Policy No: RM36

RM36 Blood Transfusion Policy Version 5.1

Policy No: RM36 Version: 5.1

Name of Policy: Blood Transfusion Policy

Effective From: 20/05/2013

Date Ratified 03/12/2012 Ratified Hospital Transfusion Committee Review Date 01/12/2014 Sponsor Director of Nursing and Midwifery Expiry Date 02/12/2015 Withdrawn Date

This policy supersedes all previous issues.

RM36 Blood Transfusion Policy Version 5.1 2

Version Control

Version Release Author/Reviewer Ratified by/Authorised

by

Date Changes (Please identify page

no.) 1.0

Oct 2003 Hospital Transfusion Committee

Oct 2003

2.0

Dec 2004 Hospital Transfusion Committee

Dec 2004

3.0

Oct 2006 Hospital Transfusion Committee

Oct 2006

4.0

09/09/2009 L Bennett Hospital Transfusion Committee

10/06/2009

5.0

11/10/2011 K Nesbitt

Hospital Transfusion Committee

29/06/2011

5.1 03/12/2012 K. Nesbitt Director of Nursing,

Midwifery and Quality

17/05/2013 Pages 10,21,23,26,28,34&40


Blood Transfusion Policy

Contents Page 1. Introduction ...................................................................................................................... 5 2. Policy scope ....................................................................................................................... 5 3. Aim of policy ..................................................................................................................... 5 4. Duties ‐ roles and responsibilities ..................................................................................... 5

4.1 The Trust Board ..................................................................................................... 5 4.2 The Hospital Transfusion Committee ................................................................... 5 4.3 The Transfusion Lab manager ............................................................................... 6 4.4 The Transfusion Practitioners ............................................................................... 6 4.5 The Laboratory staff .............................................................................................. 6 4.6 Consultant Haematologists ................................................................................... 7 4.7 Medical staff ......................................................................................................... 7 4.8 Division Managers ................................................................................................. 8 4.9 Ward Managers ..................................................................................................... 8 4.10 Nursing staff, qualified and unqualified................................................................ 8 4.11 Phlebotomy staff ................................................................................................... 8 4.12 Portering staff ....................................................................................................... 8

5 Definition of terms ............................................................................................................ 9 6 Blood transfusion .............................................................................................................. 9

6.1 General notes 6.1.1 Current legislation ..................................................................................... 9 6.1.2 Documentation ......................................................................................... 9

6.2 Patient identification and wrist bands .................................................................. 10 6.2 1 Positive Patient Identification ................................................................... 10 6.2.2 ID wristbands ............................................................................................ 11 6.2.3 The Unknown Patient ............................................................................... 11 6.2.4 Photo ID cards ........................................................................................... 12

6.3 Transfusion in Major Incident (MIP) ..................................................................... 12 6.4 The Decision to Transfuse ..................................................................................... 13

6.4.1 Consent ..................................................................................................... 13 6.4.2 The reason for transfusion ........................................................................ 13 6.4.3 Pre‐assessment ......................................................................................... 14

6.5 Transfusion samples and requesting blood .......................................................... 14 6.5.1 Timing of transfusion samples .................................................................. 14 6.5.2 Requesting blood for transfusion ............................................................. 15 6.5.3 Guidelines for irradiated components ...................................................... 15 6.5.4 Blood transfusion samples ........................................................................ 16 6.5.5 HDN samples ............................................................................................. 16 6.5.6 Zero tolerance ‐ laboratory acceptance criteria ....................................... 17


6.5.7 Sample errors Three strikes ...................................................................... 18 6.6 Massive blood transfusion .................................................................................... 18 6.7 Prescribing/Authorising blood .............................................................................. 18 6.8 Preparing the Patient for Transfusion .................................................................. 19 6.9 Collection from the blood bank ........................................................................... 20

6.9.1 Requesting collection of blood from the blood bank ............................... 20 6.9.2 Collection from blood bank ...................................................................... 21 6.9.3 Administration of blood and care of the patient ...................................... 22 6.9.4 The bedside check ..................................................................................... 22 6.9.5 Checking blood using IT ............................................................................ 23 6.9.6 Monitoring Patients .................................................................................. 23 6.9.7 Reactions and Incidents ............................................................................ 24 6.9.8 Recall of blood........................................................................................... 24 6.9.9 Technical aspects of Transfusion .............................................................. 25

6.9.9.1 General ................................................................................. 25 6.9.9.2 Infusion pumps..................................................................... 25 6.9.9.3 Drugs and blood ................................................................... 26 6.9.9.4 Escorting patients ................................................................ 26

7. Training and Competency Assessments ........................................................................... 26 8. Equality and Diversity ....................................................................................................... 26 9. Process for Monitoring Compliance with the Policy ......................................................... 27 10. Consultation and Review of this Policy ............................................................................. 27 11. Implementation of this Policy ........................................................................................... 27 12. References......................................................................................................................... 27 13. Associated Documentation Appendix 1 Jehovah’s Witnesses and Patients refusing Donor blood.......................................... 29 Appendix 2 Indication codes for Transfusion ............................................................................... 33 Appendix 3 Blood Order Tariff ...................................................................................................... 34 Appendix 4 Ordering blood in an Emergency ............................................................................... 37 Appendix 5 How to use the “Porter track” system ....................................................................... 38 Appendix 6 The Bedside check ..................................................................................................... 39 Appendix 7 Reactions flow chart .................................................................................................. 40


Blood Transfusion Policy

1. Introduction

This policy should be read in conjunction with policy RM 57 Massive blood transfusion policy. The policy applies to all patients requiring a transfusion of any blood component

2. Policy scope

This policy applies to all staff employed by Gateshead Health NHS Foundation Trust involved in the care of a patient, who may require a blood component transfusion.

3. Aim of the policy The aim of the policy is to ensure safe and appropriate use of blood products are given to all patients who may require a blood transfusion.

4. Duties ‐ Roles and Responsibilities

4.1 The Trust Board

• Must ensure a Hospital Transfusion Committee (HTC) is in place to support good transfusion practice.1

• Should support the HTC in their role within the organisation. • Provide blood transfusion training for all clinical staff at induction and

through mandatory training • Support the Laboratory to maintain accreditation and fulfil all legislation

relevant to transfusion

4.2 The Hospital Transfusion Committee (HTC)

• Must meet at least 4 times a year to discuss strategies for optimising transfusion practice

• Produce all policies relevant to transfusion of blood and blood components. • Discuss Quality performance indicators including incidents • Monitor practice through audit • Support the Transfusion Practitioners in their role • Monitor the appropriate use of blood components • Promote strategies encouraging the appropriate use of blood and

conservation of blood stocks. • Produce a contingency plan for blood shortages.2 • Produce a maximum blood order schedule.1 • Encourage the use of clinically and cost effective alternatives to donor

blood. • Produce action plans and recommendations for best practise.


