2.1. Applicable areas: Royal Cornwall Hospitals Trust; Neonatal Unit and Delivery Suite

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1 ADVANCED NEONATAL NURSE PRACTITIONERS (ANNPs) BLOOD COMPONENT AND BLOOD PRODUCT REQUESTING PROTOCOL NEONATAL CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline 1.1 The purpose of this protocol is to guide ANNPs in requesting and providing the written instruction for the administration of a range of blood components and blood derived products in the treatment of neonatal blood disorders. 2. The Guidance 2.1. Applicable areas: Royal Cornwall Hospitals Trust; Neonatal Unit and Delivery Suite 2.2 Indications for which the protocol applies: The ANNP may order blood components for indications in the neonate as listed in the RCHT Blood Transfusion Policy and Infants and Neonates Blood Transfusion Policy including: Anaemic infants requiring blood transfusion Emergency blood transfusion for anaemia at birth Emergency blood suitable for echange transfusion in the new born When clinically indicated the ANNP may also order the following blood components/ blood derived products: Platelets Fresh Frozen Plasma (FFP) Cryoprecipitate Human Albumin Solution Immunoglobulin Healthcare Professionals who may carry out written instructions described Advanced Neonatal Nurse Practitioners who have attended and passed the validated Higher Education Advanced Neonatal Nurse Practitioner course including medical assessment, diagnosis and indications for the use of blood and blood products for the treatment of neonatal blood disorders. The ANNP must also be qualified and Registered with the Nurse & Midwifery Council (NMC) as a current Non Medical Prescriber (NMP) with supporting evidence kept on the register in RCH Pharmacy Department and their NMP status recorded in their job description. ANNPs will also need to have completed mandatory Blood Transfusion training and competency assessment as per RCHT policy 3 Referral and consent process The ANNP will identify patients by diagnosing a haematological problem on clinical and/or laboratory results or after discussing with a doctor. When the transfusion is a planned (not acute life threatening) event, consent from a parent/guardian must be obtained verbally in accordance with local policy and national guidance (RCN 2011, Department of Health Page 1 of 8

2 2009, NMC 2013) and consent documented in the notes. Where clinically possible a blood sample will be obtained from the baby prior to any blood transfusion plus a neonatal screen blood spot if not previously obtained. The decision and reason for transfusion must be documented in the medical notes. Senior medical staff should be involved for any cases where a parent withholds consent. 4 Red Blood Cell transfusion Unless the blood transfusion is for resuscitation and utilises the Emergency O negative neonatal unit in Delivery Suite, the ANNP will contact the Blood Transfusion Department regarding infant/mother samples needed prior to any blood product being issued. Criteria for neonatal blood transfusion listed in the RCHT Infants and Neonates Blood Transfusion Policy will be followed. Requests for red cells will be made on the standard RCHT Transfusion request form/ocs, requesting a paediatric satellite pack to avoid multiple donor eposure. Requests for emergency echange transfusion blood will be discussed with a senior medical colleague and senior laboratory staff prior to authorisation 4.1 Blood components, plasma derived products Prior to requesting/authorising these products the ANNP will discuss with a senior medical colleague and/or Senior Laboratory staff with consultation of current RCHT neonatal guidelines 4.2 Request forms will include relevant clinical details, be legibly signed and it will be possible to clearly identify the individual who made the request. The blood/blood product to be administered will be written on the baby s IV prescription chart/epma as per RCHT Policy. It is the responsibility of the ANNP that a record of the indication and volume authorised for the blood or blood product is made in the baby s medical notes 5 Continuing Professional Development The ANNP must ensure they maintain their continuing professional development in accordance with the NMC Guidelines, RCHT mandatory update of blood transfusion training and receive ongoing clinical supervision and appraisal with their named medical Consultant 3. Monitoring compliance and effectiveness Element to be monitored Lead Tool In order to monitor compliance with this guideline it will be included in the neonatal clinical audit programme with findings presented at the Child Health directorate audit meeting. Any deficiencies/ action plan will be presented at the Clinical Governance meeting. Any clinical incident reports relating to this guideline will be monitored against it. Neonatal Unit Governance Lead Consultant Clinical audit will be undertaken to ensure requests are made appropriately with completeness of information as indicated in Section 4. Legibility, compliance with indications within RCHT Blood Page 2 of 8

