CARE PATHWAY for BLOOD TRANSFUSION - MULTIUSE For use with all patients requiring blood transfusion, day case and in-patient, in all departments

Transcription

1 CARE PATHWAY for BLOOD TRANSFUSION - MULTIUSE For use with all patients requiring blood transfusion, day case and in-patient, in all departments Warning: Does the patient have an Advance Decision to refuse Blood /Blood products This Care Pathway has been developed by a multidisciplinary team. It is intended as a guide to care and treatment, and an aid to documenting patient progress. The Care Pathway document is designed to replace the conventional medical and nursing clinical record and be retained in the patients notes within this admission episode. All healthcare professionals are of course free to exercise their own professional judgment when using this Pathway. However any decision to deviate from the Pathway should be documented. If you have any problems completing the pathway please contact: Transfusion Practitioner, ext: Approved by CEC and Issued: July 2005, Patient Safety & Quality committee approved December 2010 Next Review: November 2012 Reviewed in July 2006, October 2007 and re-issued with minor amendments. Reviewed July, October 2008 Reviewed by Blood Transfusion Team, and agreed November 2008, November 2010 Guidelines referred to when developing this Care Pathway: 1. Worcestershire Acute Hospitals NHS Trust, Policy & Guidelines for Blood Transfusion, April SHOT guidelines (serious Hazards of Transfusion) British Committee for Standards in Haematology A~Inpatient~WR2150~Version 8~Page 1 of 20

2 Abbreviations used in Care Pathway RN Registered Nurse Dr Doctor HCA Health Care Assistant (Section A only) FY1 Foundation Year One FY2 Foundation Year Two Registered Midwife All users of this pathway must enter their specimen signature and initials below PRINT NAME SIGNATURE INITIALS DESIGNATION PLEASE NOTE: Serious Hazards of Transfusion Annual Report 2005 recommends that transfusions are avoided outside of core hours unless clinically essential _ The National Comparative Audit of Overnight Transfusion 2007 recommendation 1: Patients without a clinical need should not be transfused overnight A~Inpatient~WR2150~Version 8~Page 2 of 20

3 No. Design. INTERVENTION If an intervention is not carried out for any reason, please tick no and document intervention number, reason and action taken, in multidisciplinary progress notes (Page 12) Y N Signature Y N Signature Y N Signature Date/Time Date/Time Date/Time SECTION A GROUP / CROSS MATCHING AND PRESCRIBING OF BLOOD 1 Dr Reason for transfusion:. See WAHT Guidelines appendix 1 of Blood Transfusion Policy Hb prior to transfusion: / /.g /dl 2 Dr Patient has received information re procedure, risks and benefits or Does the patient have an Advanced decision to refuse blood RN Aware of reason for transfusion Written information leaflet given Verbal explanation of procedure, risks and benefits given 3 Dr Patient wristband in place and contains: surname, first name, DOB, or ID number RN NB: If in pre-assessment clinic verbally check 3 items: name, ID number, DOB or address A~Inpatient~WR2150~Version 8~Page 3 of 20

4 No. Design. Dr 4 or RN Dr or 5 RN 6 Dr 7 Dr INTERVENTION If an intervention is not carried out for any reason, please tick no and document intervention number, reason and action taken, in multidisciplinary progress notes (Page 12) Request form fully completed Ensure the following information is included: surname, first name, gender, DOB, ID number, location of patient, time and date, type of blood product, diagnosis, reason for request and any special arrangements. Sample tube labelled with above information plus date sample taken and location of patient Tubes must be labelled by hand, after blood has been taken, by person taking blood Blood taken in Phlebotomy Clinic Y N Blood prescribed on intravenous infusion sheet Ensure the following information is included: surname, first name, DOB, ID number, blood/blood components required, plus any special requirements e.g. irradiated, quantity and duration of transfusion..max 3½ hours Any special instructions required documented: Diuretics Blood warmer Irradiated CMV Neg prescribed on medicines chart Y N Signature Y N Signature Y N Signature Date/Time Date/Time Date/Time A~Inpatient~WR2150~Version 8~Page 4 of 20