• Create a Hospital Transfusion Team (HTT) to implement the policies and recommendations of the HTC

• Support the transfusion laboratory manager to comply with the Blood Quality and Safety Regulations (BQSR) 2005 3

4.3 The Transfusion Laboratory Manager

• Ensure that staff who work in transfusion are appropriately qualified to

carry out their role. • Ensure ongoing training is maintained • Maintain CPA accreditation for the laboratory • Be a member of the HTC • Be a member of the HTT • Promote and maintain compliance with the Blood Safety and Quality

Regulations (BSQR) 2005. 3 • Monitor use of blood through statistical analysis of component use and audit

of the MSBOS. 1 • Is responsible for the implementation of the BSQR standards. • Responsible for completing the annual compliance report for the BSQR • Facilitate the MHRA if and when they carry out an inspection • Quality Manager for the Blood Transfusion Department.3 • Report financial impact of blood transfusion on the pathology budget

4.4 The Transfusion Practitioners

• Promote best practice through provision of training for all staff within the organisation according to their role.1

• Provide induction/mandatory training for all relevant staff. • Oversee relevant staff to ensure formal competency assessments are

completed every two years. • Devise and implement audits on areas of transfusion practice agreed at HTC 1 • Investigate, and report all incidents at local level i.e. DATIX and HTC and the

Serious Hazards of Transfusion (SHOT) and Medicines Healthcare Regulatory Authority (MHRA) as appropriate. 4,5, 3

• Be a member of HTC • Be a member of HTT • Be a member of the Laboratory User Committee • Lead in the writing and revision of policies related to Blood Transfusion. • Collaborate with departments to improve and manage changes in practice. • Provide information and guidance in transfusion practice

4.5 The Laboratory Staff

4.5.1 Team Leader • Promote the effective use of blood through compliance with MSBOS,

HTC guidelines and Better Blood Transfusion 3.1 • Training officer for Transfusion Laboratory staff


• Maintain a Quality Blood Transfusion service by observing stated protocols within the Quality Management System of the Clinical Pathology Services. 3

• Monitoring competency of all staff working in Blood Transfusion 3 • Responsible for the day to day running and quality control of the

Blood Transfusion Laboratory • Lead on and coordinate the production of SOPs on best laboratory

practice 1,3

4.5.2 Other Laboratory Staff • Maintain competency in Blood Transfusion Practice 1,3 • Maintain knowledge base in blood transfusion through CPD. • Promote effective use of blood through working within guidelines. 1 • Maintain a quality blood transfusion service by observing stated

protocols within the Quality Management System of the Clinical Pathology Services. 3

4.6 Consultant Haematologists

• Advise on the management of transfusion patients • Be a member of the HTT • Be a member of the HTC • Support the laboratory staff and Transfusion Practitioners in their role • Oversee competency of relevant doctors working in the Trust • Assist Transfusion Practitioners in investigation of incidents and mandatory

incident reporting. • Support the HTC audit programme • Promote effective implementation of national guidance and regulation.

4.7 Medical staff

• Promote the appropriate use of blood through observing British Committee

for Standards in Haematology (BCSH) guidelines and HTC recommendations and Trust policy 6

• Discuss risks and benefits of Blood Transfusion with the patient then obtain verbal consent wherever possible. 7

• Use effective alternatives where indicated.1 • Prescribe blood components appropriately. 7,15,16 • Maintain patient safety throughout the transfusion process. • Report any adverse reactions or events to the Blood Transfusion

Department or Hospital Transfusion Practitioners as soon as possible.3,4,5 • Attend Induction and Mandatory training.9 • Familiarise themselves with the Trust Patient ID and Blood Transfusion

policies (RM 36, RM40, RM 57and RM 77) • Record the reason for transfusion and any benefits gained in the Patient’s

health record. 7


4.8 Divisional Managers

• Ensure all staff attend appropriate training. 9 • Support the HTC in implementing strategies to improve patient care in

transfusion.

4.9 Ward Managers

• Facilitate the implementation of training and competency assessment of staff relevant to their role

• Ensure all staff attend mandatory training 9 • Follow Trust Transfusion and Patient ID Policies.10 • Ensure all staff that look after transfused patients are qualified to do so.8,3 • Ensure all adverse incidents within their area are reported through the

proper channels. 3,4 • Responsible for compliance in traceability of blood, achieved through

promoting confirmation by all staff on the ward.3

4.10 Nursing staff, qualified and unqualified

• Follow Trust Blood Transfusion and Patient ID policies. 10 • Attend nursing induction and mandatory training 9,1 • Will maintain competence following training in accordance with the TNA • Ensure all adverse incidents within their area are reported to the laboratory

immediately and are submitted to DATIX. 3,4,5 • Ensure that compliance regarding traceability is followed and confirmation

slips are returned following transfusion.

4.11 Phlebotomy staff

Follow the Trust Blood Transfusion and Patient ID policies re: blood sampling 10

• Require specific training on transfusion samples and be competency assessed every two years. 8

• Attend Induction and Mandatory training. 9 • Ensure all adverse incidents are reported to nurse in charge of the ward and

their line manager 3,4,5

4.12 Portering staff

• Follow Trust policies regarding collection and delivery of blood. • Attend specific induction training for collection of blood components with

competency assessment every two years 8,9 • Ensure all adverse incidents are reported through the proper channels. 3,4,5,


5. Definition of terms

HTT: Hospital transfusion Committee. This committee is responsible for patient safety in transfusion FFP: Fresh Frozen Plasma SHOT:‐ Serious Hazards of Transfusion This is a voluntary system for reporting blood transfusion incidents and reactions PPID:‐ Positive Patient Identification. The safest way to correctly identify the patient PAS:‐ Patient administration system SOP: ‐Standard Operational Procedure. A set of work instructions to ensure common, safe practice of work BMS: Biomedical Scientist is a scientist educated in the field of biological science. COPD: ‐Chronic Obstructive Pulmonary Disease. Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible TNA: Training Needs Analysis

6. Blood transfusion

6.1 General notes

All Blood components are covered by this policy

6.1.1 Current legislation

The Blood Safety and Quality regulations are written into British criminal law. It is our legal responsibility to comply with these regulations3

• The law covers the collection, testing, processing and storage of blood and

blood components and is relevant to hospital practice • Blood must be stored and transported appropriately maintaining the correct

temperature throughout • All components including, Blood, Platelets, FFP and Cryoprecipitate require

exactly the same degree of care for checking and administration • Each individual unit MUST be prescribed using the approved documentation • Each individual unit MUST be accounted for and every single unit transfused

or wasted MUST be confirmed to the laboratory

6.1.2 Documentation • A transfusion record is available for recording transfusions.2


• This document should only be used in the printed format and never photocopied11

• The transfusion record must be used to record transfusion in all areas with the exception of the critical care department (CCD) where it is permissible to record transfusion observations on the daily observations chart, but they must be identified as transfusion observations

• Full patient details must be recorded, including a Forename, Surname, Date of Birth, Record number* and Gender7

• A reason for transfusion must be recorded • Any special requirements must be clearly stated or “none” to be written in

the box • Each unit should be prescribed separately • The donation number of every unit given must be recorded. This is a legal

requirement 3 • All sections must be completed to comply with BCSH Guidelines3 • Each unit must be signed for by the person(s) who checked the blood. • Where two persons are used to check, two independent, separate checks

must be completed and the second checker hangs the blood product 7 • Start and finish times must be recorded • Clinical observations must be recorded and be identified as transfusion

observations, “pre transfusion, 15minutes and end of transfusion” • All adverse reactions should be recorded and reported to the laboratory or

Transfusion Practitioners then reported using DATIX • The management of any adverse events should be recorded • The patient’s response and any benefit should also be recorded

6.2 Patient Identification and Wristbands

This has been identified by Serious Hazards of Transfusion (SHOT) as an area of risk for the patient.

