transfusion policy, procedures and guidelines
TRANSCRIPT
Transfusion Policy Procedures and Guidelines
Page 1 of 14 Issue Date 15th November 2017
Review Date October 2020
Transfusion Policy Procedures and Guidelines
Issue Date 15th
November 2017
Disclaimer
Overarching policy statements must be adhered to in practice
Clinical guidelines are for guidance only The interpretation and application of them remains the responsibility of the individual clinician If in doubt contact a senior colleague or expert
The Author of this clinical document has ultimate responsibility for the information within it
This clinical document is not controlled once printed Please refer to the most up-to-date version on the intranet
Caution is advised when using clinical documents once the review date has passed
Transfusion Policy Procedures and Guidelines
Page 2 of 14 Issue Date 15th November 2017
Review Date October 2020
CONTENTS
SECTION DESCRIPTION PAGE
1 INTRODUCTION 3
2 SCOPE OF DOCUMENT 3
3 DEFINITIONS AND OR ABBREVIATIONS 4
4 ROLES AND RESPONSIBILITIES 4
5 NARRATIVE 7
6 EVIDENCE BASE REFERENCES 7
7 EDUCATION AND TRAINING 8
8 MONITORING COMPLIANCE 9
9 CONSULTATION 10
10 EQUALITY IMPACT ASSESSMENT (EIA) ndash and completed form 10
11 KEYWORDS 10
12 APPENDICES
1 ndash Procedure for consent and prescription 2 ndash Procedure for sample collection and requests for blood transfusion 3 ndash Procedure for issue collection and return of blood components 4 ndash Procedure for administration and traceability of blood components 5 ndash Massive Haemorrhage (blood loss) Protocol in Adults 6 ndash Guidelines for the recognition and management of blood transfusion reactions or adverse events in adults 7 ndash Guidelines for blood transfusion at Newark Hospital 8 ndash Procedure for the transfer and receipt of blood out of hours at Newark Hospital 9 ndash Maximum blood ordering schedule 10 ndash SFHKHA-LF-BTRO30 Blood Transfusion Reactions form 11 ndash Guideline for the use of Anti-D Prophylaxis for RhD Negative Women 12 ndash Emergency planning for the management of Blood Shortages ndash Policy and Procedure 13 ndash Collection and administration of Blood components at John Eastwood Hospice 14 ndash Guidelines for the use of red cells in adults 15 ndash Guidelines for the use of Human Albumin Solution 16 ndash Clinical guidelines for the transfusion of blood components in upper gastrointestinal bleeding 17 ndash Guidelines for the transfusion of blood components in neonates
All hyperlinked
to the separate
documents on the
intranet
DOCUMENT CONTROL 14
Transfusion Policy Procedures and Guidelines
Page 3 of 14 Issue Date 15th November 2017
Review Date October 2020
1 INTRODUCTION A blood transfusion is a potentially hazardous procedure which should be given only when the clinical benefits to the patient outweigh the potential risks the most important of these being acute haemolytic reactions and transfusionndashtransmitted infections This policy aims to promote and support safe and appropriate transfusion practice and provide patients with information about transfusion therapy and its alternatives The policy covers all stages of the transfusion process and is supported by clinical guidelines and detailed procedures all of which comply with national guidelines and statutory requirements
2 SCOPE This clinical document applies to
Staff groups
Doctors nurses midwives operating department practitioners health care assistants health care support workers phlebotomists porters and laboratory staff
Clinical areas
All in-patient day case wards and outpatients within Sherwood Forest hospitals John Eastwood Hospice and Barlborough Treatment Centre Emergency department at Kings Mill and Minor injuries unit at Newark hospital
Patient groups
All patients within Sherwood Forest Hospitals and any organisation which commissions transfusion services from the Trust
Related Trust policies and guidelines andor other Trust documents
Anaphylaxis Policy
The Observations and Escalation Policy for Adult In-Patients
Hand Hygiene policy
Incident reporting policy and procedures
Policy and procedure for the positive identification of patients Policy for consent to examination treatment or care
3 DEFINITIONS ANDOR ABBREIVATIONS
Trust Sherwood Forest Hospitals NHS Foundation Trust
Staff All employees of the Trust including those managed by a third party organisation on behalf of the Trust
Patient All patients of Sherwood Forest Hospitals Foundation Trust and those of any organisation which commissions transfusion services from the Trust
Link Trainer Designated staff members within a clinical area who have received appropriate training and are subsequently responsible for the delivery of basic blood transfusion training to all clinical staff working within their own clinical environment
Blood Product Any therapeutic product derived from human blood or plasma donations
