NOTE: Massive Transfusion Protocol (MTP) go to Appendix 17 and 17a for nursing guidelines and algorithm.

Transcription

1 NURSING PROCEDURE TITLE: BLOOD PRODUCTS ADMINISTRATION Crossmatched & Uncrossmatched Products: Packed red blood cells, platelets, plasma, cryoprecipitate (homologous, autologous & directed donor) A. Prior to Obtaining Blood B. Obtaining Blood C. Preparation to Commence Blood Product D. Commencing Blood Product E. Transfusion Reaction (Actual or Suspected) F. Following Transfusion CATEGORY: NP - General RN - General RPN - General LPN - General PURPOSE Safe administration and documentation of blood products. Report and management of adverse reactions. NOTE: For NICU administration see unit specific procedure. NOTE: Massive Transfusion Protocol (MTP) go to Appendix 17 and 17a for nursing guidelines and algorithm. NOTE: There are 3 types of blood transfusions included in this procedure: o Homologous Blood Donation blood collected by the blood agency from volunteer donors. o Autologous Blood Donation blood donated by the client for use in his / her own surgery. (Appendix #11, 11a, 11b). o Directed Blood Donation blood donated by a parent for use by their child, 18 years or younger. (Appendix # 12). Approved: October 6, 2017 Page 1 of 38

2 NURSING ALERT: Prior to obtaining blood product, VERIFY CROSSMATCH EXPIRY DATE utilizing Blood Bank Report. o Red Blood Cells (RBC) crossmatch is valid for 14 days. o For clients previously transfused or pregnant in the last 3 months, or those who are currently pregnant, crossmatch is valid for 4 days (96 hours). o Neonatal specimens may be used for up to 4 months from date of birth, regardless of previous transfusions. o Platelets, cryoprecipitate and plasma require group and screen, once per hospital stay. o If patient presents with Antibody Card, nursing to notify client s Practitioner and Transfusions Department. If blood products cannot be infused immediately, return blood product to Transfusion Department within 30 minutes of lab issue. DO NOT store in unit s refrigerator. Ensure Notification of Administration of Blood and/or Blood Products (RQHR form 425 (10/99)) is obtained from lab and signed by client prior to discharge. A. Prior to Obtaining Blood EQUIPMENT 1. Documents (see APPENDICES for sample transfusion forms): Ordering of Red Blood Cells PPO #PP-601 ( if giving Red Blood Cells) Appendix #1 & 1a Informed consent Appendix #2 & 2a o Consent for Administration of Blood/Blood Components and or Plasma Protein Products/Refusal/Withdrawal of Consent RQHR 1163 (12/15) TSIN Red Armband number Appendix #3 (if applicable) Blood and Blood Products Administration Checklist Appendix #4 Blood Product Administration Chart Appendix #5 Request for Transfusion Service Requisition for cross match Appendix #6 2. Personal Protective Equipment (PPE) 3. Equipment for starting intravenous access (IV), if not already in progress 4. Appropriate blood product administration set: Pump #313406, Gravity # Normal saline (N/S) IV Solution 6. IV Pump; if required NOTE: All blood products administered to neonates and children MUST be infused on a pump and may require a special administration set. Check unit specific guidelines. PROCEDURE 1. Verify Practitioner order (PP-601). 2. Ensure Consent/Refusal for Administration of Blood/Blood Components and or Plasma Protein Products completed by practitioner. Approved: October 6, 2017 Page 2 of 38

