Blood Transfusion Policy. (St John s Hospice)

Blood Transfusion Policy (St John s Hospice) DOCUMENT CONTROL: Version: 3 Ratified by: Quality Assurance Sub-Committee Date ratified: 6 December 2017 Name of originator/author: Macmillan Specialist Palliative Care Nurse Name of responsible Consultant Clinical Quality Group committee/individual: Date issued: 9 March 2018 Review date: December 2020 Target Audience All staff within St John s Hospice involved in the transfusion process

Section CONTENTS Page No. 1. INTRODUCTION 4 1.1 Relevant Contacts 4 2. PURPOSE 5 3. SCOPE 5 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 5 4.1 Chief Executive 5 4.2 Medical Staff 5 4.3 Area Clinical Manager, Clinical Lead and Clinical Manager 5 4.4 All Staff 6 5. PROCEDURE/IMPLEMENTATION 6 5.1 Consent 6 5.2 Prescribing Blood Products 7 5.3 Requesting Blood Products 7 5.4 Positive Identification of Patients 7 5.5 Venepuncture 8 5.6 Collection of Blood Products 9 5.7 Receipt of Blood Products on the Ward 9 5.8 Returning Blood Products to Blood Bank 10 5.9 Administration of Blood Products 10 5.9.1 Key Points 10 5.9.2 Staff Responsible 10 5.9.3 Receipt of blood products in the clinical area 10 5.9.4 Inspection of Blood or Blood Products 11 5.9.5 Responsibility for the identify check of the patient and the blood product the final bedside check 5.9.6 Traceability 12 5.9.7 Spillage 12 5.10 Technical Aspects of the Administration of Blood Products 12 5.10.1 Giving Sets 12 5.10.2 Red Cells 13 5.10.3 Platelets 13 5.10.4 Cannula 13 5.10.5 Drugs 13 5.10.6 Disposal of Blood Bags 13 5.11 Care and Monitoring of Patients 14 5.11.1 Key Points 14 11 Page 2 of 22

5.11.2 Staff Responsibility 14 5.11.3 Observation of the Patient 14 5.11.4 Completion of Transfusion Episode 15 5.12 Reporting of Adverse Events/Reactions following or during Transfusion 5.12.1 Staff Responsible for Reporting Adverse Events/Reactions 15 5.12.2 Initial Clinical Assessment 16 5.12.3 Investigation of a Suspected Transfusion Reaction 17 5.12.4 Documentation of Adverse Events/Reactions 18 5.13 Document of Transfusions 18 5.13.1 Documentation in the Patient s Notes 18 5.13.2 Documentation to be returned to Blood Bank 19 5.14 Jehovah s Witness Policy and Patient or Family Refusal of Blood Transfusion Policy 5.14.1 Jehovah s Witnesses Hospital Liaison Team 19 6. TRAINING IMPLICATIONS 20 7. MONITORING ARRANGEMENTS 20 8. EQUALITY IMPACT ASSESSMENT SCREENING 21 8.1 Privacy, Dignity and Respect 21 8.2 Mental Capacity Act 21 9. LINKS TO ANY ASSOCIATED DOCUMENTS 22 10. REFERENCES 22 11. APPENDICES (None) - 15 19 Page 3 of 22