Transfusion Policy Procedures and Guidelines
Page 4 of 14 Issue Date 15th November 2017
Review Date October 2020
Blood Component A therapeutic primary constituent of human blood (red cells white cells platelets plasma and cryoprecipitate)
Autologous Blood Transfusion
Transfusion to an individual of blood collected from him or herself
4 ROLES AND RESPONSIBILITIES
41 ALL STAFF involved in any aspect of blood transfusion are responsible for-
Adhering to this policy and any attached transfusion procedures and guidelines
Maintaining and updating their knowledge and practice
Meeting the National blood transfusion committee requirements for training and assessments in blood transfusion by having a one off practical assessment for sample labelling and enough supervised administrations to be competent followed by self-assessment every 3 years and a competency assessment every 2 years for collection
Reporting transfusion reactions or other incidents related to transfusion
Gaining the appropriate lawful consent prior to undertaking any care or treatment for patients requiring the transfusion services If capacity is in doubt it must be assessed using the two stage test and where necessary care planned in a patientrsquos best interest Staff must also document the consent gained
42 Hospital Transfusion Committee
On behalf of the Trust Clinical Governance Committee have delegated responsibility to oversee develop and implement Trust policies procedures and guidelines relating to blood transfusion
Audit the practice of blood transfusion against the Trust policy and national guidelines focusing on critical points for patient safety and the appropriate use of blood
Identify and manage risk associated with blood transfusion by reporting quarterly to the Trustrsquos Clinical Governance Committee
Review the transfusion policy related procedures and guidelines as required to ascertain changes additions or deletions deemed necessary due to changes in local national or international guidance
43 Hospital Transfusion team
Assists in the implementation of the Hospital Transfusion Committeersquos objectives
44 Service Directors and Heads of Nursing
Ensure that the policy and attached procedures are available to staff
Ensure that the policy and attached procedures are adhered to
45 Line Managers
Ensure that staff involved in the blood transfusion process are informed of the transfusion policy
Ensure staff are competent through appropriate training to follow guidelines and procedures to ensure that the right blood is given to the right patient at the right time
Time facilitation for the delivery of transfusion training by the designated link trainer(s) within their area
Investigate clinical incidents relating to transfusion which occur in their clinical area or involve a member of their staff according to the Trusts Incident Reporting policy
Transfusion Policy Procedures and Guidelines
Page 5 of 14 Issue Date 15th November 2017
Review Date October 2020
46 Medical Staff
Ensure that they are aware of the policy and associated procedures
Completion every two years of the following modules on the e-learning package wwwlearnbloodtransfusionorguk
Safe Transfusion Practice Blood components and indications for use Consent for Transfusion Acute Transfusion Reactions Safe Blood Sampling for Transfusion Video Anti-D clinical module (Obstetricians and Gynaecologists ONLY) Learn Cell Salvage (Anaesthetists and Surgeons ONLY)
If working with Paediactric patients must complete the above but Safe Transfusion Practice is replaced by -Safe Transfusion Practice for Paediatrics
The prescription of blood (including autologous) blood components and blood products
Requesting blood components and blood products from Blood Bank
Documentation of the transfusion episode in the medical notes (ie indication quantity consent and outcome)
Explaining the risks and benefits of transfusion to the patient using a patient information leaflet
Taking blood samples for group and screen andor pre-transfusion testing
Taking appropriate action in the event of adverse effects
Completing in full all accompanying paperwork associated with the transfusion
In addition front line staff expected to give blood as part of their role eg anaesthetists intensivists emergency department doctors the administration of blood components and blood products which includes monitoring of patients during transfusion
47 Registered Nursing or Midwifery Staff
Ensure that they are aware of the policy and associated procedures
Completion of a competency based training package applicable to their role upon Induction and thereafter self-assessments every 3 years with the exception of blood Collection (see point 41 above)
Taking blood samples for group and screen andor pre-transfusion testing The collection of blood components and blood products The administration of blood components and blood products
