SARASOTA MEMORIAL HEALTH CARE SYSTEM CORPORATE POLICY TITLE: ADMINISTRATION OF BLOOD AND EFFECTIVE DATE: REVIEWED/REVISED DATE: POLICY TYPE: 10/15/79 08/31/17 Clinical 1 of 7 Non-Clinical Job Title of Responsible Owner: Medical Director, Laboratory and Pathology Services PURPOSE: POLICY STATEMENT: EXCEPTIONS: DEFINITIONS: To establish guidelines for the administration of blood and blood components in areas authorized to do so. All registered nurses (RNs) who have successfully completed the Sarasota Memorial Health Care System (SMHCS) Orientation Program may administer blood and blood components. In addition, certified clinical perfusionists (CCP) and certified registered nurse anesthetists (CRNA) who have successfully completed the Perioperative Services orientation program may administer blood and blood components. Anesthesiologists (MDs/DOs) will have access to current SMHCS policies and procedures related to blood and blood administration, and are responsible for their own and their employees compliance. All licensed practical nurse IIs (LPN IIs) who have completed the blood and blood product class may administer blood and blood components via a peripheral and central line site. None None PROCEDURE: 1. SUPERVISION Transfusion must be prescribed and administered under medical direction. The patient must be observed during the transfusion and for an appropriate time thereafter for suspected adverse reactions. At SMHCS refer to Nursing Procedures (blo03, blo08, blo09) for time frames. If appropriate, subsidiaries will follow specific procedures. All transfusions shall be given in accordance with policies in the American Association of Blood Bank s Standards for Blood Banks and Transfusion Services and the policies and procedures of SMHCS. Specific instructions concerning possible adverse reactions must be provided
2 of 7 to the patient or a responsible caregiver when direct medical observation or monitoring of the patient will not be available after transfusion. (Refer to blo03 Reactions to Blood/Blood Components.) a. There shall be a system in place to ensure that physician s orders have been followed. b. At the patient s chart and prior to the administration of the blood or blood product, the RN, LPN II, CRNA, or CCP shall verify the product name with the physician s orders and charted crossmatch report. c. Personnel responsible for care of a patient receiving transfusion shall be appropriately trained in the recognition and treatment of adverse reactions. d. Personnel suspecting an adverse reaction to blood or a blood product shall discontinue the transfusion and maintain the intravenous line with normal saline. Personnel shall report any such suspected reactions to the patient s physician, obtain appropriate orders, and notify the Blood Bank immediately. 2. IDENTIFICATION There shall be positive identification of the recipient and the blood container. a. For crossmatched products, at the patient s chart and prior to administration of the blood or blood product, the RN, LPN II or CCP shall verify the product name with physician s order and the product unit number, product name and blood type with the charted crossmatch report (Refer to blo03 for specifics). b. Immediately before transfusion, and in the presence of the recipient, two approved staff (RN, LPN II, CCP, CRNA, MD/DO), one of whom is an RN, shall verify and document that all information identifying the container with the intended recipient has been matched, item by item. c. Immediately before transfusion, and in the presence of the recipient, two approved staff (RN, LPN II, CCP, CRNA, MD/DO) one of whom is an RN, shall verify and document that the unique ID number found on the blood armband the patient is wearing matches to the blood bag tag (SMH Policy 01.PAT.67, Blood Bank Identification Bands).
3 of 7 d. All identification attached to the container shall remain attached at least until the transfusion has been terminated. 3. GENERAL CONDITIONS OF TRANSFUSION Blood and components shall be maintained in a controlled environment at the designated temperature until released for transfusion. Blood and components must be transfused through a sterile, pyrogen-free transfusion set that has a filter designed to retain particles potentially harmful to the recipient. a. TRANSFUSION PROTOCOL - There shall be a written protocol for the administration of blood and blood components and the use of infusion devices and ancillary equipment. b. WARMING - Blood and blood components are generally not warmed prior to transfusion, but, when necessary, this should be accomplished during its passage through the transfusion set. (Refer to blo05-blood IV fluids warmer policy). The warming system must be equipped with a visible thermometer and, ideally, with an audible warning system. Blood must not be warmed above 37C. 1) Conditions that might require blood warming toward body temperature include massive, rapid transfusion; hypothermia; exchange transfusion of a newborn; or a patient with potent cold agglutinins. c. ADDITION OF DRUGS AND SOLUTIONS - Drugs or medications, including those intended for intravenous use, shall not be added to blood or components, nor administered via the same tubing through which blood components are infusing. 1) 0.9% sodium chloride, injection, USP, may be added to blood or components and shall be the flush solution when a flush solution is required for administration. 2) Other solutions intended for intravenous use may be used in an administration set or added to blood or components under either of the following conditions: a) They have been specifically approved for this use by the FDA.
