Receiving and Administering A Blood Component Theory Booklet (Version 2)

Transcription

1 Receiving and Administering A Blood Component Theory Booklet (Version 2) Full Name of Member of Staff: Name of Marker: Job Title: Band: Job Title: Band: Ward/Department: Ward/Department Ext Number/Bleep: Signature of Member of Staff: Ext Number/Bleep: Signature of Marker: (only sign if achieved 90% or above) Date Completed: Date Passed: (Achieved 90% +) Author: Maria O Connell: Specialist Practitioner of Transfusion Basildon and Thurrock University Hospitals NHS Foundation Trust Version 2 Review June

2 Introduction In November 2006 the National Patient Safety Agency (NPSA) released Safer Practice Notice 14. This document charges all NHS and independent sector healthcare organisations to implement an action plan for competency-based training and assessment for all staff involved in blood transfusions. In addition to passing the competencies, practitioners need to be able to prove that they have undertaken some formal training in handling blood and transfusing blood components. This workbook has been designed to guide you through the relevant information to enable you not only to pass your blood transfusion competencies, but also to have a more in-depth understanding as to the rationale behind these competencies. It is vital that you undertake your own research in order to be able to complete the workbook. Suggested learning resources can be found in the reference section at the end of the booklet. All workbooks are to be marked; the results will be fed back and will also be held centrally. Candidates will not be eligible to undertake the observational competency assessment until the workbook has been completed and a pass rate of 90% or more achieved. Candidates who fail to achieve 90% will be shown where they have gone wrong, and will have to resubmit the workbook. Although enormous effort is made to maximise the safety of blood components, they are however not 100% safe. Additionally blood donors are a limited resource. Avoiding blood transfusion if possible is the safest option; every effort to minimise the risks associated with blood transfusion should be taken, even if this requires extra work and forward planning. To remain compliant with the NPSA Safe Practice notice 14 this competency should be repeated every 3 years unless you do not administer blood on a regular basis the competency should be repeated more frequently Links to KSF C1, C2, C3, C5, HWB 5, HBW 6, HBW 7, G1 Completion of this competency will enable the practitioner to safely administer a blood component transfusion. Key elements of this competency are: Correctly identifying the patient. Correctly matching the individual to the information on the blood component label. Monitoring the effects of the transfusion. Correctly documenting information surrounding the transfusion. The British Committee for Standards in Haematology (BCSH) provide guidelines for the appropriate use of blood components in children and adults. These may be accessed via the website: 2

3 1) Legislation, Policy and Good Practice Blood Safety and Quality Regulations 2005 Two European Union Blood Safety Directives have been transposed into UK law through the Blood Safety and Quality Regulations The regulations set standards for quality and safety for the collection, testing, processing, storage, and distribution of human blood and blood components. They represent a more rigorous and formal approach to blood transfusion safety than any previous national initiatives. The regulations stipulate that all healthcare providers who handle blood components are monitored by a competent authority. For the first five years this is the Medicines and Healthcare Products Regulatory Agency (MHRA). What do the regulations mean to clinical staff? Every unit of blood must be traced from donor to recipient, and records kept for 30 years. The responsibility for proving traceability (or final fate) lies with the person administering the blood. You must be aware that it is a legal requirement to report any adverse events or reactions to the competent authority. The reporting mechanism is known as Serious Adverse Blood Reactions and Events (SABRE) Ensure that you know the correct storage requirements for blood products and return any units that will not be transfused to the Blood Bank within 30 minutes. If you collect blood products you must have documented evidence of up-to-date training and competency assessment. It is a statutory requirement to ensure full documentation is recorded for every single blood product transfused, including: Blood Bank Register (or electronic equivalent), Observation Chart, Blood Prescription Chart, Nursing and Medical Notes. There are other national drivers that are designed to promote safety in practice with blood transfusions. The Chief Medical Officer (CMO) has published three blood transfusion Health Service Circulars HSCs 1998/224, 2002/009 & 2007/001 also know as Better Blood Transfusion 3 (BBT 3), which stipulate safety initiatives, e.g. basing local policies on national guidance and ensuring training for all clinical staff involved with blood transfusion. The CMO also has a National Blood Transfusion Committee that constantly monitors and recommends changes to practice. Data on blood transfusion safety is also collected by SHOT (see page 8) and the National Patient Safety Agency. There may well be further HSCs issued by the CMO related to blood transfusion in response to new data. 3

4 Q1. Where would you find the blood administration policy? Ring the correct answer(s) a. On the Hub in the controlled documents folder b. Hard copies are available in the policies and procedures folder (2) 2) Preparing the patient Consent At present, there is no legal requirement in the UK to gain formal written consent for transfusion of blood Components. However given that a blood transfusion is a treatment modality with potentially serious adverse patient outcomes, there is an ethical obligation to obtain patient consent to a blood transfusion wherever possible. The indication for the blood transfusion should be discussed with the patient, and due attention given to the risk / benefit analysis and whether there are any alternatives. This discussion gives the patient a clear and contextual understanding of the risks of transfusion (the risks will vary depending upon the patient s condition). The only means of proving that verbal consent has been given is to record this discussion in the clinical notes, that your patient is aware of the risks and happy to proceed with the transfusion. Q2. What can you give the patient to back up any verbal information given to them ensuring they are aware of the risks involved? A. (1) 4

