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 Page 2 of 35 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 Page 3 of 35 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. Blood Transfusion Policy Page 4 of 35 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: 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: 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: 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 Blood Transfusion Policy Page 5 of 35 The Transfusion Team meets monthly. 5.5. Role of the Managers Line managers are responsible for: Ensuring all staff are aware of this policy Enabling all relevant staff attend mandatory training and appropriate assessment in Transfusion. 5.6. Role of Individual Staff All staff members are responsible for: Ensuring they adhere at all times to the Transfusion Policy Highlight to TP or laboratory staff any errors or omissions from the policy 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. 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. Blood Transfusion Policy Page 6 of 35 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: Blood Transfusion Policy Page 7 of 35 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. 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: Full name (correctly spelt) Blood Transfusion Policy Page 8 of 35 Gender Date of birth Unique identifier (NHS or Cr number) Date and time blood sample collected 6.7.5. 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. 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. 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): 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. Blood Transfusion Policy Page 9 of 35 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: 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. Blood Transfusion Policy Page 10 of 35 6.8.11. 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: Pack A - 6 red cells; 4 FFP 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 Blood Transfusion Policy Page 11 of 35 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): Hodgkin's Disease patients. Blood Transfusion Policy Page 12 of 35 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). 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) Blood Transfusion Policy Page 13 of 35 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. Blood Transfusion Policy Page 14 of 35 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: 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: 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 Blood Transfusion Policy Page 15 of 35 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 170m 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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