1. INTRODUCTION This policy is adapted from the Doncaster and Bassetlaw NHS Foundation Trust s (DBHFT) policy (2014) for Blood Transfusions, as DBHFT are our blood product provider. The transfusion of blood and blood components is a potentially dangerous treatment. It involves a complex sequence of events to ensure that the right patient receives the right blood and strict procedures need to be in place, with checks at each stage (National Patient Safety Agency, 2006). Errors in the requesting, supply and administration of blood leads to significant risks to patients. Errors either in the collection or labeling of the sample for blood grouping and compatibility testing, or in the laboratory, or the failure of the final pre-transfusion checks account for a number of patient deaths in the UK each year. The incidence of wrong blood episodes has changed little over several decades. Variation in the practice of the administration of blood is becoming increasingly evident from audit, both local and national, and from the Serious Hazards of Transfusion (SHOT) reports. Consequently the Trust is committed to the use of competency assessment of all staff involved in the transfusion process and is committed to the actions set by National Patient Safety Agency (NPSA) Safety notice 14 (Right patient, Right blood). Blood transfusions in palliative care are not given routinely, but to treat problematic symptoms of anaemia, the cause of which in palliative patients is often multifactorial. Symptom burden to the patient, such as weakness, fatigue and breathlessness and likely benefit of the transfusion are important when deciding whether to transfuse or not (Waddell et al 2011). According to a recent Cochrane review (Preston et al 2012) a third of patients with advance cancer do not benefit from blood transfusions and the duration is often short for those who do. In fact there is the potential for harm to patients at the end of life due to fluid overload. Therefore decision to transfuse must be undertaken responsibly and on an individual basis. This policy is based on recognised guidelines and provides the Trust with local procedures for the ordering and administration of blood products and the management of transfused patients. 1.1 RELEVANT CONTACTS Blood Bank: Doncaster Royal Infirmary (DRI) Tel: (01302) 366666 Contact via DRI switchboard The Hospital Transfusion Team: Contact via DRI switchboard Consultant Haematologist: Contact via DRI switchboard Page 4 of 22

2. PURPOSE The purpose of this policy is to provide guidance, minimize risk and set out organizational arrangements for implementing best practice in relation to blood transfusions within the hospice setting. It sets out the procedures to which staff should adhere when requesting and administering a blood transfusion to patients. 3. SCOPE The policy applies to all staff within St John s Hospice involved in the process of blood transfusion, which includes prescribing, obtaining blood samples, collection, administering or returning blood. Other RDASH inpatient settings are not included in this policy as they do not administer blood transfusions 4. RESPONSILIBITIES, ACCOUNTABILITIES AND DUTIES 4.1 Chief Executive The Chief Executive has overall responsibility for ensuring the Trust meets its statutory and non-statutory obligations in respect of maintaining appropriate standards contained in this policy. 4.2 Medical Staff Medical staff are responsible for prescribing blood and blood products appropriate to the need of the patient and obtaining and administering consent. Medical staff must keep up to date with training regarding blood transfusions. 4.3 Area Clinical Manager, Clinical Lead and Clinical Manager It is the responsibility of the senior team to implement this policy and assist in the monitoring and compliance with the standards contained in this policy. Also to: Provide evidence that clinical staff can demonstrate competency and compliance with the content of this policy. Keep accurate, up-to-date training records of staff Blood Transfusion training. Clinical Lead, Clinical Manager and Ward Sister will attend additional training at DBHFT regarding blood transfusions in order to practically assess the inpatient Unit (IPU) nurses. Ensure any incidents involving the use of blood and blood products is reported using the Incident Reporting processes (Safeguard IR1) and investigated appropriately Page 5 of 22

4.4 All Staff It is the responsibility of all Registered Nurses and staff involved with the transfusion process to: Comply with the requirements of this policy regarding patient identification, which is essential for safe transfusion practice. Maintain accurate records and complete documentation required for audit trail of the transfusion. Monitor the patients and comply with the policy, reporting any suspected transfusion reactions to a member of the medical staff. The responsible Trust committee is the Clinical Quality Group, which is a sub-group of the Quality Assurance Sub Committee. 5. PROCEDURE/IMPLEMENTATION Blood Transfusions should only be in usual hospice working hours (Monday to Friday 9-5) and when a doctor is on site. Blood transfusions are not to be administered out of hours or at weekend. 5.1 Consent Patients have the right to know about the treatment being offered and the available alternatives. This should be done in a timely and understandable manner. It is essential to adhere to the Trust Policy for Consent to Examination or Treatment. Patients must be given information regarding the risks/benefits and alternatives, including the option of no transfusion. This is the responsibility of a doctor; however, signed consent is not required. It is helpful to provide patients with an information sheet outlining the risks and benefits of blood transfusion. For example, the National Blood Service has produced a number of patient information leaflets; these are available to print off, as required, from www.nhsbt.nhs.uk (download Do I need a blood transfusion? Staff will ensure information about risks/benefits and alternatives to blood transfusion are provided in a format to meet the person s individual requirements. Information sheets available from the Nation Blood Service on line to print off when needed. If a patient declines a transfusion the doctor in charge of the patient should be informed and any product on the ward immediately returned to the blood bank. The following information will be documented in the case notes using blood Page 6 of 22