The monitoring of patients during transfusion
Taking appropriate action in the event of adverse effects
Completing in full all accompanying paperwork associated with the transfusion
In addition for Designated Specialist Nurses Requesting blood components from Blood Bank in accordance with the Maximum Blood Ordering Schedule (MBOS)
In addition for those nurses that have completed their specialist nurse development pack for the authorisation of blood components for adult patients authorising the transfusion of red cells and platelets 471 Nurses under Preceptorship
Duties as for a registered nurse or midwife but for the administration of blood components and blood products work through the Blood Transfusion assessment pack (part A) before becoming the primary witness To be a secondary witness must have completed the calculations test as part of the Trusts IVI study day
Transfusion Policy Procedures and Guidelines
Page 6 of 14 Issue Date 15th November 2017
Review Date October 2020
48 Operating Department Practitioners
Ensure that they are aware of the policy and associated procedures
On behalf of a named Anaesthetist verbally request blood components from Blood Bank
The collection and administration of blood components and blood products
The monitoring of patients during transfusion
Taking appropriate action in the event of adverse effects
49 Health Care Assistants (Band 3)
Ensure that they are aware of the policy and associated procedures
Taking blood samples for group and screen
Collection of blood components and blood products from Blood Bank
Undertaking observations of patients pre during and post transfusion under the direct supervision of a registered practitioner
491 Health Care Assistants (Band 2)
Ensure that they are aware of the policy and associated procedures
Collection of blood components and blood products from Blood Bank
Undertaking observations of patients pre during and post transfusion under the direct supervision of a registered practitioner
410 Phlebotomists and Emergency Support Workers
Responsibilities are restricted within this policy to the taking of blood samples for group and save
411 Porters
Responsibilities are restricted within this policy to the collection of blood components and blood products from Blood Bank to Sherwood birthing unit and neonatal unit only
412 Student Nurses Medical Students
Shadowingobserving qualified colleagues No involvement in any aspect of blood transfusion unless under strict supervision by fully qualified staff
413 Agency Staff - Nursing
No involvement in any aspect of blood transfusion unless under strict supervision by fully qualified SFH NHS Trust staff or until they are deemed competent for that procedure
414 Bank Staff - Nursing
If a SFH NHS Trust employee then duties as above for their role
If a NON SFH NHS Trust employee no involvement in any aspect of blood transfusion unless under strict supervision by fully qualified SFH NHS Trust staff or until they are deemed competent for that procedure
415 Locum Medical Staff
If a SFH NHS Trust employee then duties as above for their role
If a non-SFH NHS Trust employee can be involved in blood transfusion if they can show evidence of completion within the last two years of-
1 The Trusts Induction Package 2 Completion of the modules listed in 46 above on the e-learning package
wwwlearnbloodtransfusionorguk in accordance with their role
Transfusion Policy Procedures and Guidelines
Page 7 of 14 Issue Date 15th November 2017
Review Date October 2020
416 Biomedical Scientists
Challenging the appropriateness of requests
Pre-transfusion testing
Issuing blood components and blood products
Investigating and reporting adverse events
417 Transfusion Practitioner
The identification and provision of transfusion training within the Trust
Investigate transfusion reactions or other clinical incidents relating to transfusion with the assistance of relevant staff according to the Trustrsquos incident reporting policy
Report any serious adverse transfusion events or reactions to the Medicines and Healthcare products Regulatory Agency (MHRA) andor the Serious Hazards of Transfusion (SHOT) reporting scheme
Duties as identified as a member of the Hospital Transfusion Committee and Team
5 NARRATIVE
As per the roles and responsibilities all staff caring for patients requiring transfusion services must refer to the relevant procedures and guidelines as listed within the appendices If in doubt seek senior advice or support from the Transfusion Practitioner
6 EVIDENCE BASE REFERENCES British Society for Haematology 2016 Guidelines for the use of platelet transfusions (httpwwwb-s-horgukguidelines) British Society for Haematology 2012 Pre transfusion compatibility procedures in blood transfusion laboratories (httpwwwb-s-horgukguidelines) British Society for Haematology 2004 Guidelines for the use of Fresh Frozen Plasma Cryoprecipitate and Cryosupernatant and 2007 Amendment to the Guidelines for the use of Fresh-Frozen Plasma Cryoprecipitate and Cryosupernatant (httpwwwb-s-horgukguidelines)
