1 FY 15 BLOOD ADMINISTRATION/REACTION Patient Care Services Policies PCS-205 Blood and Blood Components Transfusion: Initiation & Maintenance PCS-206 Blood and Blood Components: Transfusion Reaction PCS-207 Blood and Blood components: Verification of Before Transfusion Developed by Employee Education
2 Blood Administration/Reaction Blood Administration is life saving Yet not without risks Our Goal at LCM is to: Decrease errors Improve and maintain patient safety Promote quality patient care According to the American Association of Blood Banks, more than 1000 units of RBC s are transfused to the wrong patient each year in the United States. (Roback, et al., 2009, p. 618)
3 The Process The Physician makes the decision to transfuse the blood or blood components The Physician provides the patient with: Need/Indications for transfusion Side effects Risks/Benefits Alternative treatments available
4 General Information Blood and blood components include: Whole blood Washed RBCs reconstituted with fresh frozen plasma (FFP) Red blood cells Including washed RBCs Platelets Random donors Plateletpheresis (single donor) Fresh Frozen Plasma (FFP) Albumin (from pharmacy) Cyroprecipitate
5 The Order Must Contain Patient Name and date of birth (key identifiers) Component to be infused Any special processing (washed, irradiation) Amount to be infused Time frame of administration Date and Time of order The order will be entered by the unit secretary A TOP Checklist will be generated as a guide for the nurse
6 Physician Order for Transfusion of Blood Products When an order for transfusion of a Blood Product is written the nursing unit will need to print a Physician Order for Transfusion of Blood Products form From the PrePrinted Orders Category in Order Entry Mnemonic: BLD PROD Name: PHY ORDER FOR BLOOD PRODUCTS The form is to be completed and signed by the ordering physician or by the RN via a telephone order and faxed to Blood Bank The Fax Number for Blood Bank is listed on the upper right portion of the order form Upon completion of the form, the order for the Blood Product will be entered into the OE application as usual If the physician has questions or concerns regarding the need to complete the form they should contact Dr. Pooley, from the Lab to discuss Forms SHOULD NOT be printed in advance, as it pulls the most recent Vital Signs and Lab Results into the order form This information is helpful for both the ordering physician and the Blood Band A new Physician Order for Transfusion of Blood Products is required every time a new order for Blood Products is received
7 Type & Crossmatch Is drawn by phlebotomy Labeled with patient name and date of birth A pink ID band is placed on the patient when the specimen is drawn and includes: Patient name Visit Number Medical Record number Blood bank specimen number **A type and Crossmatch specimen is only good for 72 hours at LCMH**
8 The Consent to Administer Blood Is computer generated Is signed by patient or surrogate Surrogate adult individual authorized according to the Illinois Health Care Surrogate Act to provide consent when the patient lacks the decisional capacity (HD 129) Is witnessed by the RN Is good for all additional transfusions during this hospitalization Is NOT required in an Emergent transfusion/lifethreatening situation However, after the emergency situation is over, if the patient requires additional transfusions, a consent is required
9 Preparation for Administration Prior to administration of any blood or blood component the nurse who will be infusing the component must verify: The patient has a patent IV with normal saline Normal Saline is the only solution compatible with blood and therefore must be used before and after a transfusion to clear the tubing and prevent injury to the cells Access must be with an IV Catheter (22ga-14ga) The order The consent Baseline vital signs If the patient s temperature is >100 degrees it is recommended to notify the physician Generate a request To Obtain Product (TOP)
10 Medications During Infusion of Blood or Blood Components Any medications that can be given prior the transfusion must be given No medications can be piggy-backed into blood or blood components IV push drugs may be injected through a port in the blood infusion set near the IV site under the following conditions: The medication being injected does not contain calcium The medication being injected can be mixed with stored blood Pharmacy must be consulted if unsure of above