3 NURSING ALERT: Informed Consent must be obtained by Practitioner as per Health Canada Blood Regulations (refer to reverse side of consent form for products requiring consent). If consent not completed, notify Practitioner to obtain one of the following: o Informed Consent, or o Practitioner order that states Ok to proceed with transfusion without signed consent, or o Order to hold transfusion until consent can be obtained. RBC s in non-urgent/non-bleeding inpatient settings should be transfused during daytime hours for patient safety and transfused one unit at a time. 3. Ask client about previous transfusions and reactions and document. 4. Prime blood administration tubing set with N/S, ensuring fluid levels remain above filter at all times. 5. Don PPE. NURSING ALERT: N/S is the only IV solution that is compatible with most blood products. If using IV solution for flushing, N/S is utilized to prevent hemolysis of RBC s. See Appendix #5 for exceptions. A separate administration set must be used for different blood products 6. Ensure patent IV access. NOTE: If central venous access device (CVAD) present, refer to appropriate procedure for checking line patency (C.2, I.7, P.11, T.3): NOTE: For routine adult Packed Red Blood Cells (PRBC) administration, a gauge is sufficient. For rapid PRBC transfusions in adults a gauge is recommended. For pediatric clients, use gauge. For all other blood products any size gauge is adequate. 7. Ensure pre-medication (if ordered), is administered prior to obtaining blood. 8. Obtain and document client s baseline vitals (T, HR, BP, R, SpO2) within 30 minutes prior to blood product. NOTE: Notify practitioner of vital signs outside parameters prior to transfusion (i.e. increased temperature). Approved: October 6, 2017 Page 3 of 38

4 B. Obtaining Blood EQUIPMENT 1. Documents (see APPENDICES for sample transfusion forms): Blood Bank Report (white, 8.5 x 11 sheet, computer generated, on chart) Appendix #7 Request for Transfusions Services Requisition Appendix # 6 TSIN Armband Appendix #3 RQHR Patient Transfusion Notification Form (Must use form RQHR 425 (10/99 Supplied by lab with 1 st transfusion during current admission) Appendix # 8 NOTE: For obtaining blood products for rural facilities: follow flow chart for receipt and transfusions of blood in rural facilities see Appendix 18 NURSING ALERT: Blood must only be warmed by an approved blood warming apparatus when ordered by a practitioner. Serious hemolysis may occur with over-enthusiastic warming. NEVER add or piggyback any medications to blood. Avoid simultaneous administration of blood products. Separate IV sites or CVAD lumens must be used if simultaneous administration is required in emergent situations. Caution when simultaneously administering medications linked to hypersensitive reactions via another line or CVAD lumen, since distinction between medication related symptoms and transfusion reactions may be difficult. PROCEDURE 1. Verify availability of product by checking Blood Bank Report or calling Transfusions Department. NOTE: If there is no Blood Bank Report on the chart, call Transfusions Department and they will print one immediately. It is not necessary to have Donor Unit # on Blood Bank Report. 2. Complete pink Request for Transfusion Service requisition including stamp with client s addressograph, requested blood product and TSIN number if applicable. 3. Present completed requisition to staff in Transfusion Department. NOTE: Any RQHR employee certified to transport blood and blood products may obtain product from Transfusion Department. Certification entails yearly completion of Portering Blood and Blood Products E-quiz. Volunteers are not regarded as employees of the RQHR. A blood receipt check is performed with lab personnel. Check Transfusion Record Tag against blood bag label for blood type, unit # and TSIN #. Any discrepancies are to be resolved before leaving the lab. It is not necessary to have Donor Unit # on Blood Bank Report. Approved: October 6, 2017 Page 4 of 38

5 4. Sign transfusion record tag in lab upon receipt of blood product. 5. Obtain a Notification of Transfusion Form (RQHR form 425 (10/99)) from Transfusions Department if first transfusion client has received on current admission. 6. Place Notification of Transfusion Form with discharge instructions. Ensure client signs and receives canary copy prior to discharge. C. Preparation and Verification of Blood Product EQUIPMENT 1. Documents (see APPENDICES for sample transfusion forms): Ordering of Red Blood Cells PPO #PP-601 ( if giving Red Blood Cells) Appendix #1 & 1a Transfusion Blood Bank Report (white, 8.5 x 11 sheet, computer generated, on chart) Appendix #7 Transfusion Record Tag (two part tag that comes with blood product pink on front, white on back) Appendix #9 Blood Bag Label (white label attached to blood bag Appendix #10 Autologous Blood Transfusion Tag (green, three part form: one part with unit of blood, one part given to client upon donation and one part kept with CBS) Appendix #11, 11b Canadian Blood Services (CBS) Autologous Transfusion Notification for Units Appendix #11a Directed Donation Blood Tag (same as autologous report except pink) Appendix #12 2. Blood Product to be transfused PROCEDURE 1. Inspect blood product for bubbles, clots, abnormal color or clouding, and port integrity. NOTE: If a problem is noted, call Transfusions Department. NURSING ALERT: All blood products must be CHECKED AT THE BEDSIDE BY TWO INDIVIDUALS from the following designations: o registered nurse (RN) o registered psychiatric nurse (RPN) o licensed practical nurse (LPN) o nurse practitioner (NP) o medical doctor (MD) o perfusionist o nursing student under supervision of instructor, RN/RPN/LPN A grad nurse (GN), Advanced Care Paramedic, or competent trained adult (for home infusion) may check blood only if checking with an RN/RPN/LPN. (See Policy #4.2.4 Administration of blood products, in the RQHR Policy Manual.) Approved: October 6, 2017 Page 5 of 38