prescription sheet WPR26562. The discussion with the patient (details of the information provided to the patient) Reason for transfusion (clinical and laboratory data) The administration of the transfusion and any complications The clinical outcome Consent to proceed 5.2 Prescribing Blood Products Blood can only be prescribed by a doctor All staff prescribing must be aware of the risks/benefits of transfusion Training all doctors prescribing blood products must have the appropriate training/competencies completed as identified by the NPSA and follow both local and national guidelines. The prescription for blood and blood products must be signed and dated by a doctor on the appropriate blood prescription form (WPR26562). It is essential that the prescription sheet contains the patient identification details surname, first name, date of birth, patient NHS number. The prescription must specify: Consent obtained What components are to be transfused? Date of transfusion. The volume/number of units to be transfused. The rate of transfusion for red cells is usually 1.5-2 hours Transfusion must be completed within 4 hours of removal from the authorised blood product transit box. Any other special instructions or requirements, e.g. Irradiated, CMV seronegative. Blood bank must be made aware of any special requirements. Requirement for any concomitant drugs. 5.3 Requesting Blood Products Blood can only be requested by a doctor or authorised non-medical staff, e.g. midwife or nurse with the appropriate training/competencies completed. All telephone requests must be followed by a written request form. Failure to do so will result in a delay in blood product provision. 5.4 Positive Identification of Patients Positive identification of the patient is essential and is based on: Page 7 of 22

Direct questioning of the patient by asking them to state their surname, first name and date of birth. This must always be done where the patient is judged capable of giving an accurate, reliable response. Staff should never lead the patient; the answer yes is not sufficient identification. Checking the details on the patient s identification wristband m a t c h those on the request form. (All inpatients and all patients undergoing a transfusion must have an ID band). All patients must have a patient identification number and an ID wristband with this number. When additional details become available the Blood Bank must be informed, but details must not be changed mid-incident. No wristband no transfusion. Positive identification of the patient must occur prior to: 5.5 Venepuncture Transfusion of blood and blood products Venepuncture Samples to be taken by a member of staff with a valid competency in venepuncture. All patients being sampled must be positively identified. Sample tubes should not be pre-labeled. The collection of the blood sample from the patient into the sample tubes and the sample labeling should be performed as one continuous uninterrupted event, involving one patient and one trained and competent healthcare worker only, samples to be labeled at the bedside using information taken from the patient s ID wristband. The Request Form: The request form must be completed in full (addressograph labels may be used) and include: Full name surname and forename. NHS number to be used. Hospital numbers from other hospitals are not accepted. Date of birth. Patient s location. Consultant. Number and type of blood products required. Date and time required. Patient s diagnosis/clinical details. Reason for the request (clinical indication) including most recent haemoglobin and/or platelet count if applicable, include date tested. Any special requirements (e.g. Irradiated, CMV negative). Date and time bled. Page 8 of 22

Gender. Requestor s name and signature. The request form should be signed by the person drawing the sample. Date of last transfusion. Any known antibodies. If pregnant within the last 6 months and RhD negative, please state the dates and doses of any prophylactic Anti-D immunoglobulin administered during this pregnancy. The Sample: Addressograph labels must not be used. The patient must be positively identified at the time a sample is taken. The sample tube must be labeled immediately after the blood has been taken (at the patient s bedside); sample tubes must not be pre-labeled. The sample tube must be labeled with the following: Full name surname and forename. NHS number hospital numbers from other hospitals are not acceptable. Date of birth. Gender. Signature of personal taking the blood sample. Ward or Clinical area. Date sample taken. Time sample taken. 5.6 Collection of Blood Products Good documentation of the blood audit trail is mandatory and a legal requirement Before collection, ensure the patient is ready to start the transfusion, baseline observations taken and has patent venous access. Ward staff arrange for blood products to be collected from the Blood Bank at Doncaster Royal Infirmary using RDaSH transport shuttle or approved taxi. Ward staff to contact a member of staff at the Blood Bank and advise transport arranged to collect blood product, ensuring appropriate clinical information is available relating to patient s name, NHS number and product requested. 5.7 Receipt of Blood Products on the Ward On arrival to the ward the blood must be immediately handed to the person responsible for administering the transfusion and not left in the nurses office or treatment room. Page 9 of 22

