bp - blood products handbook | townsville hhs | iemr · 2020. 5. 21. · iemr handbook blood &...

Handbook Blood & Blood Products Version 1.0

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ieMR Handbook

Blood & Blood Products

Blood and Blood Product Handbook, v1.0, BP004, 05/05/2020

Townsville Hospital and Health Service Page i

Contents

Prescribing – Medical Officers ......................................................................................... 1

Responsibilities ............................................................................................................................... 1

Routine Blood Products - Adult ....................................................................................... 1

Routine Blood Products – via Blood Products Folder ...................................................................... 1

Multiple transfusion rules (all patients) ............................................................................................ 3

Ordering Fresh Blood Product Administration Adult (PowerPlan) .................................................... 4

Ordering Medication within the PowerPlan ...................................................................................... 4

Ordering Blood Administration Task within the PowerPlan .............................................................. 5

Routine Blood Products – via Search Function ............................................................................... 6

Paediatric Blood Products ................................................................................................ 8

Paediatric weight rules (Patients <20kg) ......................................................................................... 8

Paediatric weight rules (Patients <16 years) ................................................................................... 9

Fresh Blood Product Administration Paediatric PowerPlan ............................................................. 9

Administration Documentation ...................................................................................................... 10

Prescribing - Urgent Blood Products including Massive Transfusion Protocol ........ 11

Responsibilities ............................................................................................................................. 11

Urgent Blood Products – via Blood Folder .................................................................................... 11

Urgent Blood Products – via Search Function ............................................................................... 12

Ordering Immunoglobulins ............................................................................................................ 13


Ordering Immunoglobulins via Blood Products Folder ................................................................... 13

Ordering Immunoglobulins via PowerPlans ................................................................................... 15

Prescribing – Albumin ..................................................................................................... 17

Administration – Nursing & Midwifery ........................................................................... 19


CareCompass – Completing Administration Tasks (Routine) ........................................................ 19

Recording Blood Transfusions – Fluid Balance ............................................................................. 20

Multiple Bags – CareCompass ...................................................................................................... 21

Urgent Bloods including Massive Transfusion Protocol– Documenting ......................................... 22


Discontinue Dynamic Group ......................................................................................................... 24

Administering Blood Products – MAR (Albumin) ........................................................................... 24


Recording Possible Transfusion Reaction ..................................................................................... 26

Recording as an Allergy ................................................................................................................ 26

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Blood and Blood Product Handbook, v1.0, BP004, 05/05/2020

Townsville Hospital and Health Service Page ii

Adding a Transfusion Reaction to Allergies ................................................................................... 26

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Blood and Blood Product Handbook, v1.0, 05/05/2020

Townsville Hospital and Health Service Page 1

Prescribing – Medical Officers

Responsibilities

• Complete the Pathology Queensland Transfusion Request form to request blood products from Transfusion Department, Pathology

• If not already completed and scanned into the patient’s ieMR record, ensure appropriate paper consent form is completed and placed in ‘end of bed chart’

• Confirm if any special requirements for blood/previous transfusion reactions by checking allergies section of the ieMR

• Order administration task on ieMR (for example routine packed cells adult task in ieMR as appropriate)

The current processes for generating an order with blood bank will remain unchanged.

There are three avenues to order fresh blood products:

1. Blood Products Folder within the orders screen OR

2. Fresh Blood Product Administration PowerPlans (Adult or Paediatric) OR

3. Orders screen search

Once you have requested the blood product from the blood bank, complete an order for administration within ieMR. This order will be used by the nursing staff to document the administration via CareCompass, Launch Point or Activities and Interventions.

Routine Blood Products - Adult

Routine Blood Products – via Blood Products Folder

Fresh Blood Products DO NOT appear on the Medication Administration Record (MAR) as they are not considered a medication. Administration tasks will appear in CareCompass, Launch Point and Activities and Interventions.

