blood transfusion policy

Policy No: RM36

Version: 7.0

Name of Policy: Blood Transfusion Policy

Effective From: 11/06/2018

Date Ratified 15/03/2018

Ratified Hospital Transfusion Committee

Review Date 01/03/2020

Sponsor Associate Director Clinical Support and Screening Services

Expiry Date 14/03/2021

Withdrawn Date

Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that

this is the most up to date version

This policy supersedes all previous issues

Blood Transfusion RM36 version 7.0 2

Version Control

Version Release Author/Reviewer Ratified

by/Authorised

by

Date Changes

(Please identify page no.)

1.0

Oct 2003 Hospital

Transfusion

Committee

Oct 2003

2.0

Dec 2004 Hospital

Transfusion

Committee

Dec 2004

3.0

Oct 2006 Hospital

Transfusion

Committee

Oct 2006

4.0

09/09/2009 L Bennett Hospital

Transfusion

Committee

10/06/2009

5.0

11/10/2011 K Nesbitt

Hospital

Transfusion

Committee

29/06/2011

5.1 03/12/2012 K. Nesbitt Director of

Nursing,

Midwifery and

Quality

17/05/2013 Pages 10,21,23,26,28,34&40

6 11/08/2015 K. Nesbitt Hospital

Transfusion

Committee

11/3/2015 Pages

13,15,16,17,19,23,24,31,33,34

,35,39 plus some minor

grammatical changes.

7.0 11/06/2018 K. Nesbitt Hospital

Transfusion

Committee

14/03/2018 Pages

3,4,6,7,9,12,13,14,15,17,18,19

,20,21,22,23,24,25,26,28,29-

33,36,39,42,44-46


Blood Transfusion Policy

Contents Page

1. Introduction .................................................................................................................................. 5

2. Policy scope .................................................................................................................................. 5

3. Aim of policy ................................................................................................................................. 5

4. Duties - roles and responsibilities ................................................................................................ 5

4.1 The Trust Board ............................................................................................................... 5

4.2 The Hospital Transfusion Committee .............................................................................. 5

4.3 The Transfusion Lab manager ......................................................................................... 5

4.4 The Transfusion Practitioners.......................................................................................... 6

4.5 The Laboratory staff ........................................................................................................ 6

4.6 Consultant Haematologists ............................................................................................. 7

4.7 Medical staff .................................................................................................................... 7

4.8 Business unit Managers ................................................................................................... 7

4.9 Ward Managers ............................................................................................................... 7

4.10 Nursing staff, qualified and unqualified .......................................................................... 8

4.11 Phlebotomy staff ............................................................................................................. 8

4.12 Portering staff .................................................................................................................. 8

5 Definition of terms ....................................................................................................................... 8

6 Blood transfusion ......................................................................................................................... 9

6.1 General notes .................................................................................................................. 9

6.1.1 Current legislation .............................................................................................. 9

6.1.2 Documentation ................................................................................................... 9

6.2 Patient identification and wrist bands ............................................................................ 10

6.2 1 Positive Patient Identification ............................................................................ 10

6.2.2 ID wristbands ...................................................................................................... 10

6.2.3 The Unknown Patient ......................................................................................... 11

6.2.4 Photo ID cards .................................................................................................... 11

6.3 Transfusion in Major Incident (MIP) ................................................................................ 11

6.4 The Decision to Transfuse ............................................................................................... 12

6.4.1 Consent ............................................................................................................... 12

6.4.2 The reason for transfusion ................................................................................. 13

6.4.3 Pre-assessment .................................................................................................. 13

6.5 Transfusion samples and requesting blood .................................................................... 13

6.5.1 Timing of transfusion samples ........................................................................... 13

6.5.2 Requesting blood for transfusion ....................................................................... 14

6.5.3 Guidelines for irradiated components ............................................................... 14

6.5.4 Hepatitis E Screening…………………………. ............................................................. 15

6.5.5 Blood transfusion samples ................................................................................. 15

6.5.6 HDN samples ...................................................................................................... 16

6.5.7 Zero tolerance - laboratory acceptance criteria ................................................. 16

6.5.8 Sample errors Three strikes ............................................................................... 16

6.6 Massive blood transfusion .............................................................................................. 17

6.7 Blood components……………………………………………………………………………………………………….17

6.8 Prescribing/Authorising blood......................................................................................... 19

6.9 Preparing the Patient for Transfusion ............................................................................. 19

6.10 Collection from the blood bank ...................................................................................... 20


6.10.1 Requesting collection of blood from the blood bank ......................................... 20

6.10.2 Collection from blood bank ................................................................................ 21

6.10.3 Administration of blood and care of the patient ............................................... 22

6.10.4 The bedside check .............................................................................................. 22

6.10.5 Checking blood using IT ...................................................................................... 23

6.10.6 Monitoring Patients ............................................................................................ 23

6.10.7 Reactions and Incidents ..................................................................................... 24

6.10.8 Recall of blood .................................................................................................... 24

6.10.9 Technical aspects of Transfusion ........................................................................ 25

6.10.9.1 General ........................................................................................ 25

6.10.9.2 Infusion pumps ............................................................................ 25

6.10.9.3 Drugs and blood .......................................................................... 25

6.10.9.4 Escorting patients ........................................................................ 25

7. Training and Competency Assessments ....................................................................................... 26

8. Equality and Diversity ................................................................................................................... 26

9. Process for Monitoring Compliance with the Policy .................................................................... 26

10. Consultation and Review of this Policy ........................................................................................ 26

11. Implementation of this Policy ...................................................................................................... 26

12. References .................................................................................................................................... 27

13. Associated Documentation

Appendix 1Patient’s declining blood products, including Jehovah’s Witness patients and women during

pregnancy ......................................................................................................................................... 29

Appendix 2 Indication codes for Transfusion ............................................................................................ 35

Appendix 3 Blood Order Tariff ................................................................................................................... 36

Appendix 4 Ordering blood in an Emergency ............................................................................................ 38

Appendix 5 Major Haemorrhage Flowchart ............................................................................................. 39

Appendix 6 How to use the “Porter track” system ................................................................................... 40

Appendix 7 The Bedside check .................................................................................................................. 41

Appendix 8 Reactions flow chart ............................................................................................................... 43

Appendix 9 Procedure for the transfer of blood components between hospitals ................................... 44


Blood Transfusion Policy

1. Introduction

This policy should be read in conjunction with policy RM 57 Massive blood transfusion policy.

The policy applies to all patients requiring a transfusion of any blood component

2. Policy scope

This policy applies to all staff employed by Gateshead Health NHS Foundation Trust involved in the

care of a patient, who may require a blood component transfusion.

3. Aim of the policy

The aim of the policy is to ensure safe and appropriate use of blood products are given to all

patients who may require a blood transfusion.

4. Duties - Roles and Responsibilities

4.1 The Trust Board

• Must ensure a Hospital Transfusion Committee (HTC) is in place to support good

transfusion practice.1

• Should support the HTC in their role within the organisation.

• Provide blood transfusion training for all clinical staff at induction and through

mandatory training

• Support the Laboratory to maintain accreditation and fulfil all legislation relevant

to transfusion

4.2 The Hospital Transfusion Committee (HTC)

• Must meet at least 4 times a year to discuss strategies for optimising transfusion

practice

• Produce all policies relevant to transfusion of blood and blood components.

• Discuss Quality performance indicators including incidents

• Monitor practice through audit

• Support the Transfusion Practitioners in their role

• Monitor the appropriate use of blood components

• Promote strategies encouraging the appropriate use of blood and conservation of

blood stocks.

• Produce a contingency plan for blood shortages.2

• Produce a maximum blood order schedule.1

• Encourage the use of clinically and cost effective alternatives to donor blood.

• Produce action plans and recommendations for best practise.

• Create a Hospital Transfusion Team (HTT) to implement the policies and

recommendations of the HTC

• Support the transfusion laboratory manager to comply with the Blood Safety and

Quality Regulations (BSQR) 2005 3

4.3 The Transfusion Laboratory Manager

• Ensure that staff who work in transfusion are appropriately qualified to carry out

their role.


• Ensure ongoing training is maintained

• Maintain CPA accreditation for the laboratory

• Be a member of the HTC

• Be a member of the HTT

• Promote and maintain compliance with the Blood Safety and Quality Regulations

(BSQR) 2005. 3

• Monitor use of blood through statistical analysis of component use and audit of the

MSBOS. 1

• Is responsible for the implementation of the BSQR standards.

• Responsible for completing the annual compliance report for the BSQR

• Facilitate the MHRA if and when they carry out an inspection

• Quality Manager for the Blood Transfusion Department.3

• Report financial impact of blood transfusion on the pathology budget

4.4 The Transfusion Practitioners

• Promote best practice through provision of training for all staff within the

organisation according to their role.1

• Provide induction/mandatory training for all relevant staff.

• Oversee relevant staff to ensure formal competency assessments are completed

following induction and as necessary based on performance

• Devise and implement audits on areas of transfusion practice agreed at HTC 1

• Investigate, and report all incidents at local level i.e. DATIX and HTC and the Serious

Hazards of Transfusion (SHOT) and Medicines Healthcare Regulatory Authority

(MHRA) as appropriate. 4,5, 3

• Be a member of HTC

• Be a member of HTT

• Be a member of the Pathology User Committee

• Lead in the writing and revision of policies related to Blood Transfusion.

• Collaborate with departments to improve and manage changes in practice.