5 No. Design. Dr 8 or RN Dr or 9 RN 10 Dr or RN INTERVENTION If an intervention is not carried out for any reason, please tick no and document intervention number, reason and action taken, in multidisciplinary progress notes (Page 12) SECTION B - COLLECTION & DELIVERY OF BLOOD Blood Transfusion Must Be Commenced Within 30 Minutes of Arriving On Ward Check patient has patent cannula: There is no minimum or maximum size of cannula for transfusion, size will depend on size of vein and speed blood is to be transfused. Blood requested / collected from blood bank Information to be taken to lab: name, DOB, ID, location, type and number of units. NB: Person collecting must have been trained in procedure. Time requested: 1st Unit 2nd... 3rd... 4th... 1st Unit 2nd... 3rd... 4th... 1st Unit 2nd... 3rd... 4th... Correct blood delivered to ward/dept and received by RN/ Dr Time blood arrives on ward/dept 1st Unit 2nd... 3rd... 4th... 1st Unit 2nd... 3rd... 4th... 1st Unit 2nd Unit 3rd Unit 4th Unit 1st Unit 2nd Unit 3rd Unit 4th Unit Y N Signature Y N Signature Y N Signature Date/Time Date/Time Date/Time A~Inpatient~WR2150~Version 8~Page 5 of 20

6 No. Design. Dr 10 or RN INTERVENTION If an intervention is not carried out for any reason, please tick no and document intervention number, reason and action taken, in multidisciplinary progress notes (Page 12) SECTION C PATIENT IDENTITY AND BLOOD UNIT CHECK - All patients undergoing blood transfusion, in ANY setting, MUST have an identification wristband in place - Blood unit and patient identity checks MUST always be done in the presence of the patient who is to receive the transfusion - Patient identity and the blood unit MUST also be checked by a second person Unit of blood inspected / no abnormalities found Check for: leaks, haemolysis, unusual discolouration or turbidity, presence of large clots 1st Unit 2nd Unit 3rd Unit 4th Unit Y N Signature Y N Signature Y N Signature Date/Time Date/Time Date/Time RN RN Patient identity checked verbally with patient Surname, first name, date of birth and identification number all identical on each of the below: 1. Wristband (N.B. A & E number can be used) 2. Blood bank slip 3. Compatibility label 4. Prescription 1st Unit 2nd Unit 3rd Unit 4th Unit 1st Unit 2nd Unit 3rd Unit 4th Unit A~Inpatient~WR2150~Version 8~Page 6 of 20

7 No. Design. 13 RN INTERVENTION If an intervention is not carried out for any reason, please tick no and document intervention number, reason and action taken, in multidisciplinary progress notes (Page 12) Blood group and blood unit number identical on each of the below: 1. Blood unit 2. Blood bank slip 1st Unit 2nd Unit 3rd Unit Y N Signature Y N Signature Y N Signature Date/Time Date/Time Date/Time 4th Unit 14 RN Blood unit within expiry date 1st Unit 2nd Unit 3rd Unit 4th Unit - The blood bank slip AND the prescription chart MUST be signed by both persons carrying out the patient and unit check, and the time and date of commencement of the unit entered - The blood bank slip to be kept with the patient during transfusion - Sign and return traceability slip A~Inpatient~WR2150~Version 8~Page 7 of 20

8 No. Design. 15 RN INTERVENTION If an intervention is not carried out for any reason, please tick no and document intervention number, reason and action taken, in multidisciplinary progress notes (Page 12) SECTION D TRANSFUSION PROCESS / MONITORING Patient informed of any possible adverse effects of procedure and the importance of reporting these immediately to clinical staff e.g. shivering, rash, flushing, shortness of breath or pain in extremities or loins. Y N Signature Y N Signature Y N Signature Date/Time Date/Time Date/Time - Blood will be transfused through a sterile giving set designed for the procedure. Additional filters are not required - Each giving set must only be used for a maximum of 12 hours RN 16 - RN 17 - Blood unit administered within 4 hours from leaving Blood Bank fridge Blood unit transfused with no adverse effects NB: details of any adverse reactions MUST be documented in multidisciplinary notes (page 13) together with any actions taken blood bank notified and reaction report completed 1st Unit 2nd Unit 3rd Unit 4th Unit 1st Unit 2nd Unit 3rd Unit 4th Unit A~Inpatient~WR2150~Version 8~Page 8 of 20