Blood should arrive in a validated cool storage box, this box must be sealed. The blood may remain in the validated cool storage box for no more than 2 hours. Once the validated cool storage box is opened the blood transfusion must be started within 30 minutes and transfused within 4 hours of removal from the validated cool storage box. NB Blood must not be stored in the ward drug or domestic fridges. 5.8 Returning Blood Products to Blood Bank Blood and blood products should be transfused as soon as possible after delivery to the inpatient unit (see section 5.7), i.e. within 30 minutes of removal from the validated cool storage box. If after collection of the blood a problem arises which prevents immediate transfusion, the unit must be returned to the Blood Bank within 2 hours of collection and the Blood Bank staff informed (if in a validated cool storage box). 5.9 Administration of Blood Products 5.9.1 Key Points Final check must be conducted next to the patient by a trained and competent licensed healthcare professional who also administers the component including: All patients receiving a transfusion must be positively identified. All patient core identifiers on the patient s identification wristband must match the details on the blood component label. All blood components should be administered using a blood administration set with integral mesh filter. Transfusion should be completed within 4 hours of leaving temperature controlled storage box. 5.9.2 Staff Responsible Blood components are excluded from the current legal definition of medicinal products and the requirement for prescription by a registered medical practitioner, but are viewed as medicines for administration purposes. Blood components should only be administered by a licensed professional such as doctor (GMC registered), or a nurse holding current registration of the NMC Professional Register as a Registered General Nurse (RGN), who have had training in administering blood transfusions. 5.9.3 Receipt of blood products in the clinical area. The blood group and unit number of the blood product must be identical to that described on the attached blood tag label. The blood or blood component must be checked for compliance with any special requirements as specified on the prescription sheet, e.g. Page 10 of 22

Irradiated, CMV negative. The blood or blood component must be checked to ensure it has not passed its expiry date. 5.9.4 Inspection of Blood or Blood Products It is essential that staff administering blood or blood products inspect each unit prior to transfusion and return the unit to the Blood Bank if any defects are found. The inspection should pay attention to: The integrity of the pack by checking for leaks at the port or seams. Evidence of haemolysis in the plasma or at the interface between red cells and plasma. Evidence of unusual discoloration or turbidity. The presence of large clots. 5.9.5 Responsibility for the identity check of the Patient and the Blood Product The final bed side check Although two members of staff may be involved in the checking procedure, it is recommended that one member of staff should be responsible for carrying out the identity check of the patient and the unit of blood at the patient s bedside. The member of staff must be a doctor or a nurse holding current registration of the NMC Professional Register as a Registered General Nurse (RGN). Positive identification of the patient the final check This is ESSENTIAL and is based on: Direct questioning of the patient by asking their surname, first name and date of birth in the case of patients who are judged capable of giving an accurate reliable response. Checking the details on the patient s identity band. Checking the ID band is mandatory even if the patient can give his/her identity. The surname, first name, gender, date of birth and unique identification number must be identical with: The compatibility label attached to the blood component (also check the blood tag label is on the correct bag by checking the donation number and product type with the information on the front of the blood product bag). Patient s identification wristband. NB Only the labeled blood product and the patient s identity band are to be used as part of the final bedside check, not a compatibility form or prescription sheet. Page 11 of 22