• Provide information and guidance in transfusion practice

4.5 The Laboratory Staff

4.5.1 Team Leader

• Promote the effective use of blood through compliance with MSBOS, HTC

guidelines and Better Blood Transfusion 3.1

• Training officer for Transfusion Laboratory staff

• Maintain a Quality Blood Transfusion service by observing stated protocols

within the Quality Management System of the Clinical Pathology Services. 3

• Monitoring competency of all staff working in Blood Transfusion 3

• Responsible for the day to day running and quality control of the Blood

Transfusion Laboratory

• Lead on and coordinate the production of SOPs on best laboratory practice 1,3

4.5.2 Other Laboratory Staff

• Maintain competency in Blood Transfusion Practice 1,3

• Maintain knowledge base in blood transfusion through CPD.

• Promote effective use of blood through working within guidelines. 1


• Maintain a quality blood transfusion service by observing stated protocols

within the Quality Management System of the Clinical Pathology services. 3

4.6 Consultant Haematologists

• Advise on the management of transfusion patients

• Be a member of the HTT

• Be a member of the HTC

• Support the laboratory staff and Transfusion Practitioners in their role

• Oversee competency of relevant doctors working in the Trust

• Assist Transfusion Practitioners in investigation of incidents and mandatory incident

reporting.

• Support the HTC audit programme

• Promote effective implementation of national guidance and regulation.

4.7 Medical staff

• Promote the appropriate use of blood through observing British Society for

Haematology (BSH) guidelines and HTC recommendations and Trust policy 6

• Discuss risks and benefits of Blood Transfusion with the patient then obtain verbal

consent wherever possible. 7

• Use effective alternatives where indicated.1

• Prescribe blood components appropriately. 7,15,16

• Maintain patient safety throughout the transfusion process.

• Report any adverse reactions or events to the Blood Transfusion Department or

Hospital Transfusion Practitioners as soon as possible.3,4,5

• Attend Induction and Mandatory training.9

• Familiarise themselves with the Trust Patient ID and Blood Transfusion policies

(RM36, RM40, RM 57and RM 77)

• Record the reason for transfusion and any benefits gained in the Patient’s health

record. 7

4.8 Business Unit Managers

• Ensure all staff attend appropriate training. 9

• Support the HTC in implementing strategies to improve patient care in transfusion.

4.9 Ward Managers

• Facilitate the implementation of training and competency assessment of staff

relevant to their role

• Ensure all staff attend mandatory training 9

• Follow Trust Transfusion and Patient ID Policies.10

• Ensure all staff that look after transfused patients are qualified to do so.8,3

• Ensure all adverse incidents within their area are reported through the proper

channels. 3,4

• Responsible for compliance in traceability of blood, achieved through promoting

confirmation by all staff on the ward.3


4.10 Nursing staff, qualified and unqualified

• Follow Trust Blood Transfusion and Patient ID policies. 10

• Attend nursing induction and mandatory training 9,1

• Will maintain competence following training in accordance with the TNA

• Ensure all adverse incidents within their area are reported to the laboratory

immediately and are submitted to DATIX. 3,4,5

• Ensure that compliance regarding traceability is followed and confirmation slips are

returned after commencing the transfusion.

4.11 Phlebotomy staff

Follow the Trust Blood Transfusion and Patient ID policies re: blood sampling 10

• Require specific training on transfusion samples and be competency assessed every

two years. 8

• Attend Induction and Mandatory training. 9

• Ensure all adverse incidents are reported to nurse in charge of the ward and their

line manager 3,4,5

4.12 Portering staff

• Follow Trust policies regarding collection and delivery of blood.

• Attend specific induction training for collection of blood components with

competency assessment every two years 8,9

• Ensure all adverse incidents are reported through the proper channels. 3,4,5,

5. Definition of terms

HTT: Hospital transfusion Committee. This committee is responsible for patient safety in

transfusion

FFP: Fresh Frozen Plasma

SHOT: Serious Hazards of Transfusion. This is a voluntary system for reporting blood transfusion

incidents and reactions

PPID: Positive Patient Identification. The safest way to correctly identify the patient

PAS: Patient administration system

SOP: Standard Operational Procedure. A set of work instructions to ensure common, safe practice

of work

BMS: Biomedical Scientist is a scientist educated in the field of biological science.

COPD: Chronic Obstructive Pulmonary Disease. Chronic obstructive pulmonary disease (COPD) is a

lung disease characterized by chronic obstruction of lung airflow that interferes with normal

breathing and is not fully reversible

TNA: Training Needs Analysis


6. Blood transfusion

6.1 General notes

All Blood components are covered by this policy

6.1.1 Current legislation

The Blood Safety and Quality regulations are written into British criminal law. It is

our legal responsibility to comply with these regulations3

• The law covers the collection, testing, processing and storage of blood and

blood components and is relevant to hospital practice

• Blood must be stored and transported appropriately maintaining the

correct temperature throughout

• All components including, Blood, Platelets, FFP and Cryoprecipitate require

exactly the same degree of care for checking and administration

• Each individual unit Must be prescribed using the approved documentation

• Each individual unit Must be accounted for and every single unit transfused

or wasted Must be confirmed to the laboratory

6.1.2 Documentation

• A transfusion record is available for recording transfusions.2

• This document should only be used in the printed format and never

photocopied11

• The transfusion record must be used to record transfusion in all areas with

the exception of the critical care department (CCD) where it is permissible

to record transfusion observations on the daily observations chart, but they

must be identified as transfusion observations

• Full patient details must be recorded, including a Forename, Surname, Date

of Birth, Record number* and Gender7

• A reason for transfusion must be recorded

• Any special requirements must be clearly stated or “none” to be written in

the box

• Each unit should be prescribed separately

• The donation number of every unit given must be recorded. This is a legal

requirement 3

• All sections must be completed to comply with BSH Guidelines3

• Each unit must be signed for by the person(s) who checked the blood.

• Where two persons are used to check, two independent, separate checks

must be completed and the second checker hangs the blood product 7

• The second checker should ensure the relevant documentation has been

completed

• Start and finish times must be recorded

• Clinical observations must be recorded and be identified as transfusion

observations, “pre transfusion, 15minutes after starting and at the end of

the transfusion”

• All adverse reactions should be recorded and reported to the laboratory or

Transfusion Practitioners then reported using DATIX

• The management of any adverse events should be recorded

• The patient’s response and any benefit should also be recorded


6.2 Patient Identification and Wristbands

This has been identified by Serious Hazards of Transfusion (SHOT) as an area of risk for

the patient.

6.2.1 Positive patient identification 1,7,8,10,12

This is an essential step in reducing the risk for the patient

• Positive Patient Identification (PPID) must be carried out regardless of what

procedure, test, or treatment the patient is to receive

• This is central to good patient care and maintains the patient’s safety at all

times.

• Even if you know the patient well, do not be tempted to avoid the process

as SHOT have evidence where regularly transfused patients, well known to

staff, were given the wrong blood

• Where possible, always positively identify the patient by asking for a full

name and date of birth

• Check this against the ID wristband, where the patient’s record number

must also be found

• This is the only safe and effective way to positively identify patients

properly

• Do not ask “are you John Smith?” as the patient may say “Yes” but could

have misheard exactly what was said

• Patients who cannot identify themselves may wholly depend upon an ID

wristband as this may be the only means of identification they have

6.2.2 ID Wristbands 7,8,10,12

All transfusion patients are required to wear an ID wristband or carry Photo ID,

However, all in patients must wear an ID wristband

• The Trust has invested in printed wristbands to promote safer patient

identification

• These wristbands are printed directly from the PAS system

• They must be used wherever they are available

• If a printer breaks down, it must be reported to IT immediately

• An attempt must be made to have a printed wristband issued from another

printer

• If this is not possible a hand written wristband must be produced.

*ALERT There is a move to using the NHS number instead of a

hospital record number (NPSA). In view of this the Trust will

move over to the NHS number as soon as it is appropriate to

do so. For the purpose of this policy “record number”

currently means the hospital record number, but may change

to the NHS number during the lifetime of this policy.


• The wristband must include the patient’s full, surname, forename, date of

birth, hospital number and gender and should remain insitu for the

duration of the transfusion process

• Addressograph labels are not suitable for patient wristbands

• If a wristband is removed for any reason e.g. to re-site a cannula, it is the

responsibility of the person who removed it to replace it immediately

6.2.3 The Unknown Patient 7

For an unknown and unconscious patient, an A&E hospital number will be

generated from PAS. The patient will be identified as, “Unknown Male/Female”,

with a date of birth gauged upon the following:

01.01.2009 if less than 16 years of age

08.08.1988 if older than 16 years

Changing over to the patient’s correct details needs to be risk- assessed as doing so

too soon can be a risk for the patient. See the “Alert box” below

6.2.4 Photo ID cards 8

• Regularly transfused patients(at least every three months) may be issued

with a Photo ID card instead of a wristband which can be used to positively

identify patients having community transfusion samples taken and out

patient transfusions

No ID, No Transfusion!

Get it right first time, every time and save time.

6.3 Transfusion in a Major Incident (MIP previously known as MAJAX) 10, 13

ALERT Caution: Once a patient’s details become known, great care is needed

in deciding when to change the wristband to the correct details. It is

essential the source of the new information is reliable.

If an unknown patient is having active treatment with blood

components, changing the patient wristband half way through will

cause confusion as the blood will be labelled as “unknown etc” and the

new wristband will not be the same. It is far safer to leave the patient

as “unknown” until the blood transfusion is finished.

The Clinician looking after the patient will decide when it is safe to

revert to the patient’s proper details

A new sample with the correct details must be sent if further blood is

required, stating clearly that these are updated patient details and

including the previous identification details


• In a “MIP” patients have to be managed in a different way from the usual

processes.

• All patients in a “MIP” will initially be given a “MIP” identity, for example: Adam

One, 18.08.1988, 0987654 and will wear an ID wristband stating the “MIP” identity.