6.2.1 Positive patient identification 1,7,8,10,12

This is an essential step in reducing the risk for the patient

• Positive Patient Identification (PPID) must be carried out regardless of what procedure, test, or treatment the patient is to receive

*ALERT There is a move to using the NHS number instead of a hospital record number (NPSA). In view of this the Trust will move over to the NHS number as soon as it is appropriate to do so. For the purpose of this policy “record number” currently means the hospital record number, but may change to the NHS number during the lifetime of this policy.


• This is central to good patient care and maintains the patient’s safety at all times.

• Even if you know the patient well, do not be tempted to avoid the process as SHOT have evidence where regularly transfused patients, well known to staff, were given the wrong blood

• ALWAYS positively identify the patient by asking for a full name and date of birth

• Check this against the ID wristband, where the patient’s record number must also be found

• This is the only safe and effective way to positively identify patients properly

• Do not ask “are you John Smith?” as the patient may say “Yes” but could have misheard exactly what was said

• Patients who cannot identify themselves may wholly depend upon an ID wristband as this may be the only means of identification they have

6.2.2 ID Wristbands 7,8,10,12

All transfusion patients are required to wear an ID wristband or carry Photo ID, HOWEVER, all in patients must wear an ID wristband • The Trust has invested in printed wristbands to promote safer patient

identification • These wristbands are printed directly from the PAS system • They must be used wherever they are available • If a printer breaks down, it must be reported to IT immediately • An attempt must be made to have a printed wristband issued from

another printer • If this is not possible a hand written wristband must be produced. • The wristband must include the patient’s full, surname, forename,

date of birth, hospital number and gender and should remain insitu for the duration of the transfusion process

• Addressograph labels are not suitable for patient wristbands • If a wristband is removed for any reason e.g. to re‐site a cannula, it is

the responsibility of the person who removed it to replace it immediately

6.2.3 The Unknown Patient 7

For an unknown and unconscious patient, an A&E hospital number will be generated from PAS. The patient will be identified as, “Unknown Male/Female”, with a date of birth gauged upon the following: 01.01.2009 if less than 16 years 08.08.1988 if more than 16 years Changing over to the patient’s correct details needs to be risk‐ assessed as doing so too soon can be a risk for the patient. See the “Alert box” below


6.2.4 Photo ID cards 8

• Regularly transfused patients(at least every three months) may be

issued with a Photo ID card instead of a wristband which can be used to positively identify patients having community transfusion samples taken and out patient transfusions

No ID, No Transfusion!

GET IT RIGHT FIRST TIME, EVERY TIME, AND SAVE TIME

6.3 Transfusion in a Major Incident (MIP previously MAJAX) 10, 13

• In a “MIP” patients have to be managed in a different way from the usual

processes. • All patients in a “MIP” will initially be given a “MIP” identity, for example:

Adam One, 18.08.1988, 0987654 and will wear an ID wristband stating the “MIP” identity.

• Patients requiring any investigations, drugs or blood will have results and blood issued using the “MIP” ID

• Adhering to policies for patient identification, sample acceptance and transfusion in general are more important than ever in a “MIP”.

• Under no circumstances will the rules be bent regardless of the situation. • Check all samples for accuracy before sending them to the lab as they will

have to be repeated if there are any discrepancies • If a patient is in the process of having a transfusion, they must continue with

the MIP identity until the transfusion is completed, as all blood components will be labelled as such.

• Once the transfusion is completed and the Clinician in charge of the patient’s care considers it safe to revert to the patient’s own identity, a new

ALERT CAUTION: Once a patient’s details become known, great care is needed in deciding when to change the wristband to the correct details. It is essential the source of the new information is reliable. If an unknown patient is having active treatment with blood components, changing the patient wristband half way through will cause confusion as the blood will be labelled as “unknown etc” and the new wristband will not be the same. It is far safer to leave the patient as “unknown” until the blood transfusion is finished. The Clinician looking after the patient will decide when it is safe to revert to the patient’s proper details A new sample with the correct details must be sent if further blood is required, stating clearly that these are updated patient details and including the previous identification details


wristband must be produced and samples sent to the lab for blood grouping if the patient is likely to require further blood components.

• The lab must be notified of the change in details. • For patients not previously registered to Gateshead, the MIP PAS number

will be retained; just the name and date of birth will change. • All results and documentation relating to the transfusion must be filed in the

“MIP” notes NOT the general Gateshead health record

6.4 The decision to transfuse

6.4.1 Consent for transfusion 7,14

• The decision to transfuse should be a joint decision between the doctor and

the patient, following a full and frank discussion including the risks and benefits of having a transfusion.

• There are patient information leaflets available to help the patient to decide.

• Where possible an alternative may be offered. • Members of staff are expected to ensure care is taken to ensure that any

communication barrier does not compromise assessment of consent. For example patients who are Deaf or hearing impaired, have profound or multiple learning disabilities, or who are unable to understand a language may need information provided in alternative formats.

• Members of staff should refer to the Mental Capacity Policy RM74 when dealing with patients who may lack capacity. The Mental Capacity Act 2005 provides a statutory framework to empower and protect vulnerable people, who may not be able to make their own decisions. It makes it clear who can take decisions on behalf of others, in which situations, and how they should go about this.

• All patients have the right to refuse blood components. The patient refusing blood or blood products will be treated appropriately and with respect.

• Where patients refuse blood transfusion.

See the policy for Jehovah’s Witnesses and patients refusing blood Appendix 1.

6.4.2 Reason for transfusion 7

• Before asking for blood to be cross‐matched consider whether a blood transfusion is necessary.

• There are many risks in transfusion and this should always be taken into account.

• First consider the patients underlying pathology and the Haemoglobin (Hb) level appropriate for transfusion. In most cases patients will tolerate an Hb of 8g/dl or less. A trigger Hb of 8g/dl, has been adopted by the Transfusion Committee where the patient is symptomatic

• Consider any co‐morbidity e.g. Coronary Heart Disease, COPD etc.


• Consider the patient’s symptoms, e.g. breathlessness, chest pain, fatigue etc.

• See the indication codes for transfusion in Appendix 2 and the Blood order tariff, Appendix 3

6.4.3 Pre assessment1

Pre assessment is an ideal opportunity to find out:

• The patient’s Haemoglobin status. • Act upon any anaemia prior to admission where possible • Commence Iron therapy if appropriate to do so. • Ask about any previous history of bleeding following surgery of tooth

extraction • Check blood group and antibody screen. • Patients with antibodies must be discussed with the Surgeon and

Anaesthetist immediately to avoid issues on the day of admission. • Some red cell antibodies may make same day admission difficult and

in some cases impossible • Patients with antibodies should ideally not be first on the list to allow

time for cross matching and obtaining the blood from the National Blood Service (NBS).

