policy is ratified as the ONLY Transfusion Policy used by all RCHT, PCH and private
healthcare sites supplied by RCHT blood transfusion department. All aspects must be
followed by all staff taking part in the transfusion process.
4. Definitions / Glossary
HTT – Hospital Transfusion Team
HTC – Hospital Transfusion Committee
TP- Transfusion Practitioner
PCH – Peninsular Community Health
BSQR – Blood Safety and Quality Regulations
MHRA – Medicines and Healthcare Products Regulatory Agency
SHOT – Serious Hazards of Transfusion
SABRE – Serious Adverse Blood Reactions and Events
FFP – Fresh Frozen Plasma
5. Ownership and Responsibilities
5.1. The policy has been produced and will be managed by the Hospital
Transfusion Team, including the Consultant in charge of Transfusion, the
Transfusion Laboratory Manager and the Transfusion Practitioners. Updates
and amendments will be sanctioned through HTT in the first instance but also
through the HTC including wider ratification.
5.2. Role of the Head of Transfusion
Responsibility for Transfusion Practice lies with the Head of Transfusion, one of the
Consultant Haematologists. He / she is answerable to the Medical Director(s) of the
Trust.
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5.3. Role of the Hospital Transfusion Committee
The Transfusion Committee (HTC) is currently chaired by the Head of Transfusion. It
reports to the Trust Board. Its objective is to promote good transfusion practice in
accordance with national guidelines.
The functions of the Transfusion Committee are:
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promote best practice through local protocols based on national guidelines
promote appropriate use of blood and blood components
lead multi-professional audit of the use of blood components within the NHSTrust,
focusing on specialities where demand is high, e.g. haemato-oncology and
certain surgical specialities
Promote a Trust wide patient blood management programme and consider
alternatives to blood transfusion
promote the education and training of all clinical and support staff involved in
blood transfusion
have the authority to modify existing blood transfusion protocols and to introduce
appropriate changes to practice
report regularly to local, and through them to national, blood user groups
consult with local patient representative groups where appropriate
contribute to the development of clinical governance
assist and endorse the Hospital Transfusion Team in appropriate rationing in the
event of a shortfall in blood supply
Membership:
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Chair – senior consultant from any specialty
Transfusion dept manager
Transfusion practitioners
Blood Safety & Quality Coordinator
Blood conservation representative
Each Clinical Directorate,
Accident and Emergency Department
Nurse Manager
Governance
Lay member
Duchy representative
PCH representative
NHSBT/Regional Transfusion Committee representative
5.4. Role of the Hospital Transfusion Team:
The transfusion team is the executive branch of the Transfusion Committee It is able
to consider immediate issues and make rapid responses. Membership:
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The Head of Transfusion
The Blood Transfusion department Manager
The Transfusion Practitioners
Blood Safety and Quality Co coordinator
A Consultant Anaesthetist
A Cell salvage co-ordinator
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The Transfusion Team meets monthly.
5.5. Role of the Managers
Line managers are responsible for:
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Ensuring all staff are aware of this policy
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Enabling all relevant staff attend mandatory training and appropriate
assessment in Transfusion.
5.6. Role of Individual Staff
All staff members are responsible for:
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Ensuring they adhere at all times to the Transfusion Policy
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Highlight to TP or laboratory staff any errors or omissions from the policy
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Ensuring they only practice if their mandatory training and assessment are up to
date.
6. Standards and Practice
6.1. Safety
6.1.1.
Blood transfusion is potentially hazardous and should only be
undertaken when the benefits to the patient outweigh the risks.
6.1.2.
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Mistakes occur in:
The collection or labelling of the crossmatch sample
Pre-transfusion checks at the bedside
The laboratory
6.1.3.
Systematic error reporting reduces subsequent error rates. All staff
are required to report errors relating to the transfusion process on the DATIX
reporting system and their line manager if necessary.
6.2. Key Points of Good Transfusion Practice
6.2.1.
Transfusion should only be given when there is no alternative.
6.2.2.
Blood transfusion should be given on the basis of symptoms and risk
rather than to achieve target haemoglobin. Avoid transfusion when alternative
measures are available (e.g. replace iron, cell salvage etc).
6.2.3.
Consider a single unit transfusion and reassess the patient’s
clinical condition
6.2.4.
In shock, oxygenate and replace fluids. Red cell transfusion is not
optimal volume replacement.
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6.2.5.
The clinician must record the reason for transfusion in the patient’s
notes. Verbal consent must be sought and recorded in the notes. Patients must
be made aware of the risks & benefits of transfusion; refer to the current patient
information leaflet titled ‘Do I need a blood transfusion?’
6.2.6.
Patients with a low body mass index (BMI) will have a smaller blood
volume and require a smaller transfusion to achieve the same increment in Hb
and are at risk of Transfusion Associated Cardiac Overload (TACO). Pretransfusion clinical assessment should identify patients at increased risk of
TACO (the elderly and those with one or more risk factors for TACO – cardiac
failure, renal impairment, hypoalbuminaemia, fluid overload).
6.3. Overnight Transfusion
There are significantly increased risks to transfusing outside core hours so the
transfusion must be clinically ESSENTIAL. If transfusions need to take place at
night the reason for this must be clearly stated in the patient notes.
All non-essential transfusions must be completed by 21:00.
Nursing staff should be vigilant for complications of transfusion. Staff should ensure
Positive Patient Identification, that the patient is clearly visible and regular
observations are undertaken.
6.4. Contacting the Transfusion Department
6.4.1.
Laboratory and general advice and urgent requests:
Biomedical Scientific Staff (BMS) in the Transfusion Department
Daytime:
RCHT
01872 252500
On-call:
RCH only - Bleep through switchboard
6.4.2.
Clinical advice:
Consultant Haematologist:
Page through switchboard.
6.4.3.
Education and Governance:
Transfusion Practitioners: 01872 253093 or bleep 3046
6.5. Education and training
6.5.1.
All staff involved with the blood transfusion process must undergo
biennial training. This can be online or face to face on the Clinical Mandatory
Day or at attendance of the transfusion session on Clinical Induction Day 3.
Online learning is via the NLMS with all staff completing Level 01: Safe
Transfusion Practice (adult) or Level 04: Safe Transfusion Practice (paediatrics)
and registered staff in both areas completing Level 02: Blood Components and
Indications for Use.
6.5.2.
In addition Midwives must complete level 05: Anti-D (Clinical). In
addition all laboratory staff must complete level 03: Good Manufacturing
Practice for laboratory staff and registered lab staff must complete Level 06:
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Anti-D (lab staff).
6.5.3.
If staff members attend a clinical face to face update that includes
blood transfusion they ARE NOT required to complete an online component.
6.5.4.
Medical staff will attend a face to face training session with Consultant
Haematologist to complete both mandatory training and assessment in
prescribing.
6.5.5.
To comply with NPSA SPN14 ‘Right Patient – Right Blood’ staff are
required to undergo observed competency assessment on a 2 yearly cycle.
These assessments can take place during clinical practice or as part of a
scenario.
6.5.6.
All clinical areas have ward-based assessors. The education and
training requirements for Blood Transfusion are also in the Trust training matrix.
The competency assessment documentation can be found on the document
library as an appendix to this policy. Competency assessment figures are held
in the MAPs system and are updated by managers from ward based assessor
data.
6.5.7.
Under no circumstances can agency staff undertake any part of the
transfusion process as they do not have appropriate training. Kernowflex staff
can take part in transfusion if they have had the appropriate training and
assessment.
6.6. Errors and near miss events
6.6.1.
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Please report all transfusion errors or near miss events to the:
Transfusion Department Manager ext 2500
Transfusion Practitioners - RCHT ext 3093 or bleep 3046
- PCH 07825933249
Blood Safety and Quality Co-ordinator (3856)
Enter directly onto DATIX
6.6.2.
There is a legal requirement to report incidents to the MHRA via one
of the above.
6.7. Specimen Collection
6.7.1.
All requests for blood or blood products must be made on a fully
completed blood transfusion request form and accompanied by a fully
hand-labelled and signed transfusion specimen.
6.7.2.
Blood will only be issued against adequately identified specimens and
request forms as outlined below.
6.7.3.
The request form
6.7.4.
Must be completed and signed by medical staff or midwife and
must contain full patient identification, including:
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Full name (correctly spelt)
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Gender
Date of birth
Unique identifier (NHS or Cr number)
Date and time blood sample collected
6.7.5.
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Product type & volume & special components e.g. irradiated
The clinical diagnosis & indication for transfusion, if different
PRE-OP is not suitable as a clinical detail
The date & time blood is required
Patient’s location and consultant
6.7.6.
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And must state:
And any history of:
Previous transfusions
Presence of atypical red cell antibodies
Any history of transplant (solid organ or marrow)
Any history of auto immune haemolytic anaemia
6.7.7.
The blood specimen
6.7.8.
6ml Crossmatch pink top tube - Specimen tubes must not be prelabelled
6.7.9.
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The specimen must be:
Labelled by hand - any specimen showing evidence of a sticky label will
be rejected
Labelled at the bedside by asking the patient for their full name and Date
of Birth and referring to wristband identification. Where the patient is
unconscious the wristband must be used as the primary source of
identification and checked against notes and with staff caring for patient.
Signed and dated by the individual taking the blood sample, while still at
the bedside.
6.7.10.
Any error or deviation will necessitate repeat sampling
6.7.11. Unknown patients (or where patient ID is not available – including
LIMS downtime):
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The Emergency Dept hold a stock of pre-registered Unknown patients
notes.
The patient’s gender and approximate age must be added.
The sample must be signed.
Samples must be taken BEFORE any Emergency O negs are given.
6.8. Red Cell Transfusion Requirements
6.8.1.
Urgent requests must be phoned to the laboratory.
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Avoid transfusion when alternative measures are available and appropriate (e.g.
iron supplements, per-operative cell salvage etc). Use the minimum number of
red cells to gain clinical effect.
6.8.2.
Elective surgical procedures
The number of units ordered should comply with that stated in the Maximum
Surgical Blood Ordering Schedule. Operations where cell salvage may be
appropriate are flagged.
6.8.3.
e-matching
6.8.4.
e-matching is the release of blood from the Transfusion Dept on the
basis of blood group, a negative antibody screen and transfusion history without
the necessity for crossmatch. If the transfusion laboratory has a valid
crossmatch specimen blood may be released on request within 5 minutes.
Requests can only be made by medical staff and midwives.
6.8.5.
Not all patients are suitable to receive e-matched blood, which is why
clear, valid clinical details are vital when requesting. Exclusions for ematching
include irregular antibodies, bone marrow transplant and solid organ transplant.
6.8.6.
Depending on previous transfusion history a group & save specimen
is valid for a limited time:
Patient transfused within
3-14 days
15-28 days
29 days to 3 months
Sample to be taken within
24 h of planned transfusion ending
72 h of planned transfusion ending
1 week of planned transfusion
6.8.7.
Patients not suitable for e-matching will require manual crossmatch
which will be available within 45 minutes of receiving an adequately labelled
request.
6.8.8.
If the recipient has red cell antibody present then please discuss red
cell provision with the Transfusion Department.
6.8.9.
Emergency O Rh (D) negatives
Available immediately from the Transfusion Department: O Rh D neg blood is
also available at:
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Delivery Suite (PAW) – both adult and paediatric
Main Theatre (3rd floor, Tower Block)
Trauma Theatre (Trelawney Wing)
West Cornwall Hospital
St Michaels Hospital (Hayle)