• Patients requiring any investigations, drugs or blood will have results and blood

issued using the “MIP” ID

• Adhering to policies for patient identification, sample acceptance and transfusion

in general are more important than ever in a “MIP”.

• Under no circumstances will the rules be bent regardless of the situation.

• Check all samples for accuracy before sending them to the lab as they will have to

be repeated if there are any discrepancies

• If a patient is in the process of having a transfusion, they must continue with the

MIP identity until the transfusion is completed, as all blood components will be

labelled as such.

• Once the transfusion is completed and the Clinician in charge of the patient’s care

considers it safe to revert to the patient’s own identity, a new wristband must be

produced and new samples sent to the lab for blood grouping if the patient is likely

to require further blood components.

• The lab must be notified of the change in details.

• For patients not previously registered to Gateshead, the MIP PAS number will be

retained; just the name and date of birth will change.

• All results and documentation relating to the transfusion must be filed in the “MIP”

notes NOT the general Gateshead health record

6.4 The decision to transfuse

6.4.1 Consent for transfusion 7,14

• The decision to transfuse should be a joint decision between the doctor and the

patient, following a full and frank discussion including the risks and benefits of

having a transfusion.

• Where practicable verbal consent should be sought and documented in the

patient’s record.

• There are patient information leaflets available and should be given to help the

patient decide.

• Where possible an alternative may be offered.

• Members of staff are expected to ensure care is taken to ensure that any

communication barrier does not compromise assessment of consent. For example

patients who are Deaf or hearing impaired, have profound or multiple learning

disabilities, or who are unable to understand a language may need information

provided in alternative formats.

• Members of staff should refer to the Mental Capacity Policy RM74 when dealing

with patients who may lack capacity. The Mental Capacity Act 2005 provides a

statutory framework to empower and protect vulnerable people, who may not be

able to make their own decisions. It makes it clear who can take decisions on

behalf of others, in which situations, and how they should go about this.

• All patients have the right to refuse blood components. The patient refusing blood

or blood products will be treated appropriately and with respect.

• Where patients refuse blood transfusion, see Appendix 1 -Patient’s declining blood

products, including Jehovah’s witness patients and women during pregnancy

6.4.2 Reason for transfusion 7


• Before asking for blood to be cross-matched consider whether a blood

transfusion is necessary.

• There are many risks in transfusion and this should always be taken into

account.

• First consider the patients underlying pathology and the Haemoglobin (Hb)

level appropriate for transfusion. In most cases patients will tolerate an Hb

of 80g/l or less.

See section 6.7 for further details

• Consider any co-morbidity e.g. Coronary Heart Disease, COPD etc.

• Consider the patient’s symptoms, e.g. breathlessness, chest pain, fatigue

etc.

• See the indication codes for transfusion in Appendix 3 and the Blood order

tariff, Appendix 4

6.4.3 Pre assessment1

Pre assessment is an ideal opportunity to find out:

• The patient’s Haemoglobin status.

• Act upon any anaemia prior to admission where possible

• Commence Iron therapy if appropriate to do so.

• Ask about any previous history of bleeding following surgery of tooth

extraction

• Check blood group and antibody screen.

• Patients with antibodies must be discussed with the Surgeon and

Anaesthetist immediately to avoid issues on the day of admission.

• Some red cell antibodies may make same day admission difficult and in

some cases impossible

• Discuss the use of cell salvage

• Patients with antibodies should ideally not be first on the list to allow time

for cross matching and obtaining the blood from the NHS Blood and

Transplant (NHSBT)

• Drugs (prescription and over the counter) should be discussed including:

o Any anticoagulant drugs or other drugs which may affect platelet

function may/may not need to be stopped prior to admission

o Discuss when to stop any of the above drugs prior to admission

o Patient’s choice regarding:

o Acceptance/refusal of blood transfusion

o Any preferred alternative to donor blood

6.5 Transfusion Samples and Requesting blood

6.5.1 Timing of transfusion samples25

The timing of transfusion samples can be critical due to the possible production of

red cell antibodies and the associated risk of a delayed transfusion reaction

Patient Sample to be taken not more than

Pregnant or transfused in the last

three months

Other patients

72 hours before transfusion

7 days before transfusion. (Day sample

taken is deemed as day 1)


6.5.2 Requesting blood for transfusion 7,17

• Only a qualified doctor or authorised Specialist Nurse may decide that blood needs

to be requested from the lab, however, blood may be requested by phone by

anyone on a doctor’s behalf.

• For telephone requests, full patient details, the name of the person making the

phone call and the requesting doctor’s name, will be recorded by the laboratory

staff, in accordance with the guideline.

• The lab will require a blood sample before they can issue blood.

• Two separate transfusion samples are required for new patients without previous

known blood group data. These samples should be taken following correct patient

identification by two different members of staff(where possible) at different times.

• Never take the two transfusion samples together from one venepuncture

• Only in an extreme emergency, e.g. where there is not enough time to wait for a

sample/ second sample to be processed by the lab, 2 units of O blood will be issued.

Before further blood is issued, an urgent sample is required. See Appendix 5

• Full patient details are required on the request form.

• This must include the surname, forename, gender, date of birth and record number

• The reason for the request needs to be clearly stated.

• Not just “anaemia” but why the patient is anaemic

• A current Haemoglobin where possible

• “Pre- op”, is insufficient information for a cross match.

• Ante natal patients must have previous pregnancies and Anti D information

completed

• The requestors name and contact number MUST be given in case there is a problem.

• Any special requirements must be stated, e.g. “Irradiated” components

• For massive haemorrhage see Appendix 6 and the full policy for Massive transfusion

policy RM57

6.5.3 Guidelines for the use of Irradiated Components

Components should be irradiated for the following:-

• All donations from first and second degree Relations

• All adults and children with Hodgkin’s lymphoma at any stage of the disease should

have irradiated products for life.

• Patients who have received purine analogue drugs (Bendamustine, Fludarabine,

Cladribine and Deoxycoformicin), monoclonal antibodies, e.g. Campath should

receive irradiated products indefinitely

• HLA matched products, usually platelets

• Granulocyte transfusions

• Neonatal transfusion for first 6 months of age if previous interuterine transfusion

(IUT) and for all IUT.

• Patients with aplastic anaemia receiving immunosuppressive therapy with anti-

thymocyte globulin (ATG)

• Allogeneic bone marrow transplant patients from the start of conditioning therapy

until completion of medication to prevent/ treat graft versus host disease

• Autologous stem cell transplants from 7 days before and during stem cell harvest,

from start of conditioning therapy until 3 months post-transplant (6 months if total

body irradiation used)

• Patients with a known or suspected T cell deficiency such as Di George syndrome


Contact the transfusion laboratory on ext 2281/6543 for advice if unsure. Wherever

possible transfusions requests for irradiated products should be made 24 hours in

advance. Only cellular components need to be irradiated.

6.5.4 Hepatitis E Screening

NHSBT first introduced hepatitis E virus (HEV) screened components for selected patients on 14 March

2016 following a recommendation from the Advisory Committee on the Safety of Blood, Tissues and Organs

(SaBTO).

• From 1 November 2017 all blood components issued by NHSBT are HEV negative with the

exception of some very rare phenotypes held by the Frozen Blood Bank. Use of these rare untested

components will be discussed on a case by case basis.

6.5.5 Blood samples for transfusion5,7,8,12

This is an area of practice highlighted by the NPSA as requiring training and competency

assessment.

• A group and save or cross match sample, should only be taken by someone who is

competent at venepuncture and has been competency assessed and deemed competent at

taking transfusion samples

Cross match samples should indicate when the transfusion is required to be available.

(Note, routine overnight transfusion should be avoided).

• Only one patient should be bled at any time to avoid confusion. If in any doubt the sample

must be repeated

• Always positively identify the patient before taking the sample.

• This can be achieved by asking the patient for a full name and date of birth.

• Check the patient’s details against the ID wristband or photo ID card, which must

be exactly the same.

• This is the only safe and effective way to positively identify patients properly

• Once taken the blood should be labelled immediately at the patient's side, by the

person who took the sample

• Never hand the sample to someone else to label for you.

• Never label a sample for someone else

• The ID wristband must be used as the source for the patient details.

• The sample details MUST be hand written unless, an order-communication two

dimensional bar-coded label, generated from the patient’s printed ID wristband is

used.

• Never:

• Pre-label samples,

• Use addressograph or ICE labels

• Use medical records and request cards for patient details.

6.5.6 HDN samples

• These samples are taken, to establish the baby’s group, where the mother is

Rhesus D negative and may require Anti D

• The babies sample is a cord blood sample and this should be taken as soon as

possible after birth.


• The mother’s sample is a venous sample. This should be taken no sooner than 1

hour after delivery.

• The samples should be sent together with the mother’s details on the request card

• They MUST be labelled as shown in the table.

“Mother’s” Blood sample “Cord” Blood sample

Surname Mother’s surname

Forename Boy/Girl

Date of birth Baby’s date of birth

Record number Mother’s record number

6.5.7 Zero tolerance – laboratory tolerance – laboratory acceptance criteria for transfusion 19

The Blood Safety and Quality regulations support zero tolerance for incorrectly labelled

samples and samples where the patient has not been sufficiently identified

• The laboratory have strict sample acceptance criteria for all transfusion lab samples

including: Group and Save, Cross match, DCT, HDN, and all Ante natal samples etc.

• The samples must include the patient’s full name, date of birth, record number or

NHS number for community samples, (in the future the NHS number may also be

used for hospital samples)

• The BMS in transfusion has the right to refuse any sample he/she feels is

inadequately labelled or if they feel the patient has not been positively identified.

• Samples inadequately labelled will not be accepted and must be repeated.