9 No. Design. INTERVENTION If an intervention is not carried out for any reason, please tick no and document intervention number, reason and action taken, in multidisciplinary progress notes (Page 12) Y N Signature Y N Signature Y N Signature Date/Time Date/Time Date/Time SECTION E DISPOSAL OF BLOOD BAGS RN 18 - Blood bag disposed of as below: 1. Sealed with a suitably sized spigot or attached blue plug 2. Placed in dated bag and stored in dirty utility room NB: After 24 hours the pack can be disposed of as clinical waste 1st Unit 2nd Unit 3rd Unit 4th Unit A~Inpatient~WR2150~Version 8~Page 9 of 20

10 BLOOD TRANSFUSION OBSERVATIONS CHART Attach Patient Sticker here or record Record temperature, pulse, respirations and blood pressure: 1. Prior to start of the transfusion minutes after each unit has commenced. 3. At the end of each unit. 4. When the transfusion has been completed. NB: These are the only recordings required UNLESS any adverse reactions occur. Date Time 1st Unit 2nd Unit 3rd Unit 4th Unit Sign and return Sign and return Sign and return Sign and return traceability slip traceability slip traceability slip traceability slip Baseline Completion Unit number of blood Temp. B.P. Pulse Resps PARS Score result A~Inpatient~WR2150~Version 8~Page 10 of 20

11 If BM <4mmols please follow Hypoglycaemic Guidelines and contact Diabetic Specialist Nurse Bleep 315 PATIENT AT RISK SCORE Score Systolic blood pressure (mmhg) Heart Rate < >190 < > 150 Respiratory Rate Conscious Level Urine output Temperature 0 2 Therapy BM Glucose Awake Voice Pain Unresponsive < >30 <0.5ml/kg/h Awake Voice Responds to Unresponsive Pain A V P U < > <4mmols Acute Confusion >60% / 10L Notes: Any abnormal measurement should trigger the calculation of the score. Points are allocated according to the reading, i.e. temperature of 35.3 = 2; heart rate of 67 = 0. Once a full set of observations have been made a total score is calculated. HIGH Score = 3 or above Call a Senior Nurse/Doctor or Outreach for ugent review within 1 hour. NB: PARS 6 or more extreme risk needs immediate Doctor review. MED Score = 2 Increase frequency of observations and inform nurse in charge Minimum frequency of observations 4 hourly for scores of 2 and above. LOW Score = 0 or 1 Continue observations at current frequency, minimum of once/shift Please inform Critcal Care Outreach of all scores 3 and above. SBAR = Situation Background Assessment Recommendation ACTION TAKEN? X No action Action taken 99 Referred to: Dr = Dr informed OR = Outreach NP = Nurse Practitioner SN = Staff Nurse PAIN SCORE - ON MOVEMENT No pain 0 MILD - some pain/discomfort which can be tolerated 1 MODERATE - causing some distress 2 SEVERE - worse pain possible 3 T1 NAUSEA & VOMITING SCORE No nausea or vomiting 0 Nausea only 1 One episode of retching/vomiting in last hour 2 More than one episode of retching/vomiting in last hour 3 T4 T6 T8 T 10 T12 L1 NIPPLE LINE UMBILICUS MOTOR BLOCK Full leg movement 0 Can move knee and ankle 1 Can move foot and ankle only 2 Full leg paralysis 3 L2 L4 L3 L5 S1 A~Inpatient~WR2150~Version 8~Page 11 of 20

12 BLOOD TRANSFUSION OBSERVATIONS CHART Attach Patient Sticker here or record Record temperature, pulse, respirations and blood pressure: 1. Prior to start of the transfusion minutes after each unit has commenced. 3. At the end of each unit. 4. When the transfusion has been completed. NB: These are the only recordings required UNLESS any adverse reactions occur. Date Time 1st Unit 2nd Unit 3rd Unit 4th Unit Sign and return Sign and return Sign and return Sign and return traceability slip traceability slip traceability slip traceability slip Baseline Completion Unit number of blood Temp. B.P. Pulse Resps PARS Score result A~Inpatient~WR2150~Version 8~Page 12 of 20