5 3) Prescribing Blood Components Responsibilities and Records It is a medical responsibility to prescribe blood products Before any blood component is administered, the indication for transfusion, type of blood component, and the prescriber s signature must be documented in the patient s healthcare records. Where it has been possible to gain consent this must also be documented, as described in the previous section. Accurate documentation is essential to safe patient care. It enables effective communication between healthcare professionals, audit of practice and assists with the investigation of adverse effects of transfusion. You need to ensure that the prescription is appropriate, i.e. that the patient is not being unnecessarily transfused, or that there is no suitable alternative. The prescription should be completed in full, e.g. the drug chart should contain the patient minimum dataset, full name date of birth and unique ID number, the prescription should contain the full date, prescriber s name signed and printed, rate of transfusion, volume and type of product indicating any special requirement and any additional medications. Medical Staff are responsible for completing the prescription; nursing (midwives and ODP) staff, are responsible for challenging incomplete/incorrect prescriptions. Incorrect component type requested and transfused despite a lack of prescription A patient s potential need for blood components was discussed with the nurse practitioner. The doctor verbally mentioned FFP but prescribed blood and platelets, and documented this prescription in the notes. The nurse practitioner thought that as she had been trained to take a G&S sample she was then able to request components and proceeded to send a request to the hospital transfusion laboratory for platelets and FFP. The FFP when thawed was checked at the bedside by two nurses who both signed, dated and timed the traceability label and medication chart. However, neither nurse noted that there was no prescription for the FFP, which was administered. The error was noticed when a third nurse replaced the patient s venflon and noticed the empty FFP bag hanging on the stand. This case is disturbing in that the nurse requested blood components without being trained and assessed as competent for this task. In doing so a request was made for a component that was neither prescribed nor documented in the case notes. A further error was made by the nurses administering the FFP in the absence of a prescription. There were a number of points in the process where the incorrect transfusion could have been prevented but these were overlooked 5

6 Q3. What is meant by the term patient s minimum data set that should be checked on the prescription and the wristband? a) b) c) d) (4) 4) Special Requirements. Many hospitals have systems in place to try to combat communication breakdown. Although these systems provide supportive and confirmatory information, the ultimate responsibility for the prescription of specialist components rests with the clinician, and the clinical team has the responsibility of informing the laboratory. Check if the patient has been previously transfused and experienced any adverse reactions. Be certain to communicate any special transfusion requirements (e.g. irradiated, CMV negative or HbS negative) to the transfusion laboratory and to clinical staff. All staff should have a basic understanding of what is meant by special requirements and which patients require these. Irradiated blood is blood that has been treated with radiation to prevent Transfusion-Associated Graft-Versus Host Disease (TA-GvHD). TA- GvHD) is rare but serious complication of blood transfusion caused by white cells (lymphocytes) in the transfused blood, even a very small number of these cells may recognise the patient receiving the blood as different, can engraft and initiate TA-GvHD. Patients develop skin rash, diarrhoea and abnormal liver function, and deteriorate, with bone marrow failure and death from infection usually within two to three weeks of transfusion. The patient may ask is this special blood or may even show you a card indicating they require irradiated blood, there should always be a sticker on the front/inside cover of the healthcare records if the patient does require irradiated blood. Always check with your patient before transfusing. An elderly patient receiving fludarabine for chronic lymphocytic leukaemia (CLL) had been given an Alert card indicating the requirement for irradiated components. However, when he was admitted to the day ward and was receiving his first red cell transfusion he enquired whether the unit was irradiated. Although the clinician had appreciated the need for irradiation, there was no awareness of the local procedure that required a special requirements form to be sent to the laboratory. A patient was admitted with an Hb of 7.0 g/dl and a possible myocardial infarct. The admitting doctor noted the past history of Hodgkin s disease but was not aware of the requirements for irradiated blood. The patient received 2 units of red cells. The patient then elected to be transferred to the local private hospital under the same consultant where a further 2 units of non-irradiated red cells were given. When the notes were reviewed by the consultant, he noted the patient s past history and contacted the local haematologist to confirm his suspicions that irradiated blood components were required. 6