British Society for Haematology 2016 Transfusion for Fetuses Neonates and Older Children (httpwwwb-s-horgukguidelines) British Society for Haematology 2009 The administration of blood and blood components and 2012 Addendum to Administration of Blood Components (httpwwwb-s-horgukguidelines)
British Society for Haematology 2010 Use of irradiated blood components and 2012 Addendum to guidelines on the use of irradiated blood components (httpwwwb-s-horgukguidelines) British Society for Haematology 2012 Investigation and management of Acute Transfusion Reactions (httpwwwb-s-horgukguidelines) British Society for Haematology 2012 Management of Anaemia and Red Cell Transfusion in Adult Critically Ill Patients (httpwwwb-s-horgukguidelines)
Transfusion Policy Procedures and Guidelines
Page 8 of 14 Issue Date 15th November 2017
Review Date October 2020
British Society for Haematology 2012 Use of Anti-D Immunoglobulin for the prevention of Heamolytic Disease of the Fetus and Newborn (httpwwwb-s-horgukguidelines) British Society for Haematology 2016 Guideline for blood grouping and red cell antibody testing in pregnancy (httpwwwb-s-horgukguidelines)
British Society for Haematology 2015 Haematological management of Major Haemorrhage (httpwwwb-s-horgukguidelines) Guidelines on the management of massive blood loss BJH 2006 135(5) 634-41 Handbook of Transfusion Medicine 2013 5th Edition Blood Transfusion Services of the United Kingdom Ed D Norfolk
Health Service Circular 2007001 Better Blood Transfusion (Available at httpwwwtransfusionguidelinesorgukindexaspxPublication=BBT ) The Blood Safety and Quality Regulations 2005 (SI 200550) and amending regulations NPSA (2006) Right Patient Right Blood Safer Practice Notice 9th November 2006 No 14 (Available at httpwwwnpsanhsuknrlsalerts-and-directivesnotices) Serious Hazards of Transfusion Annual Report wwwshotukorg
7 EDUCATION AND TRAINING
A continuous programme of education exists in the Trust for all grades of staff Any additional training will be provided by the Transfusion Practitioner based on individual or departmental need
Appropriate competency-based training will be provided to nominated link trainers in each clinical area by the Transfusion Practitioner so that they can facilitate cascade training and competency assessments (Sampling and administration are self- assessments every 3 years following a one off observational assessment for sampling and for administration completion of the Trusts IVI pack or Grandparent rights document) Blood collection competency assessments are completed every 2 years
All training and assessments provided by the link trainers will be forwarded to the Transfusion Practitioner who together with any additional training or assessments that heshe performs will be recorded on the training database held by the training educational and developmental department
Transfusion Policy Procedures and Guidelines
Page 9 of 14 Issue Date 15th November 2017
Review Date October 2020
71 Competency Assessments
Staff Group
Obtaining a sample
Collection of blood components and products
Administration of blood components and blood products
Medical staff
Registered nurse (RN)
Registered midwife (RM)
ODP
HCA-Band 3
HCA ndashBand 2
Phlebotomist
Emergency Support workers
Porter
Students
Agency RNRM
Locum medics
Bank Staff
Biomedical Scientists
Medical Laboratory Assistants
Anaesthetists intensivists and emergency department doctors only
Competency assessment linked to their role
8 MONITORING COMPLIANCE NHSLA Standard
Method of Monitoring Timescale Lead
158a How blood samples are requested for pre-transfusion compatibility testing
A fully completed transfusion request form is completed by a member of the medical staff Data is collated from the Blood Transfusion Laboratory Information System regarding any request that fails to meet the minimal criteria as stated in Appendix 2 of this Policy
Monthly Quarterly
Chair of the Blood Transfusion Incident Review Group Chair of the Hospital Transfusion Committee
158b How transfusions are administered including patient identification
National Comparative audit Incident reporting
Every 3 years
Chair of the Hospital Transfusion Committee
158c Care of patients receiving a transfusion
National Comparative audit
Every 3 years
Chair of the Hospital Transfusion Committee
158d How the organisation trains staff in line with the training needs analysis
Records are kept by the Training Department of all transfusion related training courses who then report to staff line managers
Bi-Monthly Chair of the Hospital Transfusion Committee
Transfusion Policy Procedures and Guidelines
Page 10 of 14 Issue Date 15th November 2017
Review Date October 2020
158e How the organisation assesses the competency of all staff involved in the transfusion process
