annual blood component education

Annual Blood Component Education

2017

• Identify the essential steps in the safe administration of blood components to a patient

• Identify transfusion reactions signs/symptoms• Gain understanding of transfusion reaction

management and required documentation• Identify organizational resources for blood

components

Objectives

Blood Components

Include, but are not limited to:• Packed Red Blood Cells (PRBC)• Platelet Concentrates• Plasma• Cryoprecipitate (Cryo)• Granulocytes• Rh Immune Globulin (Rhogam)

The RN is responsible for ensuring the patient/delegate will be:– Informed of the risks, benefits and alternative treatments associated with the

transfusion of blood or blood products – given the “If You Need a Blood Transfusion” brochure– Give patient/delegate an opportunity to ask questions – Asked to sign a written consent form for the transfusion of blood or blood

products.

Informed Consent:• The signed “Informed Consent for Blood and Blood Products” form is maintained

in the patient’s medical record.• For inpatients: Informed Consent is valid for the duration of the patient’s

hospitalization.• For patients receiving outpatient transfusions: Informed Consent is valid for one

year.

Blood Transfusion Consent: Non-Emergent Situation

Blood Component Administration

• BEFORE picking up blood component from the blood bank:

• Ensure the patient/delegate has signed the consent for transfusion

• The patient has a functioning IV site • You’ve taken pre-transfusion vital signs• And the patient is ready and available• Print blood pick up slip

The single most important step in blood product administration is verification of the patient and the blood product(s).

• Review medical record for transfusion order, type of component and verify consent has been obtained • Verify blood component matches order • Read aloud to second verifying clinician the below information to compare blood tag and patient ID bracelet:

•Ensure blood tag stays on blood component until it has infused • DO NOT ADMINISTER the blood if any discrepancy is noted (contact the blood bank ASAP)

Verification Procedure forBlood Component Administration

Prior to administering any blood product, complete the two-RN verification process.

Patient’s name, MR#, and patient’s blood type The unit’s number and unit blood type Unit expiration date

n/a Crossmatch interpretation (antibody screen) n/a Special transfusion requirements

Blood Component Administration

• Initiation of transfusion of blood products should begin within 5 minutes of completing blood double checks.

• If unforeseen issues arise but you can still give the blood component as long as transfusion will be completed within the 4-hour window (beginning when the blood left blood bank)

• Keep the product on the unit until you are able to transfuse.

Blood Basics

A Blood Transfusion Checklist can be found on FACETS to help you navigate through the process of blood product administration

BLOOD TRANSFUSION CHECKLIST

1. Verify that a consent form has been signed.

2. Generate a pick-up slip from the patient’s chart in Epic.

3. Document pre-transfusion vital signs (BP, Temp, Pulse, Resp). These must be documented within one hour of the transfusion start time. Vitals documented at the start of the transfusion are considered “within one hour.” Vitals documented more than 60 minutes before the start time will be considered a miss (Joint Commission standard).

4. Prior to administering any blood product, complete the two-RN verification process.

Patient’s name, MR#, and patient’s blood type The unit’s number and unit blood type Unit expiration date n/a Crossmatch interpretation (antibody screen) n/a Special transfusion requirements

5. Infuse slowly for the first 15 minutes while observing the patient for adverse reactions. It is an expectation that the primary RN stays with the patient for the first 15 minutes of the infusion.

6. Obtain and document vital signs within 15 minutes of the documented start time. Vitals

documented more than 15 minutes after the start time will be considered a miss (Joint Commission standard).

7. If no signs of a transfusion reaction are noted, increase the flow rate to the desired

speed. Document new rate using the dropdown option “Blood Rate Change” (this option does not require a dual sign-off).

8. Continue to assess the patient throughout the transfusion as needed, according to the

patient’s condition and the number of units being administered.

9. When the unit of blood has finished transfusing, document as “Infused” using the dropdown option. Enter the blood volume at this time in the volume row.

10. Document post-transfusion vital signs. These must be documented within one hour of

the transfusion end time. Vitals documented at the completion of the transfusion are considered “within one hour.” Vitals documented more than 60 minutes after the end time will be considered a miss (Joint Commission standard).

11. Complete the flowsheet rows by right clicking on the blood unit title and selecting “Complete Transfuse…”

12. Continue to monitor for signs and symptoms of delayed transfusion reaction.

13. The transfusion tag must remain on the blood product during the transfusion. Send to

lab after transfusion complete.