6 2. Check expiry date of blood product to be administered (Appendix #10). 3. Verify at the bedside by two individuals, referring to RQHR policy 0612, the following: Client s name, hospital identification number (HIN / MRN #), TSIN # if applicable and date of birth on client identification band. Verbal validation by client/family if possible. ABO Group and Rh of client found only on Transfusion Record Tag and Blood Bank Report, not contained on blood bag itself. ABO Group, Rh OF DONOR and Donor unit # found on Blood Bag Label and Transfusion Record Tag. NOTE: The ABO Group and Rh of donor is usually the same as client s ABO Group and Rh. IF THERE IS ANY CONCERN, CALL TRANSFUSIONS DEPARTMENT. NOTE: The donor unit number will only appear on Blood Bank Report if client has been crossmatched it does not appear if clients have had type and screening done. Blood Bag Label does not have client s name or MRN / HIN on it. 4. Sign Transfusion Record Tag (both individuals). 5. Detach top pink portion of Transfusion Record Tag and affix to Blood Bank Report or addressographed Lab Reports Page (RQHR 312) in client chart using adhesive tab. White back portion of Transfusion Record Tag MUST remain attached to blood bag throughout entire transfusion process. NURSING ALERT: The verification check procedure must be done in full. Failure to verify both client s and blood unit s ABO, Rh, and donor unit # is a major cause of hemolytic transfusion reactions. In the event of a crisis situation for uncrossmatched units of blood, the client s ID bracelet shall be checked to verify name, and HIN / MRN # against uncrossmatched units of blood. D. Commencing Blood Product EQUIPMENT 1. Documents (see APPENDICES for sample transfusion forms): Blood Products Administration Chart Appendix #5 2. PPE 3. Blood Product 4. Alcohol swabs 5. N/S syringe 6. Pre-primed blood product administration set (see section A) 7. IV pump if required Approved: October 6, 2017 Page 6 of 38

7 PROCEDURE 1. Don PPE. 2. Connect blood product to appropriate blood administration set. NOTE: To Spike Fenwel bags (Appendix #16): 1. Separate port cover until port exposed. 2. Port covers that are not removable must be held away from the port to prevent contamination. 3. Hold the blood bag in one hand and exposed blood tubing spike in the other (Do not hang blood bag from IV pole). 4. Insert tubing spike into port while pushing gently and turning clock-wise with ¼ turns. DO NOT over spike or tubing will stick in blood bag. 3. Scrub Micro Clave adapter port for 15 seconds with alcohol swab. 4. Access IV adapter with N/S syringe, flush with 5 ml N/S. 5. Remove flush syringe. 6. Attach blood administration tubing to IV access. NOTE: Infuse or drain 15 ml of normal saline prime to ensure blood cells have reached the client prior to commencing infusion. 7. Commence infusion at 50 ml/hr. NOTE: For Cryoprecipitate infusion rate see Blood Products Administration Chart Appendix #5. NURSING ALERT: Severe transfusion reactions commonly occur within the first 15 minutes of exposure to blood and blood products. Common transfusion reactions are due to: a) blood group incompatibility b) bacterial contamination c) client allergy d) physiological reactions, i.e. febrile Transportation of a client should not occur during the first 15 minutes of transfusion, except in emergency situation. An RN, RPN, NP, LPN, MD or Paramedic MUST accompany clients on all transportation while blood product is infusing (i.e. tests/procedures, interfacility transfers etc.). 8. Obtain client s vital signs (T, HR, BP, R, SpO2) and assess for signs of a transfusion reaction after 15 minutes). Approved: October 6, 2017 Page 7 of 38

