blood transfusion procedure

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PRINCESS ALEXANDRA HOSPITALPROCEDURE MANUAL

Section: Clinical Procedure No. 01552/v13/07/2012Procedure Title: Blood and Blood Product Transfusions

Purpose:To ensure the safe administration of blood and blood products andthe management of transfused patients based on current clinicalguidelines.

Author ised to Undertake the Procedure: Medical Officers,

Nurse Practitioners (endorsed),

Registered Nurses,

Enrolled Nurses (without restrictions),

Princess Alexandra Hospital Transfusion Service (Blood Bank).

Indications for Use: A decision to transfuse a patient is made from a medical

assessment of an individual patients clinical need which complieswith clinical transfusion guidelines.

National Health and Medical Research Counci l (NHMRC) Clin ical

Practice Guidelines (2001) are available for all commonly used blood components.

HYPERLINK TO: Australian Red Cross Blood Service Website Australian Red Cross Blood Service: Blood Component Information National Health and Medical Research Council Website Blood and Blood Products Queensland Blood Management Program Website Metro South Transfusion Resources Website

Education:Australian Council on Healthcare Standards require that training in blood policy and procedures occurs fornew staff and all staff involved in blood transfusion are required to complete specific training and educationin relation to blood transfusion. This should be completed every 2 (two) years, and/or as new guidelines orprocedures are advised.

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For online training see the Blood Safe E-Learning program: http://www.bloodsafelearning.org.au/This e-learning program has been designed to provide you with an opportunity to develop your knowledge ofblood and to encourage safe transfusion practice and the appropriate use of blood components. Completionof this course attracts 2 RCNA CNE points.

MedicalBiennial completion (every two years) of Blood Safe E-Learning It is recommended that interns and houseofficers review this training at least every two years.

Nursing StaffBiennial (two years) completion of Blood Safe E-Learning for registered nurses and enrolled nurses involvedin the transport, checking , administration and monitoring of blood transfusions is a mandatory requirementat Princess Alexandra Hospital.

HYPERLINK TO:Quick Transfusion Administration Checklist

Initiator: Metro South TransfusionCommittee

Review Officer: Chairman, TransfusionCommittee

Review Summary:13th

Version

App licable To: All Staff

Last Review Date: 04 2011

Next Review Date: 04 2013

Author ity: Transfusion Committee

..Signature of Authorising Officer

Replaces: 01552/v12

Key Words: Blood Transfusions

References: Refer to end of document

Printed version is an uncontrolled copy 1
http://www.transfusion.com.au/home.aspxhttp://www.transfusion.com.au/blood_products/componentshttp://www.nhmrc.gov.au/http://qheps.health.qld.gov.au/qbmp/home.htmhttp://paweb.sth.health.qld.gov.au/transfusion/default.asphttp://www.bloodsafelearning.org.au/http://paweb.sth.health.qld.gov.au/sqrm/qiu/documents/reviewsummary/01552v13.pdfhttp://paweb.sth.health.qld.gov.au/sqrm/qiu/documents/reviewsummary/01552v13.pdfhttp://paweb.sth.health.qld.gov.au/sqrm/qiu/documents/reviewsummary/01552v13.pdfhttp://paweb.sth.health.qld.gov.au/sqrm/qiu/documents/reviewsummary/01552v13.pdfhttp://paweb.sth.health.qld.gov.au/sqrm/qiu/documents/reviewsummary/01552v13.pdfhttp://paweb.sth.health.qld.gov.au/sqrm/qiu/documents/reviewsummary/01552v13.pdfhttp://www.bloodsafelearning.org.au/http://paweb.sth.health.qld.gov.au/transfusion/default.asphttp://qheps.health.qld.gov.au/qbmp/home.htmhttp://www.nhmrc.gov.au/http://www.transfusion.com.au/blood_products/componentshttp://www.transfusion.com.au/home.aspx


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Table of Contents

Section A: Venous Access and Equipment for Transfusion.............................................................................. 4Venous Access .............................................................................................................................................. 4Blood Administration Sets.............................................................................................................................. 5Leucodepletion (also refer to: Appendix 2: Administration of Fresh Blood Components) ............................. 6Blood Warmers .............................................................................................................................................. 7Infusion Devices............................................................................................................................................. 8

Section B: Concurrent Fluids and Medications ................................................................................................. 9Concurrent Fluids........................................................................................................................................... 9Medications .................................................................................................................................................. 10

Section C: Related Medical and Nursing Issues ............................................................................................. 11Prescription of Blood and Blood Products ................................................................................................... 11Informed Consent......................................................................................................................................... 12Pre-Transfusion Blood Sample Collection ................................................................................................... 15Transfusion Requests and Use of Transfusion Department Request Form................................................ 16Care and Monitoring of Transfused Patient (also refer to: Appendix 2: Administration of Fresh BloodComponents)................................................................................................................................................ 17Documentation of Transfusions ................................................................................................................... 18Staff Responsibility for Blood Transfusions and Handling of Products........................................................ 19Section D: Administering Blood and Blood Products ...................................................................................... 21Administration of Blood Products................................................................................................................. 21Collection of Blood Products from the Blood Bank and Delivery to Ward or Operating Room ................... 22Inspection of Blood and Blood Products...................................................................................................... 23Identity Check of Patient and Blood Product ............................................................................................... 24Completing the Transfusion ......................................................................................................................... 28

Section E: Management and Reporting of Adverse Reactions....................................................................... 29Haemovigilance............................................................................................................................................ 30

Section F: References ..................................................................................................................................... 32Section G: Glossary of Terms ......................................................................................................................... 34Section H: Appendices .................................................................................................................................... 35

Appendix 1: Queensland Incidents in Transfusion Reaction Chart ............................................................. 35Appendix 2: Administration of Fresh Blood Components ............................................................................ 36Appendix 3: Special Requirements.............................................................................................................. 37Appendix 4: Administration of Intravenous Immunoglobulin........................................................................ 38Appendix 5: Administration of Albumin ........................................................................................................ 40Appendix 6: Coagulation Factors................................................................................................................. 41Appendix 7: Transfusion Administration Checklist....................................................................................... 42Appendix 8: Pre-transfusion Sample Collection Flow Chart ........................................................................ 44Appendix 9: Administration of Blood Component Flow Chart...................................................................... 45Appendix 10: Informed Consent Quick Reference Guide for staff............................................................... 46Appendix 11: Princess Alexandra Hospital Massive Transfusion Guidelines.............................................. 47Appendix 12: Transfer of Blood Components

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Blood Management:

Blood management refers to appropriate use of blood components and derivatives. Wherever possible,utilise strategies to avoid or reduce the need for blood transfusion. Optimal patient blood management willresult in improved patient outcomes by reducing exposure to infectious and non-infectious complications ofblood transfusion. Identification and investigation of pre-operative anaemia may allow timely correction of

anaemia, thereby avoiding patient deferral or precipitous measures necessitated by immediate pre-operativerecognition of this problem. Utilise techniques and technology which will aim to conserve the patients ownblood. The following alternatives are available:

Treat preoperative anaemia wherever possible. The following factors are needed for effective red cellproduction; iron replacement, vitamin B12, folic acid and Vitamin C. Erythropoietin analogues can alsobe effectively employed in some cases. Timely and appropriate use of these therapies can assist inensuring the patient enters surgery in the best condition.

Reduction in surgical blood loss, utilising techniques which conserve the patients blood supply.Minimally invasive surgical technique, surgical instruments that prevent blood loss, medications whichmay assist in control of bleeding.

Recycling the patients own blood during surgery through intra operative cell salvage.

Not all of these options as suitable for all patients. Blood management requires a team approach to develop

a plan of care aimed at reducing blood loss.



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Section A: Venous Access and Equipment for Transfusion

Venous Access

Peripheral intravenous access should be sufficient to maintain an adequate rate for transfusion withoutcausing a risk of haemolysis.

The size of cannula chosen depends on the size and integrity of the vein.

The recommended cannula size is a standard 18-20 gauge for adul ts.Smaller gauges can be used, but this may restrict the flow rate leading to a much longer transfusion time.

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Central venous access devices can be used to safely administer blood and blood products.

Some Peripherally Inserted Central Catheters (PICC) with small tubing diameters may pose problemswith blood or platelet administration leading to slow flow rates and clogging.

Recommended Intravenous Access Set Up for Blood Transfusion Administration

During transfusion reactions it is necessary to attach a N/Saline line to keep the vein open, without removingthe transfusion giving set. Flushing the existing blood administration set during a transfusion reaction is notrecommended

3(Section E: Management and Reporting of Adverse Reactions).