• The person who took the sample is responsible for any delays this may cause, NOT

the laboratory.

Sample label must have Request form must include

Surname.

Forename(s).

Date of birth.

Record number.

Gender.

NB. Must be labelled, signed and

dated by the person who took the

sample

As for Sample plus

Consultant and Ward

The reason for transfusion.

Other relevant clinical details.

The amount of blood etc required.

The whereabouts of the patient.

Date and time required.

Any special requirements e.g.

Irradiated components

Ante natal information re, previous

pregnancies, any Anti D given

Must be signed and dated by the

person completing the form.

6.5.8 Sample Errors- HTC Three strikes

• First sample error noted but no action taken

• Second sample error, the staff member involved will be sent a letter from the HTC

informing them they have made a second error and if they make a third error

within a year they will be stopped from taking any further samples until they have

received re-training and competency assessment by the Transfusion Nurses. The

manager of the staff involved in the sample error will also be informed by letter.

• Third sample error, the member of staff involved in the error will be sent a letter

from the HTC informing them that they will not be allowed to take any further


samples until they have received re-training and competency assessment by the

Transfusion Practitioners. The manager of the staff involved in the sample error will

also be informed and asked to support staff re-training.

• Re-training should be arranged within 28 days. If, after 28 days, there has been no

contact with the transfusion practitioners a further letter will be sent informing the

member of staff that the laboratory will dispose of any of their samples without

them having been processed.

This may impact on service provision but patient safety is paramount.

6.6 Massive blood transfusion 20,21,18

• Only a doctor experienced with massive transfusion should co-ordinate and

manage this specific group of patients.

• In patients who are bleeding rapidly, Haemoglobin is a poor indicator of the need

for transfusion:

• In these cases, it is more appropriate to use the volume of blood lost either

measured or estimate, in assessing the need for transfusion.

• N.B. Patients who have lost less than 30% of their blood volume are unlikely to

require transfusion; however patients who have lost more than 40% will probably

require transfusion.

• Positive patient identification and appropriate use of all blood components must

be encouraged to minimise the risk for the patient, even in an emergency. If in

doubt, contact the on call Haematologist for advice.

• Read the Massive transfusion policy (RM 57) available for this situation. See also

Appendix 5

6.7 Blood Components

Red blood cells

Thresholds and targets

• Use restrictive red blood cell transfusion thresholds for patients who need red blood

cell transfusions and who do not:

o have major haemorrhage or

o have acute coronary syndrome or

o need regular blood transfusions for chronic anaemia.

• When using a restrictive red blood cell transfusion threshold, consider a threshold of

70 g/litre and a haemoglobin concentration target of 70–90 g/litre after transfusion.

• Consider a red blood cell transfusion threshold of 80 g/litre and a haemoglobin

concentration target of 80–100 g/litre after transfusion for patients with acute

coronary syndrome.

• Consider setting individual thresholds and haemoglobin concentration targets for each

patient who needs regular blood transfusions for chronic anaemia.

Doses

• Consider single-unit red blood cell transfusions for adults (or equivalent volumes

calculated based on body weight for children or adults with low body weight) who do

not have active bleeding.

• After each single-unit red blood cell transfusion (or equivalent volumes), clinically

reassess, check haemoglobin levels and give further transfusions if needed.

Platelets

Thresholds and Targets


Patients who are not bleeding or having invasive procedures or surgery

• Offer prophylactic platelet transfusions to patients with a platelet count below 10×109

per litre who are not bleeding or having invasive procedures or surgery, and who do

not have any of the following conditions:

o chronic bone marrow failure

o autoimmune thrombocytopenia

o heparin-induced thrombocytopenia

o thrombotic thrombocytopenic purpura.

Patients who are having invasive procedures or surgery

• Consider prophylactic platelet transfusions to raise the platelet count above 50×109

per litre in patients who are having invasive procedures or surgery

• Consider a higher threshold (for example 50–75×109 per litre) for patients with a high

risk of bleeding who are having invasive procedures or surgery, after taking into

account:

o the specific procedure the patient is having

o the cause of the thrombocytopenia

o whether the patient's platelet count is falling

o any coexisting causes of abnormal haemostasis.

• Consider prophylactic platelet transfusions to raise the platelet count above 100×109

per litre in patients having surgery in critical sites, such as the central nervous system

(including the posterior segment of the eyes).

When prophylactic platelet transfusions are not indicated

Do not routinely offer prophylactic platelet transfusions to patients with any of the following:

• chronic bone marrow failure

• autoimmune thrombocytopenia

• heparin-induced thrombocytopenia thrombotic thrombocytopenic purpura.

• patients having procedures with a low risk of bleeding, such as adults having central

venous cannulation or any patients having bone marrow aspiration and trephine

biopsy.

Doses

A single dose of platelets is sufficient for most adults

Fresh Frozen Plasma

N.B. This is a frozen product that takes 25 minutes to defrost in an approved plasma thawing

machine.

Do not offer fresh frozen plasma transfusions to correct abnormal coagulation in patients who:

• are not bleeding (unless they are having invasive procedures or surgery with a risk of

clinically significant bleeding)

• need reversal of a vitamin K antagonist.

Doses

Dose should be based on the patient’s weight, recommended 15ml/kg, ie 70kg patient needs 4

bags FFP

Granulocytes

Granulocyte infusions would not normally be given at the QE, but there may be rare occasions

in patients awaiting transfer to another hospital where this treatment may need to be started

before transfer can be arranged.


If required, Granulocytes should be infused as soon as possible after arriving on the ward,

using a standard blood transfusion giving set.

10 donations are pooled into a final volume of 200-250ml, adults may receive up to two packs

or 20 donations.

The total dose may be given over 1-2 hours

The product has a 24 hour expiry shelf-life

As this is a pooled product from several donors there is a greater risk of the patient having a

transfusion reaction and should therefore be monitored closely during and after the

transfusion. It is advisable to administer prophylactic medication pre-transfusion – 10mg iv

chlorpheniramine, 1000mg oral paracetamol, 100mg iv hydrocortisone – to reduce the risk of

reaction

6.8 Prescribing/Authorising blood components 5,7,11,25

• It is the responsibility of a doctor or authorised specialist nurse to authorise the

administration of blood components

• The decision to transfuse should be based on a recent Haemoglobin recording,

within 24 hours of transfusion for inpatients and 72 hours for outpatients.

• Each individual unit must be prescribed including the duration of the transfusion.

See table below.

• Every single blood component unit must be prescribed including any autologous

salvaged blood

• Blood should only be prescribed on the approved transfusion record.

• Any drugs which need to be given during the transfusion can be prescribed on the

same record.

• It is not necessary to routinely prescribe diuretics with blood.

• The reason for transfusion must be recorded.

• Any special requirements i.e. irradiated or CMV negative must be stated on the

prescription.

• Routine blood transfusions must not be prescribed over night. Only urgent

transfusions should be given at night.

• The HTC cannot support routine overnight blood transfusion.

Suggested component transfusion times

Component Duration Pump?

Red cells 2-3 hours

MAXIMUM 4

hours from leaving

fridge

Only a pump approved for blood may be

used with a specific blood giving set See

section on Pumps.

Platelets 20-30 mins Never use a pump for platelets

FFP 20-30 mins

Cryoprecipitate Stat

N.B. Any of the above can be

given more quickly if the

patient’s condition dictates.

2, 3.

6.9 Preparing the patient 3,7,8,23

This is an area of practice highlighted by the NPSA as requiring training and competency

assessment. All staff MUST be deemed competent.


• Written information in the form of a NHS Blood and Transplant information leaflet

is available and should be given to the patients who may have or who have had a

transfusion and their family members or carers (as appropriate).

• The reason for transfusion must be discussed with the patient, including the risks

and benefits of transfusion, the transfusion process, any transfusion needs specific

to them, any available alternatives, and how they might reduce their need for a

transfusion in the future and inform them that they will no longer be eligible to

donate blood after receiving a blood transfusion.

• Allow time for the patient and/or their family to ask questions

• Members of staff are expected to make reasonable adjustments to ensure that the

different needs of patients are met. For example, patients who are deaf, have

sensory impairments, have profound or multiple learning disabilities, or who are

unable to understand a language, may fail to comprehend instructions, give

inappropriate responses or remain silent.

• Verbal consent is required and the patient has the right to refuse. See Appendix 1

for Jehovah’ Witness and patients refusing blood transfusion

• All patients must wear an ID wristband or have a photo ID card (out patients only)

for transfusion.

No ID, No BLOOD TRANSFUSION.

• A prescription is required for transfusion. It is the responsibility of the doctor or

authorised specialist nurse requesting the blood to complete the prescription.

Failing to do this straight away can lead to a delay in starting the transfusion.

• The patients will need intravenous access.

• Check base line observations (temperature, pulse, respiratory rate, blood pressure

and oxygen saturation) prior to sending for the blood.

• Ensure there is someone available to check the blood with you before sending for

it.

• Avoid sending for blood over the handover period as this may cause a delay. N.B.

Many of these are reasons why blood is wasted. Make sure you and the patient

are ready to proceed before sending for the blood. Don’t ask for blood until then.

6.10 Collection of blood from blood bank 3,7,8

Both requesting collection and the actual collection of blood from blood bank are areas of

practice highlighted by the NPSA as requiring training and competency assessment.

6.10.1 Requesting collection of blood see appendix 6

• Blood collection requests must be made using the “PorterTrac” system if it

is available

• It is essential you remain logged into “PorterTrac” whilst it is available, as

logging on is time consuming, especially in an emergency

• Keep the system minimised on the computer screen for easy access

• You must provide all of the following:

Surname, forename, date of birth, hospital number.