Completed assessments are held by the individual or in the clinical area Evidence of completion is sent to the Transfusion Practitioner to update the training database This information is shared with the Training Department
On -going Chair of the Hospital Transfusion Committee
How the organisation evidences non SFH locum medical staff training
Locum induction checklist held by rota co-ordinators
On-going Chair of the Hospital Transfusion Committee
158f How the organisation monitors compliance with all of the above
Reports go to the HTC Quarterly Chair of the Hospital Transfusion Committee
How the organisation monitors compliance with the Blood Safety and Quality Regulations
Compliance report to MHRA
Annually Chief Executive
How the organisations monitors compliance to achieve UKAS Accreditation to standard ISO 151892012
Inspections Every 2 years
Pathology Manager
9 CONSULTATION Contributors Communication Channel eg
11 meeting phone
Group committee meeting
Date
Consultant lead for Transfusion E mail 12072017
Consultant Haematologists E mail 12072017
Hospital Transfusion Committee Committee meeting Oct 2017
10 EQUALITY IMPACT ASSESSMENT (EIA) The Trust is committed to ensuring that none of its policies procedures and guidelines discriminate against individuals directly or indirectly on the basis of gender colour race nationality ethnic or national origins age sexual orientation marital status disability religion beliefs political affiliation trade union membership and social and employment status An EIA of this policyguideline was been conducted by the author using the EIA tool developed by the Diversity and Inclusivity Committee see below Equality Impact Assessment (EqIA) Form (please complete all sections) Guidance on how to complete an EIA Sample completed form
Name of servicepolicyprocedure being reviewed Trusts Transfusion Policy Procedures and Guidelines
New or existing servicepolicyprocedure Existing Policy
Date of Assessment November 2017
Transfusion Policy Procedures and Guidelines
Page 11 of 14 Issue Date 15th November 2017
Review Date October 2020
For the servicepolicyprocedure and its implementation answer the questions a ndash c below against each characteristic (if relevant consider breaking the policy or implementation down into areas)
Protected
Characteristic
a) Using data and supporting information what issues needs or barriers could the protected characteristic groupsrsquo experience For example are there any known health inequality or access issues to consider
b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics screening
c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality
The area of policy or its implementation being assessed
Race and Ethnicity None None None
Gender
None None None
Age
None None None
Religion Currently the policy does not address patients that refuse blood components based on their religion
The Policy for refusal of blood components and products is in the final stage of approval however Maternity do have a guideline for the management of women in pregnancy who decline blood and blood products
None
Disability
None None None
Sexuality
None None None
Pregnancy and Maternity
None None None
Gender Reassignment
None None None
Marriage and Civil Partnership
None None None
Socio-Economic Factors (ie living in
a poorer neighbourhood
social deprivation)
None None None
What consultation with protected characteristic groups including patient groups have you carried out Consultation has occurred with the local hospital Jehovahrsquos witness representatives
What data or information did you use in support of this EqIA
Transfusion Policy Procedures and Guidelines
Page 12 of 14 Issue Date 15th November 2017
Review Date October 2020
As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys questionnaires comments concerns complaints or compliments No
Level of impact From the information provided above and following EqIA guidance document please indicate the perceived level of impact Low Level of Impact For high or medium levels of impact please forward a copy of this form to the HR Secretaries for inclusion at the next Diversity and Inclusivity meeting
Name of Responsible Person undertaking this assessment Jane Walden-Specialist Transfusion Practitoner
Signature
Date 20112017
11 KEYWORDS Blood
12 APPENDICES As listed in contents table
Transfusion Policy Procedures and Guidelines
Page 13 of 14 Issue Date 15th November 2017
Review Date October 2020
Document control supporting information for this clinical document
Title
Transfusion Policy Procedures and Guidelines
Document category Clinical Policies and Guidelines
Reference
CGTRANS001
Version number
80
Approval
v Approved by
Approval Date
80 Hospital Transfusion Committee October 2017
Issue date
15th November 2017
Review date October 2020
Job title of author responsible for the document author name
