Policy for the authorising of blood components by the Haematology Clinical Nurse Specialist V1.0 January 2016
Summary. This policy applies only to selected staff within the Haematology Department at the Royal Cornwall Hospital Trust and to Haematology Nurse Specialists as identified by the Lead Haematology Consultant. All training, education and governance procedures contained within the Blood Transfusion Policy must be adhered to. The Consultant Haematologist (MRC Path Haematology or equivalent): o is responsible for monitoring the patient s progress o is responsible for drawing up a clear plan of treatment for patients requiring transfusion of red cells or platelets. o will act as mentor and assessor and must be up-to-date with mandatory transfusion training. The nurse authoriser o will approach a consultant Haematologist (with responsibility for Transfusion on HTT) as a mentor and assessor. o will be responsible for gaining adequate knowledge and experience prior to assessment and must be up-to-date with mandatory transfusion training. o will demonstrate competence during a period of supervised practice and signed off by the responsible consultant o must attend NHSBT approved training Non-Medical Authorisation of Blood components, to be able to apply for the training they must have at least 3 years experience relevant to transfusion, and approval and support from the Lead Consultant Haematologist Patients must have a Haematology diagnosis Page 2 of 10
Table of Contents Summary.... 2 1. Introduction... 4 2. Purpose of this Policy/Procedure... 4 3. Scope... 4 4. Ownership and Responsibilities... 4 4.1. Role of the Hospital Transfusion Committee (HTC)... 4 4.2. Role of Individual Staff... 5 5. Standards and Practice... 5 5.1. Training... 5 5.2. Patient Selection... 5 6. Dissemination and Implementation... 6 7. Monitoring compliance and effectiveness... 6 8. Updating and Review... 6 9. Equality and Diversity... 6 9.2. Equality Impact Assessment... 6 Appendix 1. Governance Information... 7 Appendix 2. Initial Equality Impact Assessment Form... 9 Page 3 of 10
1. Introduction 1.1. A collaborative project was undertaken by NHS Blood and Transplant and the Scottish National Blood Transfusion Service to investigate the prescribing or more properly the authorisation of blood transfusions by nurses and midwives. Section 130 of the 1968 Medicines Act has been amended by Section 25 of the Blood Safety and Quality Regulations 2005 (SI2005 no 50). In effect this means that Blood and Blood Components (Red Cells, Platelets, Fresh Frozen Plasma and Cryoprecipitate) are excluded from a legal definition of medicinal products and therefore cannot be prescribed by any practitioner. There is therefore no legal barrier to nurses authorising a blood transfusion. Following wide consultation, a Governance Framework was developed to support this role development. 2. Purpose of this Policy/Procedure 2.1. In responding to the changing needs of patients and clinical practice, some senior and experienced nurses have been considered in authorising blood transfusions. 2.2. It is expected that the patient will benefit due to: 2.2.1. A reduced delay in the decision to transfuse 2.2.2. A reduced delay in authorising the transfusion 2.2.3. The decision to transfuse will be made by an experienced nurse who has an in-depth knowledge of the patients undergoing regular transfusion 2.3. This policy establishes the criteria and assessment framework required for the authorisation of red cells and platelets by nurse authorisers. 3. Scope 3.1. This policy applies only to selected staff within the Haematology Department at the Royal Cornwall Hospital Trust and to Haematology Nurse Specialists as identified by the Lead Haematology Consultant. 3.2. This policy supplements the RCHT Blood Transfusion Policy. All training, education and governance procedures contained within the Blood Transfusion Policy must be adhered to. 4. Ownership and Responsibilities 4.1. Role of the Hospital Transfusion Committee (HTC) 4.1.1. This policy will be ratified by the HTC. 4.1.2. HTC will be responsible for monitoring any recommendations arising from reviews of practice / audit reports and these will be documented within the minutes of the meeting. Page 4 of 10
4.2. Role of Individual Staff 4.2.1. Consultant haematologist: The Consultant Haematologist is responsible for monitoring the patient s progress. The Consultant Haematologist is responsible for drawing up a clear plan of treatment for patients requiring transfusion of red cells or platelets. The Consultant Haematologist (MRC Path Haematology or equivalent) will act as mentor and assessor, and must be up-todate with mandatory transfusion training. 4.2.2. Nurse Authoriser: The nurse authoriser will approach a consultant Haematologist (with responsibility for Transfusion on HTT) as a mentor and assessor. The nurse authoriser will be responsible for gaining adequate knowledge and experience prior to assessment and must be up-todate with mandatory transfusion training. The nurse authoriser will demonstrate competence during a period of supervised practice and signed off by the responsible consultant. 5. Standards and Practice 5.1. Training 5.1.1. The nurse authoriser must attend NHSBT approved training Non- Medical Authorisation of Blood components, to be able to apply for the training they must have at least 3 years experience relevant to transfusion, and approval and support from the Lead Consultant Haematologist. 5.1.2. The training will include: Overview of blood components Transfusion reactions Significance of antibodies and appropriate blood selection BCSH administration guidelines, documentation and reporting of incidents Legal requirements Appropriateness, indications for transfusion and Hb triggers. Scenarios 5.2. Patient Selection 5.2.1. Patients must have a Haematology diagnosis 5.2.2. Transfusion must be indicated as per the Blood Transfusion Policy Page 5 of 10