7 Although the junior medical staff had been aware of this patient s past history of Hodgkin s disease they were not familiar with the criteria for irradiated components. In many instances there was a lack of knowledge on the part of the junior doctor prescribing and requesting blood for the patient, but in others the procedure for transmitting this requirement to the laboratory was neither sufficiently robust nor understood by all parties. Cytomegalovirus (CMV) infection can cause serious morbidity in immunocompromised CMV-negative patients. The risk can be minimized by the use of CMV-antibody negative blood components. Here are some indications for the use of CMV- antibody-negative: All pregnant women regardless of CMV sterostatus, CMV- antibody negative recipients of allogenic stem cell grafts, intrauterine transfusion and patients with HIV disease Q4a. Which of the following patients require Irradiated blood products? ring the correct answer(s) a. Allogenic bone marrow recipient (from time of conditioning chemo/radiotherapy) b. Allogenic bone marrow/stem cell donor c. Donor/Recipient of autologous bone marrow or peripheral blood stem cell transplant d. HLA selected platelet units e. Hodgkins Disease f. Aplastic Aneamia on (ATG) g. Treatment with alemtuzumab ( Campath-IH/anti-CD52 h. Treatment with purine analogue (eg Fludarabine, 2deoxycoformycin, cladribine clofarabine, bendamustine) i. Congenital immunodeficiency state j. Exchange transfusion k. Intrauterine transfusions (11) Q4b. Name 3 groups of patients who require CMV- antibody-negative Blood. a) b) c) (3) 7

8 5) Safe Practice SHOT was set up in 1996 and can be seen as the first step in taking a national approach to monitoring safety in blood transfusion; in particular, errors and untoward effects of blood transfusion in the United Kingdom. It is a reporting scheme that has become highly valued by many Healthcare Professionals. This 2010 report is the 14th annual report of data collected and recommendations made by the Serious Hazards of Transfusion (SHOT) UK Haemovigilance Scheme. In 2010, reports were submitted by 94.7% of NHS hospitals or Trusts, and 91.4% of organisations reported incidents in all three broad categories (adverse events, near misses and physiological reactions). In total, 1464 cases were analysed (in addition to 863 instances of near miss and 137 right blood right patient incidents), which represents a 14.5% increase from Notably, this is the first year in which there has been no confirmed case of transfusion-transmitted infection (TTI). Furthermore there has been a 29% reduction overall in the number of incorrect blood component transfused (IBCT) reports: 57% less in the clinical area and 28% less in the laboratory. These figures indicate that efforts to train and competency assess clinical staff in transfusion, such as the National Patient Safety Agency (NPSA) Safer Practice Notice (SPN) 14, are having an effect in the clinical area. In the laboratory, the improvement is likely to be due to a combination of the requirements of meeting the Blood Safety and Quality Regulations (BSQR) 2005 and the recommendations of the UK Transfusion Laboratory Collaborative (UKTLC). However, transfusion-associated circulatory overload (TACO) and inappropriate and unnecessary transfusions (I&U) are becoming major issues and have been responsible for the majority of cases of mortality with imputability In 2010 the scheme captured data on the major complications of transfusion and categorised them into the following: Incorrect Blood Component Transfused (IBCT) (wrong blood ) Inappropriate & Unnecessary, and Delayed/Under Transfusion (I&U) Handling and Storage Errors (HSE) Administration of anti-d Immunoglobulin Acute Transfusion Reaction (ATR) Immune Transfusion Reactions: - Haemolytic Transfusion Reaction (HTR), both acute and delayed - Transfusion-Related Acute Lung Injury (TRALI) - Post-Transfusion Purpura (PTP) - Transfusion-Associated Graft-versus-Host Disease (TA-GVHD) Transfusion-Transmitted Infection (TTI) Transfusion-Associated Circulatory Overload (TACO) Transfusion-Associated Dyspnoea (TAD) Incidents associated with autologous transfusion (mainly cell salvage) The range of reports that we receive increases every year, so please keep checking the SHOT website 8

9 to see the latest reporting categories, which are reviewed annually. An elderly patient was admitted to the MAU with a haematemesis and an initial Hb of 10.6 g/dl. No details are provided of her observations or the findings on endoscopy but she had further episodes of vomiting blood. Five units of red cells were transfused before a repeat Hb was performed, which was 20.4 g/dl. The patient was recognised to have circulatory overload and died shortly thereafter. Q5a. How would an adverse blood transfusion event that occurred in your clinical area be reported to SHOT or SABRE if appropriate? a) Report to which department? b) What kind of form would you need to complete on line from the Hub? (2) 9

10 Transfusing at Night The 2010 SHOT (Serious Hazards of Transfusion) report states: Available data indicates that blood administration and pre-transfusion testing outside of core hours are less safe and should be avoided unless clinically essential. Safer care can be given to patients who are not acutely unwell or significantly symptomatic by avoiding overnight transfusion. Risks arise from reduced staffing levels at night (medical, nursing and laboratory) to monitor patients and manage complications. Additionally, visual observation of the patient at night is considerably impaired due to lower light levels. Every effort should be made to promote patient s normal sleep pattern (night time for most people) and, patients just woken up from sleep cannot give you an accurate description of how they are feeling. Patients who are acutely unwell exacerbated by anaemia or requirements for other blood components should be transfused without delay. The urgency of every patient s blood transfusion should be discussed with the clinical team. Patients receiving a blood transfusion should be observed throughout the transfusion episode, therefore isolated side rooms should be avoided whenever possible. A patient with known hereditary spherocytosis was admitted with an Hb of 7.2 g/dl. The consultant haematologist decided in consultation with the patient that a transfusion was not necessary. However, the low Hb was noted by a nurse on night shift who informed the on-call doctor, who then prescribed 4 units of red cells. Two were given overnight before the decision to stop transfusing was taken the following day. This is 1 of 2 cases where a decision taken during the day that was documented in the case notes was overlooked by night staff. This shows a concerning lack of continuity of patient care and unnecessary transfusions being given out of hours. The on-call doctor appears to have had no knowledge of the patient or the condition and is unlikely to have had sufficient time in an on-call situation to review the clinical need for blood. Incident only discovered after a letter of complaint to the CEO An elderly patient (group O RhD negative) had a postoperative cell salvage drain in situ following a total knee replacement (TKR). There was no prescription for allogeneic (donor) blood. The patient was wearing the correct wristband. Despite the lack of a prescription, the patient was transfused out of hours with 1 unit of O RhD positive red cells allocated to another patient. The patient s daughter complained to the CE 10