Any discrepancies identified by these checks should be reported to the Blood Bank immediately and the transfusion delayed until clarification of any point is made. The transfusion of blood and blood components should begin as soon as possible. The prescription sheet must be readily available during the transfusion. The report must then be filed in the medical noted following completion. 5.9.6 Traceability On completion of these checks staff must sign the blood transfusion compatibility report form, the peel off sticker from the blood tag label (which is then attached to the prescription sheet (WPR26562) and the blood tag for return to Blood Bank. The start and finish time of the transfusion must be recorded on the blood prescription sheet (WPR26562). The completed detachable blood tag must be returned to Blood Bank immediately following transfusion to enable full traceability and ensure the Trust fulfills its legal requirements as defined by BSQR 2005. The return of the tags is mandatory. The efficacy/outcome/benefit of this transfusion must be recorded in the patient s notes. 5.9.7 Spillage Where a spillage of blood or blood products occurs, the infection prevention and control policy Management of Blood and Body Fluid Spillages should be followed. 5.10 Technical Aspects of the Administration of Blood Products 5.10.1 Giving Sets Adhere to strict aseptic techniques when handling blood or blood components. Refer to Aseptic Technique and Aseptic Non Touch Technique Policy. Blood products should be transfused through a sterile giving set designed for the procedure. Filter size 170-200 micron filter is required. Drugs must not be added to blood products under any circumstances. Page 12 of 22

5.10.2 Red Cells Electronic infusion pumps may damage blood cells and should not be used for administration of red cells unless the manufacturers have verified them as safe to use for this purpose and staffs have been trained in their use. To prevent bacterial growth a new giving set must be used after 12 hours or after 3 units, whichever is earlier. Some giving sets may be issued with different instructions. If the usage life of a giving set is shorter, always follow the manufacturer s instructions. Start transfusion as soon as the unit is received from Blood Bank. Each unit of blood must be used within a maximum of four hours from leaving Blood Bank fridge or validated blood storage box, usually red cells are transfused over 2-3 hours. Flushing through the remainder of the blood in the line with Sodium Chloride 0.9% is not recommended. All blood products are leucocyte depleted. Usually supplied as packed red cells in additive solution (SAGM). 5.10.3 Platelets (PLT) (Mean Volume 202ml) A standard blood or platelet giving set should be used for the administration of platelets. Platelets should be transfused through a new clean standard blood or platelet giving set (not one already used for blood). Never put platelets in a fridge. Start infusion as soon as the pack is received from the Blood Bank. Infuse stat or maximum time 30 minutes in an adult. 5.10.4 Cannula 5.10.5 Drugs A 20 gauge cannula is the minimum size required for transfusion. The size of cannula chosen can affect the speed at which the blood can be transfused. Drugs must never be added to blood and products under any circumstances. Drugs should not be administered through the same cannula when transfusion of blood or blood products is in progress. 5.10.6 Disposal of Blood Bags On completion of the transfusion the empty bag should be retained for a Page 13 of 22

period of 24 hours and then discarded via the offensive hygiene waste i.e. yellow bag with black stripes if there is no evidence of a transfusion reaction. The empty bag will be stored in the designated sluice area in the nominated and labeled container. The Nurse in Charge will ensure appropriate disposal following the 24 hour period. 5.11 Care and Monitoring of Patients 5.11.1 Key Points Observations should be undertaken for every unit transfused. Minimum monitoring of the patient should include: Regular visual observation throughout the transfusion episode. Pre-transfusion pulse (P), blood pressure (BP), temperature (T), respiratory rate (RR) and O2 saturation. To be taken no more than 60 minutes before starting transfusion. A complete set of vital signs should be taken 15 minutes after the start of each component transfusion for all patients. More frequent observations may be required, e.g. rapid transfusion, or patients who are unable to complain of symptoms which would raise suspicion of a developing transfusion reaction. If the patient shows signs or symptoms of a possible transfusion reaction, the vital signs should be monitored and recorded and appropriate action taken (see section 5.12). Vital signs must continue to be monitored every 5-15 minutes depending on the severity of the reaction and until reaction has resolved or escalated to hospital. Post transfusion observations should be taken and recorded not more than 60 minutes after the end of the component transfusion. Patients should be observed during the subsequent 24 hours or, if discharged, counseled about the possibility of late adverse reactions. Clinical areas should ensure that systems are in place to ensure patients have 24 hour access to clinical advice. 5.11.2 Staff Responsible The member of staff responsible for the care and monitoring of the patient during the transfusion must be a nurse holding current registration of the NMC Professional Register as a Registered General Nurse (RGN), or a doctor. They must take charge of the patient during the transfusion and be responsible for ensuring that all care and monitoring of the patient is performed. 5.11.3 Observation of the Patient It should be stressed to the patient the importance of reporting any adverse effects that they may feel, including shivering, rashes, flushing, shortness of Page 14 of 22

