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Authorisation of Blood Components for Transfusion by Registered Practitioners Policy
Page 1 of 19 NDHT Transfusion Committee / Authorisation of Blood Components for Transfusion by Registered Practitioners Policy v1.1
Document Control
Title
Authorisation of Blood Components for Transfusion by Registered Practitioners Policy
Author
Author’s job title Haematology Clinical Nurse Specialist
Directorate Clinical Support Services
Department Clinical Haematology
Version Date
Issued Status Comment / Changes / Approval
0.1 30.11.15
Draft Draft for consultation
1.0 Dec 2015
Final Approved by Transfusion Committee 15th Dec 2015
1.1 Oct 2018
Revision Reviewed by M. Bowyer. No changes required.
Main Contact Office 1 Seamoor Corridor North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB
Tel: Direct Dial - Tel: Internal – Email:
Lead Director Director of Nursing
Superseded Documents None
Issue Date Nov 2018
Review Date Nov 2021
Review Cycle Three years
Consulted with the following stakeholders: (list all)
Head of Workforce Development
Haematology Consultants
Hospital Transfusion Committee
Approval and Review Process
Hospital Transfusion Committee
Local Archive Reference G: Pathology Local Path Transfusion Team\Policies & Guidelines folder Filename Authorisation of Blood Components for Transfusion by Registered Practitioners Policy v1.1 Oct2018.doc (right click above text, to update to new filename)
Policy categories for Trust’s internal website (Bob) Haematology
Tags for Trust’s internal website (Bob) Blood Transfusion, Components, Authorisation, Registered Practitioners, Non-Medical
Authorisation of Blood Components for Transfusion by Registered Practitioners Policy
Page 2 of 19 NDHT Transfusion Committee / Authorisation of Blood Components for Transfusion by Registered Practitioners Policy v1.1
CONTENTS
Document Control ................................................................................................................................. 1
1. Purpose .......................................................................................................................................... 3
2. Definitions ...................................................................................................................................... 3
3. Responsibilities ............................................................................................................................. 3
4. Selection Criteria ........................................................................................................................... 5
5. Training .......................................................................................................................................... 5
6. Monitoring Compliance with and the Effectiveness of the Policy ........................................... 6
7. Equality Impact Assessment ....................................................................................................... 6
8. References ..................................................................................................................................... 7
9. Appendix 1 ..................................................................................................................................... 8
10. Appendix 2 ................................................................................................................................... 17
11. Appendix 3 ................................................................................................................................... 18
12. Appendix 4 ................................................................................................................................... 19
Authorisation of Blood Components for Transfusion by Registered Practitioners Policy
Page 3 of 19 NDHT Transfusion Committee / Authorisation of Blood Components for Transfusion by Registered Practitioners Policy v1.1
1. Purpose
1.1. The purpose of this document is to detail the process for a senior Registered Practitioner, working in a relevant specialist role, who wishes to undertake the authorisation of blood component transfusions.
1.2. The policy applies to all non-medical staff.
1.3. Implementation of this policy will ensure that:
Any Registered Practitioner wishing to develop their role to include authorisation of blood component transfusion will have completed the relevant training and competency assessment.
The Registered Practitioner who takes on the role of blood component authorisation will need continued support and mentorship with a period of supervision prior to completion of competency assessment to allow independent practice.
1.4. The authorisation of a blood transfusion must only occur when NDDH
policies and guidelines are followed and when there are no alternatives to transfusion.
1.5. That non-medical authorisation is not suitable for all registered
practitioners and should only be taken on within agreed governance structures of the Trust after consideration of service and clinical need and at the recommendation of the designated consultant supervisor and assessor.
2. Definitions
Blood components consist of red cells, platelets, fresh frozen plasma and cryoprecipitate.
3. Responsibilities
3.1. There must be an identified service need within the specific department to implement the non-medical authorisation of blood components
3.2. Role of Registered Practitioner
The registered practitioner is responsible for ensuring that they meet the selection criteria and will be supported by both the lead haematology consultant for transfusion and the designated consultant supervisor and assessor.
The Registered Practitioner is responsible for:
Authorisation of Blood Components for Transfusion by Registered Practitioners Policy
Page 4 of 19 NDHT Transfusion Committee / Authorisation of Blood Components for Transfusion by Registered Practitioners Policy v1.1
Maintaining accurate documented evidence of training and practice.
Ensuring that they are familiar with current national and local guidelines and policies by accessing the relevant courses and maintaining training and competency.
Must comply with the NMC Code of Practice or equivalent Health Care Practitioner Code of Practice.
The Practitioner will be responsible for obtaining adequate knowledge and experience in authorising blood components including a period of supervision prior to assessment of competency
The practitioner is responsible for keeping training and skills up to date throughout their working life and a duty to practice within their own area of competence.