11 TOP Checklist When the Nursing Unit is ready to transfuse: Enter a To Obtain Product request via the computer Which will print in Transfusion Services If this TOP is verbally requested The patients name must be stated clearly and repeated back
12 TOP Checklist (cont.) Before a request To Obtain Product TOP is generated the RN must verify all of the following steps Product is READY Check the Status Board When blood is READY it will show up GREEN on the status board Order to Transfuse Signed Consent Patient has a pink band on IV running with Normal Saline using the appropriate size IV Catheter Vital Signs been taken and are they acceptable to start the transfusion All responses must be yes prior to entering the TOP request
13 Verification When Picking Up Blood or Blood Components When sent through pneumatic tube system: Component will be issued using the Secure Transaction function Transfusion Service will call the requesting location with the Secure Transaction Code The Transfusion Service Tech will verify donor and patient information with another Tech, in the Lab, prior to releasing the blood The Y-set tubing with filter cannot be sent via the tube system
Verification When Picked Up in Blood Bank By Unit Personnel PCS-207 14 When picking up the blood or blood components in Transfusion Service ONLY a Nurse, Care Partner or unit Secretary may pick up the blood or blood components The Unit Issue Card that is generated must be brought down to Transfusion Services when picking up blood or blood components Verification of the following information is indicated by the signature of the nursing and laboratory personnel Physicians order is verified on the unit Patient s name, visit number and donor number ABO and RH group of patient and donor Product expiration date and time Result of compatibility test if applicable Blood Bank patient ID wrist band number Component to be transfused Recipient specific donor information if applicable
15 Patient Verification On the Unit The RN who will be administering the blood product will verify the blood product with another RN or Registered Pharmacist Patient s name, visit Number and donor number ABO and RH group of patient and donor Expiration date of blood product Result of compatibility test if applicable Component being infused Blood Bank patient ID number Recipient specific donor information if applicable
16 Verification at the Bedside At the bedside the patient will again be identified by the RN who will be administering the blood product and another RN Bedside verification includes Pink transfusion service ID band for blood bank number Patient name and date of birth (patient identifiers)
17 30 minute issue hang time If blood or blood components cannot be given within a 30 minute time frame it needs to be sent back to Transfusion services Blood or blood components CANNOT be kept in the refrigerators on the units You will need to call transfusion services and let them know the blood or blood components is coming back
18 Transfusing the Blood Special Y-Tubing and/or filters can be obtained from Transfusion Service Some special tubing with filters can be obtained from MDC Transfusion Service will dispense the appropriate special filter when recommended or required or with a physician s order Elective transfusions must be completed within 2 hours Unless a physician orders otherwise Blood or blood components can be infused over 4 hours from the time of issue if needed based on the patients condition RN may make decision to split the unit based on patients condition Each half can infuse over 2 4 hours
19 Transfusing the Blood (cont.) NEVER RUN blood or blood components > 4 hours from issue time Any Blood or blood component out of Transfusion Services refrigeration for >4 is considered to have bacterial contamination To reduce the risk of bacterial contamination blood and blood component tubing should be changed With every other unit If first unit ran longer then 2 hours Blood tubing should never be used beyond the 4 hour time frame
20 Transfusing the Blood (cont.) Blood that has been typed and found to be incompatible may be administered by a nurse after the physician or his delegate has signed the Release for Dispensing Blood form The physician may request the nurse to sign the release as his delegate via a telephone order The physician must counter-sign the release form within 24 hours