11 5b. It Is appropriate to transfuse overnight when: Ring the correct answer(s) a) The patient has a low Hb and is extremely symptomatic. b) There is a bed crises and the patient is expected to be discharged tomorrow morning following an Hb check. c) The patient has a low Hb and is actively bleeding either on-going bleeding or major haemorrhage d) When clinically indicated e) The patient s Hb is 7.8 and you have extra staff on this particular night shift. (3) Infection Control The use of aseptic technique, observation of universal precautions, and product sterility are required in all infusion procedures (Standards for Infusion Therapy, RCN 2005). You must be familiar with your Trust s infection control policy. 6) Blood Administration Equipment Ensuring the necessary equipment is prepared before the blood component is collected is a vital part of transfusion safety. Some equipment is specifically required to prepare the patient; other equipment is more to do with the mechanism of transfusing blood components. Q6a. List 3 items of equipment required to transfuse a blood component from the bag into the patient s blood stream (3) Q6b. The filter size is µm in a blood transfusion giving set TRUE / FALSE (1) 11

12 Q6c. The blood component administration set should be changed when? Ring the correct answer(s) a) After every 12 hours b) After every 3 rd unit c) When changing the blood component. d) When recommencing other intravenous therapy e) If there was a blockage a kink or something generally wrong with the giving set. (5) Q6d. For non urgent transfusions what size of cannula should be used? a) (1) 7) collection Q7a. what is the collection documentation normally used within this Trusts and what details should be written on this document? a) Document used? List the details on this document: b) f) c) g) d) h) e) i) (9) 12

13 Q7b. When a blood component is collected from controlled storage conditions, how soon should the transfusion commence? Ring the correct answer(s) a) Within 15minutes b) Within 30minutes c) Within 45minutes. (1) This year has seen an increase (>100%) in incomplete cold chain documentation errors to 18 in 2010 compared with 8 in Failure to maintain an adequate or complete cold chain record can result in transfusion of a unit that has been out of CTS for a long period of time, or unnecessary wastage of blood components. Q7c If it has not been possible to commence the transfusion within the time stated above, state which action you would take and why? Action Why? (2) Q7d For non-urgent transfusions, how many single blood components should be collected for a patient at any one time? (1) Blood Warmers Rapid infusion of cold fluids (> 100 ml/minute) has been reported to cause potentially lethal cardiac arrhythmias. Infusion through a central catheter terminating in or near the right atrium may increase the risk. Only CE-marked commercial blood warmers should be used with a visible thermometer and audible warning and the manufacturer s instructions must be strictly followed, as well as the Trust Guidelines on using blood warmers. You can only use a blood warmer if you have been trained on how to use these and deemed competent. Blood must never be warmed in an uncontrolled way (e.g. in a microwave, in hot water, or on a radiator). 13

14 8) Infusion Times Adult Patients Most Prescriptions for blood components for adults are written, to be transfused over a stated period of time, but occasionally, an infusion rate may be specified. The infusion time (or rate) will depend on the individual patient s clinical parameters at the time of prescribing. It is vitally, important that changes to the patient s clinical parameters are reported and documented promptly, and necessary changes to the infusion time are made. Ensure appropriate blood/blood component sterile transfusion administration set with an integral screen filter is used, 170µm-200µm filter. Infusion set for platelets or cryoprecipitate can be collected from blood bank at time of collecting component, (stocks also available in high use areas) Electronic infusion pumps may damage blood cells and should not be used for the administration of red cells unless they have been verified as safe to use for this purpose according to the manufacture s instructions. Use of a suitable infusion pump (Alaris GP Volumetric Pump), for non-urgent red cell transfusions, is preferable to gravity feed systems because it ensures greater control of the flow of blood. Only administer blood via a pump if you have received training and deemed competent in using appropriate pumps refer to Trust guidelines, and manufactures guidelines, ensure appropriate blood transfusion administration set is used for the pump. Adults Infusion Rates Q8a Complete the following table: Component (4) Duration of Infusion in hours Red Cells, once they have been removed from storage Platelets Fresh frozen Plasma (FFP) Usual duration FFP Maximum time. Transfusion-associated circulatory overload includes any four of the following occurring within 6 hours of transfusion: 14