Assess whether the patient has alternative IV access prior to commencing the transfusion, and if there is noavailable alternative, the following can be attached to the existing venous access prior to commencement:

A Smartsite 2 way extension set, primed with 0.9% Sodium Chloride may be attached directly to thePIVC or single lumen of CVAD device to provide additional IV access point.

Alternatively, if patient already has a single extension set attached, a 3 way tap may be utilised on theend of the blood administration set. Ensure the tap is primed with 0.9% Sodium Chloride and a bung isattached to the side of the 3 way tap which is not in use.

+Either of these devices would allow attachment of a N/saline line as close as possible to the patient in theevent of a transfusion reaction. Following the completion of all prescribed blood components, the extensionset and/or 3 way tap must be removed along with the IV blood giving set and a new extension set/IV lineadded if there is to be additional fluid replacement following transfusion.



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Blood Administration Sets

All blood products must be transfused through an IV blood administration set incorporating a standardin-situ 170-200 micron fil ter, which removes clots and cellular debris

3(micro-aggregates) that may

form during collection and storage.

IV Blood administration sets must not be piggy-backed into other lines.

Medications shall not be added to any blood component prior to its transfusion.

Priming:

Prime the standard blood administration set only with 0.9% Sodium Chloride or the blood product.

DO NOT prime the blood administration set with Dextrose.

IV Set Changes:

One (1) standard blood administration set may be used for the administration of 2 4 units of red bloodcells (provided the flow rate remains adequate).

All IV blood administration sets must be changed on completion of the transfusion or with lengthytransfusions, every 8 hours

2to reduce the risk of bacterial contamination.

In an emergency or theatre situation 8 10 units may be transfused before the set is changed,provided the set is changed every 8 hours.

Extension set tubing and or 3 way tap attachments should also be changed, if attached to theblood administration set. See Princess Alexandra Hospital Procedure 01585 Peripheral IntravenousCannulation (PIVC) Insertion and Care or01505 CVC Procedure for procedure to follow for changingof extension sets and IV giving sets following blood transfusion.

If a platelet t ransfusion is required following a red cell transfusion a new IV blood administration set isrequired, as red cell clots and cellular debris trapped in the micron filter would subsequently trap theplatelets.

Central Venous Access Devices:

A standard gravity-flow IV blood administration set with an in-line 170 200 micron fil tershould beused with intravenous access devices which guarantee the maintenance of an adequate flow rate.

Picture 2. Gravity BloodAdministration set: with inline

170-200 micron filter in dripchamber.

Picture 1. Standard IV FluidAdministration set.

Not for use with Red cells,platelets, FFP, CryoprecipitateCan be used with plasmaderived blood products: IntragamP, Flebogamma, Albumex.

Picture 3. Infusion Pump BloodAdministration set with inline

170-200 micron filter.

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Leucodepletion (also refer to:Appendix 2: Administration of Fresh Blood Components)

Purpose:

To remove most of the white blood cells from either red cell or platelets.

Indications:

To reduce the risk of Cytomegalovirus (CMV) transmission in the immunosuppressed patient (CMVseronegative products may be indicated in certain patients).

To reduce the risk of platelet refractoriness from alloimmunisation to leucocyte antigens especially inpatients with malignant haematological disease.

To reduce the rate of alloimmunisation in non-hepatic solid organ transplant candidates.2-3

Pre-storage leucodepleted platelets and Red Cells are provided by the Australian Red Cross Blood Service.These products DO NOT require a Leucocyte Depletion Filter.



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Infusion Devices

The use of a gravity line is preferred when administering transfusions of fresh blood componentssuch as red cells, platelets, FFP via peripheral intravenous cannulas.

Electronic Volumetric Pumps

Infusion pumps may be used provided the manufacturer has certified that they are safe to infuse bloodcomponents.

Specific blood administration sets are available for use with IV pumps and must be used whenadministering transfusions, these have a 170-200 micron filter in-situ.

Infusion Pumps are not necessary to deliver transfusion of fresh blood components but they can assistin administering solutions at a controlled rate and measurement. Utilisation of an infusion pump forfresh blood components may be indicated if a patient is at particular risk of fluid overload.

Ideally, when using an infusion pump, 18-20 gauge cannulas should be used to decrease the risk ofhaemolysis of cells through a small gauge cannula.

Monitoring and Checking of Infusion Pump

Include pump settings, flow rates and volume of blood component in the standard checking procedure.

Both the pump setting and volume delivered shall be monitored hourly throughout the infusion to ensurethat expected volume is delivered and to monitor the patient for signs/symptoms of transfusion reactions.

Use with Central Venous Access Devices

Infusion pumps may be of use during the transfusion of blood products where a satisfactory gravity flowrate cannot be guaranteed (e.g. Peripheral Inserted Central Line PICC or Implanted Port POC).

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Ensure largest lumen of CVAD is used when administering blood products.

Plasma Derived Blood ProductsInfusion pumps are recommended for use with some plasma derived blood products such as intravenousIntragam P, Albumex, and Octagam. SeeAppendix 4 Administration of Plasma Derived Blood Products

External pressure devices SHOULD NEVER BE USED IN ROUTINE TRANSFUSIONS5

Purpose:

To administer a unit of red cell within a few minutes.

Precautions:

Should only be used in an emergency situation.

Ensure a large gauge venous access/cannula.

Exert pressure evenly over the entire bag.

Have a gauge to measure the pressure.

Never exceed 300mm Hg of pressure.

Be monitored at all times when in use.



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Section B: Concurrent Fluids and Medications

Concurrent Fluids

Only isotonic 0.9% Sodium Chloride can be added to a blood product intravenous (IV) line.

Incompatible Fluids: Infusates containing Calcium (e.g. Ringers Lactate, Haemaccel, Gelofusine) are incompatible with

blood products collected in an anticoagulant containing Citrate, as calcium-containing solutions willreverse the anti-coagulant effect of citrate resulting in clotting.

Dextrose 5% in water and hypotonic/hypertonic saline solutions may cause red cell haemolysis.



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Medications

Do not add medications to blood and blood products on the same IV line, as there may be a directincompatibility with the blood or the anti-coagulants or preservatives added to the product.

It is recommended that medications be administered via a 3 way tap or 2 way extension set if attached,

rather than the side port of the blood administration set.

In exceptional c ircumstances when there is a need for IV medications to be administered via the same IVline as a transfusion and where no alternative venous access is available.

Procedure:

STOP the transfusion.

Flush the IV line with 0.9% Sodium Chloride via the y-connector.

Administer the IV medication in accordance with the manufacturers or Pharmacy directives.

Flush the IV medication with 0.9% Sodium Chloride.

Resume the transfusion.

This must not result in the time for transfusion of red cells exceeding 4 hours from the original despatch time

from blood storage.

Co-administration of morphine, pethidine and/or ketamine diluted in 0.9% Sodium Chloride (as for patientcontrolled analgesia or continuous side arm infusion) via a non reflux valve has been shown not toadversely affect red cells.

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Section C: Related Medical and Nursing Issues

Prescription of Blood and Blood Products

Medical Officersand endorsed Nurse Practitioners (licensed to prescribe blood and blood products) aresolely responsible forprescribing blood and blood products on the appropriate form Queensland Health

Intravenous and Subcutaneous Fluid Order Form.

In addition to the patient identification details (name, date of birth, gender and UR number) theprescription should also specify:

Date for transfusion,

Type of blood or blood product to be transfused,

Volume or quantity to be given,

The duration of the transfusion,

Any special instructions (diuretics, pre-medications, CMV anti-body negative products, gamma-irradiatedproducts, or blood warming).

Medical Officers and endorsed Nurse Practitioners (licensed to prescribe blood and blood products) areresponsible for ordering blood and blood products from the Princess Alexandra Hospital Blood Bank with a

signed writ ten request or a telephone order followed by a signed written request.

Where possible Medical Officers and endorsed Nurse Practitioners are also responsible for explainingthe significant risks, benefits and alternatives to the transfusion and giving the patient an opportunity to askquestions.Hyperlink to:Consent Information Patient Copy Blood and Blood Products Transfusion Consent

Registered Nurses in some circumstances may verbally request blood and blood products2

but a medicalorder/prescription is required for their administration.

http://www.health.qld.gov.au/consent/documents/shared_file_04.pdfhttp://www.health.qld.gov.au/consent/documents/shared_file_04.pdf


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Informed Consent

Informed Consent:Informed consent for transfusion means a dialogue has occurred between the patient and the doctor. Thesignificant risks, benefits and alternatives to transfusion including the patients right to refuse the transfusionshould be discussed.