• Drugs (prescription and over the counter) should be discussed including: o Any anticoagulant drugs or other drugs which may affect

platelet function may/may not need to be stopped prior to admission

o Discuss when to stop any of the above drugs prior to admission

o Patient’s choice regarding: o Acceptance/refusal of blood transfusion o Any preferred alternative to donor blood

6.5 Transfusion Samples and Requesting blood

6.5.1 Timing of transfusion samples25

The timing of transfusion samples can be critical due to the possible production of red cell antibodies and the associated risk of a delayed transfusion reaction Patient transfused within previous

Sample to be taken not more than

3‐14 days 15‐28 days 29days – 3 months

24 hours before transfusion 72 hours before transfusion 7 days before transfusion. (Day sample taken is deemed as day 1)


6.5.2 Requesting blood for transfusion 7,17

• Only a qualified doctor or authorised Specialist Nurse may decide

that blood needs to be requested from the lab, however, blood may be requested by phone by anyone on a doctor’s behalf.

• For telephone requests, full patient details, the name of the person making the phone call and the requesting doctor’s name, will be recorded by the laboratory staff, in accordance with the guideline.

• The lab will require a blood sample before they can issue blood. • Two transfusion samples are required for new patients without

previous known blood group data. • Only in an extreme emergency, e.g. where there is not enough time

to wait for a sample to get to the lab, 2 units of O Rhesus D negative blood will be issued. A sample is required urgently in order to issue further blood. See Appendix 4

• Full patient details are required on the request form. • This must include the surname, forename, gender, date of birth and

record number • The reason for the request needs to be clearly stated. • Not just “anaemia” but why the patient is anaemic • A current Haemoglobin where possible • “Pre‐ op”, is insufficient information for a cross match. • Ante natal patients must have previous pregnancies and Anti D

information completed • The requestors name and contact number MUST be given in case

there is a problem. • Any special requirements must be stated, e.g. “Irradiated”

components • For massive haemorrhage see Appendix 4 and the full policy for

Massive transfusion policy RM57

6.5.3 Guidelines for the use of Irradiated Components

Components should be irradiated for the following:‐ • All donations from first and second degree Relations • All adults and children with Hodgkin’s lymphoma at any stage of the

disease should have irradiated products for life. • Patients who have received purine analogue drugs

(Bendamustine,Fludarabine, Cladribine and Deoxycoformicin, monoclonal antibodies, e.g. Campath or biological immunosuppressive agents should receive irradiated products indefinitely

• Neonatal transfusion if previous interuterine transfusion (IUT) and for all IUT.

• Patients with aplastic anaemia receiving immunosuppressive therapy with anti‐thymocyte globulin (ATG)

• Bone marrow transplant patients


• Congenital Immunodeficiency • Paediatric oncology patients

Contact the transfusion laboratory on ext 2281 for advice if unsure. Wherever possible transfusions requests for irradiated products should be made 24 hours in advance.

6.5.4 Blood samples for transfusion5,7,8,12

This is an area of practice highlighted by the NPSA as requiring training and competency assessment.

• A group and save or cross match sample, should only be taken by

someone who is competent at venepuncture and has been competency assessed, within the last two years, at taking transfusion samples

• Routine overnight transfusion should be avoided. Any transfusion sample which is not considered urgent should not be taken until the following morning to avoid the associated risks.

• Only one patient should be bled at any time to avoid confusion. If in any doubt the sample must be repeated

• Always positively identify the patient before taking the sample. • This can be achieved by asking the patient for a full name and date of

birth. • Check the patient’s details against the ID wristband or photo ID card,

which must be exactly the same. • This is the only safe and effective way to positively identify patients

properly • Once taken the blood should be labelled immediately at the patient's

side, by the person who took the sample • Never hand the sample to someone else to label for you. • Never label a sample for someone else • The ID wristband must be used as the source for the patient details. • The sample details MUST be hand written unless, an order‐

communication two dimensional bar‐coded label, generated from the patient’s printed ID wristband is used.

• NEVER: • Pre‐label samples, • Use addressograph or ICE labels • Use medical records and request cards for patient details.

6.5.5 HDN samples

• These samples are taken, to establish the baby’s group, where the

mother is Rhesus D negative and may require Anti D • The babies sample is a cord blood sample and this should be taken as

soon as possible after birth.


• The mother’s sample is a venous sample. This should be taken no sooner than 1 hour after delivery.

• The samples should be sent together with the mother’s details on the request card

• They MUST be labelled as shown in the table.

“MOTHER’S” Blood sample “CORD” Blood sample Surname Mother’s surname Forename Boy/Girl Date of birth Baby’s date of birth Record number Mother’s record number

6.5.6 Zero tolerance – laboratory tolerance – laboratory acceptance criteria for transfusion 19

The Blood Quality and safety regulations support zero tolerance for incorrectly labelled samples and samples where the patient has not been sufficiently identified

• The laboratory have a strict sample acceptance criteria for all

transfusion lab samples including: Group and Save, and Cross match, DCT, HDN, and all Ante natal samples etc.

• The samples must include the patient’s full name, date of birth, record number or NHS number for community samples, (in the future the NHS number may also be used for hospital samples)

• The BMS in transfusion has the right to refuse any sample he/she feels is inadequately labelled or if they feel the patient has not been positively identified.

• Samples inadequately labelled will not be accepted and must be repeated.

• The person who took the sample is responsible for any delays this may cause, NOT the laboratory.

SAMPLE label must have REQUEST FORM must include

Surname. Forename(s). Date of birth. Record number. Gender. NB. Must be labelled, signed and dated by the person who took the sample

As for Sample plus Consultant and Ward The reason for transfusion. Other relevant clinical details. The amount of blood etc required. The whereabouts of the patient. Date and time required. Any special requirements e.g. Irradiated components Ante natal information re, previous pregnancies, any Anti D given Must be signed and dated by the person completing the form.


6.5.7 Sample Errors‐ HTC Three strikes

• First sample error noted but no action taken • Second sample error, the staff member involved will be sent a letter

from the HTC informing them they have made a second error and if they make a third error within a year they will be stopped from taking any further samples until they have received re‐training and competency assessment by the Transfusion Nurses. The manager of the staff involved in the sample error will also be informed by letter.

• Third sample error. The member of staff involved in the error will be sent a letter from the HTC informing them that they will not be allowed to take any further samples until they have received re‐training and competency assessment by the Transfusion Practitioners. The manager of the staff involved in the sample error will also be informed and asked to support staff re‐training.

• This may impact on service provision but patient safety is paramount.

6.6 Massive blood loss 20,21,18

• Only a doctor experienced with massive transfusion should co‐ordinate and manage this specific group of patients.

• In patients who are bleeding rapidly, Haemoglobin is a poor indicator of the need for transfusion:

• In these cases, it is more appropriate to use the volume of blood lost either measured or estimate, in assessing the need for transfusion.

• N.B. Patients who have lost less than 30% of their blood volume are unlikely to require transfusion, however patients who have lost more than 40% will probably require transfusion.

• Positive patient identification and appropriate use of all blood components must be encouraged to minimise the risk for the patient, even in an emergency. If in doubt, contact the on call Haematologist for advice.

• Read the Massive transfusion policy (RM 57) available for this situation. See also Appendix 4

6.7 Prescribing/Authorising blood components 5,7,11,25

• It is the responsibility of a doctor or authorised specialist nurse to authorise the administration of blood components

• Each individual unit must be prescribed including the duration of the transfusion. See table below.

• Every single blood component unit must be prescribed including any autologous salvaged blood

• Blood should only be prescribed on the approved transfusion record. • Any drugs which need to be given during the transfusion can be prescribed

on the same record. • It is not necessary to routinely prescribe diuretics with blood. • The reason for transfusion must be recorded.