15 Acute respiratory distress Tachycardia Increased blood pressure Acute or worsening pulmonary oedema Evidence of positive fluid balance. Transfusion associated circulatory overload following RBC transfusion to elderly male with renal impairment and cardiac failure An 83-year-old male with refractory anaemia related to CRF received 2 units of RBCs, each over approximately hours. He had continuing bradycardia during the second unit. He remained stable, but the bradycardia persisted at beats per minute (bpm). Within 15 minutes of the start of the third unit of RBC, he became unresponsive with no assessable cardiac output. An arrest call was put out and resuscitation commenced, which was ultimately unsuccessful. A post-mortem examination showed acute left ventricular failure (LVF), hypertensive heart disease with mitral valve prolapse and hypertensive nephropathy. Q8b Circulatory overload is a risk with rapid transfusion to frail elderly patients? TRUE / FALSE (1) Neonates (Questions 6f and 6g for RSCNs and paediatric ODPs and medical staff only). Q8c. Complete the following table: (8) Component Volume (mls/kg) Infusion Rate Red cells (for top up transfusion) Platelets FFP Cryoprecipitate 15

16 Infusion rates and times are critically important. (Answers found at Infants and Children Q8d. Complete the following table: (8) Component Volume Infusion Rate Red cells Platelets FFP Cryoprecipitate Notes: These figures are only for guidance, and will depend on the exact volume given and clinical status of the patient. For neonates and children, it is important that the exact volume is prescribed, as well as the time over which it should be given. Neonate fails to respond to transfusion of red cells A top-up transfusion of 14 ml of RBCs administered to a neonate failed to increase the neonate s Hb, despite receiving a second aliquot of 14 ml. On investigation it is thought that the roller clamp between the Y-connection and the syringe driver may not have been fully engaged, resulting in the red cells being drawn back into the red cell unit. 9) Checking the Blood Component Pre-transfusion If your clinical area is able to utilise the Porters service to collect blood components, check the components on arrival, in case the porter needs to return them to the Transfusion Laboratory (within the 30minutes) If the blood component has been collected by a member of staff from the clinical area, there is no need to check the component on arrival, as this would have been checked at the time of collection and any concerns discussed with the blood transfusion lab, the pack will then be checked again prior to administration. The most important 16

17 check is the final bedside check; despite the number of previous checks that may have been made. Final Bedside Check before Administration The final check of a blood component before being administered to a patient must always take place at the patient s side. Safe checking of a component is impossible without the patient. The SHOT report for 2010 found that: there were instances in which the correct blood had been collected for the patient from the storage site but once it was on the ward it was checked away from the patient and then subsequently given to the wrong patient. This was an actual incident here at the Basildon Trust. Blood transfusion policies between different healthcare organisations vary, but in this Trust two registered healthcare professionals who have been competency assessed and NPSA Compliant are involved with the final check and in putting up the blood transfusion. The final bedside check consists of: Step 1 Right Patient Step 2 Right Blood Component (This is clearly defined in table1). If there are any mismatches or errors in any of the information do not transfuse until fully resolved. In order to be thorough, it is recommended to adopt a routine for ensuring that all necessary information is checked before the blood is administered. It is also recommended that a clear and crisp style is adopted for this purpose, a double uninterrupted independent check. Right Patient The first step consists of correctly identifying the patient with the full minimum dataset and then ensuring that all sources of this information (as outlined in table 1) match Right Blood Component The second step consists of checking the information that relates directly to the blood component with the Patient Label attached to the blood and the label applied directly to the blood component bag by the National Blood Service a. Positive Verbal identification As far as possible, the patient should always be asked to positively identify themselves; this is required at all stages of the blood transfusion process and 17

18 is vital to the final checking procedure. For orientated patients the minimum is asking the patient to state their first name, surname, and Date of Birth (DOB), some patients may be able to supply more information that may be relevant to the transfusion process. If your patient is not able to state their full name and DOB there wristband would need to be verified with another member of staff and a relative if present. b. Wristbands/Patient Identification Band All patients receiving a blood transfusion must have an accurate and clearly legible Wristband/Patient Identification Band. There are no exceptions for Patient s not wearing one. NO WRISTBAND NO TRANSFUSION Two patients on the ward required transfusing. Blood was collected from the fridge for the patient. Cross-checks were made with the documentation and the bag of blood, and found to be correct. Blood ran through and taken to patient s bedside. Turned the blood on and it wasn t running so flushed cannula again. It worked but found it positional so placed the patient s arm on a pillow. The blood was dripping fine then. Walked around to document on the fluid balance chart how much blood was in the bag and noticed it was the wrong patient. Realised then that the patient s name band had not been checked prior to connecting the blood. Turned the blood transfusion off immediately (approximately 10mL maximum would have been received). c. Compatibility The healthcare professional responsible for administering the blood transfusion must satisfy themselves that an ABO & Rh D status compatible blood component has been issued by the Blood Transfusion Laboratory before commencing the transfusion. Once 5mls have been infused or at the time of the first set off observations, complete the declaration section, tear down perforation and return by hand, to blood transfusion lab within 48hrs of administration in order to finally fate the unit. If you have administered the flying squad ensure you write the patients full details on here before returning the tag to the lab. Compatibility/Traceability Label. This section contains patient and component details, checked at the patient s bedside these are checked against the drug chart the patient and the wristband, to ensure right blood/component given to the right patient. And the red/white label matches the label attached to the component (NBS label). This section remains attached to the bag at all times, then discarded with the pack once used. Once the unit has been connected to the patient and commenced, this section must be signed by two qualified members of staff, dated and timed. 18 Peel off the sticker and file in patient s healthcare records.