13 If BM <4mmols please follow Hypoglycaemic Guidelines and contact Diabetic Specialist Nurse Bleep 315 PATIENT AT RISK SCORE Score Systolic blood pressure (mmhg) Heart Rate < >190 < > 150 Respiratory Rate Conscious Level Urine output Temperature 0 2 Therapy BM Glucose Awake Voice Pain Unresponsive < >30 <0.5ml/kg/h Awake Voice Responds to Unresponsive Pain A V P U < > <4mmols Acute Confusion >60% / 10L Notes: Any abnormal measurement should trigger the calculation of the score. Points are allocated according to the reading, i.e. temperature of 35.3 = 2; heart rate of 67 = 0. Once a full set of observations have been made a total score is calculated. HIGH Score = 3 or above Call a Senior Nurse/Doctor or Outreach for ugent review within 1 hour. NB: PARS 6 or more extreme risk needs immediate Doctor review. MED Score = 2 Increase frequency of observations and inform nurse in charge Minimum frequency of observations 4 hourly for scores of 2 and above. LOW Score = 0 or 1 Continue observations at current frequency, minimum of once/shift Please inform Critcal Care Outreach of all scores 3 and above. SBAR = Situation Background Assessment Recommendation ACTION TAKEN? X No action Action taken 99 Referred to: Dr = Dr informed OR = Outreach NP = Nurse Practitioner SN = Staff Nurse PAIN SCORE - ON MOVEMENT No pain 0 MILD - some pain/discomfort which can be tolerated 1 MODERATE - causing some distress 2 SEVERE - worse pain possible 3 T1 NAUSEA & VOMITING SCORE No nausea or vomiting 0 Nausea only 1 One episode of retching/vomiting in last hour 2 More than one episode of retching/vomiting in last hour 3 T4 T6 T8 T 10 T12 L1 NIPPLE LINE UMBILICUS MOTOR BLOCK Full leg movement 0 Can move knee and ankle 1 Can move foot and ankle only 2 Full leg paralysis 3 L2 L4 L3 L5 A~Inpatient~WR2150~Version 8~Page 13 of 20 S1

14 BLOOD TRANSFUSION OBSERVATIONS CHART Attach Patient Sticker here or record Record temperature, pulse, respirations and blood pressure: 1. Prior to start of the transfusion minutes after each unit has commenced. 3. At the end of each unit. 4. When the transfusion has been completed. NB: These are the only recordings required UNLESS any adverse reactions occur. Date Time 1st Unit 2nd Unit 3rd Unit 4th Unit Sign and return Sign and return Sign and return Sign and return traceability slip traceability slip traceability slip traceability slip Baseline Completion Unit number of blood Temp. B.P. Pulse Resps PARS Score result A~Inpatient~WR2150~Version 8~Page 14 of 20