Documentation of informed consent for blood and blood product transfusion has now been recommendedby:

Australian Red Cross Blood Service (ARCBS).

Australian and New Zealand Society of Blood Transfusion (ANZSBT) and Royal College of NursingAustralia Guidelines for the Administration of Blood Components (2004).

The National Health and Medical Research Council (NHMRC) Clinical Practice Guidelines on the Use ofBlood Components (2004).

These documents support the Australian Council of Healthcare Standards (ACHS) Safety Standard 1.5,Criterion 1.5.5 within The EQuIP4 Guide Part 1 (2007)

1, which includes the following:

A procedure exists for ensuring written consent.

The consumer is made aware the risks associated with blood component therapy.

Informed Consent must be obtained and is to be documented by a consent form or by documenting thediscussed information in the Patient Medical Record by the Medical Officer, in accordance with PAHProcedure 01542 Consent and Queensland Health Policy Statement Informed Consent for InvasiveProcedures (14025).

Informed Consent Discuss ion:As a result of this discussion the patient should:

Understand what medical action is recommended.

Be aware of the risks and benefits associated with the transfusion.

Appreciate the risks and possible consequences of not receiving the recommended therapy.

Be given an opportunity to ask questions.

Give informed consent for the transfusion.The medical officer obtaining the blood transfusion consent may discuss the current information detailed inAppendix 8: Informed Consent Quick Reference Guide with the patient prior to signing the consent form.

In the event that the patient lacks capacity to give consent, consent should be obtained from the first in orderof the following:1. The Advanced Health Directive of the patient if one exists;2. A Guardian appointed by the Guardianship and Administration Tribunal;3. A Health Attorney appointed by the patient;4. A Statutory Health Attorney; or5. The Adult Guardian as the decision maker of last resort.

The Statutory Health Attorney is the first in the order of the following:1. A spouse provided the relationships close and continuing;2. A person 18 years or over that is the patients carer (not paid carer);3. A person 18 years or over, whom is a close friend or relative of the patient.

See Princess Alexandra Hospital Procedure 01305 Substitute Decision Making for Adults who Lack CapacityWhich forms w ill need to be completed?In order to standardise the consent process for blood and blood product transfusion Queensland Health hasdeveloped a state-wide Blood and Blood Product Transfusion specific consent form and accompanyingpatient information sheet is available from the Queensland Health Informed Consent website.

Surgical Procedures: Queensland Health's procedure specific consent forms have a statementincluded within the patient's consent should a blood transfusion be required. This statement coversconsent for blood transfusions for that specific procedure only. The Blood and Blood Products

Transfusion Consent Patient Information Sheet should be given to the patient, next of kin or guardianand explain as per the above procedure for obtaining blood transfusion consent.

Transfusions in Emergency Situations and Critically Ill Patients: In the event that a critically illpatient is unable to give consent or in an emergency situation the Medical Officer may determine that the

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transfusion is in the patients best interest. Document in medical notes reason why consent could not beobtained. For further details regarding patients who are unable to provide consent, refer to: 01305Substitute Decision Making for Adults who Lack Capacity.

For Patients who are unable to consent in Non-Urgent s ituations Next-of-kin, Living will or AdultGuardian may be approached to give consent which includes documentation and provision of theinformed consent patient information Consent Information Patient Copy Blood and Blood ProductsTransfusion Consent.

Order of File:

The Queensland Health Blood and Blood Product Transfusion Consent will be located in alphabeticalorder at front of chart.

Patient Information:Patients/significant others should be provided with the Consent Information Patient Copy Blood and BloodProducts Transfusion Consent outlining the risks and benefits of blood transfusion prior to commencement ofblood transfusions. NB: These brochures do not take the place of providing verbal discussion.The information can be provided to patients:

When the patient is required to have a pre transfusion blood sample;

Prior to a blood component transfusion administration; or

Prior to a blood component transfusion treatment regime; or

As soon as possible after a transfusion when the transfusion has been administered in an emergencysituation.

An interpreter and a translated brochure must be used for non-English speaking people.The Consent Information Patient Copy Blood and Blood Products Transfusion Consent contains links tofurther information including English and multicultural information brochures from theAustralian Red CrossBlood Service.

Validity of Blood and Blood Product Transfusion Consent:

Consent may be obtained to cover a specific period/course of treatment of up to 12 months using theQueensland Health Blood and Blood Product Transfusion Consent Form for those patients who mayrequire numerous transfusions over an extended length of time/course of treatment.

For a specific time period or group of procedures covered by one informed consent, the consent needs

to be person, product and procedure specific. The specified period for which the consent is obtained must be clearly documented and flagged for

review in the patients medical record.

If there are any changes within the specified period/course of treatment (i.e. change in clinical indicationsfor transfusion, capacity of the person, change in patients condition, change in blood product used etc.)for which the consent was obtained, the consent must be reviewed by a medical officer withresponsibility for the care of the patient.

Documenting Verbal Consent:

If the Blood and Blood Product Consent Form is unavailable, consent for blood transfusion may bedocumented as a note in the medical record. This documentation should include the elements of theinformed consent discussion and a statement that the patient has agreed to the transfusion. Please noteverbal consent is not valid for 12 months but must be ascertained each transfusion episode.

Responsibilities:Medical:

Medical responsibility to obtain informed consent and ensure correct documentation is completed.

Provision of written information.

In all cases where consent is undertaken for a course of treatment/specific period of time, consentmust only be obtained by the attending registrar or consultant with responsibility for the care of thepatient.

The attending registrar or consultant may delegate the responsibility of providing information andobtaining consent to another doctor provided they are satisfied that the doctor has the necessary skillsand experience.

Nursing: Provision of written information.

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Nursing responsibility to check that all relevant documentation is completed by the medical officer, at thetime of ordering the transfusion or prior to the collection any fresh blood component for transfusion fromblood bank in non-emergency situations.

NB: Any Princess Alexandra Hospital employee who becomes aware that a patient does not have sufficientinformation to make an informed consent should notify the Attending Medical Officer, delegated doctor.

For Refusal of Blood and Blood Product Transfusion see Princess Alexandra Hospital Procedure01128 Refusal of or Limited Consent to Blood and Blood Product Transfusion .

Informed Consent Summary

Emergency/Critical Ill patients Medical Surgical

In an emergency situation orcritically ill patient, where thepatient is unable to give consentand the blood product transfusionis required immediately:(i) to save the persons life; or

(ii) to prevent serious injury to apersons health;the blood product transfusion maybe carried out in the absence ofconsent.

Separate Blood and BloodProduct Transfusion ConsentForm is required. This is valid forone transfusion episode ormultiple transfusions up to aperiod of 12 months provided

there are no changes to type ofblood products required,indications, patient condition.More than one type of bloodcomponent may be consented forat the same time with the oneform, provided it is clearlydocumented.Dates of treatment course shouldbe clearly documented in thespace provided.

A separate Blood and Bloodproduct Transfusion ConsentForm will not be required. TheQueensland Health procedurespecific consent forms have astatement regarding blood

transfusion should this benecessary. This statement coversconsent for blood transfusions forthat specific procedure provided ithas been discussed with thepatient. The consent will only bevalid if the indication for the bloodtransfusion is directly related tothe procedure for which thepatient has consented.

Consent form will not be requiredfor urgent transfusions of blood

products when a guardian or aparent or a responsible person orthe Guardianship Tribunal is notavailable.

A new blood transfusion consentform may be required if indication,

type of blood component, patientcondition or patient capacitychanges.

A separate blood transfusionconsent form may be required if

indication, type of bloodcomponent, patient condition orpatient capacity changes.

The reason for being unable toobtain consent and the indicationshould be documented in thepatient medical record as soon aspossible following the event.

The indication of each transfusionepisode needs to be clearlydocumented within the medicalrecord.

The indication in relation to theassociated surgical procedureneeds to be clearly documented,as with all transfusions, within themedical record if a transfusion isrequired postoperatively.

Patients next of kin or guardianshould be informed as soon aspossible after the transfusion of

blood and blood products. Bloodand Blood ProductsTransfusion Consent PatientInformation Sheet can be provided

The Blood and Blood ProductsTransfusion Consent PatientInformation Sheet should be given

to the patient, next of kin orguardian and explain as per theabove procedure for obtainingblood transfusion consent.