breath, pain in the extremities or in the loins. Visual observation of the patient is often the best way of assessing the condition of the patient during transfusion. Transfusions should be given in clinical areas where patients can be readily observed by members of the clinical staff. Patients should be able to alert staff if they experience any adverse effects. The start and finish time of the transfusion must be recorded on the peel off sticker from the blood tag which is attached to the blood prescription sheet (WPR26560). Vital signs temperature, pulse, blood pressure, respirations and O2 saturation MUST be measured and recorded before the start of each unit of blood or blood component, and at the end of each transfusion episode. During the first 15 minutes of the transfusion of each unit the patient MUST be regularly observed (most reactions will occur in this time and will require immediate attention) and the patient s vital signs MUST be monitored and recorded. Further observations during the transfusion of each unit of blood or blood product need only be taken should the patient become unwell or show signs of a transfusion reaction or if advised by Blood Bank. 5.11.4 Completion of Transfusion Episode If a further blood component unit is required: Repeat the administration/identify check with each unit. If no further units are prescribed: Remove the blood administration set. Ensure all transfusion documentation is completed and the tag is returned immediately to Blood Bank. Return any unused blood products to the blood bank. 5.12 Reporting of Adverse Events/Reactions following or during Transfusion 5.12.1 Staff Responsible for Reporting Adverse Events/Reactions Initial treatment of an Adverse Transfusion Reaction (ATR) is not dependent on classification but should be directed by symptoms and signs. Treatment of severe reactions should not be delayed until the results of investigations are available. Patients should be asked to report symptoms which develop within 24 hours Page 15 of 22

of completion of the transfusion. 5.12.2 Initial clinical assessment Initial clinical assessment seeks to quickly identify those patients with serious or life threatening reactions so that immediate treatment/resuscitation can be initiated. Immediate management of ATR If a patient develops new symptoms or signs during a transfusion, this should be stopped temporarily, but venous access maintained. Identification details should be checked between the patient, their identity band and the compatibility label of the blood component. Perform visual inspection of the component and assess the patient with standard observations. Mild Adverse Reactions. For patients with mild reactions, such as pyrexia (temperature of > 38 o C and a rise of 1-2 o C), and/or pruritus or rash but without other features, the transfusion may be continued with appropriate treatment and direct observation. If at any time a transfusion reaction is suspected, the doctor in charge of the patient should be contacted by the nurse responsible for the patient during the transfusion and should review the patient promptly. Any adverse events should be recorded in the patient s notes and logged on the blood prescription sheet (WPR26562). It is the doctor s responsibility to ensure the adverse reaction is reported to Blood Bank. It is the responsibility of Blood Bank staff to report the event to senior Blood Bank staff or the Transfusion Practitioner to enable external reporting to SABRE (Serious Adverse Blood Reactions and Events) and/ or SHOT if appropriate. Patients with mild isolated febrile reactions may be treated with oral Paracetamol (500-1000mg in adults). Patients with mild allergic reactions may be managed by slowing the transfusion and treatment with an antihistamine. Severe Adverse Reactions Management is guided by rapid assessment of symptoms, clinical signs and severity of the reaction. The transfusion must be stopped immediately. Page 16 of 22