The practitioner may only authorise blood components in their specific clinical area or identified group of patients and are responsible for their own actions. The practitioner will undertake the extended role solely within a clearly defined clinical management plan
3.3. Consultant Supervisor and Mentor
There must be a consultant practising in the specialist area in which the practitioner is employed.
The mentor should regularly authorise blood transfusions and make decisions to transfuse and with whom the practitioner can work alongside for learning and assessment purposes.
The mentor is responsible for and supporting the practitioner through the work-based learning and assessment.
The mentor has a critical and highly responsible role in educating and assessing the practitioner in undertaking authorisation of blood products
They are responsible for assuring competence of the practitioner by providing them with supervision, support and opportunities to develop competence in authorisation of blood components during the work based learning.
They are up to date with all mandatory training as per NDDH Trust mandatory training requirements
They have completed the safe blood transfusion e-learning modules 1 & 2 plus consent part 9 and reactions part 11 module of the ‘Learn Blood Transfusion’ e-learning programme
The mentor is responsible for the final agreement to practice. They are required to provide and signed statement of competence at the end of the period of study. They should do this after reading the professional code of conduct.
Authorisation of Blood Components for Transfusion by Registered Practitioners Policy
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3.4. Role of the Hospital Transfusion Committee
The Hospital Transfusion Committee is responsible for:
Reviewing and approving the policy in line with the National Guidance.
4. Selection Criteria
Any registered practitioner applying to undertake authorisation of blood components must:
4.1. Be currently registered as a practitioner with at least 3 years post-registration experience and have at least one year working in the Trust within the relevant specialty
4.2. Have a case-load of patients or work as part of a clinical team managing patients’ needs
4.3. Be trained to a level to include skills of history taking, physical examination, advanced communication and clinical reasoning and decision making.
4.4. Identify need for the competency that will benefit their patient caseload.
4.5. Be up to date with all mandatory training as per trust mandatory training requirements, have completed the e-learning modules ‘Safe Transfusion practice’ Part 1 & 2 plus consent part 9 and reaction part 11 on ‘Learn Blood Transfusion’ e-learning programmes.
4.6. Have completed all competency assessments for pre-transfusion blood sample taking, and administration of blood and blood components if required for their role.
4.7. Successfully complete the approved training programme such as the NHS Blood & Transplant Non-Medical Authorisation of Blood components course.
4.8. The candidate must have documented approval from their service manager and mentor.
5. Training
5.1. The candidate must submit a portfolio of evidence to demonstrate knowledge and competence to the mentor
Authorisation of Blood Components for Transfusion by Registered Practitioners Policy
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5.2. The period of supervision will be at the discretion of the mentor depending on the needs of the individual. The period of supervision must include the authorisation of blood components which must be recorded.
5.3. On completion of training and competency assessments, a competency declaration form with all the support must be completed and sent to the service manager, lead clinician for transfusion, the blood transfusion specialist nurse and Workforce Development for logging on ESR.
6. Monitoring Compliance with and the Effectiveness of the Policy
Process for Implementation and Monitoring Compliance and
Effectiveness
6.1. The Hospital Transfusion Team and Hospital Transfusion Committee will ensure that patient safety and clinical effectiveness is not adversely affected by introduction of extended practice by monitoring patient safety incidents and clinical audit by the practitioner.
6.2. All incidents will be fully investigated and re-training initiated where appropriate as detailed in the policy. Non-medical authorisers may need to be re-competency assessed following an incident and cease to authorise until this has been completed. The Hospital Transfusion Team will inform them and their mentor of the need for this following an incident.
6.3. The practitioner must ensure they keep themselves up to date with the policies and procedures associated with transfusion and maintain their competencies to authorise transfusion.
6.4. The practitioner must complete trust mandatory training on transfusion in line with Trust requirements and complete ‘learn blood transfusion’ modules every 2 years.
6.5. The practitioner is required to audit their transfusion practice.
6.6. As a ‘user’ of blood components the practitioner should attend the Hospital Transfusion Committee meeting a minimum of once a year following completion to present their audit.