Duchy Hospital
Bodmin Treatment Centre
6.8.10. The Transfusion Department Staff must be informed immediately
when these units are used. The forms MUST be filled in with patient details
and returned to the blood transfusion dept as soon as possible.
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6.8.11.
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Before using emergency O Rh D negs please ensure that:
There are no crossmatched units available for the patient
There is no ABO specific blood available for the patient
6.8.12.
O Rh D negative stock conservation must be ensured at all times.
6.8.13. Group specific (unmatched)
Available from the Transfusion Department within 10 minutes of receipt of
correctly labelled specimen.
6.9. Massive Haemorrhage Packs
6.9.1.
Massive Haemorrhage packs are available based on clinical need –
the decision to activate the massive haemorrhage protocol needs to be taken as
early as possible. Laboratory staff may well guide clinical staff to instigate this
protocol based on usage patterns
6.9.2.
Within the clinical team dealing with any massive haemorrhage
patient, a specific member of the team must be nominated to communicate with
the transfusion laboratory for the duration of the event.
6.9.3.
The massive haemorrhage packs are as follows:
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Pack A - 6 red cells; 4 FFP
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Pack B - 6 red cells; 4 FFP; 1 ATD platelets
6.9.4.
Pack A will only be used as a first line treatment, pack B is issued on
all subsequent issues.
6.9.5.
There is no need to request additional packs, as each pack will be
replaced by the next pack B issue. For optimum clinical effect the packs should
be used as issued, not selectively using products.
6.9.6.
Massive haemorrhage packs will be issued with an audit sheet to
monitor the efficacy of both the packs and the service. Please return these to
the Blood Transfusion Dept as soon as possible after the event.
6.10.
Massive Transfusion
Goal
Procedure
Comments
Restore circulating
volume
Insert wide bore peripheral or central
cannula.
Give pre-warmed crystalloid or colloid as
needed
Avoid hypotension or urine output
<0.5 ml/kg/h
14 gauge
Monitor central venous pressure
Keep patient warm
Concealed blood loss is often
underestimated
Contact key
personnel
Clinician in charge
Consultant anaesthetist
Blood transfusion Biomedical Scientist
Haematologist
A named senior person must take
responsibility for communication
and documentation.
Arrange Intensive Care Unit bed
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Goal
Procedure
Arrest bleeding
Early surgical or obstetric intervention
Interventional radiology
FBC, PT, APTT, Thrombin time,
Fibrinogen (Clauss method); blood bank
sample,
biochemical profile, blood gases and
pulse oximetry
Ensure correct sample identification
Repeat tests after blood component
infusion
Assess degree of urgency
Employ blood salvage to minimise
allogeneic blood use
Give red cells:
 Group O Rh D negative in
extreme emergency
 When ABO and Rh D groups
known give ABO group specific
 when blood group and antibody
screen negative give fully
compatible blood (time permitting)
Use blood warmer and/or rapid infusion
device if flow rate >50 ml/kg/h in adult
Request laboratory
investigations
Maintain Hb >8 g/dl
Comments
Results may be affected by colloid
infusion
Ensure correct patient
identification
May need to give components
before results
available
Collection of spilt blood can be set
up in
<10 min
D positive is acceptable if patient
is male or postmenopausal female
Further serological crossmatch
not required
after 1 blood volume replacement
Transfusion laboratory will
complete crossmatch after issue
Maintain platelet
count >75 x109/l
Allow for delivery time from blood centre
Anticipate that platelet count will be <50 x
10 9/l after 2 x blood volume replacement
Maintain PT & APTT
< 1.5 x mean control
Give FFP 12–15 ml/kg (1 l or four units for
an adult) guided by tests
Anticipate need for FFP after 1–1.5 x
blood volume replacement
Allow for 30 min thawing time
Maintain Fibrinogen >
1.5 g/l
If not corrected by FFP give
cryoprecipitate
(Two packs of pooled cryoprecipitate for
an adult)
Should be available on-site. Allow for
30 min thawing time
Cryoprecipitate rarely needed
except in DIC
Avoid DIC
Treat underlying cause (shock,
hypothermia, acidosis)
Although rare, mortality is high
6.11.
Allows margin of safety to ensure
platelet count >50 x 10 9/l
Keep platelet count >100 x 10 9./l
if multiple or CNS trauma or if
platelet function abnormal
PT/APTT >1.5 x mean normal
value correlates with increased
microvascular bleeding
Keep ionised Ca2+ > 1.13 mmol/l
Special requirements
6.11.1. Irradiation
6.11.2. Irradiated and other special blood products are not stored locally.
Please anticipate the need for these to allow time for ordering and delivery.
6.11.3. Irradiated blood and platelets are required when there is a significant
risk of the recipient developing Transfusion-Associated Graft-Versus-Host
Disease (TA-GVHD):
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Hodgkin's Disease patients.
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Patients ever treated with purine analogues: (Fludarabine, Cladribine,
deoxycoformycin, Bendamustine, Clofarabine), monoclonal antibody
therapies (Campath), Anti-Thymocyte Globulin or alemtuzumab (antiCD52).
All allogeneic Bone Marrow Transplant (BMT) / Peripheral Blood Stem Cell
Transplant (PBSCT) recipients from conditioning for 1 year, or longer if
continuing on GVHD prophylaxis or treatment.
All autologous BMT / PBSCT recipients from conditioning for 6 months, if
received Total Body Irradiation, or 3 months if received chemotherapy-only
conditioning.
Any cellular transfusion during the 10 day period prior to a PBSCT
collection.
Neonatal and some immunosuppressed paediatric patients: -please refer
to guidelines for infants and neonates.
6.11.4.
Non-cellular blood products do not require irradiation.
6.11.5. A patient information leaflet available from the Transfusion
Department must be given to all patients requiring irradiated blood. This
contains a card for the patient to carry, and an alert sticker which should be put
in the patient notes.
6.12.
Autologous pre-deposit blood
Please refer requests to the Transfusion Department / Transfusion Practitioner.
6.13.
Release, Collection and Storage of Red Cells
6.13.1. The appropriate paperwork must be fully completed when removing
blood products from controlled storage (this may be 4oC or 22oC). This is a legal
requirement that the Trust is required to provide 100% evidence of compliance
to MHRA.
6.13.2. Any ward, unit or department that does not comply with the cold
chain audit trail or bedside fating of units will be summarily warned to
improve compliance. If an immediate improvement is not seen the issue
will be logged as a Level 20 risk on the Trust Risk Register and reported
to all relevant Divisional Directors.
6.13.3.
Collection and Storage of matched red cells
6.13.4. Blood should only be removed from the Transfusion Department
dispatch fridge or any of the satellite blood fridges by personnel who have
completed transfusion training and passed the relevant competency (medical,
nursing or theatre staff).
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Check patient information for exact match against form before removing
blood from the fridge.
Ensure exact match of compatibility label with patient information.
Ensure exact match of unit number on compatibility report, compatibility
label and with NBS label (black and white label)
Check group and expiry date on NBS label.
Check there are no leaks or holes in the blood pack (give the pack a
gentle squeeze)
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Check for obvious signs of discolouration.
Sign, date and time the removal of the unit(s).
6.13.5.
Never remove blood for more than one patient at a
time.
6.13.6.
fridge.
Blood must NEVER be stored in any ward/pharmacy/domestic
6.13.7. The transfusion should start as soon as possible after a unit of blood
is removed from a blood fridge, and certainly within 30 minutes. Contact the
Transfusion Department or Practitioners for advice if unsure.
6.13.8. Blood MUST NEVER be returned to a blood fridge if it has been
out for more than 30 mins. If it is not going to be transfused to the patient
within 4 hours of removal from fridge it must be returned to the Blood
Transfusion Dept.
6.13.9. If not removed from the blood fridge within 24 hours of the date for
which blood was requested, units will be de-reserved and returned to stock.
6.14.
Transporting Blood in Temperature Controlled Boxes
6.14.1. Blood is sent to outlying hospitals in Blood Transport Boxes. Boxes
must be packed following the local procedure. Boxes should only contain 2 units
if being sent to a location with no blood fridge. Boxes must only contain blood
for 1 patient. Boxes must be sealed with a label stating time and date of sealing,
and must be accompanied by a Transport and Delivery Record. This is
required both when sending blood products from RCHT and returning them to
RCHT. They must be signed for and received by an appropriately trained
member of staff. Blood boxes should never be left unattended.
6.14.2. The time expiry for keeping blood components in boxes once units
leave temperature control is 3 hours. If no fridge is available once the 3 hour
expiry has passed all units contained in the box must be transfused within 4
hours or returned to RCHT. Red blood cells should be put into a blood fridge (if
available) as soon as box is received. Please refer to the appropriate fridge and
transport procedure.
6.15.
Blood arriving with patients from other hospitals
6.15.1. The Blood Transfusion Department MUST be informed
immediately when blood products from other hospitals arrive onsite. This
is a LEGAL requirement. Take all blood and products to the Transfusion
Department.
6.15.2. Blood being transferred with patient to another hospital
6.15.3. The Transfusion Department MUST be informed if blood is to be
transferred out of the hospital.
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6.15.4. All blood products must be transferred in a blood transport box packed
by the Transfusion Department staff.
6.15.5. Patients should not be transported with a transfusion running as
ambulance crews do not have transfusion training. In an urgent situation
patient must be accompanied by a member of clinical staff with up to date
transfusion training and assessment.
6.16.
Administration of the Blood Transfusion
6.16.1. Patients should be informed of their need for transfusion and the risks
involved, including symptoms that should be reported during the infusion. The
patient information leaflet ‘Do I need a blood transfusion’ should have been
given to the patient prior to this.
6.16.2. The patient’s verbal consent to transfusion should be
documented in their notes. This must be evidenced on the yellow compatibility
form by the staff member administering the first unit of each episode.
6.16.3.
Information about blood administration sets is given in 6.21
6.16.4. All patients receiving blood should be in a clinical area with
resuscitation facilities available. Routine blood transfusions should be
performed during the day, when the patient would normally be awake and able
to report abnormal symptoms. The infusion time for a unit of blood should
typically be 1.5 hours and never exceed 4 hours.
6.16.5. Bedside checking procedure
6.16.6. A single unit of blood is withdrawn from an approved blood storage
fridge and taken to the patient’s bedside. The patient should be positively
identified both verbally (wherever possible) and by checking their wristband.
6.16.7. These checks must be undertaken by a single trained member of staff
(doctor, operating department practitioner, midwife or qualified nurse).
ALL CHECKS MUST TAKE PLACE AT THE PATIENT’S BEDSIDE
6.16.8. Patient identification details (full name, date of birth and hospital
number) must be checked and found to be identical on:
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Patient wrist band
Compatibility report and prescription chart
Compatibility label attached to unit of blood
6.16.9. The blood group and unit number of the blood to be transfused must
be checked and found to be identical on:
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Unit of blood (or blood component). Check information on both
labels
Compatibility report
6.16.10. On rare occasions there is difficulty obtaining compatible group
identical blood and the blood group of the unit differs from the blood group of
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the patient. This discrepancy will always be highlighted by a specific comment
from the Transfusion Department in the ‘Comments’ section of the compatibility
report.
6.16.11. If the patient has special requirements (e.g. irradiated blood) the unit
should be checked to confirm its suitability (i.e. indicator window on RAD-SURE
label turned from red to black).
6.16.12. Any discrepancy identified in the above checking procedure must be
notified to the nurse in charge who can discuss the matter with the Transfusion
Department staff prior to commencing the infusion.
6.16.13. The unit donation number is printed on a peel off strip on the
compatibility label; this strip should be stuck in the prescription chart as a record
of transfusion.
6.16.14. The compatibility report should be returned to the Transfusion
Department at the end of the transfusion.
6.16.15. Drugs MUST NEVER be added to blood or blood components.
6.17.
Patient Observations during Transfusion
6.17.1. Conscious Patients
6.17.2. Observations (temperature, pulse, respirations, and blood pressure)
should be measured and recorded at:




Baseline - before the start of each unit (within 30 mins of transfusion
commencing)
At 15 minutes after the start of each unit
Repeated if the patient reports new symptoms or becomes unwell
At the end of each transfusion episode.
6.17.3. Unconscious patients
6.17.4. Observations (temperature, pulse, respirations, blood pressure and
urine output) should be measured and recorded at:



Baseline - before the start of each unit (within 30 mins of transfusion
commencing).
At 15 minutes after the start of each unit
Repeated hourly thereafter
6.17.5. Transfusion reactions should be considered when assessing a change
in patient observations, particularly within the first 15 minutes following the start
of a transfusion.
6.17.6. Hypotension, bleeding, haemoglobinuria or oliguria may be the first
indications of a transfusion reaction in these patients.
6.18.
On Completion of the Transfusion
On completion of transfusion all blood or blood product packs should be disposed of
in yellow waste bags after 2 hours unless there has been a suspected transfusion
Blood Transfusion Policy
Page 16 of 35
reaction when they should be returned to the Transfusion Department immediately
for investigation.
6.19.
Blood Transfusion Reactions
6.19.1. The Handbook of Transfusion Medicine includes an algorithm for
management of severe acute reaction:
6.19.2. Acute haemolytic reactions
6.19.3. A major haemolytic reaction is often due to the infusion of ABO
incompatible blood. The reaction is usually most severe if Group A blood is
infused into a Group O patient. These reactions are almost always due to
clerical error or to failure of adequate checking of patient identification prior to
transfusion.
6.19.4.