1. Navigate to orders page and select +Add

2. Select the Blood Products folder

3. Select Routine Fresh Blood Products

4. Select the required blood product from the list (Adult or Paediatric);

i. Cryodepleted Plasma – Administration

ii. Cryoprecipitate – Administration

iii. Plasma - Administration

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iv. Fresh Blood Product Administration Adult (PowerPlan) – see instructions below

v. Fresh Blood Product Administration Paediatric (PowerPlan)

vi. Haemopoietic Progenitor Cells – Administration

vii. Granulocytes – Administration

viii. Red Cell Concentrate – Administration

ix. Fresh Frozen Plasma Paediatric – Administration

x. Red Cell Paediatric – Administration

xi. Platelets Paediatric – Administration

xii. Platelets – Administration

xiii. Platelets Apheresis – Administration

xiv. Platelets HLA – Administration

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5. Select Done

6. Within the order entry field (OEF), complete the following:

a. Volume to be Infused

b. Volume to be Infused Unit of Measure

c. Requested Start Date/Time

d. Reason for Transfusion

e. Rate (i.e. over 3 hours)

7. Once the information has been completed within the OEF, sign and enter your password.

8. Refresh the orders page

Multiple transfusion rules (all patients)

• If a clinician attempts to order more than one unit of a blood product within a single administration task, the following alert will be generated and will direct the clinician to either modify or cancel the order.

• Clinicians are required to continue to place one administration task per blood product.

• If more than one unit is required, clinicians are required to order multiple administration tasks to reflect this.

Volume to be infused (VTBI), VTBI unit of measure, reason for transfusion and rate are

mandatory fields.

The VTBI unit of measure will pre-fill, depending on the selected order sentence. Note:

for adult patients, VTBI unit of measure requires to be unit(s) only.

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The administration task will then display on CareCompass, Launch Point and Activities and Interventions to be actioned.

Ordering Fresh Blood Product Administration Adult (PowerPlan)

The PowerPlan contains several orders that may be required to support the administration of blood products, including:

• Patient care orders

• Medication orders

• Pathology orders

Ordering the PowerPlan can be completed via the blood product folder or by searching the title of the PowerPlan.

1. Navigate to the orders page and select +Add

2. Select the: Blood Products folder

3. Select: Routine Fresh Blood Products

4. Select: Fresh Blood Product Administration Adult (PowerPlan)

5. Select Done

6. Select the patient care tasks, medications and laboratory that is clinically relevant for your patient from the PowerPlan.

Ordering Medication within the PowerPlan

1. Select the required medication

2. Use the drop-down arrow to select the order sentence

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3. Review the order details and modify if required

Ordering Blood Administration Task within the PowerPlan

1. Select the required administration task

2. Right click and select modify

3. Complete the following fields within the OEF:






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If more than one laboratory task is required, you can +Add to Phase to ensure all orders are within the PowerPlan. For example, the patient requires 2 (two) units of packed cells. This will place multiple administration tasks on CareCompass for the nursing staff.

If you do not require additional tasks, skip forward to step 20 below.

4. Select: +Add to Phase

5. Select: Add order


7. Select: Routine Fresh Blood Products

8. Select the required administration task (i.e. Packed Red Cells - Administration)

9. Select Done

10. Complete the following fields within the OEF:






11. Select Initiate Now, Orders for Signature and Sign

12. Refresh the orders page and review

Routine Blood Products – via Search Function


2. Search for the blood product administration task you require (i.e. Packed Red Cells – Administration) – refer to the list above

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3. Select the required administration task

4. Complete the fields within the OEF

5. Sign and refresh the orders page

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Paediatric Blood Products

For Paediatric patients under 20kg, Volume to be Infused Unit of Measure is required to be selected as mLs

Blood orders for paediatric patients are appropriately weight filtered, including pre-medications and flushes within the Fresh Blood Product Administration Paediatric PowerPlan.

Bloods for paediatric patients can be ordered by the steps outlined above;

1. Blood Products Folder within the orders screen OR

2. Fresh Blood Product Administration Paediatric PowerPlan OR

3. Orders screen search: this will now populate with an order sentence for mLs and completed special instructions.

Paediatric weight rules (Patients <20kg)

• The system now requires clinicians to order a volume to be infused in mLs, rather than units for paediatric patients that weigh less than 20kgs.

• If a clinician attempts to order blood products in units, the following alert will be generated and will direct the clinician to either modify or cancel the order.

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Paediatric weight rules (Patients <16 years)

The following discern rules will be generated if a patient does not have:

• A. Weight recorded • B. Recent weight recorded (within 90 days)

Clinicians can launch the Paediatric Growth Chart PowerForm from the discern alerts to Document a weight and proceed with ordering by selecting ‘Document’ within the discern alert.

Fresh Blood Product Administration Paediatric PowerPlan

• Allows clinicians to order patient care tasks, medications, pathology and blood administration tasks within one plan, grouped together.

• Contains evidence-based links for blood product ordering procedures and QLD health consent guidelines.

• Appropriate age and weight filtering on order sentences, including IV flushes.