What you need collecting, eg Blood, FFP, Platelets, Cryoprecipitate.

If more than one unit is required, you need to state clearly how much you need


• Take the patient information with you to the computer, as you cannot

request blood without it

• You will have to repeat the process if it is wrong

• If there are any omissions or queries, the charge-hand will contact you by

phone to ask you to repeat the request including the missing information.

• This will cause a delay.

• Porters cannot collect blood without full patient details, as several patients

may share the same name and date of birth.

• Remember to ask for collection from Pathology otherwise the porter will

come to collect blood from your ward to return to pathology

• Only select “Bleeder” if the patient is haemorrhaging and you require a lot

of blood.

• Emergency O negative blood is available from Pathology or 2 units are in

the blood fridge situated in main theatres. For emergency use only, where

testing of group and save samples have not been completed.

• The emergency units of blood held in the fridge in main theatres cannot be

replaced out of hours. Transfusion staff must be informed if this blood is

used.

• A porter will be sent to act as runner in this situation.

• It is inappropriate to select Bleeder for a single unit of blood.

• Inappropriate use of this category will be monitored.

• Blood transfusion is a priority for all concerned, but rules apply which must

be followed

• Urgent requests for blood should be ordered via PorterTrac and then

followed by a telephone call to confirm the necessary information has been

received by the porters

6.10.2 Collection from blood bank 7,8, 3

• Blood may be collected by, any member of staff who has had specific

training and competency assessment.

• Most of the time this will be a porter. See previous section for requesting

collection.

• Anyone collecting blood must be trained and assessed before they will be

given the authority to carry out this task.

• The transfusion nurse provides this training.

• The person collecting the blood from blood bank must have the patient

details available to them so they can check the patient details match.

• There is a printer connected to PorterTrac in the blood bank to facilitate

this for the porters.

• Only one unit should be taken from the blood bank fridge at a time (unless

the patient is bleeding and requires a lot of blood over a short period of

time)

• Single units should be transported to the ward/dept in a white transfer bag

• Unused blood must be returned to the laboratory within 30 minutes

• If more than one unit is required they must be transported in a WHITE

insulated blood box (2 hour expiry), which can be only be obtained from blood

bank staff

• This WHITE box will have a 'use by' time written on a card in the front

pocket of the box

• These units must be transfused or returned to the lab before this time

expires or returned to blood bank


• Blood should be stored in the box until it is ready to be given

• Boxes should be returned to blood bank as soon as possible

Collection of emergency O negative blood from main theatres

• Blood may be collected by, a designated member of staff who has had

specific training and competency assessment.

• If the emergency units are no longer required they MUST only be returned

to Pathology

6.10.3 Administration of blood and care of the patient

Administration of blood and care of the transfused patient are both areas of


All staff MUST be competent.

N.B. This is the final opportunity to detect any errors before the patient receives

blood. The patient may have a reaction within the first few mls. of blood

transfused.

6.10.4 The bed side check 7,8,10,12

• Each unit of blood should be checked at the patient's bedside. Blood

should never be checked away from the patient’s side.

• This should take place immediately before administration

• Use of a bedside check list is advised, see appendix 7

• The check should be carried out by two independent checkers: a qualified

doctor, nurse, midwife or ODP. Only staff who have been competency

assessed will be allowed to check blood.

• Where the IT barcoded system is used for checking blood, only qualified

staff will be trained to use it.

• Where possible, always positively identify the patient by asking for a full

name and date of birth prior to the pre transfusion check .

• Check the details given against the patient's ID wristband where the

hospital number will also be found.

• Printed wristbands will have eye readable information as well as barcoded

information.

• Check the blood is correctly prescribed for the patient and the details on

the prescription form match the patient’s wristband.

• Check the patient details on the blood compatibility label match the

patient’s wristband exactly.

• Check the patient’s blood group on the blood compatibility label.

• Check the donor blood group on the compatibility label and blood bag.

• Check the donation number on compatibility label and the blood bag.

• Check the expiry date on the compatibility label and the blood bag.

• Check the use by date on the compatibility form (this is the last date you

should give the unit to that specific patient).

• Check any special requirements against the prescription.

• Visually inspect the bag for any leaks, discolouration and obvious clots etc.

This is an important step as there is a risk of bacterial contamination in a

damaged bag.

• If there are any discrepancies, no matter how minor, phone Blood Bank on

2281/6543, who will advise you.


• Once the necessary checks have been completed the person who

completed the second independent check should hang the blood, start

the transfusion and ensure that the relevant documentation has been

completed (including check label in place on the transfusion record and

that the traceability label has been completed and sent to the laboratory)

See Appendix 8

6.10.5 Checking blood using IT ie. safe TX

• Only qualified staff will be able to use this system for checking blood

following training and competency assessment

6.10.6 Monitoring of patients 5,7,8,11

N.B. Overnight transfusions should only be given in an emergency based on clinical

need. The decision to give a routine transfusion over night cannot be supported

by the HTC

• Patients receiving transfusion should only be nursed in an area where they

can be easily observed and monitored throughout the transfusion.

• This is especially important during the first 15 minutes when they are

most likely to have a reaction and is the main reason routine transfusions

should not be given at night.

• Clinical observations can be carried out by anyone who is trained and

competent. Any unqualified staff i.e. Nursing assistants, who carry out

clinical observations must complete a competency assessment for that

specific task for transfusion patients.

• All transfusion observations should be recorded as such and be easily

identified on the observations chart.

• Baseline observations of temperature, pulse, respirations, blood pressure

and oxygen saturation should be carried out not more than one hour

before the transfusion.

• Record the start time of the transfusion

• Repeat and record observations of temperature, pulse, respirations, blood

pressure and oxygen saturation after 15 minutes.

• Repeat and record observations at the end of transfusion.

N.B. This is the minimum requirement.

• Observations at the end of each unit, provide a base line for the next

provided they are given in succession.

• More frequent observations are suggested if the patient’s condition

warrants it, or the person looking after the patient feels it is appropriate.

• Each unit is a separate transfusion.

• Encourage the patient to tell someone if they feel ill or different once the

transfusion has started

• At the end of the transfusion, document the finish time on the Transfusion

record.

Record the effectiveness of the transfusion, any adverse events and subsequent

treatment in the notes.

6.10.7 Reaction and incidents in transfusion3,4,5,7,27


Incident reporting of all adverse reactions and events in transfusion is an area of


• Reactions. See also the flow chart, Appendix 7

• If you suspect the patient is having a reaction i.e. the patient develops a

rash, rigor, shivering, pain to the chest, loin, or abdomen, or reports feeling

unwell or is distressed or agitated in any way

Stop the transfusion immediately

• Send for a doctor.

• Repeat clinical observations.

• In severe reactions keep the patient under constant observation until

medical help arrives.

• Repeat the bedside check to make sure it is the right blood for the patient.

• If you find the patient has received blood for another patient, find the

other to make sure they are not also receiving the wrong blood.

• In the case of a severe reaction the Transfusion laboratory should be

contacted and they will advise you of the procedure to follow.

• All transfusion reactions (except mild) and incidents must be reported by

LAW.

• You should contact the Transfusion laboratory, ext 2281/6543 or

Transfusion nurse, ext 3645 if a transfusion reaction or incident occurs.

• All incidents will be reported using the DATIX reporting system in the Trust.

• All transfusion incidents will be investigated by the hospital transfusion

team and serious incidents must be reported to and discussed by the HTC.

• All appropriate incidents will be reported to external bodies, i.e. The

Serious Hazards of Transfusion (SHOT) and the Medicines and Healthcare

Products Regulatory Agency (MHRA), as deemed appropriate by the HTT

6.10.8 Recall of blood

• Blood can be recalled for a number of reasons, either by the transfusion

laboratory or NHS Blood and transplant.

• If this occurs the laboratory will contact you either:

o To try to stop the blood from being given.

o To ask you to discontinue the transfusion

o To confirm who the blood has been given to.

• It is essential you follow the laboratory’s advice immediately

• If the patient has had any/all of the blood they must be closely observed as

the blood may not have been completely compatible and the patient may

show signs of a transfusion reaction.

6.10.9 Technical aspects of transfusion7,24,26

6.10.9.1 General

• A standard blood giving set should be used which includes a 150

micron filter.

• It is perfectly acceptable to use a free flow giving set for transfusion

• Sets should be changed every 12 hours or four units which ever

come first (except in massive transfusion)


• Blood given at a rate of more than one unit per hour, should be

given through a blood warmer.

• Giving sets should be changed between different types of

components to prevent the risk of clotting. This includes changing

from O rhesus D negative to the patient’s own group.

• Giving sets should be discarded after use in a large sharps bin, the

same as for any other infusion

• The blood component bags must be kept for 48 hours after use in a

clinical waste bag in the dirty utility on the ward.

6.10.9.2 Infusion pumps7

• Only pumps approved for transfusion may be used along with a

specific blood giving set.

• Free flow giving sets can deliver blood over a specific time if the

patient is monitored closely enough.

• It is vitally important the patient is monitored, by regular checking

throughout the transfusion, with or without a pump.

• Pumps should never be used to “monitor” a patient having a

transfusion.

• A pump will only alarm if the flow of blood is restricted or there is

air in the line.

• Pumps do not inform you if the patient has had a reaction.

• Generally giving sets for pumps are more expensive than free flow

giving sets

• A pump is no substitute for good patient care

6.10.9.3 Drugs and blood7

• Blood cells and platelets are fragile structures which can be easily

damaged by rough handling, fluids and chemicals. Even plain water

can haemolyse (destroy) blood cells. Care is needed to prevent any

damage to the cells being transfused.