an acute deterioration in the patients condition
major feelings of apprehension
rigors
chest pain
loin pain
abdominal pain
dyspnoea
shock
hypotension
oliguria and at times
haemoglobinuria - then assume an acute haemolytic reaction
6.19.5.








If there is:
An immediate response is required:
Stop transfusion
Report to Nurse in Charge who will notify medical staff
Check patient identification against the pack, Patient’s notes copy and
patient wristband
Take down the blood pack and blood administration set
Replace with fresh administration set and keep line open with saline
Maintain airway
Catheterise and measure hourly urine volume.
Dipstick urine for haemoglobinuria and send urine for analysis
6.19.6. Notify duty BMS staff in the Transfusion Department and request a
‘transfusion reaction form’
6.19.7. Document any reactions in patient’s notes and carry out observations
at regular intervals. If further blood transfusion is required discuss with duty
haematologist.
6.19.8. Febrile non-haemolytic transfusion reactions
6.19.9. Fever and shivering during transfusion may suggest an acute
haemolytic reaction but may also result from leucocyte antibodies and
cytokines. When this type of reaction is suspected:
Blood Transfusion Policy
Page 17 of 35




Check blood group of unit is compatible with patient
Slow the transfusion and observe the patient
Give antipyretic (e.g. paracetamol)
Discuss with Consultant Haematologist if symptoms severe or recurrent.
6.19.10. Allergic reactions
6.19.11. These reactions are more likely following platelet or FFP infusions and
result from infusion of plasma proteins or allergens to which the patient has
preformed antibodies.
6.19.12. Allergic reactions are suggested by: Urticaria / Itching occurring within
minutes of starting the transfusion.
6.19.13. Treat with antihistamine (e.g. chlorpheniramine 10-20mg iv). The
transfusion may be continued slowly if there is no progression of symptoms
after 30 minutes
6.19.14. Severe anaphylaxis
6.19.15. This is a rare complication and occurs most commonly with the
administration of plasma based products.