21 In an Emergency Uncrossmatched universal donor (O negative) or type specific blood may be administered on a physician s direct order. A Transfusion Service Uncrossmatched Release form must be documented as to the emergent need and signed by the physician This can be done after the emergency situation has ended
22 Suggested Infusion Rates of Components in Nonemergency Settings* Suggested Infusion Rate Suggested Infusion Rate Component Adult Pediatric Red Blood Cells 150-300 ml/hr 2-5 ml/kg/hr Fresh Frozen Plasma 200-300 ml/hr 60-120 ml/hr Platelets 200-300 ml/hr 60-120 ml/hr Cryoprecipitate AHF As rapid as tolerated As rapid as tolerated Granulocytes 75-100 ml/hr 65-100 ml/hr *Transfusion must be completed in <4 hours. Hr=hour kg=kilograms ml=milliliter
23 Administering Blood Components PCS- 205 Cryoprecipitate May be administered IV push through a Component Infusion set or hung like RBCs through a Y-type infusion set Administer as rapidly as patient tolerates Platelets May be administered IV push through a Component Infusion set or hung like RBCs through a Y-type infusion set Administer as per instructions on a Component Infusion Set or as RBCs Administer as rapidly as patient tolerates Do not use an infusion pump Flush IV with normal saline before and after infusion Fresh Frozen Plasma Must be thawed prior to infusion Blood Bank must be notified 35 to 45 minutes prior to infusion Administer in the same manner as blood Administer as rapidly as patient tolerates Albumin Serum Albumin and tubing are obtained from the Pharmacy and documented on the emar No consent is necessary
24 Administering Blood Components PCS- 205 An infusion pump or pressure bag may be used to regulate administration of red blood cells and fresh frozen plasma ONLY Platelet/platelet pheresis should not be transfused through and infusion pump If the four hour time from issue is reached and the transfusion is still infusing Stop the infusion immediately Flush the tubing Document the amount infused Document the reason transfusion was stopped
25 Patient Assessment During Transfusion It is recommended to initially infuse blood and blood components slowly 2 ml to 5 ml per minute for first 15 minutes Observe patient closely in the first 15 20 minutes after the start of the transfusion Sever reactions can occur with as little as 10 ml infused Life threatening reactions usually occur within the 10 to 20 minutes Educate patient in symptoms of reaction Shivering Rashes Flushing SOB Pain in extremities Back or loin pain (Roback, el al. 2009, Wilkinson,2001)
26 Vital Signs During Transfusion PCS-205 Temperature, Pulse, Respiration & Blood Pressure Prior to start of the infusion (baseline) 15 min X 2 after the start of the infusion 30 minutes later Every 60 minutes until the infusion is completed One hour after completion of the infusion Vitals signs should be assessed more frequently when the patient s condition is unstable Document all vital signs
27 Documentation of the Transfusion PCS-205 Blood Bank will no longer send a YELLOW COPY with the Blood Transfusion Form for any patient in: Adult ICU s, the 7 adult Med/Surg Units, Pediatrics, M/B, L&D, SCU, ED or PACU The Transfusion Request and Record form will have a Red Stamp USE TAR Information entered here is now entered on the online TAR screens Documentation of the transfusion on the Transfusion Request Record is only required if the patient had the blood product started in surgery Any units that administer Blood Products and are not up on line with the TAR will continue to receive the Yellow Copy The white Transfusion Request Record is placed in the patient s chart
28 Documentation of the Transfusion in Meditech Go to your Status Board Select the patient that has blood products that will be transfused Click on the Transfusion button in the lower right hand corner of the screen
29 Transfusion Reactions The chance of having a reaction to blood is very small Allergic and febrile reactions make up over half of all adverse reactions reported (CDC 1/2013) Although rare, serious reactions can occur and are a potentially serous complication requiring prompt nursing and medical attention The RN initiation the transfusion is responsible for observing the patient for a possible transfusion reaction Types of reactions Allergic reaction Acute hemolytic transfusion reaction Febrile non-hemolytic transfusion reaction Transfusion related circulatory overload Transfusion related acute lung injury