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Administration Documentation

The documentation process remains unchanged for paediatric patients. In addition, paediatric patients under 20kg have the following selection available when documenting within the dynamic group:

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Prescribing - Urgent Blood Products including Massive Transfusion Protocol Urgent blood products are defined as blood products required during emergency situations only for example during Rapid Response/Code Blue, Resuscitation or as part of Massive Transfusion Protocol. Urgent blood product administration orders are for retrospective documentation.

Responsibilities

• Complete the Pathology Queensland Transfusion Request form to request blood products from transfusion department pathology or follow local protocol

• Ensure appropriate consent form is completed and placed in ‘end of bed chart’ (as clinically appropriate)

• Only place urgent blood product administration orders for Rapid Response/Code Blue, Resuscitation or as part of Massive Transfusion Protocol

• Order urgent blood product administration task retrospectively in ieMR if unable to document in real time

• Order administration task in ieMR as appropriate

Urgent Blood Products – via Blood Folder



3. Select: Urgent Fresh Blood Products

4. Select the required blood product from the list

i. Urgent Cryoprecipitate – Administration

ii. Urgent Plasma – Administration

iii. Urgent Red Cell Concentrate – Administration

iv. Urgent Fresh Frozen Plasma Paediatric – Administration

v. Urgent Red Cells Paediatric – Administration

vi. Urgent Platelets Paediatric – Administration

vii. Urgent Platelets – Administration

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5. Select Done

6. Enter: Number of Units Requested

7. Select Sign, refresh the orders page and review

This will not place multiple tasks for nursing staff to action, this function is to be used to document URGENT administration (of up to 5 bags) and will be documented in retrospect.

Urgent Blood Products – via Search Function


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2. Search for the blood product administration task you require (i.e. Urgent Packed Cells – Administration) – refer to the list above

3. Select the required task

4. Complete the fields within the OEF

5. Sign and refresh the orders page

Ordering Immunoglobulins

Responsibilities

• Prior to the ordering of an intravenous immunoglobulin on the ieMR, approval and ordering is required from BloodSTAR registered user

• Order intravenous immunoglobulin administration task in ieMR

• Can use the Blood Products folder and Immunoglobulin Adult/Paediatric PowerPlan as required

• Immunoglobulins are listed under brand name in the ordering catalogue

• Pre and post transfusion medication orders are to be placed as separate medication orders in the ieMR

• Will review transfusion information in Interactive View via the Fluid Balance navigator band or the Blood Product Administration navigator band

Ordering Immunoglobulins via Blood Products Folder



3. Select: Immunoglobulins

4. Select the required item from the folder:

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5. Complete the relevant fields within the OEF

6. Sign and refresh to review the orders page

The individually available Immunoglobulin products vary. Some are Administration orders such as for Intragam, which are assigned to the Laboratory section of the orders screen and generate nursing administration tasks. Others are medication orders, and administration will be charted using the MAR.

As with fresh blood products, the current process for obtaining products from the blood bank remains unchanged. The immunoglobulin PowerPlan contains additional orders, including; medications, patient care tasks and pathology orders. The PowerPlan also displays which products are obtained through Pharmacy and which are obtained through the blood bank.

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Ordering Immunoglobulins via PowerPlans

Note: within the PowerPlan, the information will allow the clinician to view where the product is sourced from (i.e. Pharmacy, BloodSTAR, etc).


2. Search: Immuno Adult

3. Select: Immunoglobulins Adult PowerPlan

OR

a. Search: Immuno Paed

b. Select: Immunoglobulins Paediatric PowerPlan

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4. Select Done

5. Select the required tasks and/or medications from the PowerPlan by placing a tick into the checkbox

Note: Selecting items under the Medications header, will place the items onto the MAR.

Note: Selecting items under the Laboratory header, will place the items onto

CareCompass, NOT the MAR.

6. Once required items have been selected and the information within the order entry field (OEF) is completed, select Initiate Now and continue signing the PowerPlan.

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7. Refresh the orders page and navigate to the respective areas to ensure the orders and/or administration tasks have fallen correctly.

Prescribing – Albumin

Albumin administration WILL appear on the MAR for administration.


2. Search: albumin

3. Select the required order sentence (e.g. albumin human 4% intravenous solution (intermittent))

4. 500mL IV intermittent infusion, ONCE only, infuse over 2 hours, 250mL/hr)

5. Complete all relevant fields within the OEF, including; first dose date/time

6. Select sign and enter your password

7. Refresh the orders page, navigate to the MAR and refresh

8. Review the order on the MAR

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Transfusion order information can be viewed through the orders page and via interactive view in the Blood Product Administration Band.