Stop the transfusion
Give supportive and anti-anaphylactic measures.
6.19.16. Expert advice from the duty anaesthetist may be required (bleep
through switchboard).
6.20.
Cells
Blood Components and Products other than Packed Red
6.20.1. Ordering blood components and products
6.20.2. Blood components and products can only be issued against an
adequately identified blood transfusion request form.
6.20.3. Particular care is required to ensure accurate identification of the
patient on the blood transfusion request form. Sufficient information must be
supplied, on both specimen and request form, for positive identification of the
recipient.
6.20.4. Ordering of a blood component or product is the responsibility of
medical staff or midwives.
6.20.5. Request form should give the blood product requirements, the clinical
diagnosis, date and time required, ward, Consultant and if in theatre, specify
which theatre. If urgent, the laboratory should be notified by telephone
(x2500).
6.20.6. Platelets
6.20.7. Platelets are supplied in a single adult dose. They must be stored at
22oC (+/- 2oC) and NEVER put in a blood fridge. Platelets should be transfused
over a maximum of 30 mins (but may be given more rapidly).
6.20.8.
Platelet transfusions are contra-indicated in:
Blood Transfusion Policy
Page 18 of 35



Haemolytic uraemic syndrome (HUS)
Thrombotic thrombocytopaenic purpurae (TTP)
Heparin induced thrombocytopenia (HIT).
6.20.9. The cause of thrombocytopaenia should be sought before giving
platelet replacement.
6.20.9.1.



Massive bleeding/red cell transfusion (if platelets < 50 x 109/l)
Significant bleeding with marrow failure (if platelets 30-50 x 109/l)
Significant bleeding with dysfunctional platelets
6.20.9.2.


Therapeutic:
Prophylactic:
Pre-operatively / lumbar puncture (if platelets < 50 x 109/l)
Marrow failure / post chemo (if platelets < 10 x 109/l)
(< 20 x 109/l if septic or high risk of bleeding)
6.20.10. FFP
6.20.11. FFP is available in single donor units (approximately 200ml). It should
be transfused using a standard blood giving set typically over 20-30 mins. It
contains most plasma proteins, including all coagulation factors (Fibrinogen 25g/l, Factor VIII >70 iu/dl). FFP is collected from the blood fridge.
Clinical indications for FFP (usually at a dose of 12-15ml/Kg) include:



DIC (cryoprecipitate will also be required if measured fibrinogen
<1gram/litre)
Massive transfusion dependent on the results of coagulation testing
Replacement therapy in patient with single coagulation factor deficiency,
for which a specific factor concentrate is not available (Methylene Blue
Treated FFP preferred)
6.20.12. In Thrombotic Thrombocytopenic Purpura the correct replacement
product to use for plasma exchange should be discussed with a Consultant
Haematologist.
6.20.13. FFP is rarely indicated in Liver Disease unless there is clinically
significant haemorrhage, where use of PCC should be considered.
6.20.14. Over-anticoagulation from excessive effects of warfarin should be
managed according to the British Committee for Standards in Haematology
Guidelines (BCSH, 2005). FFP has only a partial effect, is not the optimal
treatment, and should never be used for the reversal of warfarin anticoagulation
in the absence of severe bleeding. Also refer to RCHT Anticoagulation Policy on
document library.
6.20.15. Cryoprecipitate
6.20.16. A typical adult dose is 2 pooled units. It should be transfused using a
standard blood giving set typically over 20-30 mins. Each unit contains 3-6g
Blood Transfusion Policy
Page 19 of 35
fibrinogen in a volume of 200-500ml. One such treatment administered to an
adult would typically raise the plasma fibrinogen level by approx 1g/l.
Cryoprecipitate is collected from the lab it is stored at 22oC.
6.20.17. Indications:


DIC when measured fibrinogen <1gram/litre.
Fibrinogen replacement therapy in congenital deficiency/dysfunctional
states
6.20.18. Pooled Cryoprecipitate looks almost identical to FFP – ensure
that adequate label checks take place.
6.20.19. Haemophilia products
6.20.20. Clinicians are advised to ask patients which specific bleeding disorder
they have, the severity of their disorder and which products they use. This
information should be passed to both a Consultant Haematologist and the
Transfusion Laboratory as soon as possible.
6.20.21. NovoSeven
6.20.22. NovoSeven (eptacog alfa (activated)) is recombinant activated human
coagulation factor VII (rVIIa). It is licensed for the treatment of congenital and
acquired haemophilia A and B with antibodies against factors VIII and IX. rVIIa
induces haemostasis at the site of tissue injury by forming complexes with
exposed tissue factor (TF), and by directly activating factor X on the surface of
an activated platelet potentiating a ‘thrombin burst’. rVIIa has a short half-life of
around 2 hours.
6.20.23. rVIIa has been used in the treatment of catastrophic haemorrhage
unresponsive to FFP/cryoprecipitate/platelets or surgical treatment. The use of
rVIIa as a ‘last ditch’ treatment for patients with massive haemorrhage has been
shown to be ineffective. rVIIa is not licensed for this indication.
6.20.24. Thromboembolic events outside licensed indications
6.20.25. NovoSeven has been studied in placebo controlled trials outside the
approved indications to control bleeding in intracerebral haemorrhage,
advanced liver disease, trauma, cardiac surgery, spinal surgery, and other
therapeutic areas. Safety and effectiveness has not been established in these
settings and its use in these settings in not approved. Two meta analyses of
these pooled data indicate an increased risk of thrombotic events. Arterial
thromboembolic adverse events including myocardial infarction, myocardial
ischemia, cerebral infarction and cerebral ischemia were statistically
significantly increased with the use of NovoSeven compared to placebo. Other
arterial thromboembolic events (such as retinal artery embolism, renal artery
thrombosis, arterial thrombosis of limb, bowel infarction and intestinal infarction)
have also been reported.
6.20.26. In ALL cases rVIIa will only be issued following discussion with
and approval by the Consultant Haematologist
Blood Transfusion Policy
Page 20 of 35
6.21.
Blood Administration Sets, Rates and Equipment
6.21.1. Standard blood giving sets have a double chamber, which contains a
standard 170m filter. Blood infusion sets are calibrated to deliver 1ml in 20
drops. The fastest rate at which blood can be transfused by gravity is
60ml/min. If a faster rate is required then either multiple lines or a pressure cuff
may be used. Peripheral or central access may be used.
6.21.2. The gauge of cannula should be chosen according to the vein size.
Venous access should be established before blood is collected from the blood
fridge.
6.21.3. Blood should not be transfused through a giving set that has
contained solutions other than 0.9% saline. Dextrose may cause haemolysis.
Calcium containing solutions such as Ringer’s may cause citrated blood to
coagulate in the line. Other drugs must not be administered through the giving
set of a blood transfusion – a separate line must be used. Priming with saline is
not necessary. The giving set must be changed every 12 hours to avoid
bacterial growth, or when advised to do so on the Patient’s notes form. A new
giving set should be used when changing between red cells, platelets and/or
FFP.
6.21.4. In Theatres it is not always practical to change the giving set between
blood and other fluid administration. In cases where it cannot be changed, the
giving set must be primed with saline before and after the transfusion. This is
valid only in a theatre/recovery setting and has an associated risk assessment
on the Trust Risk Register.
6.21.5. Filters
All blood components are leucocyte depleted by the NHSBT and do NOT
require further filtration.
6.21.6. Pumps
Electronic pumps for blood transfusion are not permitted for any adult red cell
transfusion. Pumps may be used for paediatric transfusions, and the decision
to use a pump needs to be based on a case by case basis.
6.21.7. Blood Warmers
6.21.8. The routine warming of blood and blood products is not
recommended, as it is of limited benefit and is potentially dangerous. Keeping
the patient warm is probably more important than warming the infused blood.
6.21.9. Blood warmers should be used when the flow rate exceeds 50ml/kg/hr
in adults and 15ml/kg/hr in infants and in exchange transfusions.
7. Dissemination and Implementation
7.1. The policy is hosted by the Trustwide Intranet (DL2). The ‘clinical guidelines’
section of the intranet is a site recognised by all clinical staff as that where they will
find an up to date Transfusion Policy.
7.2. Alterations are notified to appropriate clinicians either as correspondence
following a Hospital Transfusion Team meeting, or through the Transfusion
Blood Transfusion Policy
Page 21 of 35
Committee, according to urgency. The daily email bulletin will be used to alert all staff
to publication of new versions and ward based Transfusion Assessors will be
educated where significant changes alter nursing practice.
8. Monitoring compliance and effectiveness
Element to be
monitored
a. duties
b. process for the request of blood samples for pre-transfusion
compatibility testing
c. process for the administration of all transfusions, including
patient identification
d. care of patients receiving a transfusion
e. organisation’s expectations in relation to staff training, as identified
in the training needs analysis
f. requirements for the competency assessment of all staff involved in
the transfusion process
Lead
Tool
Transfusion leads (HTT)
The Trust takes part in the audit schedules for National Comparative
Audit, Regional Transfusion committee and the internal audit cycle
(both clinical and laboratory). The subject of these audits includes
patient wristbands and identification, bedside transfusion practice,
overnight transfusion, appropriate use of components but this is not an
exhaustive list.
All errors and incidents are reported to DATIX, SHOT and SABRE
(when necessary). Outcomes of investigations are entered onto the
Corrective and Preventative Actions and Improvements Log (this is
used for trend analysis).Corrective Actions entered via SABRE are
monitored by the MHRA. All SHOT data is compiled in an annual
national report.
Education is biennial and role specific: the requirements for staff are
entered in the Trust Training Matrix. Staff receive face to face training
at Induction, biennial face to face or online learning. Observed
competency assessment on a 2 year cycle is undertaken by ward
based assessors and the Transfusion Practitioners. Training and
assessment figures are reported to ward based assessors, ward
managers, HTC, Governance Committee and Senior Nurses via
Learning and Development.
Frequency
Reporting
arrangements
Information disseminated via HTT (monthly) and HTC (3x year).
NCA audit 2-3x year.
Monthly reports from MAPs data for assessment progress.
The results of the audits are reported to the HTT, HTC, clinical audit
dept (external audits), Clinical Governance Committee and Senior
Nurse Steering Group.
Blood Transfusion Policy
Page 22 of 35
Acting on
recommendations
and Lead(s)
Change in
practice and
lessons to be
shared
HTC, HTT, Senior Matrons, Transfusion Assessor Network, PCH
Transfusion Practitioner
HTC meetings, audit meetings (specifically theatres), emailed daily
bulletin for general awareness. L+D for changes to mandatory
education.
9. Updating and Review
9.1. This policy is due for a full review in Sep 15.
9.2. As there are only minor amendments and a change into the new RCHT
policy template, this policy was sent straight to the Medical Director for approval.
10. Equality and Diversity
10.1.This document complies with the Royal Cornwall Hospitals NHS Trust
service Equality and Diversity statement.
10.2. Equality Impact Assessment
10.3. The Initial Equality Impact Assessment Screening Form is at Appendix 1.
Blood Transfusion Policy
Page 23 of 35
Appendix 1. Blood Transfusion Policy - Blood Transfusion
Competencies Pack
This appendix is available for download separately via the Trust’s Document Library.
Search for ‘blood transfusion’ and select ‘Audience: = RCHT’.
Blood Transfusion Policy
Page 24 of 35
Appendix 2. Blood Transfusion Policy - Blood Products Guide
Product name
Flebogamma DIF
Kiovig
Octagam
Privigen
Product
description
Licensed Use
Special
requesting
instructions
Human normal
immunoglobulin
Used to treat conditions
where the body's defence
system against disease is
not working properly
Patient must
be registered
on national
IVIg
database
Human normal
immunoglobulin
Replacement
therapy:immunomodulatio
n:post bone marrow
infection prevention
Patient must
be registered
on national
IVIg
database
Human normal
immunoglobulin
Replacement
therapy:immunomodulatio
n:post bone marrow
infection prevention
Patient must
be registered
on national
IVIg
database
10
Human normal
immunoglobulin
Replacement
therapy:immunomodulatio
n:post bone marrow
infection prevention
Patient must
be registered
on national
IVIg
database
10
%
*/ml
IU
Reconstitution
<30oC
Administration
IV
Initial infusion
rate is 0.01-0.02
ml/kg/min to be
increased if
tolerated to 0.1
ml/kg/min).
Ready to use
Protect from
light
2oC-8oC
IV. Bring to room
temp prior to use
Ready to use
Protect from
light
2oC-8oC
Ready to use
<25oC
50 mg/ml
100 mg/ml
Blood Transfusion Policy
Page 25 of 35
100 mg/ml
NA
Storage
IV. Bring to room
temp prior to use
IV
Initial infusion
rate is 0.3 ml/kg
bw/hr. If well
tolerated,
increase to 4.8
mlkg bw/hr. In
PID patients who
have tolerated
4.8 ml/kg bw/hr
well the rate may
be rather
increased
gradually to a
maximum of 7.2
Product name
Viagam
Hizentra
Beriplex P/N
NovoSeven
Product
description
Human normal
immunoglobulin
Licensed Use
Replacement
therapy:immunomodulatio
n:post bone marrow
infection prevention
Replacement
therapy:immunomodulatio
n:post bone marrow
infection prevention
Human normal
immunoglobulin
Subcutaneous
Human
coagulation
factors II, VII, IX
and X
(prothrombin
complex)
Prevention and treatment
of bleeding caused by lack
of acquired or congential
vitamin K dependent
coagulation factors
Recombinant
VIIa
Treatment of bleeding
events in acquired
haemophilia or VII
deficiency
Special
requesting
instructions
%
Patient must
be registered
on national
IVIg
database
Patient must
be registered
on national
IVIg
database
5
*/ml
IU
2.5, 5, 10gm
Blood Transfusion Policy
Page 26 of 35
NA
Administration
ml/kg bw/hr
2oC8oC.
Storage
for up to
3
months
at 25oC
<25oC
Subcutaneous
use. Loading
dose may be
required.
Bring to room
temperature and
follow
instructions
<25oC
Via separate IV
line approx
8ml/min
Bring to room
temperature and
follow
instructions
<25oC
IV. Rate as
prescribed.
Ready to use
250 (10
ml) and
500
(20ml)
IU
1mg
(50KIU)
2mg
(100KIU
) 5mg
(250)
8mg
(400KIU
)
Storage
IV. Bring to room
temp. Infusion
rate of 0.01-0.02
ml/kg/min for first
30 minutes.
Gradually
increase to
0.04ml/kg/min up
to max of 3
ml/min
Ready to use
200 mg/ml
(5,10,15 or
20ml)
NA
Reconstitution
Product name
FEIBA
Haemate P
Kogenate
ReFacto AF
Product
description
Licensed Use
Human
coagulation
factors
Human
coagulation
factors VIII and
von Willebrand
factor
To aid clotting in patients
who have developed
inhibitors to factor VIII.
Prevention and treatment
of bleeding caused by lack
of factor VIII (haemophilia
A) or von Willebrand
factor
Recombinant
coagulation
factor VIII
Recombinant
coagulation
factor VIII
Special
requesting
instructions
%
*/ml
IU
Reconstitution
500,
1000
500 and
1000
Treatment and
prophylaxis of bleeding in
patients with haemophilia
A (factor VIII deficiency)
Treatment and
prophylaxis of bleeding in
patients with haemophilia
A (factor VIII deficiency)
Blood Transfusion Policy
Page 27 of 35
Room
temperature and
follow
instructions
1000
Room
temperature and
follow
instructions
250,
500,
1000,
2000
Room
temperature and
follow
instructions. Use
within 3 hours of
reconstitution
Storage
Administration
<25oC
IV. Do not
exceed rate of 2
units FEIBA
kg/bw/min
<25oC
2oC8oC.
Can be
stored
<25oC
for a
single
period
of up to
12
months
2oC8oC.
Can be
stored
<25oC
for a
single
period
of up to
3
months
IV. Do not
exceed 4ml per
minute.
IV. Rate
determined by
patients comfort
level (maximal
rate 2ml/min
injection)
IV. Rate as
prescribed.
Product name
Product
description
Licensed Use
Benefix
Recombinant
coagulation
factor IX
Treatment and
prophylaxis of in patients
with Haemophilia B.
Factor X
Plasma derived
Factor X
Treatment and
prophylaxis of bleeding in
patients with hereditary
factor X deficiency
Berinert
C1 esterase
inhibitor
Treatment of hereditary
angiodema type I and II
Zenalb 4.5
Human Albumin
Solution
To replace fluid lost by
bleeding, surgery, dialysis,
centesis
Zenalb 20
Human Albumin
Solution
Rhophylac
Immunoglobulin
from human
source
To replace fluid lost by
bleeding, surgery, dialysis,
centesis
Active ingredient is anti-D
to prevent immunisation of
anti-D, mainly in obstetric
setting.
Special
requesting
instructions
%
*/ml
IU
Reconstitution
250,
500,
1000,
2000
Named
patient basis
only
nominal
500
Bring to room
temperature.
Complete
infusion within
60 mins of
reconstitution
500
Use within 8
hours of
reconstitution
4.5
20
RhD group
must be
available
Blood Transfusion Policy
Page 28 of 35
Ready to use
200g/litre
Ready to use
but warmed to
room temp
2ml
Ready to use in
pre loaded
syringe
1500
Storage
Administration
2-30oC
IV. Rate as
prescribed.
2oC25oC
IV. Rate no faster
than 3ml per min.
IV. 20iu per kg
bodyweight
<25oC
In fridge
or cool
place
between
2-25oC.
Protect
from
light.
In fridge
or cool
place
between
2-25oC.
Protect
from
light.
IV undiluted or in
solution
containing 5%
glucose or 0.9%
sodium chloride
2oC-8oC
IM into deltoid
muscle. IV via
slow injection.
Product name
Product
description
Human Tetanus
immunoglobulin
Immunoglobulin
from human
source
Tisseel Lyo Twocomponent Fibrin
Sealant
Fibrinogen and
thrombin
Licensed Use
Special
requesting
instructions
%
Used to protect against
tetanus
Application to tissues
either to control bleeding
or stop leaks of other
types of fluid by creating a
watertight seal
*/ml
100iu/ml
Blood Transfusion Policy
Page 29 of 35
IU
Reconstitution
Storage
Reconstituted
stable at 37 oC
for 6 hours
2oC-8oC
In fridge
or cool
place
between
2-25oC.
250
Administration
Precaution use
250iu. Treatment
for tetanus
150iu/kg bw
Appendix 3. Governance Information
Document Title
Blood Transfusion Policy
Date Issued/Approved:
1 Sep 12
Date Valid From:
1 Sep 12
Date Valid To:
1 Sep 15
Directorate / Department responsible
(author/owner):
Deb Thomas – Lead Transfusion Practitioner
Dr Richard Noble – Consultant
Haematologist
Stephen Bassey – Blood Transfusion
Manager
Nicola Jannaway – Transfusion Practitioner
Contact details:
01872 253093
The policy covers all aspects of Positive
Patient Identification throughout sample
taking for blood transfusion, collection of
blood products and administration. Practical
guidance on all aspects of blood product
transfusion is included.
Transfusion blood sample taking
haematology SPN14 BSQR
RCHT
PCT
CFT