7. Equality Impact Assessment
Table 1: Equality impact Assessment
Group Positive Negative No Comment
Authorisation of Blood Components for Transfusion by Registered Practitioners Policy
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Impact Impact Impact
Age X
Disability X
Gender X
Gender Reassignment X
Human Rights (rights to privacy, dignity, liberty and non-degrading treatment)
X
Marriage and civil partnership
X
Pregnancy X
Maternity and Breastfeeding
X
Race (ethnic origin) X
Religion (or belief) X
Sexual Orientation X
8. References
J Green RN and L. Pirie RN. A Framework to Support Nurses and Midwives Making the Clinical Decision and Providing the Written Instruction for Blood Component Transfusion. 2009 Denise Watson Regional Lead: Patient Blood Management Team NHSBT Newcastle Upon Tyne. Implementing Nurse Authorisation of Blood Components Blood and Transplant Matters information for hospitals served by NHS. Blood and Transplant Mat 2013 issue 39 p 5. Kirsty Dalrymple Jill Martin, Kerri Davidson and Elisabeth Pirie. Extending the role of a senior haematology or oncology nurse. October 2011; Cancer Nursing Practice: volume 10 number 8. All Wales policy for Non-Medical Authorisation of Blood Component Transfusion. September 2013. Policy Template for the Authorisation of Blood Component Transfusion by Advanced / Specialist Nurses Caring for Adult and/or Paediatric Patients Requiring Transfusion London and South East Regional Transfusion Committees Non-Medical Authorisation of Blood Components Working Group September 2014 http://www.transfusionguidelines.org.uk/uk-transfusion-committees/regional-
transfusion-committees/london/policiesRelatedDocuments
Authorisation of Blood Components for Transfusion by Registered Practitioners Policy
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9. Appendix 1
Portfolio of evidence to support Registered Practitioners in
making the clinical decision and providing the written
instruction for blood component transfusion
NAME (CANDIDATE NAME (CONSULTANT MENTOR)
Job Title: Job Title:
Hospital: Hospital:
Ward/Dept: Ward/Dept:
Study Completion
Details
Date Copy of certificate Attached to Portfolio
Safe transfusion Practice 1
Safe transfusion Practice 2
Consent Module 9
Reaction Module 11
Non-medical authorisation
course
Trust Mandatory Individual
Training Matrix
Authorisation of Blood Components for Transfusion by Registered Practitioners Policy
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Understanding
of
Knowledge &
Competencies Evidence Submitted
Signed
Practitioner Mentor Date
Patient
Assessment
and clinical
decision
making
How to take
a patient
history
Accounting
for co-
morbidity
Consent
issues
Prescribing
of
concomitant
drugs
Understand the
requirement to
accurately document all
actions and
conversations with the
patient
Ability to make
appropriate referral if
the patient refuses
blood transfusion or has
an advanced directive
Ability to take a medical
history
Ability to link the clinical
picture with the
interpretation of blood
results
Understands how to
explain the risks and
benefits of transfusion
and available
alternatives
Know to provide patient
information leaflets
Can assess the patient
is fit for transfusion i.e
take account of co-
morbidities, day case or
in-patient
Know which
concomitant drugs may
be required
Authorisation of Blood Components for Transfusion by Registered Practitioners Policy
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Understanding
of
Knowledge &
Competencies Evidence Submitted Signed
Interpreting
blood results
Can demonstrate
knowledge and
understanding:
Of normal, variations of
normal and abnormal
haemoglobin and
platelets counts &
clotting results
Ability to interpret
results and initiate
treatment
Know if more tests
and/or further evaluation
is required
Writing the
Instruction to
transfuse the
blood
component
Demonstrates knowledge
that the written instruction
includes
Patient’s full name
Date of birth
Hospital number
Product description
The route of
administration
The length of time the
transfusion is to take
place
The number of
units/volume
Any special
requirements
Concomitant drugs that
need to be administered
Authorisation of Blood Components for Transfusion by Registered Practitioners Policy
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Understanding
of
Knowledge &
Competencies Evidence Submitted
Signed
Practitioner Mentor Date
Constituents of
blood
components
Gain insight into the
production from whole
blood of:
Red cells
White cells
Platelets
Plasma
Has knowledge of:
Storage
Safe handling
Temperature
control/cold chain
requirements
Understanding
of
Knowledge &
Competencies Evidence Submitted
Signed
Practitioner Mentor Date
Understanding
of anaemia
Can define the types of
anaemia
Understands
physiological process
for iron deficiency
anaemia
Knows when to refer
patients for further
investigation and
treatment
Knows how to order
appropriate
investigations
Understands the
different types of iron
therapies
Understands the use of
EPO
Authorisation of Blood Components for Transfusion by Registered Practitioners Policy
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Understanding
of
Knowledge &
Competencies Evidence Submitted
Signed
Practitioner Mentor Date
Pre-transfusion
testing process
Can demonstrate an
understanding
of the:
Pre-transfusion
sampling process
Sample labelling
requirements
BSCH guidelines for pre
transfusion testing
Time limits surrounding
the validity of samples in
storage
The laboratory
processes for pre-
transfusion testing
including how long
testing takes
Indications for
the use of
Platelets
Demonstrates a clear
understanding for the
use of platelets
(including platelet count)
Uses local policy and
national indication
codes to demonstrate