8 NURSING ALERT: With each unit of blood or blood product restart vital signs and follow rates. Decrease rate as per protocol. 9. Document: Date and time infusion commenced Donor unit number and type of blood product Infusion site Rate of infusion Vital Signs 10. Increase rate of infusion per practitioner s orders if there are no signs of transfusion reaction. NOTE: If no specific administration rate or time ordered by practitioner, refer to Blood Administration Chart. Appendix #5 NOTE: For neonatal and pediatrics, practitioner to determine volume of blood product per kg of recipient body weight. Follow practitioner order for administration. 11. Document rate change. 12. Obtain vital signs (T, HR, BP, R, SpO2) every hour, PRN and upon completion of transfusion and document accordingly. NOTE: All blood and blood products should be administered within 4 hours of issue from Transfusions Department. If at 4 hours transfusion is not complete, discontinue infusion and see discard instructions as per Section F. Filtered tubing should be changed after every 4 units of blood, every 4 hours or if occluded. E. Transfusion Reaction (Actual or Suspected) EQUIPMENT 1. Documents as required (see APPENDICES for sample transfusion forms): Saskatchewan Hospitals Transfusion Adverse Event Report Form Appendix #13, 13a Bedside transfusion reaction algorithm Appendix 4a gorithm.pdf 2. N/S IV Solution 3. IV tubing Plumset # Gravity # Approved: October 6, 2017 Page 8 of 38

9 4. Oxygen tubing and Oxygen as required 5. Transfusions Blood Bank Report Appendix #7 6. Plastic Blood Product bag NURSING ALERT: The following are common signs of a transfusion reaction: Early (first 1-2 hours): o Increased pulse o Hives or itching / allergic reaction o Temperature elevation >1 C o Hypo or hypertension o Chills o Dyspnea / hypoxemia Later symptoms of a severe reaction (up to 6 hours): o Bleeding from mucous membranes o Back pain PROCEDURE 1. STOP TRANSFUSION IMMEDIATELY if a transfusion reaction is suspected. Leave unit of blood and blood administration set intact until further instruction. 2. Keep IV open with N/S in a NEW PRIMARY LINE to ensure no further blood/blood product is administered. 3. Obtain vital signs (T, HR, BP, R, SpO2) and document in unit specific vital signs record. NURSING ALERT: Implement Code Blue and resuscitation for severe reactions as client symptoms indicate. 4. Apply supplemental oxygen if required. 5. Re-check client identification and blood product. 6. Notify Practitioner and Transfusion Department for further instruction. 7. Return residual blood product(s) and tubing in plastic bag (clamped and capped) to transfusion department if discontinued. 8. Complete Saskatchewan Hospitals Transfusion Adverse Event Report Form whenever client experiences a blood reaction or suspected reaction and document on health record. Approved: October 6, 2017 Page 9 of 38

10 F. Following Transfusion EQUIPMENT 1. Client information Appendix #15, 15a 15b CEAC 0235 Blood Transfusion Information, Inpatient CEAC 0689 Transfusion of Blood or Blood Products, Outpatient 2. Plastic Blood Product bag 3. Alcohol swabs 4. N/S syringe flush (5-20 ml) PROCEDURE 1. Close clamp on Blood bag side of administration set. 2. Open clamp on N/S side of administration set. 3. Flush administration tubing with N/S at current rate to clear remaining blood cells. NOTE: Flush tubing with N/S between consecutive units of blood if infusing multiple units of same products within 4 hour time limit. 2. Discontinue blood administration infusion set. 3. Scrub Micro Clave adapter port for 15 seconds with alcohol swab. 4. Access IV adapter with N/S syringe, flush using 5 ml or see CVAD procedure for flushing post blood products. 5. Remove flush syringe. 6. Remove spike from blood product bag using ¼ turn counter clockwise and discard tubing. NOTE: Plug open port of blood bag with sample tubing attached to bag (Appendix #11) to prevent any remaining blood from leaking out. Place each empty blood bag in a separate securely sealed plastic bag, with white tag hanging outside of plastic bag. See Appendix # Document completion of transfusion and volumes infused. 8. Provide CEAC documents as applicable. 9. Retain empty blood bag and white Transfusion Record Tag in designated area on ward for 12 hours post transfusion. See Appendix # Remove white Transfusion Record Tag from blood bag 12 hours post transfusion if no reaction. 11. Discard empty blood bag into appropriate container and send tag to Transfusion Department. Approved: October 6, 2017 Page 10 of 38