Brief summary of contents
Suggested Keywords:
Target Audience
Executive Director responsible for
Policy:
Medical Director
Date revised:
1 Sep 12
This document replaces (exact title of
previous version):
Blood Transfusion Policy
Approval route (names of
committees)/consultation:
Hospital Transfusion Team
Hospital Transfusion Committee
Divisional Manager confirming
approval processes
Head of Diagnostics and Therapeutics –
Bruce Daniel
Name and Post Title of additional
signatories
Not Required
Signature of Executive Director giving
approval
Publication Location (refer to Policy
on Policies – Approvals and
Ratification):
{Original Copy Signed}
Internet & Intranet
 Intranet Only
Document Library Folder/Sub Folder
Clinical / Haematology
Links to key external standards
NPSA SPN 14, BBT3, BSQR, CQC
Blood Transfusion Policy
Page 30 of 35
Related Documents:
Training Need Identified?
National Directives and Health Service
Circulars which underpin this policy:
 Better Blood Transfusion 3 - Appropriate
Use of Blood.
 Health Service Circular 2007/001
Department of Health
 NHS Litigation Authority Inspection
Standards
 British Committee for Standards in
Haematology
 UK Blood Transfusion and Tissue
Transplant Guidelines
Other Guidelines
Blue Book Transfusion Guidelines
 Bradbury M, Cruickshank JP. Blood
transfusion: crucial steps in maintaining
safe practice. British Journal of Nursing,
2000; 9: 134-138.
 Royal College of Physicians of
Edinburgh. Consensus Conference on
Platelet Transfusion: Final Statement.
Transfusion Medicine, 1998; 8: 149-151.
 SIGN guideline 105 – Management of
acute upper and lower GI bleeding
Other blood transfusion related policies
to be found on the Document Library:
 Blood Transfusion Policy for Infants and
Neonates
 Maximum Blood Ordering Schedule
 Intraoperative Cell Salvage and
Administration of Autologous Blood
 Prophylactic and Postnatal anti-D
including flowchart
 Guidelines for Transfusion of Blood
Products in the Community
 Blood and Blood Product Refusal
 Intrapartum Care of Women Declining
Blood Products
Yes – Mandatory training and assessment
done 2 yearly, minor changes only in this
version
Version Control Table
Date
Apr 05
Version
No
1
Summary of Changes
Re written
Blood Transfusion Policy
Page 31 of 35
Changes Made by
(Name and Job Title)
Deb Thomas –
Transfusion
Jun 07
1.1
Update following audit outcome of overnight
transfusion
Jun 09
2
Full review
Nov 09 3
Correcting some spelling mistakes, addition of
use of pump in paediatric transfusions,
formatting changes
Nov 10 4
Addition of paragraph to clarify use of giving
sets in Theatres
Update to include new computer system
paperwork.
Revise sample validity table.
Training requirements for all staff added,
Changes to Haemostatic pack – name change
to Massive Haemorrhage Pack (and format of
pack)
rViia amendment
Nov 10 4
NPSA competency assessment every 2 years
inline with mandatory training
Add peel out strip from compatibility label to
prescription.
Nov 10 4
Addition to clarify transfusion in transit
between hospitals
Nov 10 4
Dissemination and Implementation
Jun 11
4.1
Transfer into new policy format
Deb Thomas –
Transfusion
Practitioner
Nicki Jannaway –
Transfusion
Practitioner
Nicki Jannaway –
Transfusion
Practitioner
NIcki Jannaway –
Transfusion
Practitioner
Stephen Bassey –
Transfusion Manager
Deb Thomas
Transfusion
Practitioner
Nicki Jannaway –
Transfusion
Practitioner
Dr Richard Noble –
Transfusion
Consultant
Deb Thomas – Lead
Transfusion
Practitioner
Dec 11 4.2
Throughout policy changed PCT to PCH and
NBS to NHSBT.
Addition of No Wristband, No transfusion
TACO recommendations from SHOT
Retrospective consent in line with SaBTO
recommendations
FFP volumes changed from 12-15ml to 1015ml per Kg.
Recording competency data on Maps rather
than L+D for nursing staff.
Deb Thomas – Lead
Transfusion
Practitioner
Sept 12 4.3
Into new policy format
TACO information (pg 9)
Additional info re consent and overnight tx
Added Competency Pack as App
Added Blood Product Overview as App
Deb Thomas – Lead
Transfusion
Practitioner
Blood Transfusion Policy
Page 32 of 35
All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.
Blood Transfusion Policy
Page 33 of 35
Appendix 4.Initial Equality Impact Assessment Screening Form
Name of service, strategy, policy or project (hereafter referred to as policy) to be
assessed: Blood Transfusion Policy
Directorate and service area:
Is this a new or existing Procedure?
Diagnostics and Therapeutics Division
Existing
Name of individual completing
Telephone:01872 253093
assessment: Deb Thomas
1. Procedure Aim*
To ensure adherence to national guidelines and best
practice on all issues affecting safe appropriate blood
transfusion.
2. Procedure Objectives* To provide accurate advice on all relevant aspects of the
transfusion of blood and blood products within both Acute
and Community setting.
3. Procedure – intended
Positive Patient Identification – in all aspects of process
Outcomes*
from sample taking to administration. Staff Education
programme signposted. Haemovigilance.
4. How will you measure
the outcome?
5. Who is intended to
benefit from the
Procedure?
6a. Is consultation
required with the
workforce, equality
groups etc. around this
procedure?
See more thorough section in policy relating to audit,
competency assessment and incident reporting and
trending.
Any patient requiring treatment that may lead to transfusion
of blood or blood products. Staff directly involved in the
care of this patient group.
No
b. If yes, have these
groups been consulted?
c. Please list any groups
who have been consulted
about this procedure.
*Please see Glossary
7. The Impact
Please complete the following table using ticks. You should refer to the EA guidance notes
for areas of possible impact and also the Glossary if needed.