Click HERE

http://intranet.parknicollet.com/Nursing/Pages/Blood-administration.aspx

• Blood can only be returned to blood bank within 5 minutes of leaving the lab. Ensure everything is in order before picking up the blood components to avoid wasting resources.

• Blood component must be transfused within 4 hours or before stated expiration.

• Blood tubing/filter is only good for 4 hours! • Get new Y-blood tubing for a second unit if it will take 4

hours or more to complete both transfusions. • When administering blood components, never mix or

administer simultaneously any other I.V. solution except normal saline solution.

Did You Know???

Blood Component Documentation in EPIC (inpatient)

• Make sure to bar code scan the patient and scan the normal saline prior to starting.

• On the Blood Administration flowsheet, ensure a recent set of vital signs have been documented and answer the Pre-Transfusion Documentationquestions.

• Scan the patient• Before scanning blood product click the syringe in

the blood unit rate row.


Once the administration has been accepted, the Dual Signoff Summary window will display. A second nurse will verify the correct patient and correct blood information then click the Sign Off button in the lower right corner.

Once you have selected the correct blood product, you will see a green thumbs up

• Adults: Packed Red Blood Cell (PRBC) Rates: • Initial rate- slowly infuse 1mL/minute (60 mL/hour) to allow for recognition of

an acute adverse reaction. • If no reaction occurs in the first 15 minutes, the rate may be increased to 4

mL/minute (240 mL/hour)• For patients with heart failure do not exceed 125mL/hour

• Pediatric: Packed Red Blood Cell (PRBC) Rates: • Initial rate- slowly infuse at no more than 3-5 mL/kg/hour• If no reaction occurs in the first 15 minutes, the rate may be increased 10-20

mL/kg/hour. • For newborns do not exceed 5 mL/kg/hour

Suggested Flow Rates for PRBC Administration

First 15 Minutes• Platelets: 2-5ml/min(120-

300 ml/hour)

• Plasma: 2-5ml/min (120-300 ml/hour)

• Cryoprecipitate: As rapidly as tolerated

After 15 Minutes• Platelets: 300 ml/hour or

as tolerated

• Plasma: As rapidly as tolerated: approximately 300 ml/hour

Suggested Blood Component Transfusion Rates (Adult Patients)

**Remember if the patient has heart failure or is prone to fluid overload to use the lower end of the infusion time.**

Signs & Symptoms of a Transfusion Reaction

Transfusion Reaction

Chills Fever Flushing Headache Chest Pain

Shortness of Breath

Back Pain Vomiting Decreased

Blood Pressure Pain at Site

Tingling Skin Irritation Itching Nausea Diarrhea

Remember to report ANY suspected reactionIt does not matter how minor the symptoms

Transfusion Reactions

• Can be life-threatening• Can occur with even the smallest amount of

blood– This is why transfusion should be started slowly

unless a patients condition requires a rapid life sustaining transfusion.

Delayed Transfusion Reaction

• In some instances, transfusion reactions may take place days after the transfusion.

• Ensure patient/delegate have been educated to pay close attention to their body after a transfusion.

• Patient/delegate should be instructed to alert a health care provider if they experiences any signs/symptoms of a transfusion reaction.

• Observation & EMIC patients are given a brochure upon discharge outlining signs and symptoms of transfusion reaction and what to do.

What causes the transfusion reaction?

• Antibodies in the recipient’s blood can attack the donor blood if the two are not compatible.

• If the recipient’s immune system attacks the red blood cells of the donor, it is called a hemolytic reaction.

• Patients can have an allergic reaction to a blood transfusion as well. These symptoms can include hives and itching. This reaction type is often treated with antihistamines.


• Another transfusion reaction type is the transfusion related acute lung injury (TRALI).

• Reaction may occur when donor plasma contains antibodies that cause damage to the immune cells in the lungs.

• Lung damage results in fluid buildup in the lungs and can severely limit the ability of the lungs to supply oxygen to the body.

• This reaction usually occurs within six hours of receiving blood.


• A transfusion reaction can also occur if a person receives too much blood.

• This is known as transfusion-associated circulatory overload (TACO).

• Having too much blood can overload the heart, forcing it to work harder to pump blood through the body and resulting in fluid buildup in the lungs.