The blood administration set should be changed and venous access maintained using Sodium Chloride 0.9% running slowly to keep the vein open. The doctor must be informed and must assess the patient. Escalate to DRI via 999 ambulance (all patients with severe reaction) A Consultant Haematologist must be informed. The reaction should be reported immediately to the Blood Bank, who will issue a Transfusion Reaction Investigation sheet. Follow the instructions carefully, complete the sheet and return to Blood Bank as instructed along with any remaining blood products which may have been involved in the reaction Whilst awaiting the ambulance - the vital signs should be monitored immediately, recorded, and appropriate action taken. Vital signs must continue to be monitored every 5-15 minutes depending on severity of reaction and until the possible reaction has resolved. The volume and colour of any urine passed should be recorded in the patient s notes. Anaphylaxis Anaphylaxis should be treated with intramuscular adrenaline (epinephrine) according to UKRC guidelines. Patients who are thrombocytopenic or who have deranged coagulation should also receive intramuscular adrenaline if they have an anaphylactic reaction Hypotension If a patient being transfused for haemorrhage develops hypotension, careful clinical risk assessment is required. If the hypotension is caused by haemorrhage, continuation of the transfusion may be life-saving. In contrast, if the blood component is considered the most likely cause of hypotension, the transfusion must be stopped or switched to an alternative component and appropriate management and investigation commenced. Febrile symptoms of moderate severity If a patient develops sustained febrile symptoms or signs of moderate severity (temperature > 39 o C or a rise of > 2 o C and/or systemic symptoms such as chills, rigors, myalgia, nausea or vomiting), bacterial contamination or a haemolytic reaction should be considered. 5.12.3 Investigation of a Suspected Transfusion Reaction The completed form and samples should be sent immediately to the Blood Page 17 of 22

Bank with the Blood Product bag(s) and giving set. Samples required: Group & save, FBC, U/E, LFT, coagulation screen, blood cultures. The Blood Bank will report on its investigation as soon as possible. No further transfusion of units currently cross-matched should be undertaken until the blood bank investigation is complete this may be mitigated by the Consultant Haematologist depending on circumstances. 5.12.4 Documentation of Adverse Events/Reactions Any adverse events should be recorded in the patient s notes and logged on the blood prescription sheet (WPR26562). Complete an incident form (IR1) and ensure a copy is sent to Blood Bank. All adverse events related to blood/blood product transfusion will be reviewed by the Hospital Transfusion Committee. Serious adverse events should be reported to the MHRA (Medicines and Healthcare Products Regulation Agency) via SABRE (Serious Adverse Blood Reactions and Events) and to SHOT (Serious Hazards of Transfusion) via the Blood Bank. Suspected cases of transfusion-transmitted infection should be reported immediately to the local Transfusion Centre via the Blood Bank. 5.13 Documentation of Transfusions Full documentation of transfusion is mandatory and a legal requirement. 5.13.1 Documentation in the Patient s Notes A permanent record of the transfusion must be held in the patient s medical notes, including: A complete record of the transfusion on the blood prescription sheet (WPR26562), with the following information: o Start and finish time of the transfusion on the blood prescription sheet (WPR26562). o The indication for the transfusion. o The type and number of blood products used. o Whether or not the desired effect was achieved. o The occurrence and management of any adverse effect. o The peel off sticker from the blood tag must be attached to the prescription sheet Page 18 of 22

The sheets used for nursing observations during the transfusion. 5.13.2 Documentation to be returned to Blood Bank The return of the tags is mandatory The completed detachable blood tag must be returned to Blood Bank immediately following transfusion to enable full traceability and ensure the Trust fulfills its legal requirements as defined by BSQR 2005. The return of the tags is mandatory. 5.14 Jehovah s Witness Policy and Patient or Family Refusal of Blood Transfusion Policy Some people may refuse blood transfusion for a variety of reasons. The aim of this policy is to ensure that Jehovah s Witnesses beliefs are acknowledged and respected and to provide information with regard to the treatment of all patients who refuse blood transfusion. If refusal by non-jehovah s Witnesses is based on fear of transfusion transmitted infection, the risks should be clearly explained. Refusal of blood transfusion should be carefully documented in the patient s medical notes by the consultant/most senior doctor present, with the reasons given together with date, time and signature. Jehovah s Witnesses have definite objections to blood transfusions for both religious and medical reasons. Jehovah s Witnesses rule out the transfusion of red cells, whole blood, fresh frozen plasma, platelets and white cells, Predonation (PAD) and may refuse to donate bone marrow/stem cells. Anti-D immunoglobulin and Cryoprecipitate may be accepted and should be offered where appropriate. However this is not available in the hospice and would need to be explained to the patient. Following consent, transfer to DBHFT would need to be arranged. 5.14.1 Jehovah s Witnesses Hospital Liaison Team Contact the Jehovah s Witnesses Hospital Liaison Committee with regard to alternative care or to locate doctors experienced in the management of Jehovah s Witnesses. The following website has additional resources: https://www.jw.org/en/medical-library/hospital-liaison-committee-hlccontacts/united-kingdom/ Hospital Information Services (United Kingdom) 24-Hour Contact Number: (020) 8906 2211 Hospital Information Services for Jehovah s Witnesses IBSA House, The Ridgeway, London, NW7 1RN Page 19 of 22