The Blood and Blood ProductsTransfusion Consent PatientInformation Sheet should be given

to the patient, next of kin orguardian and explain as per theabove procedure for obtainingblood transfusion consent.

http://paweb.sth.health.qld.gov.au/sqrm/qiu/documents/procedures/01128.pdfhttp://www.health.qld.gov.au/consent/documents/shared_file_04.pdfhttp://www.health.qld.gov.au/consent/documents/shared_file_04.pdfhttp://www.health.qld.gov.au/consent/documents/shared_file_04.pdfhttp://www.health.qld.gov.au/consent/documents/shared_file_04.pdfhttp://www.health.qld.gov.au/consent/documents/shared_file_04.pdfhttp://www.health.qld.gov.au/consent/documents/shared_file_04.pdfhttp://www.health.qld.gov.au/consent/documents/shared_file_04.pdfhttp://www.health.qld.gov.au/consent/documents/shared_file_04.pdfhttp://www.health.qld.gov.au/consent/documents/shared_file_04.pdfhttp://www.health.qld.gov.au/consent/documents/shared_file_04.pdfhttp://www.health.qld.gov.au/consent/documents/shared_file_04.pdfhttp://www.health.qld.gov.au/consent/documents/shared_file_04.pdfhttp://www.health.qld.gov.au/consent/documents/shared_file_04.pdfhttp://www.health.qld.gov.au/consent/documents/shared_file_04.pdfhttp://www.health.qld.gov.au/consent/documents/shared_file_04.pdfhttp://www.health.qld.gov.au/consent/documents/shared_file_04.pdfhttp://www.health.qld.gov.au/consent/documents/shared_file_04.pdfhttp://www.health.qld.gov.au/consent/documents/shared_file_04.pdfhttp://www.health.qld.gov.au/consent/documents/shared_file_04.pdfhttp://www.health.qld.gov.au/consent/documents/shared_file_04.pdfhttp://paweb.sth.health.qld.gov.au/sqrm/qiu/documents/procedures/01128.pdf


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Pre-Transfusion Blood Sample Collection

Experience has shown that many errors occur in documentation when labelling samples and completingforms.It is recommended that verbal verification be sought with the patient or a second person verifies that thepatient is correctly identified and that the patient details have been correctly written on both the sample tube

and Clinical and Statewide Services (CaSS) Pathology Queensland Request Form (Form A/3879).

ENSURE IN LEGIBLE HANDWRITTING

Only Phlebotomists, Medical Officers and Registered Nurses deemed competent in venipuncture shouldcollect blood samples for pre-transfusion compatibility testing.

Authorisation for pre-transfusion testing is with a legibly written Clinical and State-wide ServicesPathology Queensland Request Form (Form A/3879) and includes:

Patient surname, given name, date of birth and UR number,

Location of the patient,

Date and time of collection,

Name of requesting medical officer and signature,

Reason for the request (e.g. group and hold), Date required,

Name and signature of the collector in the ALL collectors must complete section to confirm thecorrect labelling and time of collection of the sample.

The patient is asked to state their surname, given name, date of birth and is checked against the patientidentification band and Clinical and Statewide Services Pathology Queensland Request Form (FormA/3879).

Outpatients must be asked forevidence of identity.

Only one patient is to be bled at a time. Af ter blood col lection , the pathology sample tube must be legiblylabelled immediately before leaving the patient with the following:

Patient surname, given name, date of birth, gender, location and UR number.

Time and date of collection.

Signature of the collector confirming the patients identity.

Blood tubes must NOT be pre-labelled.

DO NOT use printed labels for labelling the blood tubes.2

Both the Clinical and State-wide Services Pathology Queensland Request form (Form A/3879) andpathology cross-match tube must have identical patient identification information.Hyperlink: Pathology Queensland Blood Bank: Specimen Collection

Princess Alexandra Hospital Blood Bank will d iscard any incor rectly labelled tubes and theprocedure will need to be repeated.

http://qheps.health.qld.gov.au/pathology/tests/blood-bank/how-to-order/spec-collect.htmhttp://qheps.health.qld.gov.au/pathology/tests/blood-bank/how-to-order/spec-collect.htm


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Transfusion Requests and Use of Transfusion Department Request Form

A correctly completed State-wide Transfusion Department Request Form wil l be required for theissue of any blood products from the blood bank(includes Red Blood Cells (RBC), Fresh Frozen Plasma (FFP), Platelets (PLT), Cryoprecipitate (CRYO),Cryo-Depleted Plasma (CDP), Prothrombinex (PTX), anti-D Ig, Hep B IG, Tetanus Ig, Zoster Ig, Biostate and

Albumin).N.B. Zoster Ig and Biostate are Restricted Products. The requesting Medical Officer is still responsiblefor obtaining ARCBS Medical Officer approval.

The purpose of the transfusion department request form is to:- Improve provision of patient clinical information for the request of red blood cells and specialised

products.- To highlight the National Health and Research Medical Council Practice Guidelines on the Use of

Blood Components and collect accurate information on the laboratory parameters related to therequest.

- Improvements in safety and quality of blood transfusion practice across Queensland includingappropriate blood use and haemovigilance.

- A higher standard of safety and care for patients.

Mandatory fields are clearly marked with a red asterisk ( * ), and includes Haemovigilance information(relevant test results (Hb, Plt, Count, and/or INR/Fib) and Clinical Indication Code).

Test results and Clinical Indication Code (IC) (Indication for Use detailed on the back of the requestform) are only required for the relevant blood product, i.e. Hb and IC for RBC; Plt Count and IC forPlatelets; INR/Fib for FFP or Cryoprecipitate.

Incomplete or incorrect Transfusion request forms will be NOT TESTED until correctly completed, thismay result in delays in processing transfusion request UNLESS the situation is clinically urgent, whereEmergency procedures will be activated uncross matched products issued in most circumstances(except for IVIg which has a separate procedure).

Pathology request forms should be used for all Transfusion Department blood test requests, e.g. Group& Hold, antenatal tests, cord blood testing, DAT, transfusion reaction investigations. Transfusion requestform is only to be used for requesting blood products.

PLEASE NOTE no other Pathology requests, e.g. FBC, U&E, BHCG etc are to be made on thetransfusion request form.

All phone requests for blood products must be followed Transfusion Department request Form (only theMassive Transfusion Protocol is exempt after the initial transfusion request form (or phone call); clinicalinformation will be obtained by direct contact with the Clinicians).

Follow this link for further information on how to complete the Transfusion Department Transfusion Requestform http://qheps.health.qld.gov.au/pathology/tests/blood-bank/how-to-order/request-form.htm

http://qheps.health.qld.gov.au/pathology/tests/blood-bank/how-to-order/request-form.htmhttp://qheps.health.qld.gov.au/pathology/tests/blood-bank/how-to-order/request-form.htm


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Care and Monitoring of Transfused Patient (also refer to:Appendix 2: Administration of FreshBlood Components)

The most basic principle of patient care during transfusion is to ensure patient safety.

Patients receiving transfusions shall be monitored for signs of the potential complications of transfusion and

any suspected problems dealt with swiftly and efficiently. There is wide variation in the frequency of nursingobservations during transfusion8

and it is not clear what is the optimum type and frequency of observations.

Whenever possib leavoid overnight transfusion.2

Blood product transfusion between 2000 0700hrs is not recommended forstable patients due toreduced overnight staffing and medical cover on the wards. Direct observation of patients and ability torecognise and respond to transfusion reactions is reduced.

Check u rgency with Medical Officer.

If there is doubt, do not delay transfusion.

Severe reactions are most likely to occurwithin the first 15 minutes of the start of each blood product,and patients should be most closely observed during this period.

Instruct the patient to immediately report any signs of a transfusion reaction, e.g. fever, chills, pruritus,urticaria, chest or lower back pain, headache, nausea, bleeding, tachycardia or dyspnoea.

Observation and monitoring of transfusions (refer toAppendices)It is recommended

2-4that a patients temperature, pulse, respirations and blood pressure be recorded with

the administration of each unit of blood and blood product as follows:

Immediately before starting the transfusion.

Repeated 15 minutes after the start, during which time the patient is closely monitored for any adversereactions.

At the end of each unit.

Flow rate and cannula site must be monitored hourly.

Frequent visual observations are to be maintained throughout the transfusion for signs of transfusionreactions or fluid overload.

Frequency of observations during a transfusion depends on the patients condition before thetransfusion, or if the patient becomes unwell, or shows s igns of a transfusion reaction.

Observations of patient vital signs, the date and the time are to be recorded on the Form: PA 216 AcuteObservation Chart.