• Any special requirements i.e. Irradiated or CMV negative must be stated on the prescription.

• Routine blood transfusions must not be prescribed over night. Only urgent transfusions should be given at night.

• The HTC cannot support routine overnight blood transfusion.

Suggested component transfusion times

COMPONENT DURATION PUMP ? Red cells 2‐3 hours

MAXIMUM 4 hours from leaving fridge

Only a pump approved for blood may be used with a specific blood giving set See section on Pumps.

Platelets 20‐30 mins Never use a pump for platelets FFP 20‐30 mins Cryoprecipitate Stat N.B. Any of the above can be given more quickly if the patient’s condition dictates. 2,3.

6.8 Preparing the patient 3,7,8,23

This is an area of practice highlighted by the NPSA as requiring training and competency assessment. All staff MUST be deemed competent.

• Written information in the form of a National Blood Service information

leaflet is available and should be given to the patient. • The need for transfusion must be discussed with the patient, including the

risks and benefits of transfusion so an informed choice can be made. • Members of staff are expected to make reasonable adjustments to ensure

that the different needs of patients are met. For example, patients who are Deaf, have sensory impairments, have profound or multiple learning disabilities, or who are unable to understand a language may fail to comprehend instructions, give inappropriate responses or remain silent.

• Verbal consent is required and the patient has the right to refuse. See Appendix 1 for Jehovah’ Witness and patients refusing blood transfusion

• All patients must wear an ID wristband or have a photo ID card (out patients only) for transfusion.

No ID, No BLOOD TRANSFUSION.

• A prescription is required for transfusion. It is the responsibility of the

doctor or authorised specialist nurse requesting the blood to complete the prescription. Failing to do this straight away can lead to a delay in starting the transfusion.

• The patients will need intravenous access.


• Check base line observations (temperature, pulse, blood pressure, and respiratory rate prior to sending for the blood.

• Ensure there is someone available to check the blood with you before sending for it.

• Avoid sending for blood over the handover period as this may cause a delay. N.B. Many of these are reasons why blood is wasted. Make sure you and the patient are ready to proceed before sending for the blood. Don’t ask for blood until then.

6.9 Collection of blood from blood bank 3,7,8

Both requesting collection and the actual collection of blood from blood bank are areas of practice highlighted by the NPSA as requiring training and competency assessment.

6.9.1 Requesting collection of blood see appendix 5

• Blood collection requests must be made using the “Porter trac”

system if it is available • It is essential you remain logged into “Porter trac” whilst it is

available, as logging on is time consuming, especially in an emergency

• Keep the system minimised on the computer screen for easy access • You must provide all of the following:

Surname, forename, date of birth, record number. What you need collecting, eg Blood, FFP, Platelets, Cryoprecipitate. If more than one unit is required, you need to state clearly how much you need

• Take the patient information with you to the computer, as you

cannot request blood without it • You will have to repeat the process if it is wrong • If there are any omissions or queries, the charge‐hand will contact

you by phone to ask you to repeat the request including the missing information.

• This will cause a delay. • Porters cannot collect blood without full patient details, as several

patients may share the same name and date of birth. • Remember to ask for collection from Pathology otherwise the porter

will come to collect blood from your ward to return to pathology • Only select “Bleeder” if the patient is haemorrhaging and you require

a lot of blood. • A porter will be sent to act as runner in this situation. • It is inappropriate to select Bleeder for a single unit of blood. • Inappropriate use of this category will be monitored.


• Blood transfusion is a priority for all concerned, but rules apply which must be followed

• Out of hours the porters will need to be phoned or bleeped and provided with the same information as above.

• The porter must complete a green slip for collection out of hours • Urgent requests for blood should be ordered via porter track (when

available) and then followed by a telephone call to confirm the necessary information has been received by the porters

6.9.2 Collection from blood bank 7,8, 3

• Blood may be collected by, any member of staff who has had specific training and competency assessment.

• Most of the time this will be a porter. See previous section for requesting collection.

• Anyone collecting blood must be trained and assessed before they will be given the authority to carry out this task.

• The transfusion nurse provides this training. • The person collecting the blood from blood bank must have the

patient details available to them so they can check the patient details match.

• There is a printer connected to porter track in the blood bank to facilitate this for the porters.

• Out of hours porters must use green slips for blood collection. • All other staff collecting blood will need to use a green collection slip.

These are available from the transfusion lab • Only one unit should be taken from the blood bank fridge at a time

(unless the patient is bleeding and requires a lot of blood over a short period of time)

• Single units should be transported to the ward/dept in a BLUE blood box (30 minute expiry).

• Unused blood must be returned to the laboratory within this time

NB. BLUE boxes are not suitable for storage on the ward

• If more than one unit is required they must be transported in a WHITE insulated blood box (2 hour expiry), which can be only be obtained from blood bank staff

• This WHITE box will have a 'use by' time written on a card in the front pocket of the box

• These units must be transfused or returned to the lab before this time expires or returned to blood bank

• Blood should be stored in the box until it is ready to be given • Boxes should be returned to blood bank as soon as possible • In extreme emergencies only, the pneumatic tube system may be

used to transport a maximum of two units of blood. • In this case the blood must be double bagged before being put into

the pod


• Staff on the ward must phone the lab to confirm the blood has been received.

6.9.3 Administration of blood and care of the patient

Administration of blood and care of the transfused patient are both areas of practice highlighted by the NPSA as requiring training and competency assessment. All staff MUST be competent. N.B. This is the final opportunity to detect any errors before the patient receives blood. The patient is most likely to have a reaction within the first few mls. of blood transfused.

6.9.4 The bed side check 7,8,10,12

• Each bag of blood should be checked at the patient's bedside. Blood

should never be checked away from the patient’s side. • This should take place immediately before administration • The check should be carried out by two independent checkers, a

qualified doctor, nurse, midwife or ODP. The second checker hangs the blood. Only staff who have been competency assessed will be allowed to check blood.

• Where the IT barcoded system is used for checking blood, only qualified staff will be trained to use it.

• ALWAYS positively identify the patient by asking for a full name and date of birth prior to the pre transfusion check .

• Check the details given against the patient's ID wristband where the hospital number will also be found.

• Printed wristbands will have eye readable information as well as barcoded information.

• Check the blood is correctly prescribed for the patient and the details on the prescription form match the patient’s wristband.

• Check the patient details on the blood compatibility label match the patient’s wristband exactly.

• Check the patient’s blood group on the blood compatibility label. • Check the donor blood group on the compatibility label and blood

bag. • Check the donation number on compatibility label and the blood

bag. • Check the expiry date on the compatibility label and the blood bag. • Check the use by date on the compatibility form (this is the last date

you should give the unit to that specific patient). • Check any special requirements against the prescription. • Visually inspect the bag for any leaks, discolouration and obvious

clots etc. This is an important step as there is a risk of bacterial contamination in a damaged bag.

• If there are any discrepancies, no matter how minor, phone Blood Bank on 2281, who will advise you.


See Appendix 6

6.9.5 Checking blood using IT ie. safe TX

• Only qualified staff will be able to use this system for checking blood

following training and competency assessment

6.9.6 Monitoring of patients 5,7,8,11

N.B. Overnight transfusions should only be given in an emergency based on clinical need. The decision to give a routine transfusion over night cannot be supported by the HTC

• Patients receiving transfusion should only be nursed in an area

where they can be easily observed and monitored throughout the transfusion.