11 REFERENCES American Association of Blood Banks (2014). Technical Manual, 18 th Edition. Administration of Blood Components. Callum, JL., Pinkerton, Ph., & Lima, A.,(2016) Bloody Easy 4, Blood Transfusions, Blood Alternatives and Transfusions Reactions Canadian Blood Services ( ). Circular of Information: For The Use of Human Blood and Blood Components. Ottawa. Retrieved from Canadian Society for Transfusion Medicine Standards, Version 4. April Caple, C., Schub, T. & Pravidkoff, D. (2017) Blood transfusion: Administering Red Blood Cells in Adults. Retrieved from Nursing Reference Center %3d#AN=T706674&db=nup Infusion Therapy (2016) Standards of Practice from Art and Science of Infusion Nursing (online edition) Lima, A. (2014) Bloody Easy Blood Administration Version 2 Ontario Regional Blood Coordinating Network Regina Qu Appelle Health Region. Laboratory Services Manual and Test Compendium (2016). Saskatoon Health Region 2015 Blood, Blood components & Plasma Protien - Administration of. Policies and Procedures The Canadian Blood Services (2017) Clinical Guide to Transfusion (online edition) The Canadian Blood Services. Retrieved from: Revised by: Haley Mahnic, CNE 3D Date: April 2016 Revised by: Anita MacPherson and Lisa Roland CNE s, Paula VanVliet, Inter-regional Transfusions Safety Manager Date: September 2017 Approved by: Date: 6-Oct-17 Approved: October 6, 2017 Page 11 of 38

12 Appendix 1 PPO Addressograph Code: B.1 Revised: Sept 2014 Approved: October 6, 2017 Page 12 of 38

13 Appendix 1a PPO reverse side Code: B.1 Revised: Sept 2014 Approved: October 6, 2017 Page 13 of 38

14 Appendix 2 Consent Code: B.1 Revised: Sept 2014 Approved: October 6, 2017 Page 14 of 38

15 Appendix 2a Consent Reverse Side Code: B.1 Revised: Sept 2014 Approved: October 6, 2017 Page 15 of 38

16 TRANSFUSION SERVICES IDENTIFICATION NUMBER (TSIN) Appendix 3 TSIN Transfusion Services Identification Number (TSIN): MRN / HIN # is assigned only upon admission to hospital system. If clients have their cross match done as an outpatient, the TSIN is a unique number that maintains continuity of identification from time of collection. For outpatients and clients transferred between RQHR facilities the TSIN will be displayed as a number on the armband. TSIN s WILL NOT APPEAR FOR EVERY CLIENT. If the client is cross matched while they are an inpatient, they will not have a TSIN blood product armband. If the client may be transferred to another facility, ask the lab to put a TSIN blood product armband on the client at the time of cross match. The blood product armband must not be removed. If the armband is removed for any reason, the client must be re-cross matched. Code: B.1 Revised: Sept 2014 Approved: October 6, 2017 Page 16 of 38