30 Allergic Reaction An allergic reaction results from an interaction of an allergen in the transfused blood with preformed antibiotics in the person receiving the blood transfusion (CDC 1/2013) A mild allergic reaction symptoms Uticaria Itching Stridor Dyspnea A sever allergic reaction symptoms Hypotension Bronchospasm
31 Acute Hemolytic Transfusion Reaction An acute hemolytic transfusion reaction is the rapid destruction of red blood cells that occurs during, immediately after or within 24 hours of a transfusion when a patient is given an incompatible blood type (CDC 1/2013) The recipient s blood immediately begins to destroy the donated red blood cells. Possible symptoms include: Fever Pain Bronchospasm Hypotension Hematuria Sometimes severe complications such as Shock Kidney failure
32 Febrile Non-hemolytic Transfusion Reaction Febrile non-hemolytic transfusion reactions are the most common reaction Characterized by fever and/or chills in the absence of hemolysis (breakdown of red blood cells) occurring in the patient during or up to 4 hours after a transfusion These reactions are usually mild and respond quickly to treatment
33 Transfusion Related Circulatory Overload Transfusion related circulatory overload occurs when the volume of blood or blood components transfused cannot be effectively processed by the recipient (CDC 1/2013) It can occur due to excessively high infusion rate and/or volume or due to an underlying heart of kidney condition (CDC 1/2013) Symptoms may include: Hypertension Tachycardia Dyspnea Cough Pulmonary Edema CHF Cyanosis Hypoxia
34 Transfusion Related Acute Lung Injury Transfusion related acute lung injury is a serious but rare reaction that occurs when fluid builds up in the lungs but is not related to excessive volume of blood or blood products infused (CDC 1/2013) The mechanism of transfusion related acute lung injury is not well understood it is thought to be associated with the presence of antibodies in donor blood (CDC 1/2013) Symptoms include: Dyspnea Hypoxia Pulmonary Edema
35 Treatment of Transfusion Reactions When a transfusion reaction is suspected the RN will STOP the infusion immediately Notify the attending MD or the house MD Notify Transfusion Services Change IV tubing - Run 0.9NaCl at KVO rate Re-verify all patient and donor information Check V.S. every 15 minutes and document
36 Treatment of Transfusion Reactions (cont.) Immediately collect a voided urine specimen label specimen Post Transfusion Specimen #1 and send it to Blood Bank This is to differentiate between hemoglobinuria vs. acute hemolytic reaction Collect a second voided specimen 5 hours later label Post Transfusion #2 and send to Blood Bank Observe patient closely and document findings All bags and tubing with completed reaction form are returned BY HAND to the Blood Bank
37 Documentation of Transfusion Reactions PCS-206 Check yes for transfusion Reaction on the Transfusion Request & Record Complete the Blood Transfusion Reaction report on line using: OE.LCI (order entry) The Nursing Status Board This is the preferred method because the information will automatically pass over to the Blood Bank 2 1 3
38 Clarification from Blood Bank All calls to Blood Band are acceptable and encouraged Calls to check if blood is ready are unnecessary This information is available in PCI Look at your status board in PCI If the status board reads: READY-component is crossmatched and order can be sent to TOP Packed Cells are ready to be transfused Fresh Frozen Plasma is thawed and ready to be transfused Platelet Pheresis has arrived at LCMH and is ready to be transfused DO NOT TOP for blood if PC reads: ISSUED-blood has been issued to the floor TRANSFUSED-blood has been transfused NOT AVAILABLE-blood is no longer available XMC-blood is in the progress and is not ready
39 References Centers for Disease Control and Prevention, ( 2013) Basics Blood Safety, cdc.gov/retrieved from http://www.ckc.gov/bloodsafety/basics.html on 4/29/2013 Nowlin, Ann. (2006), Your guide to safe transfusions. RN Modern Medicine. Com/retrieved from http: rnmodernmedicine.com on 12/01/2009 Roback, J., et al. Administration of blood components. Chapter 21. Technical Manual. American Association of Blood Bands. 16 th Ed Smith, S., et al., (2008), Clinical nursing skills: basic to advanced skills. 7 th Ed., Pearson Eduction, INC., Upper Saddle River, NJ Wilkinson, J., & Wilkinson, C., (2001) Administration of blood transfusions to adults in general hospital settings: a review of the literature. Journal of Clinical Nursing, Vol. 10, p161-170