Unconscious or Anaesthetised Patients5

It is more difficult to monitor for signs of transfusion reactions unconscious or anaesthetised patients. Duringthe first 15-20min following the start of a unit of blood or blood component, transfusion reactions should beconsidered when assessing a change or deterioration in the patients condition.Closer observation patients who are unable to verbalise symptoms or use the call bell due to mental or

physical limitations.

Hypotension, uncontrolled bleeding or generalised oozing during surgical procedures may indicate acoagulopathy, e.g. disseminated intravascular coagulation. However, these symptoms may suggest thepossibility of an acute haemolytic reaction due to an incompatible red cell transfusion.

Haemoglobinuria or oliguria may also be an early sign of an acute haemolytic transfusion reaction due to anincompatible red cell transfusion.

Medical Officer Approval must be obtained for the transfusion of blood and blood products to febrilepatients.



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Documentation of Transfusions

Complete documentation of transfusions is essential so that the cause of serious adverse effects can beadequately investigated, which can entail a retrospective look back. It also facilitates auditing of all aspectsof the transfusion process.

9

Patient Medical Record:A permanent record of the transfusion of blood and blood components and the administration of bloodproducts must be kept in the Patient Medical Record including:

Blood transfusion compatibility report with date, time and signatures denoting that correct checkingprocedures have been followed.

Prescription of blood products on the Queensland Health Intravenous and Subcutaneous FluidOrder Form.

Including:- Name and signature of prescriber,- Date, time, route of administration, transfusion rate, special requirements,- Signatures of staff checking and administering blood product,- Volume, start and finish times,- A complete record of the blood product or donation numbers transfused (yellow sticker).

Nursing observations during the transfusion PA 216 Acute Observation Chart.- Minimum observations, baseline/at 15mins/post transfusion. Observations may be more frequent

dependant on patient condition.

Transfusions are to be documented by both medical and nursing staff to include:5

Indication for the use of blood product.

Outcome of the transfusion including whether or not it achieved the desired effect.

Occurrence and management of any adverse effects.



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Staff Responsibility for Blood Transfusions and Handling of Products

Many groups of staff are involved in one or more aspects of blood transfusion. Some procedures arespecific to one staff group, but many can be carried out by more than one.

Medical Staffand Endorsed Nurse Practitioners (licensed to prescribe blood and blood products) are

solely responsible for prescribing blood and blood products and for ensuring adequate documentation ofblood transfusion in the patient medical record PA Patient Progress Notes, including documentingconsent.

Registered Nurses can perform the following actions and be responsible for:

Follow-up/arranging the venepuncture for the pre-transfusion blood samples for compatibility testing

Collection of blood and blood products from the Princess Alexandra Hospital Blood Bank.

Provision of patient information brochures relating to blood transfusion to patients.

Ensuring consent for blood transfusion is appropriately documented by a medical officer prior tocommencing transfusions. Explanation to the patient of the signs and symptoms of possible bloodtransfusion reactions and procedures to follow in the event of this occurrence.

Safely carrying out the procedure for the administration of blood and blood products.

Monitoring patients during transfusion, and carrying out the appropriate actions in the event of adverse

effects. Reporting of transfusion reactions or other incidents related to the transfusion to the Medical Officers, to

the service provider (Princess Alexandra Hospital Blood Bank) and PRIME incident reporting system.

Documentation of the procedure in the medical record.

Enrolled Nurses (Medication Endorsed), when delegated by a Registered Nurse can perform thefollowing actions and be responsible for:

Checking order for blood and blood products, calculating administration rate, priming IV lines, connectingblood product to line, except via Central Venous Access Lines .

Monitoring patients during transfusion, and carrying out the appropriate actions in the event of adverseeffects, including notification of delegating Registered Nurse.

Phlebotomists responsibili ties are restricted to:

Venepuncture of blood samples for compatibility testing.

Anci llary staff responsibil it ies are restr icted to :

The collection of blood and blood products from the Princess Alexandra Hospital Blood Bank or bloodstorage refrigerator.

It is emphasised that this is a vital role, and errors in blood co llection have been identified as animportant cause of administ ration of the wrong blood.

10

Staff of Princess Alexandra Hospital Transfusion Service (Blood Bank) are responsible for:

Ensuring that the labelling of request forms and blood samples comply with best practice guidelines.

Blood grouping and compatibility testing.

Checking whether there are any special requirements whenever blood or blood products are requested.

Ensuring that blood and blood components are properly labelled, and the identification details of thepatient and the blood to be transfused are the same on the compatibility label attached to the componentand the blood transfusion report form.

Investigation and reporting of transfusion reactions or other incidents related to transfusion.

Clinical Governance:The Princess Alexandra Hospital Clinical Executive is responsible for ensuring that all health careprofessionals are informed of, and follow, policies on blood transfusion through its arrangements for clinicalgovernance with an established Transfusion Committee.

Princess Alexandra Hospital Transfusion Committee is responsible fo r:

Reviewing transfusion policies and procedures.

Reviewing the arrangements for training of staff in transfusion policies and procedures.

Reviewing adverse transfusion events including near misses. Reviewing the appropriateness of blood transfusion, and making recommendations about the proper use

of blood and blood products.



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Recommending corrective action in transfusion practice, where indicated.

Promoting continuing education in transfusion medicine for all relevant members of staff.

Investigating the use of Information Technology (or other technology) to improve transfusion safety.

Current Representation on the Princess Alexandra Hospital Transfusion Committee:

Division of Medicine,

Division of Surgery,

Division of Cancer Services, Division of Nursing,

Pathology Queensland: Laboratory/Blood Bank,

Australian Red Cross Blood Service,

Anaesthesia,

Intensive Care,

Transfusion Clinical Nurse Consultant.

Scheduled Meetings:

Every three four months.

Report to:

Princess Alexandra Hospital Safety and Quality Committee.

Transfusion Clinical Nurse Consultant is responsible for:Working in conjunction with Metro South Transfusion Committee, Blood Bank and Clinicians to:

Promote safe and appropriate blood transfusion practice.

Promote the continuing education of best practices in blood transfusion for hospital medical and nursingstaff.

As a clinical resource for staff, answer questions regarding blood component and blood productadministration.

Ensure blood transfusion procedures and guidelines reflect the available national and internationalstandard practice.

Provide assistance in the reporting and follow up of adverse transfusion events including near missesand transfusion reactions.

When required, recommend corrective action in transfusion practice. Increase staff awareness of the availability of patient information materials and encourage provision of

these materials to all patients receiving blood products.

Liaise between laboratory and clinical areas.

Ensure quality improvement in transfusion practice:- Auditing of transfusion practice to make certain key performance indicators are identified,

attainable and monitored to continuously improve our service.- Audit adherence to transfusion related guidelines and disseminate data effectively.- Effectively manage/coordinate improvement initiatives and changes within the organisation across

all domains of transfusion practice.- Report to the District Safety and Quality Committee through the Quality Department.



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Section D: Adminis tering Blood and Blood Products

Administ rat ion of Blood Products

Errors at the time of administration of blood or blood products are the most frequent documented site of errorculminating in the transfusion of the wrong blood.

11-12

However, preceding errors in blood sampling, laboratory procedures and especially in withdrawal ofblood components from storage refrigerators were found to be an important contributory factor in many of theincidents.

13

Two (2) members of nursing or medical staff, one of whom must spike and hang the bag, shall beresponsible for carrying out the final identity check of the patient and blood/blood product.

5

Checking o f blood and blood products at the patients bedside must be audible to the patient.

Checking of blood and blood products in the operating theatre must be audible to the attendingclinical staff.

The following checks are to be carried out at the patients bedside to ensure the right patient receives the

right blood/blood products: The bag is inspected for any leaks, discolouration or the presence of large clots.

Identify the patient by asking them to state their name and date of birth, UR Number and/or Address andcheck this against the patients identity band. NO WRISTBAND = NO TRANSFUSION

Check that the patients name, date of birth and UR number on the blood transfusion compatibility reportform matches the patients identity band.

Check that the blood product number on the compatibility report matches the label/tag number on theproduct bag or bottle.

Check that the patients Blood Group and Rh D status on the compatibility report matches the label/tagon the product bag.

Check that any special requirements on the medical order match the compatibility form and productbag(s) (e.g. CMV status and/or irradiation).

Check the expiry date on the bag(s) or bottle.

Check the medical orders for type of blood product, special requirements, number or quantity of bloodproduct required, rate of administration and indication for pre-medications or diuretic.