17 Appendix 4 Checklist BLOOD AND BLOOD PRODUCTS ADMINISTRATION CHECKLIST **Refer to Applicable Nursing Procedures (B.1, B.1.1, B.1.2, B.1.3, B.1.6)** 1 Practitioner Order Verified Consent for Administration of Blood/Blood Products Signed Yes Proceed to #3 No Was the Practitioner notified to obtain 2 informed consent or have a Practitioner Order that states: Ok to proceed with transfusion without signed consent Patient Education Completed 3 Yes No Record reason in notes Patient Identity Confirmed (2 Client Identifiers) 4 ID band Verbal confirmation Crossmatch Results (Required for PRBC, Cryoprecipitate, Plasma, Platelets) 5 On chart Using uncrossmatched blood (practitioner s signature required) IV in place, IV Fluid 6 0.9% Sodium Chloride Baseline Vital Signs (T, P, R, B, SpO 7 2 ) Recorded within 30 minutes prior to initiation Premeds 8 Ordered Administered N/A 9 Visual Inspection/Expiry Acceptable (If not acceptable, return to Transfusions Department) Verbal Validation (Blood Unit Label, Blood Bank Report, Transfusion Record Tag & Patient Armband) - Done at bedside by 2 appropriate designates) Note: It is not necessary to have Donor Unit # on Blood Bank Report Name and Date of Birth MRN/HIN and/or Transfusion Services Identification Number (TSIN) 10 Client ABO and Rh (required for cellular products) Unit ABO and Rh (required for cellular products) Unit # (verify Transfusion Record Tag and Blood Unit Label) 2 signatures on tag Final Verification 11 Crossmatch tag verified with armband Documentation Transfusion initiated within 30 minutes of issue Vital Signs (T, P, R, BP SpO 2 ) 15 minutes 12 Every hour and PRN Upon completion Infused within 4 hours of issue Pink copy of transfusion record tag affixed on chart Transfusion Reaction (Algorithm Appendix 4a) Adverse Reaction Noted See Below No Adverse Reaction Transfusion stopped immediately IV patency maintained with compatible fluid 13 Practitioner notified Vitals signs taken every 15 minutes Client identification And blood product re-checked Transfusion Service/Lab notified SK Transfusion Adverse Event Report form completed Following Transfusion Retain empty blood bag and white Transfusion Record Tag in designated area on ward for 12 hours post transfusion. 14 Remove white Transfusion Record Tag from blood bag after 12 hours and send to Transfusions Department Discard empty blood bag after 12 hours into appropriate container Notification of Blood and Blood Products (RQHR #425) 15 On chart with discharge planning Approved: October 6, 2017 Page 17 of 38

18 Appendix 4a Appendix # 8 Saskatchewan Transfusion Resource Manual Version August 22, 2016 Approved: October 6, 2017 Page 18 of 38

19 Appendix 5 Blood Product Administration Chart Approved: October 6, 2017 Page 19 of 38

20 Request for Transfusion Services Requisition Appendix 6 Code: B.1 Revised: Sept 2014 Approved: October 6, 2017 Page 20 of 38

21 Blood Bank Report Appendix 7 Code: B.1 Revised: Sept 2014 Approved: October 6, 2017 Page 21 of 38

22 Appendix 8 Code: B.1 Revised: Sept 2014 Approved: October 6, 2017 Page 22 of 38

23 Appendix 9 Pink Transfusion Tag TRANSFUSION RECORD TAG Code: B.1 Revised: Sept 2014 Approved: October 6, 2017 Page 23 of 38

24 Appendix 10 SAMPLE BLOOD BAG WITH LABEL Code: B.1 Revised: Sept 2014 Approved: October 6, 2017 Page 24 of 38

25 Appendix 11 AUTOLOGOUS BLOOD DONATION Autologous Blood is blood donated by the client for use in his / her own surgery. The Canadian Blood Services (CBS) has a green three part tag for autologous blood donations (see next page). The top part of the tag is kept with the blood. The middle portion is given to the client. The bottom portion is on the transfer pack for the plasma. The Transfusion Department receives the blood just prior to the proposed surgery date. The blood bag will have the top portion of the green tag from the CBS as well as a Transfusion Record tag (see page 14). On admission, the client is to present their part of the green tag and a Notification from CBS to nursing personnel. When checking the blood, verify that the blood bag tag matches the bottom part of the tag provided by the client. The client s portion of the tag is to be stapled to the Notification from CBS and inserted under the Laboratory / Transfusions section on the client s chart. Clients who have provided an autologous blood donation must be provided with that donation if a transfusion is required. Failure to comply with the client s request may result in litigation. Accurate surgery date is imperative since autologous donations expire after 42 days. Procedure for accessing blood is the same as per homologous donation. Procedure for transfusing blood is the same as per homologous donation. Code: B.1 Revised: Sept 2014 Approved: October 6, 2017 Page 25 of 38