19 d) Blood Component The blood component itself should be inspected, to make sure that there are no signs of damage to the bag and no evidence of infection in the product. Check for leaks at the ports and seams, check for evidence of haemolysis in the plasma or at the interface between red cells and plasma, check for unusual discoloration or turbidity and check for the presence of large clots, if there is any evidence of the above, the unit should not be used and returned to a member of staff in Blood Transfusion. Good Manufacturing Practice. (GMP) NBS Label attached to components Donor no Component Type ABO and RhD Expiry Date Volume e) Blood Prescription Chart Check the prescription chart contains the patient s minimum data set and is clearly and accurately completed; including the Dr s signature and that all special requirements are stated. Check the rate of infusion is correct. It is also important to check whether the patient has been prescribed a premedication before commencing the transfusion. Appropriate patient assessment and prescribing 110 patients received inappropriate and unnecessary transfusions, which in 1 case contributed to their deaths. 48 transfusions were given on the basis of erroneous blood count results and 52 were due to lack of knowledge and inappropriate prescribing. 1 patient died following significant delays in providing blood component support in the emergency situation 19

20 Transfusion associated circulatory overload following RBC transfusion to elderly female with renal impairment and cardiac failure A frail 91-year-old female with a history of CRF and CCF had anaemia, Hb 8.1/dL, associated with intermittent rectal bleeding. She was stable with pulse 70 bpm, BP 110/50 and good oxygen saturation. She became SOB, po2 8 kpa, during transfusion of a unit of RBC given over 5 hours and covered with furosemide 80 mg IV. The next morning a second RBC unit was transfused, making NB. Medication should never be added to a blood component Q9a. Identify the greatest risk of: - Not performing the Final Check at the patient s side (1) State the worst potential outcome of this risk (1) Q9b. The NPSA stipulated that the compatibility form and patient notes must not be used as part of the final check by the patient s side as nurses were tempted to check the blood against the form and not the patient? TRUE / FALSE (1) Q9c. Describe which members of staff are permitted to perform the Final Check of blood components within your Trust in accordance with local policy. Ring the correct answer(s) a) Two qualified members of staff who have been practical assessed to the NPSA competency standards for blood administration. b) A qualified Dr, Nurse, Midwifes who have completed the intravenous therapy course c) Any qualified Dr, Nurse or Midwife (1) Q9d Positive patient identification means asking the patient to state their full name and Date of Birth. Is The above statement TRUE OR FALSE (1) 20

21 Q9e Our Trust no longer issue the blood compatibility form to avoid the risk that it is still used as part of the final bedside check. Name 5 items which must be checked on the blood bag label(white NBS Label stuck on the bag) prior to administration a) b) c) d) e) (5) Q9f. List the actions you would take if only one piece of information, e.g. a single letter or number was found to be different between any of the items listed in table (2) Q9g Refer to the Trust s policy and explain how you would identify the following groups of patients: Unconscious patients Patients unable to verbally identify themselves Unknown patients (6) 21

22 Final Bedside Check before Administration Step 1 Right Patient Step 2 Right Blood Table1 Verbal response Wristband Blood prescription chart Patient label attached to component First name First name First name First name Surname Surname Surname Surname DOB DOB DOB DOB Unique ID no. Unique ID no. Unique ID no. Component type,special ABO &Rh D requirements Premedications Ward NBS label stuck directly to component N/A N/A N/A ABO & Rh D ABO & Rh D Unique donor Unique donor no. no. Special requirements N/A Correct component Special requirements Expiry date 10) Observation Schedule The BCSH released comprehensive guidelines in 1999 called, The administration of blood and blood components and the management of transfused patients. The observation schedule applies to every single component transfused. It is recommended that all blood transfusion observations be recorded on one single patient observation chart, in order to detect a change in the trend. The blood transfusion observations should be clearly identified dated and timed included start and finish times with any entry in the patient s documentation. Patients who are unconscious or confused require more frequent observations and should be very closely monitored for the first 20 minutes 22