The compatibility report and prescription forms are to be signed by both staff members.

The staff member who administered the blood product is also required to enter the time and date on bothforms.

If using an infusion pump: pump settings, flow rates and volume of blood component should be includedin the checking procedure.

Infusion Rates (Refer to:Appendices)All individual units of blood and blood product transfusions must be completed within 4 hours of removalfrom designated blood storage.

2,5

If there has been a delay in starting the transfusion, and the blood has been out of the fridge for more than30mins, it may still be used for that patient provided transfusion of the unit will been completed within 4hours of the original despatch time.

Princess Alexandra Hospital Blood Bank staff or the Haematology Registrar should be consulted if it appearsthat the hang time may exceed the 4 hour timeframe.



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Inspection of Blood and Blood Products

Princess Alexandra Hospital Blood Bank staff checks the expiry date and inspect blood product before issuewith particular attention to:

Integrity of the pack by checking for leaks at the ports and the seams.

Evidence of haemolysis in the plasma or at the interface between red cells and plasma (check interface

in attached donor segments). Evidence of unusual discolouration or turbidity.

Presence of large clots.

If there is evidence of any of the above, the blood product should not be used and should be returned tothe issuing blood service (Princess Alexandra Hospital Blood Bank, Australian Red Cross Blood Services,CSL or other manufacturer).

It is best practice for the staff administering blood products to inspect each blood product in a similar waybefore its transfusion and to return the blood product to the Princess Alexandra Hospital Blood Bank if anydefects are found.



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Identity Check of Patient and Blood Product

The bedside check is a vital step in preventing transfusion error, andALL staf fshall be vigilant in thechecking procedure to ensure that the right bloodproduct is given to the right patient.

Two (2) members of staff shall be responsible for carrying out the identity check of the patient and the blood

product at the patient bedside. The members of staff shall be doctors or nurses holding current registration.

The patient shall be positively identified by asking the patient to state their surname, given name anddate of birth (whenever possible) and make sure that the surname and first name are the same as on thepatient identification bracelet. NO WRISTBAND = NO TRANSFUSION

Special care should be taken for those patients who cannot state their name for whatever reason.

ALL Princess Alexandra patients having a blood t ransfusion must have at least one securelyfastened Patient Identification Bracelet indicating the patient surname, given name, date of birth andUnique Record (UR) number.

Exceptions to this rule:

Emergency retrieval:where an emergency UR number has been allocated to an unknown patient

Issue of blood products to patients with an Unknown IdentityBlood and blood products are issued to the patient details as specified on the cross-match request form andblood specimen tube. When a cross match specimen is labelled with an Unidentified Patient Identity isprocessed by the laboratory, blood products will be issued to the Unidentified Patient only. To pick upblood products from the blood bank take the Unidentified Patient ID label.

Issue of blood products when the patients identity has changedOnce a patients identity has changed, a new blood sample must be taken if the patient requires bloodproducts.When a group and hold or cross-match has been taken from a patient in DEM whos identity is unknown, ifany details for that patient are changed in HBCIS than a new sample MUST be taken. Blood Bank cannot

release crossmatched blood for any other patient details but they can release MEDEVAC,uncrossedmatched Type O negative. This ensures the Blood Bank release the right blood product to theright patient, preventing transfusion errors.

See Princess Alexandra Hospital Procedure: 01915 Unidentified Patients in Emergency Department Administrative and HBCIS Management ofVerification of patient identity should be checked with parent/carer/spouse if the patient is unable to statehis/her name.

The staff member spiking/hanging the component shall be one of the two (2) personswho haveundertaken the component and patient identity check.

The following details (patient surname, given name, date of birth, patient UR number) shall be checkedand found to be identical on:

The patients identification band,

The compatibility label attached to the blood/blood product,

The prescription,

The blood transfusion compatibility report form.

In addition the following checks are to be made:Blood group and donation/batch number on the blood product bag/bottle shall be checked and found to beidentical to the information on the label attached by the laboratory.

Blood group on the blood product shall be compatible with the blood group of the patient as indicated on thecompatibility label attached to the blood product. If the blood group of the blood product and the patient are

not identical, the Princess Alexandra Hospital Blood Bank will make a specific comment to indicate that theblood is compatible (or most suitable available).

http://paweb.sth.health.qld.gov.au/sqrm/qiu/documents/procedures/01915.pdfhttp://paweb.sth.health.qld.gov.au/sqrm/qiu/documents/procedures/01915.pdfhttp://paweb.sth.health.qld.gov.au/sqrm/qiu/documents/procedures/01915.pdfhttp://paweb.sth.health.qld.gov.au/sqrm/qiu/documents/procedures/01915.pdf


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Blood product shall be checked for compliance with any special requirements on the prescription sheet(gamma-irradiated, CMV-seronegative).

Blood product shall be checked to ensure it has not passed its expiry date, or expiry time in the case of bloodproducts with a short shelf-life (washed red cell and platelet concentrates).

Check for consent documented in medical record (except during emergency transfusions) and any pre-medications required.

If a DISCREPANCY IS FOUND during the bedside identity checking procedure and is not covered by acomment by the issuing Princess Alexandra Hospital Blood Bank, the blood or blood product shall not be

transfused until the discrepancy is resolved with Princess Alexandra Hospital Blood Bank.



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Red Cell

26

Unique identifier

Collectiondate Expiry date and

time

Component

Specific details(Inc. Modifications)e.g. CMV Negative,Irradiated

Blood Group

Red Cell (phenotyped)

Unique identifier

Component

Specific details(Inc. Modifications)

Expiry date andtime

Collection

date

Blood Group

Red cellphenotype

Printed version is an uncontrolled copy


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Platelet

Blood Group

Specific details(Inc. Modifications)

Unique identifier

Component

Expiry date andtime

Preparationdate

Irradiated Blood Labels

If Irradiated blood components are required irradiated labels are attached to the bag prior to gammairradiation to ensure that the correct dose was received. Once the correct dose is received the NOT on thelabel turns opaque so that it cannot be seen. Please note: Plasma blood components and plasma derivedblood products do not require irradiation.



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Completing the Transfusion

All blood individual units of blood should be infused within 4 hours of removal from designated bloodstorage (with exception of Factor VIII or IX prepared for continuous infusion).

Ensure the blood transfusion compatibility report form is filed in the Patient Medical Chart.

Ensure documentation is completed (see Section C: Documentation of Transfusions).

Ensure empty transfusion bags/blood product bottles are disposed into clinical waste plastic (glass bottlesare not suitable for recycling).

Retention of empty blood bags for a period of 48hrs after transfusion has been previouslyrecommended

4so that they are available if a severe transfusion reaction occurs some hours after

discontinuation of the transfusion. This can be considered to be good practice, but it i s cumbersome toimplement and the benefits are uncertain.

Blood bags need only be retained and sent to back to blood bank in the event of an acute transfusionreaction occurring.



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Section E: Management and Reporting of Adverse Reactions

Many of the serious adverse events following blood transfusion are unpredictable. The most important areacute and delayed haemolytic transfusion reactions, febrile (nonhaemolytic) transfusion reactions, urticariaand anaphylaxis (including IgA/anti-IgA reactions), transfusion-related acute lung injury (TRALI), post-transfusion purpura (PTP), transfusion-associated graft-vs.-host disease (TA-GvHD)

4and transmission of

infection.(Refer to :Section H Appendices)

If a transfusion reaction is suspected remember, a second patient may be at risk and other bloodproducts collected from the same donor may be implicated.

Transfusion reactions are unpredictable and may vary from mild to life threatening.

Any change in a patients vital signs or complaints of symptoms must be acted upon immediately.

In the event of a transfusion reaction (SeeAppendix 1 Queensland Incidents in Transfusion ReactionChart):

STOP the transfusion and leave the giving set attached until situation has been discussed or a medical

officer has reviewed the patient. Keep the vein (KVO) open with saline using a new giving set.

Check and record the patients vital signs: monitor: temperature, blood pressure, pulse and respirationsevery 15mins.

Repeat checks of all labels, forms and patient identity, including the patient wristband, to determinewhether the right blood component was given to the right patient.

Notify Medical Staff.- Management of the patient will depend on the severity of the transfusion reaction. In the case of a

mild transfusion reaction, the Medical Officer may recommend the transfusion be recommencedafter the administration of the appropriate medications, e.g. anti-pyretic or anti-histamine.

Notify Princess Alexandra Hospital Blood Bank, who may request the return of the blood product and thecollection of appropriate blood samples for further investigations.