• Drugs must never be added to blood components under any

circumstance

• Generally speaking a transfusion should have a dedicated cannula

for the duration of the transfusion

• Continuous infusions must not be given through the same cannula

as a blood transfusion.

• Cannulas may be flushed with 0.9% sodium chloride solution if

required.

• It is unnecessary to prime or flush the blood administration set with

saline prior to and/or after administration of the blood products

6.10.9.4 Escorting patients

If a patient needs to be transferred to another ward/department and they are

in the middle of a transfusion, a decision needs to be made to either:

• Wait until the transfusion is completed.

• Send the patient with a qualified nurse escort if the patient is to be

transferred during a blood transfusion, but avoid this where

possible, during the first 30 minutes of a transfusion starting.


• The patient should not be allowed off the ward unaccompanied

while a blood transfusion is in progress.

7. Training and competency assessment 3,7,8,9

See the Trust learning needs analysis.

8. Diversity and Inclusion

The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to

the public and the way we treat staff reflects their individual needs and does not unlawfully discriminate

against individuals or groups on the grounds of any protected characteristic (Equality Act 2010). This policy

aims to uphold the right of all staff to be treated fairly and consistently and adopts a human rights

approach. This policy has been appropriately assessed.

9. Process for monitoring compliance with the policy

Standard/process/issue Monitoring and audit

Method By Committee Frequency

National Comparative

Audit of aspects of the

blood transfusion

pathway

National audit Transfusion

Practitioners

HTC Annual

Snapshot local Lee Sudlow HTC Annual

MHRA

Compliance report Lee Sudlow HTC Annual

Sample errors

Continual

surveillance

Transfusion

Practitioners

HTC Continuous

Ad hoc audit Transfusion

Practitioners

and laboratory

staff

HTC Ad hoc

10. Consultation and review of this policy

This policy has been reviewed in consultation with the Membership Co-ordinator, Counter Fraud

Specialist, Hospital Transfusion Committee and other relevant clinical staff

11. Implementation of this policy

This policy will be circulated by the Trust Secretary as detailed in OP 27 Policy for the development,

management and authorisation of policies.


12. References

1. Department of Health (2007) Health service circular, Better Blood Transfusion: The safe and

appropriate use of blood.

2. Gateshead Contingency plan for blood shortages.

3. The Blood Safety and Quality Regulations 2005. Statutory Instrument 50 2005. These are based

upon the European Union regulations: Directive 2002/98/EC. (2003) Setting standards of

quality and safety for the collection, testing, processing, storage and distribution of human

blood and blood components and amending Directive 2001/83/EC. The European

Parliament.

4. Gateshead Trust policy; Incident reporting and investigation RM 4

5. The Serious Hazards of Transfusion annual reports (1996-2016)

6. The British Society for Haematology:

a. Guidelines for use of red cells. British Journal of Haematology (2001), 113(1) 24-31

b. Guidelines for the use of fresh-frozen plasma, cryoprecipitate and cryosupernatant,

British Journal of Haematology (2004),126,11-28)

c. Guidelines for the use of platelet transfusions. British journal of haematology (2016),

176(3) 365-394

7. BSH (2017) Guidelines on the administration of blood products.

https://www.b-s-h.org.uk/guidelines/guidelines/administration-of-blood-components/

8. The National Patient Safety Agency safer practice notice No.14, Right patient, right blood

(2006)

9. Gateshead Trust policy for Mandatory Training and Induction

10. Gateshead Trust policy for Patient Identification RM40

11. Gateshead Health NHS Trust (2004). Blood and Blood components Transfusion record.

(LP15554)

12. The National Patient Safety agency safer practice notice No 24 (2007): Standardising wristbands

improves patient safety: following on from, Safer practice notice 11: Wristbands for

hospital inpatients improves safety (2005)

13. Gateshead Health Trust Major Incident plan (MIP )

14. Gateshead Health Trust Consent policy

15. Indication codes for transfusion

16. Blood order tariff

17. The Medicines act (1968)

18. Gateshead policy for Massive blood transfusion RM57

19. Laboratory specimen acceptance criteria. Genman PR 012 Guidelines for massive transfusion.

British journal of Haematology (2006) 135(5) 634-41

20. European guidelines for massive transfusion

21. Guidelines on the use of irradiated blood components prepared by the British Committee

Standards in Haematology blood transfusion task force. British Journal of

Haematology(2011), 152 , 35-51

22. NHS Blood and Transplant Patient information leaflet for transfusion

23. RCN guidelines for transfusion “right patient right blood” RCN (2010) Standards for Infusion

therapy.

24. BSH Guidelines for pre-transfusion compatibility procedures in blood transfusion laboratories.

Transfusion medicine.(2013), 23, 3-35

25. Gateshead Trust policy for Waste disposal and recycling policy IC 9

26. Equality Act (2010)

27. BSH (2012) Guideline on the investigation and management of acute transfusion reactions

28. HA-BTX-SOP-001.UN Sample Acceptance for Blood Transfusion

29. Blood Transfusion NICE guideline, NG 24(2015)

https://www.nice.org.uk/guidance/ng24


Useful websites

• British Society for Haematology website www.b-s-h.org.uk/guidelines

• SHOT Website www.shotuk.org

• Department of Health, “Better Blood Transfusion”

http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/

Lettersandcirculars/Healthservicecirculars/DH_080613

New Blood Components app

The NHS Blood and Transplant Patient Blood Management team have worked with the National Blood

Transfusion Committee to develop an app which is based on the national transfusion guidelines for adults,

infants & children and neonates.

The app is an update of the previous NBTC app based on the NBTC indication codes and will act as a prompt

for clinicians, to facilitate appropriate use of blood and enable robust documentation of indications.

It is available to download on Apple iTunes and Android phones from Google Play, with the download for

Windows phones coming soon.


Patient’s declining Blood products, including Jehovah’s Witness Patients and Women during

pregnancy

Suggested management of Jehovah’s Witness patients

The same principles should apply to any patient refusing donor blood.

Jehovah’s Witnesses accept most medical treatments, surgical and anaesthetic procedures devices

and techniques as well as haemostatic and therapeutic agents that do not contain blood. They

accept non-blood volume expanders, pharmaceutical that control haemorrhage and stimulate the

production of red cells, and other non-blood management.

However all Jehovah’s Witnesses will find the following unacceptable:-

• Transfusions of whole blood, packed red cells, plasma, and platelets.

• Pre-operative autologous blood collection and storage for later re-infusion (pre-deposit).

Each Witness decides whether he/she wishes to accept the following as a matter of individual

choice. It is therefore important to discuss with each patient whether or not these are

acceptable.

• Blood salvage (intra-operative & post-operative, haemodilution, haemodialysis, heart

bypass (pumps must be primed with non-blood fluids)

• “Fractions” of plasma or cellular components (e.g. Albumin, Immunoglobulins, clotting

factors and Haemoglobin based oxygen carriers).

On admission

Whenever a Jehovah’s Witness patient is admitted to hospital please ensure they are asked if they

have an “Advance Medical Directive document ”** with them. This document is very specific in

advising medical staff on their personal treatment preferences and identifying acceptable and

unacceptable treatment options.

** A photocopy of the document must be taken and placed prominently within the medical notes,

where it can be used as necessary. This advance medical directive is a legal document and the

patient’s wishes should be honoured.

Staff should also complete the following safety precautions:-

• Apply a red alert wristband to the patient. The red band should clearly state “no blood

products”.

• Contact the transfusion laboratory and have an alert flag applied to the patient’s record to

record that the patient is a Jehovah’s Witness.

Pre assessment

Pre-assessment of the patient is vital, Please take the following points into consideration:

Appendix 1


1. Always notify the Surgeon Anaesthetist and Haematologist as soon as it is established the

patient is a Jehovah’s Witness.

2. Take a history of any medication which could affect coagulation e.g. Warfarin, Aspirin and

NSAID’s

3. Check bloods for FBC, B12, Folate, ESR, LFT’s, U +E’s. The results will need to be checked

early on, in case of anaemia etc.

4. For patients where there is little or mild blood loss anticipated, no pre-op treatment is

considered necessary.

5. If moderate blood loss is anticipated, start oral Iron (e.g. Ferrous sulphate 200mgs TDS) for

14 days pre-op.

6. For patients where severe blood loss is anticipated, or if the Hb is low, start oral Iron and

contact a Haematologist for advice concerning Erythropoietin, IV Iron and Vitamin K.

7. Check exactly which products/fractions the patient would or would not accept.

8. Discuss if cell salvage is acceptable. Inform the Surgeon and Anaesthetist if cell salvage is

required. See action plan

Anticipated blood loss can be assessed by, looking at the MSBOS blood order tariff.

Where a group and save is required, this suggests a risk of mild blood loss only.

Where a 2 unit cross match is required, this suggests moderate blood loss.

Where more than a 2 unit cross match is required, this suggests severe blood loss.

Plan of action

This should involve the patient, pre- assessment nurse, anaesthetist and surgeon.

The plan should consider:

• The date of the surgery.

• When to stop drugs e.g. Aspirin, Warfarin and NSAID’s.

• Should the surgery be staged?

Can cell salvage be used?

• Discuss in advance with the on call Consultant Anaesthetist (bleep 2012) and theatre ODP

staff. For maternity patients contact bleep 5028, non-maternity bleep 1301 or Transfusion

Nurses (Ext 3645).

• Is haemodilution an option?

• Is regional anaesthesia an option?

• Should hypotensive anaesthesia be considered?

• Could Tranexamic Acid be used?

• Should supplemental Iron and Erythropoietin be prescribed?

Peri-operative management

The above non-blood alternatives should always be considered when managing a Jehovah’s

Witness patient

• Tranexamic acid is the first line treatment for patients who are bleeding


• Vitamin K could also be used to prevent coagulopathy due to vitamin K deficiency or

consumption.