Transfusion PractitionerJane Walden
Division amp Specialty Department Service responsible for reporting the status of the document
Diagnostic and Rehabilitation Haematology (Transfusion Services)
Document Sponsor
Medical Director
Date Equality Impact Assessment completed updated
As dated in relevant section of document
Superseded document(s) (Ref No Version number previous title if changed date issued ndash review date)
v70 Issued 8th April 2015 to August 2017
Version History and Practice Changes Amendments
Issue Date Version Comments (Section Change)
15-11-2017 70 41
46 and 415
47
471
6
7
Update to training and competency assessments
Update to e-learning modules for medical staff
Role of nurse authorisers
Preceptorship nurses and administration of blood
Update to references (change to British Society for Haematology from British Standard in Haematology
Changes to frequency of competency assessments addition of self-assessments
Transfusion Policy Procedures and Guidelines
Page 14 of 14 Issue Date 15th November 2017
Review Date October 2020
01-02-2015 70 415
471
60
Additional module ndash Safe Blood Sampling for Transfusion for locum medics
Nurses under preceptorship
Updated References
23-09-2014 62 Appendix 16 NEW Guideline for the transfusion of blood components in acute upper gastrointestinal bleeding
17-04-2014 61 41
46
Appendix 15
Appendix 6
Collection competency assessment to be undertaken every 2 years
Additional module ndash Safe Blood Sampling for Transfusion
New Appendix ndash Guidelines for the use of Human Albumin Solution
New table inserted ndash Transfusion reactions in adults nursing guidance
Distribution (Circulation)
This document will be accessible via the Trustrsquos intranet
Communication
Information regarding the initiation and subsequent updates of this document will be communicated via the earliest weekly Trust staff bulletin nursing bulletin and or other agreed communication method
Transfusion Policy Procedures and Guidelines
Page 2 of 14 Issue Date 15th November 2017
Review Date October 2020
CONTENTS
SECTION DESCRIPTION PAGE
1 INTRODUCTION 3
2 SCOPE OF DOCUMENT 3
3 DEFINITIONS AND OR ABBREVIATIONS 4
4 ROLES AND RESPONSIBILITIES 4
5 NARRATIVE 7
6 EVIDENCE BASE REFERENCES 7
7 EDUCATION AND TRAINING 8
8 MONITORING COMPLIANCE 9
9 CONSULTATION 10
10 EQUALITY IMPACT ASSESSMENT (EIA) ndash and completed form 10
11 KEYWORDS 10
12 APPENDICES
1 ndash Procedure for consent and prescription 2 ndash Procedure for sample collection and requests for blood transfusion 3 ndash Procedure for issue collection and return of blood components 4 ndash Procedure for administration and traceability of blood components 5 ndash Massive Haemorrhage (blood loss) Protocol in Adults 6 ndash Guidelines for the recognition and management of blood transfusion reactions or adverse events in adults 7 ndash Guidelines for blood transfusion at Newark Hospital 8 ndash Procedure for the transfer and receipt of blood out of hours at Newark Hospital 9 ndash Maximum blood ordering schedule 10 ndash SFHKHA-LF-BTRO30 Blood Transfusion Reactions form 11 ndash Guideline for the use of Anti-D Prophylaxis for RhD Negative Women 12 ndash Emergency planning for the management of Blood Shortages ndash Policy and Procedure 13 ndash Collection and administration of Blood components at John Eastwood Hospice 14 ndash Guidelines for the use of red cells in adults 15 ndash Guidelines for the use of Human Albumin Solution 16 ndash Clinical guidelines for the transfusion of blood components in upper gastrointestinal bleeding 17 ndash Guidelines for the transfusion of blood components in neonates
All hyperlinked
to the separate
documents on the
intranet
DOCUMENT CONTROL 14
Transfusion Policy Procedures and Guidelines
Page 3 of 14 Issue Date 15th November 2017
Review Date October 2020
1 INTRODUCTION A blood transfusion is a potentially hazardous procedure which should be given only when the clinical benefits to the patient outweigh the potential risks the most important of these being acute haemolytic reactions and transfusionndashtransmitted infections This policy aims to promote and support safe and appropriate transfusion practice and provide patients with information about transfusion therapy and its alternatives The policy covers all stages of the transfusion process and is supported by clinical guidelines and detailed procedures all of which comply with national guidelines and statutory requirements
2 SCOPE This clinical document applies to
Staff groups
Doctors nurses midwives operating department practitioners health care assistants health care support workers phlebotomists porters and laboratory staff
Clinical areas
All in-patient day case wards and outpatients within Sherwood Forest hospitals John Eastwood Hospice and Barlborough Treatment Centre Emergency department at Kings Mill and Minor injuries unit at Newark hospital