Note – It is important to view orders via both sections for a complete history of the order status.

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Administration – Nursing & Midwifery

Blood products DO NOT always appear on the MAR. Blood and blood products that are not visible on the MAR, are to be documented via the task on CareCompass which will complete the task.

Tasks documented from CareCompass will open in the Blood Product Administration through Activity View. Once the task is signed off, any further documentation is done via the Blood Product Administration band.

Documenting a task via Activities and Interventions will flip the encounter being documented against, to the encounter that the task was ordered in. This can be identified by the location information in the patient’s banner bar at the top of the chart.

Responsibilities

• Two nurses will be required to fill out and sign the Transfusion Report form that is supplied with the blood products AND

• Two nurses will be required to complete the ‘Blood Unit Verification checklist’ in ieMR

Clinicians are required to document each blood product in dynamic groups as per the list below:

• Red Cell concentrate- one (1) dynamic group per unit (five (5) units per dynamic group for large

• volume transfusion)

• Platelets- one (1) dynamic group per unit only

• Cryoprecipitate- three (3) units per one (1) dynamic group

• Fresh Frozen Plasma- three (3) units per one (1) dynamic group

• Hemopoietic progenitor cells- one (1) unit per one (1) dynamic group

• Granulocytes- one (1) unit per one (1) dynamic group

CareCompass – Completing Administration Tasks (Routine)

1. Navigate to CareCompass

2. Highlight the administration task and select ‘Document’

You will be navigated to Blood Product Administration within Interactive View (iView). If your patient requires more than one bag of blood, multiple care tasks may appear in CareCompass. Tasks are required to be documented within a dynamic group, as per the list above

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3. Record your baseline observations (all subsequent observations as per procedure are also to be recorded here)

4. Create a dynamic group for the administration task

5. Enter the required information into the dynamic group cells:

i. Blood unit product

ii. Blood unit ID number (you can manually type this or scan the blood bag)

iii. Blood unit group

iv. Patient blood type

6. Select OK

7. Enter the information and complete the fields;

Blood unit volume to be infused is the volume in mLs that is recorded on the blood

bag.

8. Select the green tick to sign

9. Enter the nurse witness username and password and select OK

Recording Blood Transfusions – Fluid Balance

1. Complete the fluid balance via the Blood Product Administration band within the cell: Blood unit volume infused (mL)

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2. The amount documented will also show under the Fluid Balance navigator band

Multiple Bags – CareCompass

1. Navigate to CareCompass

2. Highlight the first administration task and select ‘Document’

You will be navigated to Blood Product Administration within Interactive View (iView), If your patient requires more than one bag of blood, multiple care tasks may appear in CareCompass. Tasks are required to be documented within a dynamic group, as per the list above You will be navigated to Blood Product Administration within Interactive View (iView).

3. Record your baseline observations (all subsequent observations are also to be recorded here)

4. Create a dynamic group for the administration task

5. Enter the required information into the dynamic group cells:

i. Blood unit product

ii. Blood unit ID number (you can manually type this or scan the blood bag)

iii. Blood unit group

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iv. Patient blood type

6. Select OK

7. Enter the information and complete the fields

Blood unit volume to be infused is the volume in mLs that is recorded on the blood

bag.

8. Select the green tick to sign

9. Enter the nurse witness username and password and select OK

10. At the time of completion enter:

a. blood unit time completed

b. total blood unit volume infused

c. blood unit treatment outcome (including any adverse events. If no issues, then document nil concerns)

d. If applicable, blood unit reason not completed.

Urgent Bloods including Massive Transfusion Protocol– Documenting

Responsibilities

• Follow Townsville Hospital and Health Service Blood and Blood Products procedure

• Nurses can place urgent blood product administration orders on behalf of a prescriber but must select a communication type that routes for co-sign

• Check blood product administration task via Care Compass, Launch Point or Activities and Interventions- may be retrospective if in an emergency situation

• Two nurses must fill out and sign the Transfusion Report form that is supplied with the blood

• products (Must be completed even in urgent situations) AND

• Two nurses will complete the ‘Blood unit verification checklist’ in ieMR against the first

• documented unit of blood (may be completed retrospectively)

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• Record adverse reaction to blood products in Blood Product Administration band in Interactive View. This will enable an alert to fire should a subsequent blood product be ordered during the current encounter

A single dynamic group can be used to document the same blood unit products in the event of a massive transfusion protocol.