If the post-operative Hb is <70g/dl begin:

• Erythropoietin 10,000u three times a week until the Hb is above 80g/dl

Parenteral Iron - There are a number of parenteral iron compounds available on the market. The

recommended product may be different depending on the patients’ needs.

For advice on the current iron product in use and administration guidelines, please contact the

Pharmacy information line or Aseptics

Tranexamic Acid. (Cyclokapron)

• 500-1000mg by very slow* IV injection or orally up to three times a day.

*Often makes the patient very nauseated. This effect is reduced if it is given slowly enough.

Tranexamic Acid can also cause diarrhoea.

NOVOSEVEN (Recombinant factor VII a).

• This is available to correct bleeding. Seek advice from the Haematologist

Women declining blood or blood products

Antenatal Management:

1. All women declining blood or blood products in pregnancy will need to be booked with a

consultant for obstetric care. Detailed care plan for remainder of pregnancy and labour

should be documented.

2. Obtain from the patient a clear statement of the blood products and techniques that are

acceptable or not to her. Document clearly in patient notes about the same.

Product/Technique Acceptable Not acceptable

Whole blood

Packed red cells

Platelets

Fresh frozen plasma

Cryoprecipitate

Immunoglobulin’s

Recombinant Factor VII a

Intraoperative cell salvage

3. Explain the risks of refusal of blood products including the possibility of an earlier surgical

intervention including an early decision to proceed with a caesarean hysterectomy in

uncontrolled post-partum haemorrhage (PPH). This discussion should be take place in a

non-confrontational manner and respecting the patient’s beliefs.


4. A photocopy of the advanced medical directive must be taken and placed within the

medical notes. This is a legal document, which outlines patient wishes and should be

honoured.

5. The woman should be given an opportunity to speak with the Hospital Liaison committee

for Jehovah’s Witness. (Contact details at the end of this appendix)

6. An anaesthetic alert should be completed.

7. Haemoglobin and serum ferritin must be checked at booking and 28 weeks and every 4

weekly thereafter. Iron supplementation should be considered throughout pregnancy to

maximise iron stores and prevent anaemia.

8. If Hb <105gm/l, ferrous sulphate 200mg TDS with folic acid should be prescribed. If

unresponsive to oral iron therapy then IV iron therapy should be considered.

9. The woman’s blood group and antibody status must be checked in the usual way at

booking and 28 weeks. Administration of Anti D injections to be discussed with the patient

if rhesus negative.

10. An ultrasound should be carried out for placental localisation as routine practise and

consideration given for a repeat scan around 34 weeks.

11. For elective caesarean sections arrangements should be made for intra operative cell

salvage. This is to be liaised with the main theatre team on an individual case.

Intrapartum Management:

1. Consultant obstetrician and Anaesthetist should be informed when a woman who declines

blood or blood products is admitted in labour.

2. The ST/Consultant on call should document a final care plan for labour and delivery in the

patient’s notes.

3. IV access (Grey venflon) should be obtained and Haemoglobin checked on admission.

4. Consultant on call to be present for all operative procedures.

5. Active management of 3 stage is recommended. Syntometrine IM to be used in the

absence of maternal hypertension. The alternative is Oxytocin 10IU IM

6. 40 units oxytocin infusion should be considered post delivery

7. The woman should be cared for by experienced midwifery staff and should be monitored

closely following delivery.

8. Check patients vital signs and evidence of uterine contraction very 15 minutes for 2 hours

post delivery.

9. All vaginal/perineal trauma must be repaired ASAP to minimise blood loss.

10. To request cell saver in the event of emergency caesarean section from main theatres.

Management of major haemorrhage:

1. Management of PPH should be in accordance with the trust guideline on Postpartum

Haemorrhage.

2. The main principles of management are to avoid delay and prompt decision making.

3. Pharmacological, mechanical and surgical procedures should be considered at an earlier

stage and there should be a low threshold for intervention.


4. Involve obstetric, anaesthetic and haematology consultants in the management of such

women.

5. Pharmacological agents used in the management of PPH:

Syntometrine 1 amp IM (contraindicated in hypertensive women)

Oxytocin 5 IU by slow IV and repeat one further dose if indicated

Carboprost (Haemabate) 250mcg/ml IM repeated after 15 minutes to a maximum of 8

doses

Misoprostol- rectal 800-1000mcg, Sublingual 600-800mcg

Tranexamic acid 1 Gram slow Intravenous TDS

Vitamin K: Dose Dilute 5mg konakion in 50mls 5% glucose, administered as a slow IV blolus

over 5 minutes upto a maximum of 25mg in 24 hours.

Recombinant Factor VIIa (NovoSeven): Dose 90mcg/kg

not licensed in pregnancy as is given under consultant guidance in life threatening

haemorrhage not responding to standard therapies . To avoid failure of rFVIIa ensure

fibrinogen level is adequate, correct acidosis and hypothermia and use tranexamic acid

beforehand to stabilise the clot.

• Fibrin sealants: Flowseal used to arrest massive bleeding in surgical bed following

hysterectomy; Tisseel has controlled bleeding of complicated vulval and vaginal lacerations

when suture haemostasis failed due to tissue friability

• Avoid hypothermia (impairs coagulation),

• Avoid unnecessary over-dilution.

• Use micro sampling techniques to conserve blood (e.g. HemoCue), as well as paediatric

sample tubes.

6. Mechanical methods to control PPH

Uterine massage

Bimanual compression

Intra uterine balloon tamponade with Bakri balloon

7. Surgical methods to control PPH

Compression sutures- B Lynch or Hayman suture

Hysterectomy: Sub total hysterectomy is just as effective to control PPH and is quicker and

safer.

Uterine or Internal iliac artery embolization or ligation

Management of postpartum anaemia

• IV iron should be considered for severe anaemia as oral iron is known to be slow and

unreliable.

• Erythropoiesis-stimulating agents (ESAs) should be administered together with IV iron in

life-threatening anaemia to further accelerate erythropoiesis. An EPO dosage of 300 IU/kg

x 3 weekly together with IV iron (200mg x 3 weekly) has also proved efficacious for

postpartum anaemia. Augment with vitamin B-12 and folic acid.

• Check oxygen saturations: Give 100% oxygen if necessary (no contraindications for 48-72

hrs of use).


The Jehovah’s Witness Hospital Liaison Committee.

• Jehovah’s Witnesses understand the challenge that their decisions can sometimes pose for

doctors and nurses when they are treating them. In an effort to alleviate these situations they

have established a network of Hospital Liaison Committees throughout Britain.

• Members of these groups are trained to facilitate communication between medical staff and

Witness patients and are available at any time, day or night, to assist with difficulties either at

the request of the treating team or the patient.

Ian Philp

70 Sandringham Ave,

Benton.

Newcastle Upon Tyne

NE12 8JX

TEL/FAX 0191 2664482/07982235366

Ken Murr

32 Whittingham Close

North Shields

Tyne and Wear

NE30 3TJ

TEL 0191 2586804/07940893797

John Barber

Dunmarvic

Strathmore Ave

Rowlands Gill

Tyne and Wear

NE39 1HY

TELE/FAX 01207 542123/07889903312

Alan Sanderson

8 Prudhoe Grove

Jarrow.

Tyne and Wear

NE23 5YF

TEL 0191 428 1731/07792725284

Jack Marshall

24 Summerhill

Blaydon

Tyne and Wear

NE21 4JS

Tel 0191 4205370/07952225325

EMERGENCY 24 HOUR MOBILES.

0788 9733798

0779 0311576

Hospital Information Services

The Ridgeway

London

NW7 1RN

TELE 020 89062211


Appendix 2


BLOOD ORDER TARIFF (MSBOS)

Recommendations below are based on assumption that all elective patients have an electronic x-match, and no antibodies. (The laboratory recommends that a patient with antibodies will have 2 or 4 units standing by depending on the antibody and samples should be sent to the lab 24-48 hours prior to surgery)

Operation Recommendation

GENERAL SURGERY

Anterior resection G&S

Cholecystectomy G&S

Colostomy / ileostomy G&S

Gastrectomy partial G&S

Hemicolectomy G&S

Laparotomy G&S

Pan-proctocolectomy G&S

Sigmoid colectomy G&S

Splenectomy 2 units

Varicose Veins Not required

Hernia repair Not required

Appendix G&S

Mastectomy G&S

Endoscopic Retrograde Cholangio-pancreatography (ERCP) G&S

Laparoscopic Nissen Fundoplication G&S

ORTHOPAEDIC SURGERY

# NOF and Long bone fracture fixation G&S

THR G&S

TKR G&S

Revision hip 2 units depending on antibody

Revision knee G&S

Total shoulder repl G&S

Total elbow repl G&S

Rev T shoulder G&S

Major trauma D/W Blood Bank ASAP

Iliac bone grafting (to any site) G&S

Clavicle fracture fixation G&S

Bone grafting of a non union humorous G&S

Tibial/femoral osteotomies G&S

OBSTETRICS

C/Section 2-4 units depending on antibody

Suspected ectopic pregnancy G&S

Suspected ruptured ectopic 2 units

Manual removal of placenta G&S

Placenta praevia 2-4 units depending on grade

Appendix 3


ARTERIAL SURGERY

Iliac aneurysm 2 units

Femoral aneurysm G&S

Popliteal aneurysm G&S

Ileo-femoral graft G&S

Aorto-bifemoral graft 2 units

Fem pop graft G&S

Fem distal G&S

Carotid endarterectomy G&S

Embolectomy/thrombectomy G&S

GYNAECOLOGY

TOP G&S

Laparoscopic sterilisation G&S

D&C G&S

Hysterectomy G&S

Oophorectomy/ovarian cyst G&S

Prolapse repair G&S

Laparotomy G&S

GYNAE-ONCOLOGY

Cone biopsy G&S

Laparotomy (ovarian Ca) 2 units

RHND 2 units

Vulvectomy G&S

Debulking 2 units

Exenteration 2 units

SPINAL SURGERY

Spinal Decompression G&S

Spinal Discetomy G&S

Microdiscectomy G&S

Laminectomy G&S

Foraminotomy G&S

ACUTE BLEEDING (NON-OPERATIVE)