23 a. Early Warning Score If your Trust uses an Early Warning Score (PARS) (Meows) system, this should also be completed in full. EWS Systems have been devised to assist in the recognition of the deteriorating patient. They assign a numerical value to an abnormal vital sign. When the total score of all the key vital signs are added together; this gives an indication of the severity of the patient s condition. The EWS also triggers appropriate medical assistance to be sought. The higher the score, the more senior review indicated, and within a shorter time period. The systems used can vary from hospital to hospital, but the fundamentals remain the same. The EWS can give an early indication of change and allow you to track patients' progress. b. The first five minutes It is good practice to spend the first five minutes with the patient at the start of the transfusion to identify early signs of an anaphylactic, allergic, or an Acute Haemolytic Transfusion Reaction. This time can also be used to remind the patient to inform the ward staff if they feel in any way unwell or different throughout the transfusion. Also ensure that all documentation relating to the transfusion has been clearly completed (Blood Prescription Chart, Observation Chart, fluid balance chart and mechanism for blood traceability), such as ensuring once the blood has been checked and connected to the patient the sticky label is dated timed and signed by both qualified members of staff and placed in the health care records in the relevant place An elderly patient was found to be unconscious and not breathing 4 hours into the first unit of a red cell transfusion for anaemia of unknown cause. Resuscitation was unsuccessful. A post mortem mast cell tryptase (MCT), taken several days later, was stated to be markedly raised. Unit cultures were negative. It was concluded that the patient had died of anaphylaxis due to the transfusion. In the acute situation, it can be difficult to determine whether new adverse clinical features are due to an ATR, to other complications of transfusion or to the patient s illness. The over-riding priority is to manage the clinical condition, whether or not the cause is clear. Reactions can present in any patient, irrespective of whether they have experienced a reaction previously, this highlights the need for patients to be transfused where there are adequate resources for managing acute reactions, particularly anaphylaxis. Temperature, Pulse, Blood Pressure, and Respiratory Rate should be repeated 15minutes after starting the blood. 23

24 Patients with a fever There is misunderstanding around patients who present with a fever prior to receiving a blood transfusion. Having a fever is not a contra-indication to a patient receiving a blood transfusion; however, if the fever is new, it is advised that medical advice should be sought before the transfusion commences in case treating the fever is deemed to be a higher priority than the transfusion. You should always do a full set of observations before connecting the blood to the patient,( baseline obs) if you have already collected the blood and the medical team advise to take blood cultures or give paracetamol and allow the temperature to settle before commencing the transfusion then return the blood ASAP to the blood bank fridge to prevent any wastage. c. Care during transfusion Observe the patient throughout the transfusion, regularly asking the patient if they feel well. Trust not only the patient s response, but also your instincts as to how the patient appears and whether they are changed from how they are normally. Ensure the patient s call bell is within reach of the patient. Even greater care is required for patients who are unconscious or confused because they cannot reliably inform you of any untoward symptoms. These patients should have a more frequent observation schedule. Even if your patient is stable you will still need to do 30minutes visual checks, check the infusion is running to the correct time, ensure veflon in situ and patent, always document when you check you patient and what checks were carried out. If there is any cause for concern the transfusion should be stopped and the patient s signs and symptoms investigated, calling on medical help if necessary. d. Completing a Blood Transfusion A full set of observations is required on completion of every single blood component. For acutely unwell patients, it is particularly important to be able to reestablish a baseline after a transfusion, so that further untoward symptoms can be more likely attributed to the possible cause, e.g. would a fever be due to the blood transfusion or a new infection, could an allergic reaction be due to the blood transfusion or a new drug. Dispose of all equipment safely in accordance with your Trust s sharps and infection control policy. Dispose of empty blood component bags in accordance with your Trust s transfusion policy. (a blood bag and giving set should not be pulled apart but disposed of as one whole unit and discarded in the clinical waste). Flush the venflon to ensure patency and prevent blockage. 24

25 e. Documentation It is vitally important to record the start and end time of each blood component on the blood prescription chart, the patient observation chart and or patient health Care Records. This is proof that the transfusion was given in the correct time. The duration of the transfusion is helpful for monitoring fluid balance (essential for patients with renal impairment). The transfusion should be fully described in the evaluation, including any reported or observed symptoms and what action was taken. The patient s future safety depends on accurate documentation of blood transfusion episodes. Q10a Briefly state the correct observation schedule for every blood component transfused to patients. (4) 25

26 Q10b. What does your Trust s blood transfusion policy state about the observations required for unconscious or confused patients? (Ring the correct answer) a) Closely monitor for the first 5 minutes b) Closely monitor for the first 10 minutes c) Closely monitor for the first 20 minutes (1) Q10c. What action(s) would you take if the baseline observations showed that the patient had a new fever? (2) Q10d. How would you describe the symptoms of a transfusion reaction to your patient and give one example? 1. Give an example: (2) There has been a further 27% increase in the number of reports of Acute Transfusion Reactions (increased from 400 reports in 2009 to 510 in 2010) in 21 cases death occurred at around the time of, or shortly after the transfusion 26

27 Q10e. Why is it important that a full set of observations is completed at the end of every transfused blood component? a) (1) Q10f. Describe the recommended practice in your Trust for disposing of empty blood component bags and giving sets. a) (2) Q10g. Why it is vitally important to ensure continued patient safety by keeping all the documentation relating to the blood transfusion accurate and completely filled in? (2) Transfusion-Transmitted Infection (TTI) There have been no confirmed cases of transfusion-transmitted viral infections since Transmission of viruses through transfusion may make the headlines, however, risk estimates for the UK from the Health Protection Agency (Aug 2010) are very low: Hepatitis B 1 in 670,000 HIV 1 in 5 million Hepatitis C 1 in 83 million HTLV 1 in 18 million Although the risk of getting variant Creutzfeldt Jacob Disease (v-cjd) is probably very low with a single blood transfusion, the risk of any infection will 27