6. TRAINING IMPLICATIONS Staff groups requiring training All staff involved in the process of blood transfusion, which includes prescribing, obtaining a blood sample, collect, administering or returning blood. Blood Transfusion Policy How often Length of Delivery should this be training method undertaken Annually. Competence assessment every 2 years. 1 2 hours Face to face/ e- learning Training delivered by whom NHS England E-learning and Senior nursing team who have attended further training Where are the records of attendance held? Electronic Staff Record system (ESR) All members of staff involved in the process of blood transfusions, which include prescribing, obtaining a blood sample, collecting, administering or returning blood, must have completed training on Blood transfusions and be assessed as competent. National guidance (BCSH 2012) states update training may be performed using an E-learning package appropriate to role and undertake competency assessments every 2 years. All training will be recorded using electronic staff records and also held by their line manager. Clinical Lead and the clinical manager will receive additional training provided by DBHFT regarding blood transfusions in order to practically assess the hospice nurses All training must be documented and records retained. Staff will receive instruction and direction regarding Blood Transfusion from a number of sources: Policies and Procedures Manuals Line Manager/ Clinical Lead Training via NHS England E-learning Communication methods (e.g. Team Brief/team meetings) 7. MONITORING ARRANGEMENTS Area for Monitoring How Who by Reported to Frequency Monitoring and review of transfusion process Audit Hospital Transfusion Team, DRI Hospital Transfusion Committee Annual Compliance with Policy re documentation and traceability Return of Blood tags to Blood Bank Blood Bank staff Ward Each transfusion Page 20 of 22

8. EQUALITY IMPACT ASSESSMENT SCREENING The completed Equality Impact Assessment for this Policy has been published on this Policy s webpage on the Trust Policy website. 8.1 Privacy, Dignity and Respect The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi s review of the NHS, identifies the need to organise care around the individual, not just clinically but in terms of dignity and respect. Indicate how this will be met No issues have been identified in relation to this policy. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided). 8.2 Mental Capacity Act Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the Court Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible. Indicate How This Will Be Achieved. All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act 2005. (Section 1) Page 21 of 22

9. LINKS TO ANY ASSOCIATED DOCUMENTS Trust Website:- Management of blood and body fluid spillages policy, Clinical Policies, Infection Prevention and Control Aseptic technique and aseptic non-touch technique policy, Clinical Policies, Infection Prevention and Control Standard Precautions policy, Clinical Policies, Infection Prevention and Control Hand hygiene policy Clinical Policies, Infection Prevention and Control Policy pathology specimens, clinical policies, infection prevention and control Waste policy, corporate polices, estates and facilities Policy for Consent to Care and Treatment, general clinical, admissions/access to service 10. REFERENCES British Committee for Standards in Haematology (2012) Guideline on the Administration of Blood Components. BCSH, London. British Committee for Standards in Haematology (2012) Guideline on the Investigation and Management of Acute Transfusion reactions. BCSH, London. Doncaster, Bassetlaw NHS Foundation Trust (2014) Blood Transfusion Policy Malia, C (2015) Standard operating procedure: transfusion of blood and blood components. St Gemma s Hospice, Leeds National Patient Safety Agency (2006) Safer practice notice 14: Right Patient, Right Blood. Available at http://www.nrls.npsa.nhs.uk/resources/collections/right-patient-rightblood/ (accessed 9/10/17). Preston, N. Hurlow, A. Brine, J. Bennett, M. (2012) Blood transfusions for anaemia in patients with advanced cancer (review) The Cochrane Collaboration. John Wiley & Sons Ltd. London. Page 22 of 22