TRALI & TACOTRALI

Transfusion-Related Acute Lung Injury

Acute onset of Acute Lung Injury within 6 hours of infusion

Hypoxemia

Oxygen saturation less than 90% on room air

Respiratory distress

Life-threatening transfusion reaction

TACO Transfusion-Related Acute Injury

Pulmonary congestion

Moderate to severe respiratory distress

Hypertension

Tachycardia

Assessing and Managing TACO

• Identify at risk patients for transfusion-associated circulatory overload (TACO), e.g. a previous TACO reaction, history of congestive heart failure, history of chronic pulmonary disease or high BNP.

• A patient with a previous TACO reaction will have a Blood Transfusion Reaction FYI that will trigger a BPA when ordering blood products.

• Jump to the FYI to review the comment and recommendations.

Recommendations to Considerif a patient has a history of TACO

• a slower rate of transfusion• split units• volume-reduction of platelet components• prophylactic diuretic therapy• avoiding concurrent crystalloid infusion with

transfusion• careful assessment during transfusion for possible

diuresis • more frequent monitoring during and immediately

after transfusion.

Transfusion Reaction Management

If you suspect a transfusion reaction: • STOP the infusion and notify the provider immediately.• Start a saline infusion using a new I.V. administration

set.• Do not discard the blood bag or administration set.• Notify the Blood Bank.• Document Transfusion Reaction in EPIC

– I

– It is imperative to include the Unit Number & Total Volume infused on the Transfusion Reaction Form

EPIC Documentation of Transfusion Reaction

If a transfusion reaction is suspected, document YES in the flow sheet row and then a BPA will fire, taking you to the transfusion reaction report to complete detailed documentation.

You MUST document the following information on the Transfusion Reaction Report:

• Perform and document a re-check of the patient ID with the component tag

• The blood component unit number(s)• Vital signs before, during, and after (transfusion)• Clinical manifestations noted before, during, and after

administration• Infusion start time and stop time, reaction time, and total

volume of blood product infused

Transfusion Reaction Documentation

EPIC Documentation of Transfusion Reaction

Once you have completed documentation on the Transfusion Reaction Report, select PRINT the report, and then send form to lab WITH the blood

bag and tubing.

Blood Reaction Resources

EPIC Tips sheets are available with step-by-step instruction for managing blood reaction documentation in the EC and Inpatient settings. The tip sheets can be found on FACET by searching blood. Here is the link:Blood Administration Page


Clinical Keys:• Blood Product Administration (Pediatric)• Blood Product Administration (Adult)• Transfusion ReactionFACETS: Nursing ~ Blood Administration

Additional Blood Component Resources

http://lms.elsevierperformancemanager.com/ContentArea/NursingSkills/GetNursingSkillsDetails/?skillkeyid=854&skillid=CCP_132

http://lms.elsevierperformancemanager.com/ContentArea/NursingSkills/GetNursingSkillsDetails/?skillkeyid=201&skillid=EN_074

http://lms.elsevierperformancemanager.com/ContentArea/NursingSkills/GetNursingSkillsDetails?skillid=GN_28_2&skillkeyid=397&searchTerm=blood%20transfusion&searchContext=nursingskills


Reminders & Tips

•Remember: The prep order alerts the blood bank to prepare the product. The transfuse order is what allows nursing to be able to document on the unit of blood.

•You cannot release blood in EPIC without a transfuse order. Please ensure you have both the prep and transfuse orders before proceeding.

•Starting on April 3rd, 2017 the blood bank will ONLY accept EPIC printed blood pick up slip for all blood products (including Rhogam). The ONLY exception is for emergency transfusions with O negative uncrossmatched products.

Reminders & Tips

•You cannot scan the blood component when CAPS lock is on.•If you do not enter “0” when the blood is finished transfusing, the status will never switch to “Infused”.•Remember to document on the patient education section in EPIC regarding the transfusion.

References

Blood Production Administration. (n.d). In Elsevier Clinical Skills. Retrieved from http://mns.elsevierperformancemanager.com/NursingSkills/ContentPlayer/SkillContentPlayerIFrame.aspx?KeyId=201&Id=EN_074&IsConnect=False&bcp=SpecialtyId~0~blood administration~False&Section=7

Fung, M. K., Grossman, B. J., Hillyer, C. D., & Westhoff, C. M. (Eds.). (2014).Technical manual. American Association of Blood Banks.

Transfusion Reaction. (n.d.). In Elsevier Clinical Skills. Retrieved from http://mns.elsevierperformancemanager.com/NursingSkills/ContentPlayer/SkillContentPlayerIFrame.aspx?KeyId=397&Id=GN_28_2&IsConnect=False&bcp=SpecialtyId~0~transfusion reaction~False&Section=7

annual blood component education

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