3 Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Transfusion Policy and Infants and Neonates Blood Transfusion Policy, a recorded entry in the medical notes and correctly written/electronic instruction on prescription sheet. Within neonatal audit programme Any incident arising or audit findings outwith the protocol will be presented at Child Health Directorate Governance meeting Any case where these criteria are not met will be discussed with the ANNP and additional training needs identified and acted upon. In the event of non-compliance with this protocol the Clinical Director for Child Health or Hospital Transfusion Committee may withdraw that individual s right to request blood products Lessons will be shared with all relevant stakeholders 4 Equality and Diversity 4.1 This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website. 4.2 Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendi 2. Page 3 of 8

4 Appendi 1. Governance Information Document Title Date Issued/Approved: May 2015 ADVANCED NEONATAL NURSE PRACTITIONERS (ANNPs) BLOOD COMPONENT AND BLOOD PRODUCT REQUESTING PROTOCOL NEONATAL CLINICAL GUIDELINE Date Valid From: May 2015 Date Valid To: May 2018 Directorate / Department responsible (author/owner): Judith Clegg, Advanced Neonatal Nurse Practitioner, Neonatal Unit Contact details: Brief summary of contents Suggested Keywords: Target Audience Eecutive Director responsible for Policy: Date revised: This document replaces (eact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Guidance for ANNPs for requesting, documenting and auditing blood component orders for neonatal patients Neonatal. Neonate. Blood. Transfusion. ANNP. Advanced Neonatal Nurse Practitioner. Platelets. FFP. Cryo. RCHT PCH CFT KCCG Eecutive Director CLINICAL GUIDELINE FOR ADVANCED NEONATAL NURSE PRACTITIONERS (ANNPs) BLOOD COMPONENT AND BLOOD PRODUCT REQUESTING PROTOCOL RCH Neonatal Guidelines Group, RCHT Blood Transfusion Committee Sheena Wallace Name and Post Title of additional signatories Not Required Signature of Eecutive Director giving approval {Original Copy Signed} Publication Location (refer to Policy on Policies Approvals and Internet & Intranet Intranet Only Ratification): Page 4 of 8

5 Document Library Folder/Sub Folder Links to key eternal standards Child Health, Neonatal Guidelines 1. RCHT Blood Transfusion Policy RCHT Infants and Neonates Transfusion Policy Green,L,Pirie,E (2009) A Framework to support Nurses and Midwives making the clinical decision and providing the written instruction for blood component transfusion. SBTS Related Documents: 4. Nursing and Midwifery Council (2013) Standards of Conduct, performance and ethics for Nurses and Midwives NMC, London 5. Royal College of Nursing (2011) Informed consent in health and social care RCN, London 6. Department of Health (2009) Reference Guide to consent for eamination for treatment. 2 nd edition. HMSO, London Training Need Identified? No Version Control Table 2010 Date Versi on No V1.0 Summary of Changes Initial Issue, Child Health Directorate neonatal guideline Changes Made by (Name and Job Title) Judith Clegg, ANNP. Dr P Munyard, Paediatric Consultant 2014 V2.0 Amended to document library format, references updated Judith Clegg, ANNP. Dr P Munyard May 2015 V2.0 Version 2.0 reviewed and approved by Neonatal Guidelines Group. No Changes Made All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of epiry. Page 5 of 8

6 This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the epress permission of the author or their Line Manager. Page 6 of 8

7 Appendi 2. Initial Equality Impact Assessment Form Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): Advanced Neonatal Blood Component and Blood Request Protocol. Neonatal Clinical Guideline Directorate and service area: Is this a new or eisting Policy? eisiting Women and Children s Name of individual completing assessment: Judith Clegg 1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at? 2. Policy Objectives* As Above Telephone: This guideline is aimed at Advanced Neonatal Nurse Practitioners responsible for requesting Blood Productions within the hospital setting. 3. Policy intended Outcomes* 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? As Above Audit Neonatal Patients Medical and Nursing staff No. consultant led Neonatal Guidelines Group approval b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure. 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Eisting Evidence Age Page 7 of 8

8 Se (male, female, transgender / gender reassignment) Race / Ethnic communities /groups Disability - learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership Pregnancy and maternity Seual Orientation, Biseual, Gay, heteroseual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this ecludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. No 9. If you are not recommending a Full Impact assessment please eplain why. No area indicated Signature of policy developer / lead manager / director Paul Munyard Date of completion and submission 08:07:2015 Names and signatures of members carrying out the Screening Assessment Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust s web site. Signed Kim Smith Date 08:07:2015 Page 8 of 8