4 of 7 b) There is documentation available to show that addition to the component involved is safe and efficacious. Normosol-R, ph 7.4 meets these requirements and is acceptable for use. NOTE: Lactated Ringers Injection USP, 5% Dextrose and Hypotonic Sodium Chloride solutions, as well as many other solutions and medications, shall NOT be used since they do NOT meet the requirements of Procedure #3.6.a. or b. above. 4. AUTOLOGOUS AND/OR DESIGNATED PRODUCTS There shall be policies and procedures in place to ensure that patients who have autologous or designated blood units set aside for them are given these units before allogeneic (regular Blood Bank inventory) units are given. a. Autologous units shall be selected and infused first. b. Designated units shall be selected and infused second. c. Allogeneic units shall be selected and infused last. 5. URGENT REQUIREMENT FOR BLOOD There shall be procedures for obtaining and administering blood and blood components in an emergency situation. a. In an emergency situation where delay in receiving blood components may jeopardize the patient s life, the physician must weigh the risk for transfusing uncrossmatched or incompletely crossmatched blood against the hazard of waiting for completed compatibility tests. In emergency situations, Group O red cells will be available from the Blood Bank on request. b. When uncrossmatched blood is released, a crossmatch shall be performed after receipt of a patient specimen in the Blood Bank. The physician shall be notified immediately of any incompatibilities. c. In an emergency, crossmatched blood will generally be available within 30-40 minutes of receipt of a patient specimen in the Blood Bank. d. Established nursing procedures for the administration of blood and blood components shall be followed. 6. SPECIAL CONSIDERATIONS FOR ADMINISTRATION
5 of 7 OF BLOOD There is a marked increase in the danger of bacterial proliferation and red blood cell hemolysis of the blood unit if the transfusion extends longer than four hours per unit. The administration of blood components should begin within thirty (30) minutes after the product is removed from the Blood Bank. If it is not, it must be returned to the Blood Bank to be discarded. a. Blood components should be requested one at a time unless specifically ordered otherwise by the physician. b. Patient vital signs and patency of the intravenous access should be assessed prior to requesting the blood components. c. Blood and blood components must be infused per procedural guidelines and patient tolerance. d. Blood must be infused within four (4) hours. e. If for any reason it is suspected that the infusion of RBCs cannot be completed in the four (4) hour time limit, blood may be ordered in two (2) smaller units. Enter the request into the comment field of the blood requisition. The four (4) hour time limit will apply to the smaller unit sent. f. Specific situations may permit blood storage in a specifically designated, temperature-monitored Blood Bank refrigerator located in the Operating Room, Surgery Core, 4 EB, 5 EB, OR 22, 4 th floor Courtyard, 4 th floor OR. Red blood cells must not be allowed to cool below 1C or warm above 10C during transportation. 7. BLOOD OR BLOOD COMPONENT LOOKBACK Potentially HIV or HCV infectious blood and blood components are prior collections from a donor who tested negative at the time of donation but tests repeatedly reactive for the antibody to HIV or HCV on a later donation (window period of infectivity). a. Sarasota Memorial Health Care System has contracted with Suncoast Communities Blood Bank for transfusion services. Article 6.8 of that contract stipulates that Suncoast Communities Blood Bank will provide Look-back services for Sarasota
6 of 7 Memorial Health Care System as required by the Federal Department of Health and Human Resources and 42 CFR Section 482.27. RESPONSIBILITY: REFERENCES: Directors of patient care areas will be responsible for ensuring that nursing personnel are aware and adhere to the provisions of this policy. American Association of Blood Banks, American Red Cross, the Americas Blood Centers. (Current Edition). Circular of information for the use of human blood and blood components. Arlington, VA: Author. Sarasota Memorial Heath Care System Policy. (2012) Blood Bank Identification Bands (01.PAT.67), SMH : Author Standards Committee for the American Association of Blood Banks, (Current Edition). Standards for Blood Banks and Transfusion Services. Bethesda, MD Author. U.S. Dept. of Health & Human Services. NH Publication Number 90-2668. (1990). Transfusion therapy guidelines for nurses. Washington, DC: Author. Suncoast Communities Blood Bank: Quality Assurance: Quarantine and Lookback, A0190, Rev. 09/14 AUTHOR(S): ATTACHMENT(S): Sue Key, MT (ASCP) SBB, Administrative Director of Laboratory Services of Suncoast Communities Blood Bank, Inc. Thomas J. Reed, MD, Medical Director, Laboratory and Pathology Services Jeffrey Zacks, M.D, Medical Director, North Port Laboratory Harold Vore, Administrative Director, Laboratory Services Maribeth Desiongco, Clinical Educator None
7 of 7 APPROVALS: Signatures indicate approval of the new or reviewed/revised policy. Committees/Sections/Departments: N/A Date Director Laboratory Services, Suncoast Community Blood Bank Medical Director, North Port Laboratory Services Medical Director, SMH Laboratory Services Director/Responsible Owner: Chief of Nursing (if clinical policy or appropriate) Vice President/Executive Director: Chief of Medical Operations: (if clinical policy or appropriate) Chief of Staff: (if clinical policy or appropriate) Medical Executive Committee: (if clinical and review requested by CMO and COS) Sue Key 7-18-17 Dr. Jeffrey Zacks, M.D. 7-11-17 Dr. Thomas Reed, M.D. 7-11-17 Harold Vore 7-12-17 Connie Anderson 7-29-17 Lorrie Liang 7-24-17 Steve Taylor, M.D. 7-24-17 N/A N/A Chief Executive Officer: David Verinder, CEO 8-14-17