15 If BM <4mmols please follow Hypoglycaemic Guidelines and contact Diabetic Specialist Nurse Bleep 315 PATIENT AT RISK SCORE Score Systolic blood pressure (mmhg) Heart Rate < >190 < > 150 Respiratory Rate Conscious Level Urine output Temperature 0 2 Therapy BM Glucose Awake Voice Pain Unresponsive < >30 <0.5ml/kg/h Awake Voice Responds to Unresponsive Pain A V P U < > <4mmols Acute Confusion >60% / 10L Notes: Any abnormal measurement should trigger the calculation of the score. Points are allocated according to the reading, i.e. temperature of 35.3 = 2; heart rate of 67 = 0. Once a full set of observations have been made a total score is calculated. HIGH Score = 3 or above Call a Senior Nurse/Doctor or Outreach for ugent review within 1 hour. NB: PARS 6 or more extreme risk needs immediate Doctor review. MED Score = 2 Increase frequency of observations and inform nurse in charge Minimum frequency of observations 4 hourly for scores of 2 and above. LOW Score = 0 or 1 Continue observations at current frequency, minimum of once/shift Please inform Critcal Care Outreach of all scores 3 and above. SBAR = Situation Background Assessment Recommendation ACTION TAKEN? X No action Action taken 99 Referred to: Dr = Dr informed OR = Outreach NP = Nurse Practitioner SN = Staff Nurse PAIN SCORE - ON MOVEMENT No pain 0 MILD - some pain/discomfort which can be tolerated 1 MODERATE - causing some distress 2 SEVERE - worse pain possible 3 T1 NAUSEA & VOMITING SCORE No nausea or vomiting 0 Nausea only 1 One episode of retching/vomiting in last hour 2 More than one episode of retching/vomiting in last hour 3 T4 T6 T8 T 10 T12 L1 NIPPLE LINE UMBILICUS MOTOR BLOCK Full leg movement 0 Can move knee and ankle 1 Can move foot and ankle only 2 Full leg paralysis 3 L2 L4 L3 L5 S1 A~Inpatient~WR2150~Version 8~Page 15 of 20

16 BLOOD TRANSFUSION OBSERVATIONS CHART Attach Patient Sticker here or record Record temperature, pulse, respirations and blood pressure: 1. Prior to start of the transfusion minutes after each unit has commenced. 3. At the end of each unit. 4. When the transfusion has been completed. NB: These are the only recordings required UNLESS any adverse reactions occur. Date Time 1st Unit 2nd Unit 3rd Unit 4th Unit Sign and return Sign and return Sign and return Sign and return traceability slip traceability slip traceability slip traceability slip Baseline Completion Unit number of blood Temp. B.P. Pulse Resps PARS Score result A~Inpatient~WR2150~Version 8~Page 16 of 20

17 If BM <4mmols please follow Hypoglycaemic Guidelines and contact Diabetic Specialist Nurse Bleep 315 PATIENT AT RISK SCORE Score Systolic blood pressure (mmhg) Heart Rate < >190 < > 150 Respiratory Rate Conscious Level Urine output Temperature 0 2 Therapy BM Glucose Awake Voice Pain Unresponsive < >30 <0.5ml/kg/h Awake Voice Responds to Unresponsive Pain A V P U < > <4mmols Acute Confusion >60% / 10L Notes: Any abnormal measurement should trigger the calculation of the score. Points are allocated according to the reading, i.e. temperature of 35.3 = 2; heart rate of 67 = 0. Once a full set of observations have been made a total score is calculated. HIGH Score = 3 or above Call a Senior Nurse/Doctor or Outreach for ugent review within 1 hour. NB: PARS 6 or more extreme risk needs immediate Doctor review. MED Score = 2 Increase frequency of observations and inform nurse in charge Minimum frequency of observations 4 hourly for scores of 2 and above. LOW Score = 0 or 1 Continue observations at current frequency, minimum of once/shift Please inform Critcal Care Outreach of all scores 3 and above. SBAR = Situation Background Assessment Recommendation ACTION TAKEN? X No action Action taken 99 Referred to: Dr = Dr informed OR = Outreach NP = Nurse Practitioner SN = Staff Nurse PAIN SCORE - ON MOVEMENT No pain 0 MILD - some pain/discomfort which can be tolerated 1 MODERATE - causing some distress 2 SEVERE - worse pain possible 3 T1 NAUSEA & VOMITING SCORE No nausea or vomiting 0 Nausea only 1 One episode of retching/vomiting in last hour 2 More than one episode of retching/vomiting in last hour 3 T4 T6 T8 T 10 T12 L1 NIPPLE LINE UMBILICUS MOTOR BLOCK Full leg movement 0 Can move knee and ankle 1 Can move foot and ankle only 2 Full leg paralysis 3 L2 L4 L3 L5 A~Inpatient~WR2150~Version 8~Page 17 of 20 S1

18 MULTI-DISCIPLINARY PROGRESS NOTES Affix Patient Label here or record NAME: D.O.B: D D M M Y Y Y Y MALE FEMALE WARD Consultant: Please use this sheet to document any additional communications required to ensure appropriate care for patient. Sign/Print Name No Designation Date & Time A~Inpatient~WR2150~Version 8~Page18 of 20