• This is especially important during the first 15 minutes when they are most likely to have a reaction and is the main reason routine transfusions should not be given at night.

• Clinical observations can be carried out by anyone who is trained and competent. Any unqualified staff i.e. Healthcare assistants, who carry out clinical observations must complete a competency assessment for that specific task for transfusion patients.

• All transfusion observations should be recorded as such and be easily identified on the observations chart.

• Baseline observations of temperature, pulse, respirations and blood pressure should be carried out not more than one hour before the transfusion.

• Record the start time of the transfusion • Repeat and record observations of temperature, pulse, respirations

and blood pressure after 15 minutes. • Repeat and record observations at the end of transfusion.

N.B. This is the minimum requirement. • Observations at the end of each unit, provide a base line for the next

provided they are given in succession. • More frequent observations are suggested if the patient’s condition

warrants it, or the person looking after the patient feels it is appropriate.

• Each unit is a separate transfusion. • Encourage the patient to tell someone if they feel ill or different

once the transfusion has started • At the end of the transfusion, document the finish time on the

Transfusion record . • Record the effectiveness of the transfusion, any adverse events and

subsequent treatment in the notes.


6.9.7 Reaction and incidents in transfusion3,4,5,7,27

Incident reporting of all adverse reactions and events in transfusion is an area of practice highlighted by the NPSA as requiring training and competency assessment.

• REACTIONS. See also the flow chart, Appendix 7

• If you suspect the patient is having a reaction i.e. the patient

develops a rash, rigor, shivering, pain to the chest, loin, or abdomen, or reports felling unwell or is distressed or agitated in any way

STOP THE TRANSFUSION IMMEDIATELY

• Send for a doctor. • Repeat clinical observations. • In severe reactions keep the patient under constant observation until

medical help arrives. • Repeat the bedside check to make sure it is the right blood for the

patient. • If you find the patient has received blood for another patient, find

the other to make sure they are not also receiving the wrong blood. • In the case of a severe reaction the Transfusion laboratory should be

contacted and they will advise you of the procedure to follow. • All transfusion reactions and incidents MUST be reported BY LAW. • You should contact the Transfusion laboratory or Transfusion nurse if

a transfusion reaction or incident occurs. • All incidents will be reported using the DATIX reporting system in the

Trust. • All transfusion incidents will be investigated by the hospital

transfusion team and serious incidents must be reported to and discussed by, the HTC.

• All appropriate incidents will be reported to external bodies I.E. The Serious Hazards of Transfusion (SHOT) and the Medicines and Healthcare Products Regulatory Agency (MHRA) as appropriate by the HTT

6.9.8 Recall of blood

• Blood can be recalled for a number of reasons, either by the

transfusion laboratory or the National Blood Service. • If this occurs the laboratory will contact you either: • To try to stop the blood from being given. • Ask you to discontinue the transfusion • Confirm who the blood has been given to. • It is essential you follow the laboratory’s advice immediately


• If the patient has had any/all of the blood they must be closely observed as the blood may not have been completely compatible and the patient may show signs of a transfusion reaction.

6.9.9 Technical aspects of transfusion7,24,26

6.9.9.1 General

• A standard blood giving set should be used which includes a

150 micron filter. • It is perfectly acceptable to use a free flow giving set for

transfusion • Sets should be changed every 12 hours or four units which

ever come first (except in massive transfusion • Blood given at a rate of more than one unit per hour, should

be given through a blood warmer. • Giving sets should be changed between different types of

components to prevent the risk of clotting. This includes changing from O rhesus D negative to the patient’s own group.

• Giving sets should be discarded after use in a large sharps bin, the same as for any other infusion

• The blood component bags must be kept for 48 hours after use in a clinical waste bag in the dirty utility on the ward.

6.9.9.2 Infusion pumps7

• Only pumps approved for transfusion may be used, complete

with a specific blood giving set. • It is not absolutely necessary to use a pump for blood

transfusion. • Free flow giving sets can deliver blood over a specific time if

the patient is monitored closely enough. • Before using a pump ask yourself, “Is it necessary? • It is vitally important the patient is monitored, by regular

checking throughout the transfusion, with or without a pump.

• Pumps should never be used to “monitor” a patient having a transfusion.

• A pump will only alarm if the flow of blood is restricted or there is air in the line.

• Pumps do not inform you if the patient has had a reaction. • Generally giving sets for pumps are more expensive than free

flow giving sets • There are other infusions much more dependant on a pump

than blood • A pump is no substitute for good patient care


6.9.9.3 Drugs and blood7

• Blood cells and platelets are fragile structures which can be easily damaged by rough handling, fluids and chemicals. Even plain water can haemolyse (destroy) blood cells. Care is needed to prevent any damage to the cells being transfused.

• Drugs must never be added to blood components under any circumstance

• Generally speaking a transfusion should have a dedicated cannula for the duration of the transfusion

• Continuous infusions must not be given through the same cannula as a blood transfusion.

6.9.9.4 Escorting patients

• If a patient needs to be transferred to another

ward/department and they are in the middle of a transfusion, a decision needs to made to either:

• Wait until the transfusion is completed. • Send the patient with a qualified nurse escort if the patient is

to be transferred during a blood transfusion, but avoid this where possible, during the first 30 minutes of a transfusion starting.

7. Training and competency assessment 3,7,8,9

See the Trust learning needs analysis.

8. Equality and diversity

The Trust is committed to ensuring that ,as far as reasonably practicable, the way we provide services to the public, staff and visitors reflects their individual needs and does not discriminate against individuals or groups on the grounds of any protected characteristic. The Human Rights Act (1998) places a positive duty upon ‘public bodies’ to act compatibly with the 1950 European Convention on Human Rights. This includes a duty to intervene proportionately to protect the rights of citizens, including Article 2: ‘The right to life’. This policy enables staff to ensure safe and appropriate blood products are given to all patients who may require a blood transfusion.

Whilst the policy does not aim to promote disability equality, it does enable the Trust to make reasonable adjustments to ensure that the different needs of patients are met.

Where patients refuse blood products on religious grounds, as in the case of Jehovah’s Witnesses, the policy enables staff to discuss their individual wishes and beliefs and their relevance to the proposed treatment at the earliest opportunity to enable safe and effective care. Patients will be treated appropriately and with respect.

This policy has been appropriately equality impact assessed.


9. Process for monitoring compliance with the policy

Standard/process/issue Monitoring and audit

Method By Committee Frequency Bedside check National audit Transfusion

Practitioners HTC 3 years

Snapshot local John Barker HTC Annual

MHRA

Compliance report John Barker HTC Annual

Sample errors

Continual surveillance Annual report

Transfusion Practitioners

HTC Continuous

Ad hoc audit Transfusion Practitioners and laboratory staff

HTC Ad hoc

10. Consultation and review of this policy

This policy has been approved by the Hospital Transfusion Committee. The policy will be reviewed every two years and as new guidelines become available to ensure compliance with current legislation.

11. Implementation of this policy

This policy will be circulated by the Trust Secretary as detailed in OP 27 Policy for the development, management and authorisation of policies.