Collect other pathology specimens, e.g. blood cultures or urine, as requested.

Continue to closely monitor the patients vital signs every 15mins until reaction resolves.

If requested, return the blood product with the administration set attached and appropriate specimens tothe Princess Alexandra Hospital Blood Bank; the blood product/administration set combination withoutsharps should be double plastic bagged and tightly sealed for transport. Care must be taken not tocontaminate the blood product and administration set, as this may confound any microbiology tests.

Document the reaction and all interventions in the patients medical record.

Complete a PRIME Incident Report The QiiT Transfusion Reaction Chart can assist staff in selectingthe appropriate category for the transfusion reaction in PRIME as possible aetiologies are listed withcorresponding signs and symptoms. Some mild reactions may not require a report seeAppendix 1: QiiTTransfusion Reaction Chart.

Hyperlink to :Prime.

Refer ALL enquiries to: Princess Alexandra Hospital Blood Bank (ext. 2727 or pager 496)ALL HOURS;

OR

Haematology Registrarduring normal working hours.

Bacterial Contamination of PlateletsIt has been recognised that bacterial contamination is a significant residual infectious risk; bacterialcontamination is the second most common cause of death related to transfusion. Australian Red CrossBlood Service now screen all platelet components for bacterial contamination.

3

Platelet components are sampled at 24 hours after collection and will be available for issue from AustralianRed Cross Blood Service with bacterial contamination screening status as negative to date. The culture willbe incubated during the full shelf life of the platelet components. Due to the short shelf life of platelets, there

may be instances where contaminated platelets may have already been transfused. In the event of thisoccurring, blood bank will notify the treating clinician and prophylaxis with antibiotics must commenceimmediately. See Queensland Blood Management Program information sheets, Bacterial ContaminationScreening Clinician Advisory orBacterial Contamination of Platelets: Patient Information.

http://connect.health.qld.gov.au/prime/http://www.health.qld.gov.au/qhcss/qbmp/documents/bcs_clinician.pdfhttp://www.health.qld.gov.au/qhcss/qbmp/documents/bcs_clinician.pdfhttp://www.health.qld.gov.au/qhcss/qbmp/documents/bcs_pt_info.pdfhttp://www.health.qld.gov.au/qhcss/qbmp/documents/bcs_pt_info.pdfhttp://www.health.qld.gov.au/qhcss/qbmp/documents/bcs_clinician.pdfhttp://www.health.qld.gov.au/qhcss/qbmp/documents/bcs_clinician.pdfhttp://connect.health.qld.gov.au/prime/


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Haemovigilance

Haemovigilance consists of the detection, gathering and analysis of information regarding untoward andunexpected effects of blood transfusion.

14

Queensland has a state-wide, haemovigilance program, Queensland Incidents in Transfusion (QiiT),established by the Queensland Blood Management Program to fulfil Queensland Health's obligations to

promote safe use of blood products under the National Blood Agreement.

Hyperlink to:Queensland Incidents in Transfusion WebsiteQiiT will contribute to a national Haemovigilance system currently being developed by the National BloodAuthority as well as defining the degree of risks associated with current transfusion practice in Queensland.The QiiT system is designed to extract information from the PRIME system. Hyperlink to:PRIMEThe QiiT haemovigilance system will only be collecting information from events related to fresh blood andblood components:

Red cells,

Platelets,

Fresh frozen plasma,

Cryoprecipitate, Cryo-depleted plasma,

Whole blood.

Any event related to incident, near miss or reaction to a plasma derived blood product should bedocumented within PRIME but these will not be forwarded to QiiT.

Information to Assist PRIME ReportingThe QiiT Reaction Chart can assist staff in selecting the appropriate category for the transfusion reaction aspossible aetiologies are listed with corresponding signs and symptoms.The categories for Patient Reactions for the incident Type, Blood Products, Transfusion andHaemovigilance, within PRIME are listed below. Multiple items may be selected if required.

None: This option is always displayed, as completion of the Patient Reaction field is mandatory.

Febrile Non Haemolytic Transfusion Reaction (FNHTR): Select when the transfusion of a blood producthas caused a febrile non haemolytic transfusion reaction defined as one or more of following within 4 hoursof transfusion without any other cause (e.g. haemolytic transfusion reaction or infection) rise in temperatureduring transfusion of 1

OC or temp. = 38.0

OC; chills; sensation of cold; rigors.

Transfusion Associated Cardiac Overload (TACO): Select when volume overload led to congestivecardiac failure within 24 hours of transfusion.

Severe Allergic Reaction: Severe allergic reaction (one or more of rash, wheezing, dyspnoea, stridor,angioedema, generalised pruritus, and/or urticaria) during or within 24 hours of a transfusion of a bloodcomponent or a plasma component that requires pharmacological treatment.

Anaphylaxis: Allergic reaction (one or more of rash, wheezing, dyspnoea, stridor, angioedema, generalisedpruritus, and/or urticaria) with hypotension (drop in systol ic blood pressure of equal to or more than 30mmHg) during or within 24 hours of a transfusion of a blood component or plasma component.

Transfusion Related Acute Lung Injury: Occurrence of acute respiratory distress and bilateral pulmonaryinfiltrates on CXR with no evidence of circulatory overload or other potential cause within 6 hours oftransfusion of a blood component or plasma component.

Post Transfusion Purpura: An acute episode of thrombocytopenia occurring within 12 days of a transfusion(red cells or plasma) and confirmed by the presence of platelet specific alloantibodies (usually anti-HPA1a)in recipients blood and presence of the antithetical antigen on donor platelets, or by positive platelet crossmatch.

Delayed Haemolytic Transfusion Reaction: Haemolytic transfusion reaction occurring more than 24 hoursafter the transfusion.

http://www.health.qld.gov.au/qhcss/qbmp/qiit.asphttp://qheps.health.qld.gov.au/qbmp/qiit.htmhttp://connect.health.qld.gov.au/prime/http://connect.health.qld.gov.au/prime/http://qheps.health.qld.gov.au/qbmp/qiit.htmhttp://www.health.qld.gov.au/qhcss/qbmp/qiit.asp


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Acute Non-ABO Haemolytic Transfusion Reaction: Haemolytic transfusion reaction (not due to ABOincompatibility) occurring within 24 hours of a transfusion.

Transfusion Associated Acute Graft versus Host Disease: Development of symptoms and signs (fever,erythematous skin rash, hepatic dysfunction, diarrhoea and bone marrow hypoplasia/pancytopenia) 1-6weeks following transfusion with no other apparent cause. The diagnosis is confirmed by skin and/or bonemarrow biopsy appearances and/or the demonstration of genetic chimerism in the recipients peripheralblood lymphocytes.

Transfusion Transmitted Infection (including Bacterial Contamination of Blood Component): A post-transfusion infection (viral, bacterial or parasitic) not present in the recipient before transfusion of a bloodcomponent or plasma component and present in either one of the components transfused or the donor ofone of the transfused components. Includes Bacterial Contamination of blood component detection andconfirmation of bacteria in a blood component or plasma component, which has either not been transfused tothe intended patient or was transfused but no bacteria was detected in cultures of the recipients blood.

ABO Haemolyt ic Transfusion Reaction: Haemolytic transfusion reaction (due to ABO incompatibility)occurring within 24 hours of a transfusion.The reporter is able to define the nature of the problem further with the following additional categories.

Multiple items may be selected as required.

Incorrect Blood Component Transfused (IBCT) wrong patient: Select when a blood component orplasma component was administered to the wrong patient and there was no harm to the patient.Incorrect blood component transfused (IBCT) not suitable: Inappropriate product/requirement not met, i.e.Select when a blood component or plasma component ordered or administered did not meet the appropriaterequirements (expired, non irradiated, CMV negative, leucodepleted, etc.) for the intended recipient.

Transfusion time outside of prescribed rate, without ci rculatory overload: This category should beselected when, as per best practice, transfusion of a blood product bag was either not completed in 4 hours,or was significantly different from the prescribed rate and without evidence of circulatory overload. If theincident results in circulatory overload, reporter should select the corresponding entry under the "PatientReaction" section.

Wrong dose/volume: This category should be selected when either the dose or volume transfused isoutside the prescribed dose or volume and without evidence of circulatory overload. If the incident results incirculatory overload, reporter should select the corresponding entry under the "Patient Reaction" section.

Administered with contraindicated substance: Administration of an incompatible substance through thesame intravenous route as the blood component.