Active haematemesis or melaena with cardiovascular compromise 2 units & review

Variceal haemorhage 2 units & review

Melaena or coffee ground vomit in haemodynamically stable patient 2 units & review

Open trauma with continued blood loss 2 units & review

PR bleed, PV bleed in haemodynamically stable patient G&S pending Haemoglobin

HA-BTX-FOR-001.QE Blood Order Tariff (MSBOS) Ver 1.3


ORDERING BLOOD IN AN EMERGENCYSomeone senior MUST co-ordinate care in an emergency

This is very important as inexperience can cause delays

Phone the lab immediately and inform them of the impending need for blood products

Is there a G&S sample

already in the lab

YES

Decide how quickly you

need the blood

Take a specimen and

send it immediately to the

Lab

YES

NO

Emergency ‘O’ Negative

Full Serological cross

match

Group Specific

Only available in a DIRE emergency

where there is insufficient time to

establish a blood group

A sample MUST be sent for further

blood

Not suitable for everyone

Will NOT be crossmatched

Clinician who decides takes full

responsibility for the decision

Max 2 units Ready within 5 minutes

The same group as the patient

Will NOT be crossmatched

Clinician who decides takes full

responsibility for the decision.

Ready within 5-10 minutes

Will be fully cross matched

Less chance of a reaction

Ready within 45 minutes of sample

arriving in lab

PLEASE NOTE

The co-ordinator should communicate with the lab

Contact details are essential for good communication

with the lab extn on 2281 bleep 2082

Only specifically trained people are allowed to

collect blood. Use THEM

In a dire emergency only 1 unit of Blood can be sent in

the chute

Appendix 4


Contact Blood Bank

Ext.2281 / Bleep 2082 Admission Blood Samples

Ward to contact Porters

Ext 2330

State “I wish to activate the Major

Haemorrhage Protocol” and confirm

that you are sending for blood.

Identify Patient

• Name

• Date of birth

• Hospital Number

Or

• Unknown Male/Female

identifiers

• Major incident number If MIP

confirmed

Send to lab:

• 6ml EDTA transfusion

sample (pink tube)

• FBC (purple tube)

• Coagulation screen (light

blue tube)

In order to allow rapid issue of blood

a second sample will be required for

patients who have not had a previous

group and save sample recorded at

this hospital. (Historical group)

Request blood products for collection

via PorterTrac

Emergency O Negative

Send for emergency

O negative units if required.

(available from blood bank or 2 units

in theatre fridge)

Inform Blood Bank ASAP if units are

used.

Initial Transfusion Preparation Second / subsequent transfusion packs

You will receive:

• 4 units red cells (may be group O if no current

sample processed)

Laboratory staff will defrost 4 units FFP and contact the

ward/theatre as soon as ready (approx. 30 mins)

You will receive

• 4 units red cells

• 4 units FFP

If Platelets are required ask lab to order and confirm when

available

Consider Adjuncts Repeat blood Samples

Trauma

• Tranexamic Acid 1g slow IV bolus

Warfarin therapy

• Vitamin K 5mg IV

• Beriplex 30 units/kg

• Recheck coagulation screen immediately following

Beriplex administration

After every 8 units of red cells transfused repeat

• FBC

• Coagulation screen

Actions for all patients

1. Plan definitive management

• Surgical, endoscopic or radiological intervention

• Trauma – consider transfer to Major Trauma

Centre

2. Monitor for complications of massive transfusion

• Hypothermia: Warm patient, red cells and IV Fluids

• Hypocalcaemia: Slow injection 10mls 10%

calcium chloride

• Hyperkalaemia: Insulin/glucose infusion

Notes

1. Group O red cells

• Females under 50 years old will receive O RhD

negative red blood cells

• Males and females > 50 years old will receive O

RhD positive red blood cells

2. Do not open boxes until blood components needed

3. Disseminated intravascular coagulation: consider

coagulation may be normal

Discuss with Haematologist on call

• Cryoprecipitate maybe required in third and

subsequent packs (Maintain fibrinogen >1g/l)

• Additional interventions may be advised

Ring lab to stand down Major Haemorrhage

Return unused products immediately

to blood bank

Documentation

Complete documentation and return

traceability labels to laboratory

Remember to update transfusion lab between packs

Consultant/Registrar decision to activate Major Haemorrhage Protocol (eg: life threatening haemorrhage, trauma, ruptured AAA, multiple units required immediately)

Major Haemorrhage Flowchart

Appendix 5


To order Blood Components through the Porters

Appendix 6

When ordering blood components using the porter track system you

MUST provide the following information.

• The Patient’s: Name, Date of Birth and Record number, MUST be

typed into the “PATIENT” box

• You MUST select “Pathology” if the blood is to be collected from

blood bank OR your ward if the blood is being returned to blood

bank

• You MUST select which blood product you need, Blood, FFP,

Platelets, Cryo, Beriplex or Novoseven (Factor VIIa)and how much

you require

“BLEEDER” should only be used in a “dire emergency” and you must

remember to state what needs to be collected in the comments box

• Porter track has been introduced to improve patient safety and efficiency.

• All blood requests are a priority.

• Failure to provide essential information will delay the transfusion as porters are not allowed to collect blood without it.

• It is not the porter’s fault when transfusions are delayed due to lack of

information. They are not being difficult, they are keeping your

patient safe!

Get it right first time, every time and it will save you time!!

For urgent delivery, you must telephone the request to

the porters (ext. 2330) after completing the PorterTrac

request. You MUST provide:

Patient’s full name

Date of birth

Record number

• Which blood component you want collected and

how much.

• Where it is to be delivered.


BLOOD SHOULD BE CHECKED AT THE BEDSIDE.

THE COMPATIBILITY LABEL LINKS THE PATIENT TO A SPECIFIC UNIT OF BLOOD.

THE LABEL SHOULD BE CHECKED AGAINST THE WRISTBAND AND THE UNIT OF BLOOD

THE COMPATIBILITY FORM IS NO LONGER NECESSARY

b

bbbbbbbbbbbbbbbbbbbbbbbbbb

Appendix 7

CHECK.

Donation number

Record number

Surname

Forename

Date of birth

Patient’s blood group

Use by date

Donation blood group

Expiry date


Flow Diagram for recognition, initial management and subsequent management and investigations.

Appendix 8


Procedure for the transfer of Blood Components between

Hospitals

The majority of the process involves laboratory staff and has therefore been inserted as a PDF at

the end of the appendix.

Key information for clinical staff is given below.

If you need to transfer blood with a patient the laboratory staff must be informed as soon as

possible.

DO NOT send blood that has been collected from blood bank for use in

this hospital

NORTHERN REGIONAL PROCEDURE

PROCEDURE FOR THE TRANSFER OF BLOOD COMPONENTS BETWEEN HOSPITALS

1.0 INTRODUCTION The Blood Safety and Quality Regulations (BSQR) 2005 require protocols to be in place within all hospitals to trace unambiguously the fate of all units from donor to patient, or if not transfused the final fate of each unit. This document seeks to standardise the procedures for the transfer of blood and components between hospitals in the North East Region. It is intended as a general guide to encompass practices for all users. Hospitals are encouraged to add local protocols to the policy where appropriate but not to detract from the practices outlined in this document. It is accepted that transport of blood is optimally managed by transfer from one blood transfusion laboratory to another blood transfusion laboratory. However, in clinical practice this is not always possible. It should only be on rare occasions that transfer of blood with a patient is undertaken1,2 When there is a high risk of the patient bleeding en route blood components may be transferred with the patient. In this clinical scenario the receiving hospitals blood transfusion laboratory must be given the accompanying paperwork and details of all units transfused as soon as possible. 2.0 PRINCIPLE Blood components are often transferred between hospitals either with a patient, or as an efficient use of blood stocks. It is essential for legal reasons (BSQR, 2005) to ensure the audit trail is

Appendix 9


maintained when blood is transferred and to ensure patient transfusion records are updated accordingly (HSC 2007/001 Better Blood Transfusion Safe and Appropriate Use of Blood). The BSQR requires adequate systems to be in place to ensure traceability of blood components. As such it is essential for laboratories to ensure the cold chain and traceability audit trails are maintained and records updated accordingly when blood is transferred between hospitals. Blood components may be transferred for the following reasons:

• Blood components allocated to a specific patient may be needed urgently for resuscitation en route or on arrival at the receiving hospital.

• Routinely, blood component allocated to a specific patient may require transfer to a blood fridge located in a satellite hospital/unit of the dispatching hospital.

• Agreed transfer of blood component stock between hospital blood transfusion laboratories.

Advice for staff when transferring blood with a patient.

• Contact transfusion staff, ext 6543/2281

• Confirm urgency of blood issue

• Using PorterTrac, request that blood is collected directly from Transfusion lab staff and not from Pathology (blood issue fridges)

• Do Not send blood that has been issued from blood bank for use in this hospital.

• Follow the Blood Transfer Advice sheet for staff (on the following page) or accompanying the Blood transfer box.

The full guideline is available to view below

NORTHERN REGIONAL POLICY Version updated2 (2).pdf

blood transfusion policy

Documents