Where you think that the policy could have a positive impact on any of the equality
group(s) like promoting equality and equal opportunities or improving relations
within equality groups, tick the ‘Positive impact’ box.
Where you think that the policy could have a negative impact on any of the equality
group(s) i.e. it could disadvantage them, tick the ‘Negative impact’ box.
Blood Transfusion Policy
Page 34 of 35

Where you think that the policy has no impact on any of the equality group(s) listed
below i.e. it has no effect currently on equality groups, tick the ‘No impact’ box.
Equality
Group
Age
Positive
Impact
Negative
Impact
No
Impact

Disability

Religion or
belief

Gender

Transgender

Pregnancy/
Maternity
Race

Sexual
Orientation

Marriage / Civil
Partnership

Reasons for decision

You will need to continue to a full Equality Impact Assessment if the following have
been highlighted:
 A negative impact and
 No consultation (this excludes any policies which have been identified as not
requiring consultation).
8. If there is no evidence that the policy
promotes equality, equal opportunities
or improved relations - could it be
adapted so that it does? How?
Full statement of commitment to policy of
equal opportunities is included in the policy
Please sign and date this form.
Keep one copy and send a copy to Matron, Equality, Diversity and Human Rights,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Chyvean
House, Penventinnie Lane, Truro, Cornwall, TR1 3LJ
A summary of the results will be published on the Trust’s web site.
Signed ________ Deb Thomas __________
Date ___________ 21 Jun 11 ___________
Blood Transfusion Policy
Page 35 of 35
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