6. Dissemination and Implementation 6.1. All relevant clinicians and lab staff will be informed of enhanced role and policy changes. 6.2. Not relevant to other staff. All training identified above. 7. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Incidents or adverse events involving blood transfusion are reported and monitored through Datix. Prescribing/authorising practice with regard to compliance to the policy will be monitored. Haem consultant and Haematology Transfusion Team (HTT) The Datix reporting system will be used to monitor incidents. There is currently no tool to monitor compliance. When appropriate data can be collected via NCA AFFINITE Monitoring will be ongoing through existing governance strategies in the haematology laboratory. There will be a review of practice at 6 and 12 months, an audit will be completed and report produced two yearly thereafter. The report will be presented to the HTC/HTT. HTC/HTT will be responsible for making any recommendations, these will be documented within the minutes of the meeting. HTC/HTT will be responsible for making any recommendations, these will be documented within the minutes of the meeting. Required changes to practice will be agreed by HTC/HTT and Haematology CNS. All relevant clinicians, lab staff and nursing staff will be informed either by email or at staff meetings. 8. Updating and Review 8.1. This policy will be updated at least every 3 years. 8.2. Any amendments or working changes will be assessed and agreed by the Haematology Transfusion Team. 9. Equality and Diversity 9.1. 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. 9.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 6 of 10
Appendix 1. Governance Information Document Title Date Issued/Approved: January 2016 Date Valid From: January 2016 Date Valid To: January 2019 Policy for the authorising of blood components by the Haematology Clinical Nurse Specialist Directorate / Department responsible (author/owner): Caroline Edwards, Haematology CNS, CSSC Contact details: 01872 253239 Brief summary of contents Suggested Keywords: Target Audience Executive Director responsible for Policy: Date revised: This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Name and Post Title of additional signatories Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Details training needs, patient group within which the haematology CNS can prescribe blood components. Blood, transfusion, nurse authorisation RCHT PCH CFT KCCG Medical Director N/A N/A Haematology Transfusion Team Hospital Transfusion Committee CSSC Divisional Governance Board Sally Kennedy, Divisional Director CSSC Not required {Original Copy Signed} Name: Janet Gardner, Governance Lead CSSC {Original Copy Signed} Internet & Intranet Intranet Only Clinical / Haematology Page 7 of 10
Links to key external standards Related Documents: Training Need Identified? Section 130 of the 1968 Medicines Act as amended by Section 25 of the Blood Safety and Quality Regulations 2005 (SI2005 no 50). RCHT Blood transfusion Policy No Version Control Table Date Version No Summary of Changes Changes Made by (Name and Job Title) Jan 2016 V1.0 Initial Issue Caroline Edwards, Haematology CNS 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 expiry. 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 express permission of the author or their Line Manager. Page 8 of 10
Appendix 2. Initial Equality Impact Assessment Form Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): Policy for the authorising of blood components by the Haematology Clinical Nurse Specialist Directorate and service area: Is this a new or existing Policy? Clinical Haematology New Name of individual completing Telephone: assessment: Caroline Edwards 1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at? 01872 253239 To provide a structure within which the Haematology CNS can prescribe blood components. 2. Policy Objectives* To ensure safe practice. 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? Safe, evidence based prescribing/authorisation of blood components. Audit of compliance to policy. Haematology patients. No 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 / Existing Evidence Age Page 9 of 10
Sex (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 Sexual Orientation, Bisexual, Gay, heterosexual, 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 excludes 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. Yes No 9. If you are not recommending a Full Impact assessment please explain why. No potential for differential impact identified Signature of policy developer / lead manager / director Date of completion and submission Names and signatures of members carrying out the Screening Assessment 1. Caroline Edwards 2. 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 Date Page 10 of 10