12. References

1. Department of Health (2007) Health service circular, Better Blood Transfusion: The safe and appropriate use of blood.

2. Gateshead Contingency plan for blood shortages. 3. The Blood Quality and Safety Regulations 2005. Statutory Instrument 50 2005.

These are based upon the European Union regulations: Directive 2002/98/EC. (2003) Setting standards of quality and safety for the collection, testing, processing, storage and distribution of human blood and blood components and amending Directive 2001/83/EC. The European Parliament.

4. Gateshead Trust policy; Incident reporting and investigation RM 4 5. The Serious Hazards of Transfusion annual reports (1996‐2011) 6. The British Committee for Standards in Haematology:

a. Guidelines for use of red cells. British Journal of Haematology 2001: 113(1) 24‐31 (2001)

b. Guidelines for the use of fresh‐frozen plasma, cryoprecipitate and cryosupernatant, British Journal of Haematology 2004,126,11‐28)

c. Guidelines for the use of platelet transfusions. British journal of haematology 2003: 122(1) 10‐23


d. Guidelines on the use of irradiated blood components. British Journal of Haematology 2010:152, 35‐51

7. BCSH (2009) Guidelines on the administration of blood products. www.bcshguidelines.com/documents

8. The National Patient Safety Agency safer practice notice No.14, Right patient, right blood (2006)

9. Gateshead Trust policy for Mandatory Training and Induction 10. Gateshead Trust policy for patient identification RM40 11. Gateshead Health NHS Trust (2004). Blood and Blood components Transfusion

record. (LP15554) 12. The National Patient Safety agency safer practice notice No 24 (2007):

Standardising wristbands improves patient safety: following on from, Safer practice notice 11: Wristbands for hospital inpatients improves safety (2005)

13. Gateshead Health Trust Major Incident plan (MIP ) 14. Gateshead Health Trust Consent policy 15. Indication codes for transfusion 16. Blood order tariff 17. The Medicines act (1968) 18. Gateshead policy for Massive blood transfusion RM57 19. Laboratory specimen acceptance criteria. Genman PR 012 Guidelines for massive

transfusion. British journal of Haematology (2006) 135(5) 634‐41 20. European guidelines for massive transfusion 21. BCSH guidelines for gamma irradiation of blood components for the prevention of

transfusion‐associated graft‐versus‐host disease. Transfusion Medicine 1996; 6|:261‐71

22. National Blood Service Patient information leaflet for transfusion 23. RCN guidelines for transfusion “right patient right blood” RCN (2003) Standards for

Infusion therapy. 24. BCSH (2004) Guidelines for compatibility procedures in blood transfusion

laboratories. Transfusion medicine. 14, 59‐73 25. Gateshead Trust policy for Waste disposal and recycling policy IC 9 26. Equality Act (2010) 27. BCSH (2012) Guideline on the investigation and management of acute transfusion

reactions Useful websites

• British Committee for Standards in Haematology website www.bcshguidelines.com • SHOT Website www.shotuk.org • Department of Health, “Better Blood Transfusion” website www.dh.gov.uk


Suggested management of Jehovah’s Witness patients The same principles should apply to any patient refusing donor blood. Jehovah’s Witnesses accept most medical treatments, surgical and anaesthetic procedures devices and techniques as well as haemostatic and therapeutic agents that do not contain blood. They accept non‐blood volume expanders, pharmaceutical that control haemorrhage and stimulate the production of red cells, and other non‐blood management. However all Jehovah’s Witnesses will find the following unacceptable:‐

• Transfusions of whole blood, packed red cells, plasma, and platelets. • Pre‐operative autologous blood collection and storage for later re‐infusion (pre‐deposit).

Each Witness decides whether he/she wishes to accept the following as a matter of individual choice. It is therefore important to discuss with each patient whether or not these are acceptable.

• Blood salvage (intra‐operative & post‐operative, haemodilution, haemodialysis, heart bypass (pumps must be primed with non‐blood fluids)

• “Fractions” of plasma or cellular components (e.g. Albumin, Immunoglobulins, clotting factors and Haemoglobin based oxygen carriers).

On admission Whenever a Jehovah’s Witness patient is admitted to hospital please ensure they are asked if they have an “Advance Medical Directive/Release”** with them. This is a card, which they normally carry with them. They may also use a more detailed “Health‐Care Advance Directive”** which is a three page A4 document. This is very specific in advising medical staff on their personal treatment preferences. This specifically states acceptable and unacceptable treatment options. ** A photocopy of the document must be taken and placed prominently within the medical notes, where it can be used as necessary. This advance medical directive is a legal document and the patient’s wishes should be honoured. Pre assessment Pre‐assessment of the patient is vital, Please take the following points into consideration:

1. Always notify the Surgeon Anaesthetist and Haematologist as soon as it is established the patient is a Jehovah’s Witness.

2. Take a history of any medication which could affect coagulation e.g. Warfarin, Aspirin and NSAID’s

3. Check bloods for FBC,B12,Folate, ESR, LFT’s, U +E’s. The results will need to be checked early on, in case of anaemia etc.

4. For patients where there is little or mild blood loss anticipated, no pre‐op treatment is considered necessary.

Appendix 1


5. If moderate blood loss is anticipated, start oral Iron (e.g. Ferrous sulphate 200mgs TDS) for 14 days pre‐op.

6. For patients where severe blood loss is anticipated, or if the Hb is low, start oral Iron and contact a Haematologist for advice concerning Erythropoietin, IV Iron and Vitamin K.

7. Check exactly which products/fractions the patient would or would not accept. Anticipated blood loss can be assessed by, looking at the MSBOS blood order tariff. Where a group and save is required, this suggests a risk of mild blood loss only. Where a 2 unit cross match is required, this suggests moderate blood loss. Where more than a 2 unit cross match is required, this suggests severe blood loss. Plan of action This should involve the patient, pre‐ assessment nurse, anaesthetist and surgeon. The plan should consider:

• The date of the surgery. • When to stop drugs e.g. Aspirin, Warfarin and NSAID’s. • Should the surgery be staged? • Can cell salvage be used? Discuss in advance with Jill Dixon, Mark Fernie, Sarah Bone

(theatres), Dr Linnett Anaesthetist, (bleep #6329) or Transfusion Nurses (Ext 3645). • Is an ITU bed available? • Is haemodilution an option? • Is regional anaesthesia an option? • Should hypotensive anaesthesia be considered? • Could Tranexamic Acid be used? • Should supplemental Iron and Erythropoietin be prescribed?

Peri‐operative management The above non‐blood alternatives should always be considered when managing a Jehovah’s Witness patient

• Tranexamic acid is the first line treatment for patients who are bleeding

• Vitamin K could also be used to prevent coagulopathy due to vitamin K deficiency or consumption.

If the post‐operative Hb is <7g/dl begin:

• Erythropoietin 10,000u three times a week until the Hb is above 8g/dl • Parenteral Iron (Venofer) 100mg IV three times a week (see below). • Check coagulation. Use agreed treatment option if abnormal, or ask Consultant

Haematologist for advice.


VENOFER (see data sheet)

• Venofer should be given 100mgs in Saline by slow intravenous injection three times a week.