26 Appendix 11a Code: B.1 Revised: Sept 2014 Approved: October 6, 2017 Page 26 of 38

27 AUTOLOGOUS BLOOD DONATION TAG Appendix 11b Autologous Transfusion Tag (GREEN) Typenex Number Code: B.1 Revised: Sept 2014 Approved: October 6, 2017 Page 27 of 38

28 DIRECTED BLOOD DONATION Appendix 12 Directed Transfusion Tag (PINK) A Directed Blood Donation is blood donated by a parent for use by their child, 18 years or younger. Procedure is the same as for autologous donation except the three part blood tear-off tag is pink in color. Code: B.1 Revised: Sept 2017 Approved: October 6, 2017 Page 28 of 38

29 Appendix 13 Adverse Events Form Code: B.1 Revised: Sept 2014 Approved: October 6, 2017 Page 29 of 38

30 Appendix 13a Adverse Events Form Reverse Side Approved: October 6, 2017 Page 30 of 38

31 Appendix 14 Empty Blood Bag with Tag in Plastic Blood Bag for Safe Storage in Designated Area on Unit Code: B.1 Revised: Sept 2014 Approved: October 6, 2017 Page 31 of 38

32 Patient Information (CEAC) Appendix 15 Code: B.1 Revised: Sept 2014 Approved: October 6, 2017 Page 32 of 38

33 Appendix 15a Reverse Side Approved: October 6, 2017 Page 33 of 38

34 Appendix 15b Outpatient Transfusion Instructions Approved: October 6, 2017 Page 34 of 38

35 Appendix 16 Fenwel Bag Not Spiked Fenwel Bag Spiked Approved: October 6, 2017 Page 35 of 38

36 Appendix 17 Approved: October 6, 2017 Page 36 of 38

37 Appendix 17a Approved: October 6, 2017 Page 37 of 38

38 Appendix 18 FLOWCHART FOR RECEIPT AND TRANSFUSION OF BLOOD IN RURAL FACILITIES: Blood Product sent in Transport boxes 1 unit/box and each box will contain all information Each box has the following: 1. Tamper-proof tie (example 1) 2. Human Blood For Transfusion card (example 2) 3. Envelope with issue voucher (example 3) Yes Upon receipt of storage box(es) 1. Tamper-proof tie intact? 2. Human Blood for Transfusion card shipping/storage time is valid? No Open Envelope with Issue Voucher 1. Acknowledge on issue voucher that Tamper-proof tie on shipping container intact. Do Not Transfuse Contact Transfusions RGH Immediately Yes Ready to transfuse patient? No Open Storage box (1 at a time when transfusion ready to start) 1. Record on Issue Voucher Visual Inspection 2. Inside storage box Patient s report (example 4) and Notification of Administration of Blood and Blood Products form (example 5) 3. Place report on patient chart 4. Follow instructions for transfusing in RQHR nursing procedure 5. Prior to starting transfusion, perform visual inspection and record on RQHR Blood/Blood Product issue voucher 6. Following patient identification at bedside by two individuals as outlined in nursing procedure, sign Transfusions record tag (both individuals checking blood products must sign tag.) (example 6) 7. Remove pink portion of Transfusion Record tag and apply to patient s chart 8. Complete documentation required in nursing procedure and complete RQHR Blood/Blood Product s issue voucher Leave sealed storage box at Room Temperature until ready to transfuse up to time valid on Human Blood for Transfusion Card Transfuse Patient using RQHR nursing procedure B.1 Following transfusion of each unit of blood, follow steps listed in Nursing Section of RQHR Blood issue Voucher for Rural Facilities Approved: October 6, 2017 Page 38 of 38