appropriate use
Can demonstrate in
which conditions their
use is not appropriate
Authorisation of Blood Components for Transfusion by Registered Practitioners Policy
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Understanding
of
Knowledge &
Competencies Evidence Submitted
Signed
Practitioner Mentor Date
Indications for
the use of red
cells
Demonstrates a clear
understanding for the
use of red cells
Uses local policy and
national indication
codes to demonstrate
appropriate use
Indications for
the use of
Fresh Frozen
Plasma
Demonstrates a clear
understanding of
appropriate use of FFP
in the context of
correction of deranged
INR results in the face
of bleeding or invasive
procedures which may
cause bleeding
Can demonstrate the
indications for which
FFP is not used
Uses local policy and
national indication
codes to demonstrate
appropriate use
Aware of normal and
abnormal clotting results
Authorisation of Blood Components for Transfusion by Registered Practitioners Policy
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Understanding
of
Knowledge &
Competencies Evidence Submitted
Signed
Practitioner Mentor Date
Special
Transfusion
Requirements
Demonstrates knowledge
and understanding of:
Which patient groups
will have special blood
requirements and why
Understands the
process to prevent
these patient’s receiving
the wrong blood
Transfusion
guidelines and
protocols
Can demonstrate
knowledge and
understanding of:
SABRE/SHOT
HSC Better Blood
Transfusion
1998/224, 2002/009,
2007/001
BSCH guidelines
Blood Safety and
Quality Regulations
2005 including
traceability
requirements
Patient information
leaflets
Authorisation of Blood Components for Transfusion by Registered Practitioners Policy
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Understanding
of
Knowledge &
Competencies Evidence Submitted
Signed
Practitioner Mentor Date
Legal
responsibilities
Record
keeping
Has knowledge and
understanding of NMC
Standards of conduct,
performance and ethics
Can explain why the
reason for transfusion
should be recorded in
the patient’s notes
Can explain why all
actions must be
documented
Ordering blood
components
Has knowledge of local
guidelines for ordering of
blood components and the
need to provide the
following details:
Full name of patient
Date of birth
Hospital number
When the patient is to
be transfused
How many units and
any special
requirements
Where the patient is to
be transfused
Diagnosis
Indication code
Appropriate for
overnight transfusion or
not
Contact name / bleep
number
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Understanding
of
Knowledge &
Competencies
Evidence Submitted Signed
Practitioner Mentor Date
Risks and
adverse events
associate with
transfusion and
how to deal
with them
Demonstrates knowledge
and understands the risks
of transfusion and describe
the management of the
following:
Transfusion and
transmitted bacterial
and viral infections
Transfusion Related
Acute Lung Injury
(TRALI)
Acute haemolytic
transfusion reaction
Wrong blood to wrong
patient
Fluid overload
Anaphylaxis
Iron overload
Authorisation of Blood Components for Transfusion by Registered Practitioners Policy
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10. Appendix 2
Log of transfusions
Hospital Number Location Number of units Diagnosis
Rationale for the transfusion Any other medication prescribed
Comments
Signature of RP
Signature of Mentor
Hospital Number Location Number of units Diagnosis
Rationale for the transfusion Any other medication prescribed
Comments
Signature of RP
Signature of Mentor
Authorisation of Blood Components for Transfusion by Registered Practitioners Policy
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11. Appendix 3 Record of supervised authorisation of Blood Components
Date Patient Hospital Number
Component Rationale for transfusion Comments on review of transfusion episode
Mentor signature if transfusion was satisfactory
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12. Appendix 4
Declaration of Competence Form
Registered Practitioner Authorisation and Written Instruction of
Blood Components
I have met the knowledge and competency criteria and I am proficient to undertake the
authorisation and written instructions for red cells and platelets
Name
……………………………………………………………………………………………………………
……………………………..
Signature………………………………………………………………………………………………
Clinical Area / Specialty:
…………………………………………………………………………………………………………
I have assessed the above practitioner and deem them proficient to undertake the authorisation and
written instructions for red cells and platelets. If practitioner is a nurse I have read the NMC code of
conduct http://www.nmc.org.uk/standards/code/read-the-code-online/
Name: ……………………………………………………………………………………………………………
Signature: …………………………………………………………………………………………………………
Date: ……………………………………………………………………………………………………………
Lead Haematology consultant for transfusion:
I agree the above practitioner proficient to undertake the authorisation and written instructions for red
cells and platelets
Name: ………………………………………………………………………………….......
Signature: …………………………………………………………………………………
Date: ………………………………………………………………………………………
Please send a copy of this form with Appendix 1, 2 and 3 to: -
Your clinical manager
The Transfusion Practitioner
Workforce Development for logging on ESR
Keep the original for your own records.
Copy of form will be returned to all individuals by BTNS
I have met the knowledge and competency criteria and I am proficient to undertake the authorisation and written
instructions for red cells and platelets
Name ……………………………………………………………………………………………………………………………
Signature………………………………………………………………………………………………………………………
Clinical Area / Specialty: …………………………………………………………………………………………………….
Date:……………………………………………………………………………………………………………………………