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Section F: References

1. Australian Council on Healthcare Standards. The ACHS EQuIP 4 Guide, Part 1 Accreditation,Standards, and Guidelines. [Online]. 2007 [cited 2010 May 11th]. Available from: URL:http://www.achs.org.au

2. Australian and New Zealand Society of Blood Transfusion Inc. Guidelines for the administration of bloodcomponents. [Online]. 2004 [cited 2010 May 11th]. Available from: URL:http://www.anzsbt.org.au/publications

3. Australian Red Cross Blood Service [Online]. 2010 [cited 2010 May11th]. Available from: URL:http://www.transfusion.com.au

4. British Committee for Standards in Haematology. Guidelines for the administration of blood and bloodcomponents. [Online]. 2009 [cited 2010 May 11th]. Available from: URL: http://www.bcshguidelines.com

5. Australian and New Zealand Society of Blood Transfusion Inc. Guidelines for the Gamma Irradiation ofBlood Components. [Online]. 2003 [cited 2010 May 11th]. Available from: URL:http://www.anzsbt.org.au/publications

6. South Australian Dept of Health funded Blood Safe Program. Flippin blood. [Online]. 2006 [cited 2010May 11th]. Available from: URL: http://www.health.sa.gov.au/bloodsafe

7. Birch C, Hogan C, Mahoney. Co-Administration of drugs and blood products.Anaesthesia & IntensiveCare 2001; 29: 137140.

8. Standards Australia. Medical refrigeration equipment for the storage of blood/blood components, AS3864. [Online].1997 [cited 2010 May 11th]. Available from: URL: http://infostore.saiglobal.com.store

9. Queensland Blood Safety Management Program. Ordering receipting blood system (ORBS). [Online].2009 [cited 2010 May 11th]. Available from: URL: http://www.health.qld.gov.au/qhcss/qbmp.orbs

10. Williamson LM, Lowe S, Love E et al. Serious Hazards of Transfusion Annual Report 1996/97. [Online].1998 [cited 2010 May 11th]. Available from: URL: http://www.shotuk.org/shot-reports/reports-and-summaries-19967

11. McClelland DBL, Phillips P. Errors in blood transfusion in Britain: survey of hospital haematologydepartments. British Medical Journal 1994; 308:1205-1206.

12. Sazama K. Reports of 355 transfusion associated deaths: 1976 through 1985. Transfusion 1994; 30:583-590.

13. Waters AH, Skace P, Murphy MF, Wilkinson J, Hartigan G. National audit of the clinical blood transfusionprocess. Research Unit of the Royal College of Physicians; 1998.

14. Council of Europe. Guide on the preparation, use and quality assurance of blood components. No. R(95)15. [Online]. 2003 [cited 2010 May11th]. Available from: URL:http://www.coe.int/t/dg3/health/publications_en.asp

15. Hussain MA, Fletcher R, Long T, Zuccaro K, Bolwel, BB, Hoeltge G. Transfusion of platelets 2h after thecompletion of amphotericin-B decreases its detrimental effect of transfused platelet recovery.Transfusion Medicine 1998; 8: 43-47.

16. Royal Brisbane and Womens Hospital Health Service District Safety and Quality Unit. 06603/CPP:Blood and blood components, administration of (excluding Anti D) [Online]. 2008 [cited 2010 May 11th].Available from: URL: http://hi.bns.health.qld.gov.au/rbh/policies/06603cpp.pdf

Appendix 1: Queensland Incidents in Transfusion Reaction ChartAppendix 2: Administration of Fresh Blood ComponentsAppendix 3: Special RequirementsAppendix 4: Administration of Intravenous ImmunoglobulinAppendix 5: Administration of Albumin

http://www.achs.org.au/http://www.anzsbt.org.au/publicationshttp://www.transfusion.com.au/http://www.bcshguidelines.com/http://www.anzsbt.org.au/publicationshttp://www.health.sa.gov.au/bloodsafehttp://infostore.saiglobal.com.store/http://www.health.qld.gov.au/qhcss/qbmp.orbshttp://www.shotuk.org/shot-reports/reports-and-summaries-19967http://www.shotuk.org/shot-reports/reports-and-summaries-19967http://www.coe.int/t/dg3/health/publications_en.asphttp://hi.bns.health.qld.gov.au/rbh/policies/06603cpp.pdfhttp://hi.bns.health.qld.gov.au/rbh/policies/06603cpp.pdfhttp://www.coe.int/t/dg3/health/publications_en.asphttp://www.shotuk.org/shot-reports/reports-and-summaries-19967http://www.shotuk.org/shot-reports/reports-and-summaries-19967http://www.health.qld.gov.au/qhcss/qbmp.orbshttp://infostore.saiglobal.com.store/http://www.health.sa.gov.au/bloodsafehttp://www.anzsbt.org.au/publicationshttp://www.bcshguidelines.com/http://www.transfusion.com.au/http://www.anzsbt.org.au/publicationshttp://www.achs.org.au/


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Appendix 6: Coagulation FactorsAppendix 7: Transfusion Administration ChecklistAppendix 8: Pre-transfusion Sample Collection Flow ChartAppendix 9: Administration of Blood Component Flow ChartAppendix 10: Informed Consent Quick Reference Guide for staffAppendix 11: Princess Alexandra Hospital Massive Transfusion GuidelinesAppendix 12: Transfer of Blood Components



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Section G: Glossary of Terms

TERM DESCRIPTION

AABB American Association of Blood BanksAIMS Australian Incident Monitoring System

Anci llary staff Patient care assistants, orderliesARCBS Australian Red Cross Blood ServiceANZSBT Australian & New Zealand Society of Blood Transfusion

BMT Bone Marrow Transplant

CMV CytomegalovirusComponent Used throughout these guidelines to describe all components and products,

including such terms as units, packs, bottles, etc.CSL CSL Limited

Factor VIII Antihaemophilic factor used to treat Haemophilia AFactor IX Antihaemophilic factor used to treat Haemophilia B

FNHTR Febrile non-haemolytic transfusion reaction

HLA Human leucocyte antigenHTC Hospital transfusion committee

ISO International Standards Organisation

NHMRC National Health Medical Research Council [Australia]NPAAC National Pathology Accreditation Advisory CouncilNZBS New Zealand Blood Service

PBSC Progenitor (Peripheral) Blood Stem CellPICC Peripherally inserted central catheter

PTP Post transfusion purpura

QBMP Queensland Blood Management ProgramQiiT Queensland Incidents in Transfusion [Qld] Haemovigilance reporting system

RCNA Royal College of Nursing Australia

SHOT Serious Hazards of Transfusion [UK] adverse event reporting system

TA-GvHD Transfusion associated graft versus host diseaseTRALI Transfusion related acute lung injury



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Section H: Appendices

Appendix 1: Queensland Incidents in Transfusion Reaction Chart

T


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Appendix 6: Coagulation Factors

Plasma Derived & Recombinant Coagulation Factors

Clinical Indication: HTUQHPS Blood Bank: Recombinant Clotting Factors UTH HTUARCBS Factor ConcentratesUTH

Refer to individual product information for reconstitution and administration instructions

Plasma DerivedFactor VIIIBiostate:HTUManufacturers

InformationUTH

Recombinant FVIIIKogenateXyntha

Plasma derivedFactor IXMonoFIX VFHTUManufacturers

InformationUTH

Recombinant FactorIXBenefix

Warfarin ReversalHTUProthrombinex VF:Use andAdministration (02201) UTH(previously known asProthrombinex HT)

Medical staff have discussed use of the blood product with thepatient/carer. Qld Health does not require written consentprocess for plasma derived blood products Tas they carrying lowerrisks than fresh blood components T.

Reconstitution for CSL Plasma derived clot ting factorsImportant: Reconstitute as per HTUmanufacturers instructions withplastic Mix2VialUTH filter transfer set; dissolve the powder by gentleagitation to avoid frothing. The product vial must always be on alevel surface, do not insert at an angle or the vacuum may bereleased from the product vial and water for injection will nottransfer into product vial.

Products are stored at 2-6C anreconstitution.Administer within 3 hours of recoAdministered by the intravenous

Recombinant FactorVIIa (Novoseven)

HTUNovoSeven RT Information Booklet FULL UTH(PDF 1.1MB)

HTUNovoSeven RT Information Booklet Part AUTH(PDF 366kB)

HTUNovoSeven RT Information Booklet Part BUTH(PDF 345kB)

HTU

NovoSeven RT Information Booklet Part CUTH

(PDF 474kB)

Presentation A single pack conwater for injection and a filter neProduct is stored at 2-6C and m

reconstitutio

blood transfusion procedure

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