28 increase with additional blood transfusions. Within the UK there have been just a handful of cases where patients are known to have become infected with v-cjd from a blood transfusion. There were no confirmed reports of bacterial infection by transfused components in Each year approximately 2.5 million units of blood are transfused. 11) Traceability All staff who are deemed competent to administer blood components must be aware of their responsibilities under the Blood Safety and Quality Regulations 2005, including assisting the transfusion laboratory in proving the final fate of the blood components issued (Traceability). At the end of the transfusion the appropriate action for informing the laboratory of the final fate of the blood component must be completed. Q11a. Describe the traceability Red/White tags/label system in place in the Trust. Who takes the responsibility in the clinical area to ensure that traceability (final fate) has been proven? a) Once you connect the unit of blood and start the infusion what do you need to do? Where would you put this? b) Once 5mls have been administered or you are doing the observations after the 1 st 15 minutes (whatever sooner) what do you need to check against the patient? What do you document on this and then what do you do with this c) What is the time frame? For doing this? d) Who is responsible for ensuring this happens? (7) 28

29 Q11b. How long does your Trust legally need to keep traceability records for? Ring the correct answer a) 10 years b) 20years c) 30years (1) 12) Management of Transfusion Reactions As with all areas of practice in healthcare, confidence grows with continued learning from experience. Management of transfusion reactions is one such area, especially as they are not seen every day. This is more significant for clinical settings that transfuse blood components infrequently. However, safe patient care can be delivered as long as the staff, Involved take, a sensible approach. When a reaction is suspected, the transfusion should be stopped. Contact the Medical Dr ASAP Take and record a full set of observations, temperature, pulse, respirations, blood pressure, oxygen saturations, check for any signs of bleeding and check/monitor urine output. For cases of suspected Febrile Non-Haemolytic Transfusion Reaction and Mild Allergic Reactions, the transfusion may be restarted and completed after the appropriate intervention. For cases of suspected Acute Haemolytic Transfusion Reaction, Anaphylaxis or severe allergic reaction, the transfusion should: Not be restarted. Managed by senior medical team. Transfusion laboratory informed immediately, so they can also support and give you further advice about any tests they need to repeat Complete and on line clinical incident form, access via the Hub When preparing to administer a blood transfusion it is good practice to remind you of the different signs and symptoms of a transfusion reaction. These must be discussed with the patient at the start of the transfusion, making sure you use words to describe potential symptoms that your patient will understand, not medical jargon, ensure they are aware they should feel no different than at the point of starting the transfusion. Refer to Trust guidelines for further information and management of Transfusion Reactions.. 29

30 Q12a. Which department in the hospital must be informed of suspected blood transfusion reactions and why? Department Informed: Why: (2) Q12b. What symptoms may a patient experience if they are having a transfusion reaction? (10) Q12c. Describe where you can find information in your clinical area that you could access quickly which will guide you through the correct management of a transfusion reaction. A. (1) 30

31 Febrile Non-Haemolytic Transfusion Reaction Symptoms Fever, generally < 1.5 o C from baseline. May have slight increase in pulse and respirations. Generally, the patient feels well despite the fever. Action Stop Transfusion Get Medical Assistance Administer Paracetamol Re-start transfusion within 30 minutes of stopping at a slower rate Monitor patient more frequently to record response to medication Mild allergic reaction Symptoms Action May be red/ flushed Stop the transfusion Reports itching Get Medical Assistance May show urticaria or hives Administer IV Chlorphenamine 10mg Re-start within 30 minutes of stopping at a slower rate Observe more frequently 31

32 Anaphylaxis/Severe Allergic Reactions Symptoms Action Hypotension Bronchospasm Angioedema Periorbital and Laryngeal Oedema Nausea and Vomiting Erythema Urticaria Conjunctivitis Dyspnoea Chest Pain. Abdominal Pain Stop transfusion Get Medical Assistance, pull crash buzzer, treat as Medical Emergency Take down blood unit and giving set, return intact to transfusion laboratory Inform transfusion laboratory, send any patient blood samples as requested Slowly administer IV Chlorphenamine 10mg Commence O 2 Give Salbutamol nebuliser If severe hypotension, give adrenaline 0.5ml of 1:1000 (i.e. 0.5mg) IM Acute Haemolytic Transfusion Reaction Symptoms Pain at cannula site Feeling of something wrong, or apprehensive Flushed red Agitated Pain in abdomen, flank, or chest Haematuria Oozing from wounds or puncture sites Fever normally > 1.5 o C above baseline Hypotension/hypertension Increased pulse and respiration rate Action Stop Transfusion Get Medical Assistance Take down blood unit and giving set, return intact to blood transfusion lab Inform blood transfusion laboratory of patient s symptoms; send any patient blood samples as requested Commence IV Saline infusion Maintain urine output >100ml/hr Give furosemide if urine output falls/absent 32