19 ADVICE FOR PATIENTS FOLLOWING BLOOD TRANSFUSION Affix Patient Label here or record NAME: D.O.B: D D M M Y Y Y Y MALE FEMALE WARD Consultant: Most blood transfusions take place without problems but having a blood transfusion carries with it a very small risk of developing side effects. These may develop within several hours, or in some cases may happen days or weeks later. These side effects are often mild, but it is still important to report any unusual or unexpected symptoms to a doctor or nurse (or midwife if your transfusion was related to pregnancy/childbirth). Please contact the hospital for advice if you experience any of the following after having a blood transfusion: A high temperature - feeling feverish, hot and clammy Shivering or cold chills Breathing problems Extreme tiredness Passing blood in your urine Passing much less, or very dark urine Itchy skin rash Pain in the lower back (loin pain) Unexpected or unexplained bruising Jaundice (yellow colour of the white of your eyes or your skin) When contacting the hospital for advice, please inform the hospital staff that you have recently had a blood transfusion. This section to be completed by staff on discharge. Explain to the patient how to obtain assistance in the event of a problem (both in hours and out of hours ), and then give the leaflet to the patient, before they leave the ward/clinic. Ward/Department: Contact Tele No(s) Daytime Night time/weekends: Date and time of last transfusion: If you are unable to make contact with the hospital where you had your transfusion, then please contact your GP as soon as possible. In the rare event of an emergency (life threatening problems, for example difficulty with breathing) call 999 for an ambulance and bring this leaflet into hospital with you. If you would like further information and advice about this, or other aspects of blood transfusion, please discuss this with your hospital doctor, nurse or midwife. (Acknowledgements: The Leeds Teaching Hospitals NHS Trust, Taunton & Somerset Hospitals NHS Trust) Information contained in this leaflet has been produced in collaboration with the NHSBT Better Blood Transfusion Team. Patient Advice. V.1 A~Inpatient~WR2150~Version 8~Page 19 of 20

20 ADVICE FOR PATIENTS FOLLOWING BLOOD TRANSFUSION (OUTPATIENTS ONLY) Affix Patient Label here or record NAME: D.O.B: D D M M Y Y Y Y MALE FEMALE WARD Consultant: Most blood transfusions take place without problems but having a blood transfusion carries with it a very small risk of developing side effects. These may develop within several hours, or in some cases may happen days or weeks later. These side effects are often mild, but it is still important to report any unusual or unexpected symptoms to a doctor or nurse (or midwife if your transfusion was related to pregnancy/childbirth). Please contact the hospital for advice if you experience any of the following after having a blood transfusion: A high temperature - feeling feverish, hot and clammy Shivering or cold chills Breathing problems Extreme tiredness Passing blood in your urine Passing much less, or very dark urine Itchy skin rash Pain in the lower back (loin pain) Unexpected or unexplained bruising Jaundice (yellow colour of the white of your eyes or your skin) When contacting the hospital for advice, please inform the hospital staff that you have recently had a blood transfusion. This section to be completed by staff on discharge. Explain to the patient how to obtain assistance in the event of a problem (both in hours and out of hours ), and then give the leaflet to the patient, before they leave the ward/clinic. Ward/Department: Contact Tele No(s) Daytime Night time/weekends: Date and time of last transfusion: If you are unable to make contact with the hospital where you had your transfusion, then please contact your GP as soon as possible. In the rare event of an emergency (life threatening problems, for example difficulty with breathing) call 999 for an ambulance and bring this leaflet into hospital with you. If you would like further information and advice about this, or other aspects of blood transfusion, please discuss this with your hospital doctor, nurse or midwife. (Acknowledgements: The Leeds Teaching Hospitals NHS Trust, Taunton & Somerset Hospitals NHS Trust) Information contained in this leaflet has been produced in collaboration with the NHSBT Better Blood Transfusion Team. Patient Advice. V.1 A~Inpatient~WR2150~Version 8~Page 20 of 20