• There is a small risk of anaphylaxis and a test dose should be given to new patients

COSMOFER 1G IV (see data sheet) TRANEXAMIC ACID. (Cyclokapron)

• 500‐1000mg by very slow* IV injection three times a day. *Often makes the patient very nauseated. This effect is reduced if it is given slowly enough. TRANEXAMIC Acid can also cause diarrhoea.

NOVOSEVEN (Recombinant factor VII a).

• This is available to correct bleeding. Seek advice from the Haematologist


THE JEHOVAH’S WITNESS HOSPTIAL LIAISON COMMITTEE.

• Jehovah’s Witnesses understand the challenge that their decisions can sometimes pose for doctors and nurses when they are treating them. In an effort to alleviate these situations they have established a network of Hospital Liaison Committees throughout Britain.

• Members of these groups are trained to facilitate communication between medical staff and

Witness patients and are available at any time, day or night, to assist with difficulties either at the request of the treating team or the patient.

Ian Philp 70 Sandringham Ave, Benton. Newcastle Upon Tyne NE12 8JX TEL/FAX 0191 2664482

Ken Murr 32 Whittingham Close North Shields Tyne and Wear NE30 3TJ TEL 0191 2586804

John Barber Dunmarvic Strathmore Ave Rowlands Gill Tyne and Wear NE39 1HY TELE/FAX 01207 542123

Alan Sanderson 8 Prudhoe Grove Jarrow. Tyne and Wear NE23 5YF TEL 0191 428 1731

David Raynor The Sheeling Nedderton Village Bedlington Northumberland NE22 6AX TEL 01670 823 409

Jack Marshall 15, Caledonia Winlaton Blaydon Tyne and Wear NE22 6AX Tel 020 89062211

EMERGENCY 24 HOUR MOBILES.

0788 9733798 0779 0311576

Hospital Information Services

The Ridgeway London NW7 1RN

TELE 020 89062211


Appendix 2


BTXROUFO001 v1.3 Date of issue 13.2.2012

Blood order tariff

Recommendations below are based on assumption that all elective patients have an electronic x‐match, and no antibodies. (The laboratory recommends that a patient with antibodies will have 2 or 4 units standing by depending on the antibody)

Operation Recommendation GENERAL SURGERY Elective Amputation G&S A‐P resection G&S Anterior resection G&S Cholecystectomy G&S Colostomy / ileostomy G&S Gastrectomy partial G&S Hemicolectomy G&S Laparotomy G&S Pan‐proctocolectomy 2 units Sigmoid colectomy G&S Splenectomy 2 units Varicose Veins Not required Hernia repair Not required Appendix G&S Mastectomy G&S ORTHOPAEDIC SURGERY # NOF G&S THR G&S TKR G&S Revision hip G&S Revision knee G&S Total shoulder replacement G&S

Appendix 3


Total elbow replacement G&S Rev T shoulder 2 units Trauma Senior review and discuss with blood bank ARTERIAL SURGERY Ruptured AAA 4 units and discuss with blood bank Elective AAA 2 units AAA stent G&S Iliac aneurysm 2 units Femoral aneurysm G&S Popliteal aneurysm G&S Ileo‐femoral graft G&S Aorto‐bifemoral graft 2 units Fem pop graft G&S Fem distal G&S Carotid endarterectomy G&S Embolectomy/thrombectomy G&S OBSTETRICS C/Section G&S Suspected ectopic pregnancy G&S Suspected ruptured ectopic 2 units Manual removal of placenta G&S Placenta praevia 2‐4 units depending on grade GYNAECOLOGY TOP G&S Laparoscopic sterilisation G&S D&C G&S Hysterectomy G&S Oophorectomy/ovarian cyst G&S Prolapse repair G&S Laparotomy G&S GYNAE‐ONCOLOGY Cone biopsy G&S Laparotomy (ovarian Ca) 2 units RHND 2 units Vulvectomy G&S Debulking 2 units Exenteration 2 units


SPINAL SURGERY Spinal Decompression G&S Spinal Discetomy G&S Microdiscectomy G&S Laminectomy G&S Foraminotomy G&S ACUTE BLEEDING (NON‐OPERATIVE) Divide into cause / severity. eg Active haematemesis or melaena with cardiovascular compromise 2 units & review Variceal haemorhage 2 units & review Melaena or coffee ground vomit in haemodynamically stable patient G&S Open trauma with continued blood loss 2 units& discuss with blood bank PR bleed, PV bleed in haemodynamically stable patient G&S pending haemoglobin

BTXROUFO001 v1.3 Date of issue 13.2.2012


ORDERING BLOOD IN AN EMERGENCYSomeone senior MUST co-ordinate care in an emergencyThis is very important as inexperience can cause delays

Phone the lab immediately and inform them of the impending need for blood products

Is there a G&S sample already in the lab

YESDecide how quickly you need the blood

Take a specimen and send it immediately to the

Lab

YES

NO

YE

S

Emergency ‘O’ Negative

Full Serological cross match

Group Specific

Only available in a DIRE emergency where there is insufficient time to establish a blood groupA sample MUST be sent for further bloodNot suitable for everyoneWill NOT be crossmatchedClinician who decides takes full responsibility for the decisionMax 2 units Ready within 5 minutes

The same group as the patientWill NOT be crossmatchedClinician who decides takes full responsibility for the decision.Ready within 5-10 minutes

Will be fully cross matchedLess chance of a reactionReady within 45 minutes of sample arriving in lab

PLEASE NOTEThe co-ordinator should communicate with the labContact details are essential for good communication with the lab extn on 2281 bleep 2082Only specifically trained people are allowed to collect blood. Use THEMIn a dire emergency only 1 unit of Blood can be sent in the chute

Appendix 4


TO ORDER BLOOD COMPONENTS THROUGH THE PORTERS.

Appendix 5

When ordering blood components using the porter track system you MUST provide the following information.

• The Patient’s: Name, Date of Birth and Record number, MUST be typed into the “PATIENT” box

• You MUST select “Pathology” if the blood is to be collected from blood bank OR your ward if the blood is being returned to blood bank

• You MUST select which blood product you need, Blood, FFP, Platelets, Cryo, Beriplex or Novoseven (Factor VIIa)and how much you require

“BLEEDER” should only be used in a “dire emergency” and you

must remember to state what needs to be collected in the comments box

• Porter track has been introduced to improve patient safety and efficiency.

• All blood requests are a priority. • Failure to provide essential information will delay the transfusion as

porters are not allowed to collect blood without it. • It is not the porter’s fault when transfusions are delayed due to lack of

information. They are not being difficult, they are keeping your patient safe!

Out of hours you must telephone the request to the porters. You MUST provide: Patient’s full name

• Date of birth • Record number • Which blood component you want

collected and how much. • Where it is to be delivered.


BLOOD SHOULD BE CHECKED AT THE BEDSIDE. THE COMPATIBILITY LABEL LINKS THE PATIENT TO A SPECIFIC UNIT OF BLOOD.

THE LABEL SHOULD BE CHECKED AGAINST THE WRISTBAND AND THE UNIT OF BLOOD THE COMPATIBILITY FORM IS NO LONGER NECESSARY

Appendix 6

CHECK. Donation number

Record number Surname Forename

Date of birth

Patient’s blood group Use by date

Donation blood group Expiry date


Flow Diagram for recognition, initial management and subsequent management and investigations.

Appendix 7

Documents

Policy No: RM36