In the event of a massive transfusion;

1. In the Blood Unit ID number field, input the unique lab number code located on the Pathology Queensland blood product request form (cross match blood form).

2. Select the Blood unit group that is most represented in the bags to be infused and select OK.

3. Perform PPID then enter in the relevant details required with your nurse witness present.

4. If no written consent was obtained from the patient, select emergency from the blood consent form documented field.

5. As the documentation is being done in retrospect, enter the actual time and date that the transfusion commenced.

6. Your witness will need to enter their Novell username and password to co-sign this documentation.

7. At the time of completion enter:

a. blood unit time completed

b. total blood unit volume infused

c. blood unit treatment outcome (including any adverse events. If no issues, then document nil concerns)

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d. If applicable, blood unit reason not completed.

Remember, the process remains unchanged with two nurses being required to complete and sign the transfusion report from that is supplied with the blood products from the blood bank. This documentation also requires to be sent for scanning as part of normal discharge processes.

Discontinue Dynamic Group

Once the infusion is completed, the dynamic group is required to be discontinued.

1. Navigate to the Blood Products Administration tab

2. Locate the appropriate Dynamic group

3. Right click on the dynamic group and select Inactivate

4. The dynamic group will now appear as inactive

5. You can collapse the information, or review the information by clicking on the black arrow next to the dynamic group name

Repeat steps above to document the next bag of blood.

Administering Blood Products – MAR (Albumin)

Responsibilities

• Nurses will review blood derived product orders on the MAR

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• Nurses will take a patient identification label to transfusion department pathology to collect product, provide details to support service staff for collection or follow local protocol

• Two nurses will sign the administration of a blood derived product via the MAR or MAW administration window

1. Navigate to the MAR to review the medication order

2. Hover over the order sentence to review order comments and special instructions

3. Prepare the Albumin with your nurse witness

4. At the bedside, open PowerChart and perform verbal PPID, complete the allergy check

5. Navigate to the MAW and scan your patient’s wristband

6. Select the Albumin from the list of medications

7. Select the results column to display the administration window

8. Enter your nurse witness

9. Enter the batch number provided

10. Enter the site

11. Review the infused over and fluid balance

12. Sign the medication as per usual medication processes. The nurse witness will be required to enter their password.

13. Navigate the MAR, refresh and review the administration.

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Recording Possible Transfusion Reaction

All possible transfusion reactions are to be documented within the dynamic group.

1. Navigate to the Blood Product Administration tab and locate the appropriate dynamic group

2. If a transfusion is paused while seeking review, record the rate within the dynamic group as 0ml/hr.

3. From the Blood unit reason not completed tab, select possible transfusion reaction

4. Select the appropriate reaction signs (choose all that apply)

5. Record the transfusion reaction interventions (choose all that apply)

6. Select the appropriate staff members who have been notified

7. Record your incident report number (This can be recorded retrospectively) (incident reports are recorded through RiskMan)

8. Click green tick to sign.

Once you have signed the information for a possible infusion reaction an automated

email will be sent to the lab and to the hemovigilance CNC. Staff must still complete

the appropriate RiskMan as per current processes.

Recording as an Allergy

To ensure seamless and timely access to blood transfusion reaction history, or special blood requirements, information should be added to the Allergies section of the ieMR. This will allow information to be clearly displayed in the banner bar of the patient file. Confirmed transfusion reactions should be recorded as a sensitivity rather than an allergy, however caution should be applied in doing so as this practice may not be applicable in all instances. While previous reaction can be added into Alerts and Problems, this is not as visible as the Allergies section.

Adding a Transfusion Reaction to Allergies

1. Navigate to the Allergies section of PowerChart by either clicking on the Allergies hyperlink at the top left of the screen OR from the left hand menu

2. Click Add to navigate to the search function of the catelogue

3. Navigate to the ellipsis next to the vocabularies section

4. From the source vocabularies page select All Vocabularies

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5. In the search banner, type the product that patient has had a reaction to, for example, ‘red blood’ Make the appropriate selection from list and select button

6. Fill out all appropriate details for the reaction:

• Category: Other

• Reaction type: Sensitivity

• Severity: Use drop-down selection

• Reaction symptoms: Use Catalog or search to complete

• Info source and onset: as per patient

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7. Click Apply and OK when all information is entered

8. Navigate to the Patient Banner to confirm Allergy is recorded (you may need to refresh for the information to update)

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