Patient groups
All patients within Sherwood Forest Hospitals and any organisation which commissions transfusion services from the Trust
Related Trust policies and guidelines andor other Trust documents
Anaphylaxis Policy
The Observations and Escalation Policy for Adult In-Patients
Hand Hygiene policy
Incident reporting policy and procedures
Policy and procedure for the positive identification of patients Policy for consent to examination treatment or care
3 DEFINITIONS ANDOR ABBREIVATIONS
Trust Sherwood Forest Hospitals NHS Foundation Trust
Staff All employees of the Trust including those managed by a third party organisation on behalf of the Trust
Patient All patients of Sherwood Forest Hospitals Foundation Trust and those of any organisation which commissions transfusion services from the Trust
Link Trainer Designated staff members within a clinical area who have received appropriate training and are subsequently responsible for the delivery of basic blood transfusion training to all clinical staff working within their own clinical environment
Blood Product Any therapeutic product derived from human blood or plasma donations
Transfusion Policy Procedures and Guidelines
Page 4 of 14 Issue Date 15th November 2017
Review Date October 2020
Blood Component A therapeutic primary constituent of human blood (red cells white cells platelets plasma and cryoprecipitate)
Autologous Blood Transfusion
Transfusion to an individual of blood collected from him or herself
4 ROLES AND RESPONSIBILITIES
41 ALL STAFF involved in any aspect of blood transfusion are responsible for-
Adhering to this policy and any attached transfusion procedures and guidelines
Maintaining and updating their knowledge and practice
Meeting the National blood transfusion committee requirements for training and assessments in blood transfusion by having a one off practical assessment for sample labelling and enough supervised administrations to be competent followed by self-assessment every 3 years and a competency assessment every 2 years for collection
Reporting transfusion reactions or other incidents related to transfusion
Gaining the appropriate lawful consent prior to undertaking any care or treatment for patients requiring the transfusion services If capacity is in doubt it must be assessed using the two stage test and where necessary care planned in a patientrsquos best interest Staff must also document the consent gained
42 Hospital Transfusion Committee
On behalf of the Trust Clinical Governance Committee have delegated responsibility to oversee develop and implement Trust policies procedures and guidelines relating to blood transfusion
Audit the practice of blood transfusion against the Trust policy and national guidelines focusing on critical points for patient safety and the appropriate use of blood
Identify and manage risk associated with blood transfusion by reporting quarterly to the Trustrsquos Clinical Governance Committee
Review the transfusion policy related procedures and guidelines as required to ascertain changes additions or deletions deemed necessary due to changes in local national or international guidance
43 Hospital Transfusion team
Assists in the implementation of the Hospital Transfusion Committeersquos objectives
44 Service Directors and Heads of Nursing
Ensure that the policy and attached procedures are available to staff
Ensure that the policy and attached procedures are adhered to
45 Line Managers
Ensure that staff involved in the blood transfusion process are informed of the transfusion policy
Ensure staff are competent through appropriate training to follow guidelines and procedures to ensure that the right blood is given to the right patient at the right time
Time facilitation for the delivery of transfusion training by the designated link trainer(s) within their area
Investigate clinical incidents relating to transfusion which occur in their clinical area or involve a member of their staff according to the Trusts Incident Reporting policy
Transfusion Policy Procedures and Guidelines
Page 5 of 14 Issue Date 15th November 2017
Review Date October 2020
46 Medical Staff
Ensure that they are aware of the policy and associated procedures
Completion every two years of the following modules on the e-learning package wwwlearnbloodtransfusionorguk
Safe Transfusion Practice Blood components and indications for use Consent for Transfusion Acute Transfusion Reactions Safe Blood Sampling for Transfusion Video Anti-D clinical module (Obstetricians and Gynaecologists ONLY) Learn Cell Salvage (Anaesthetists and Surgeons ONLY)
If working with Paediactric patients must complete the above but Safe Transfusion Practice is replaced by -Safe Transfusion Practice for Paediatrics
The prescription of blood (including autologous) blood components and blood products
Requesting blood components and blood products from Blood Bank
Documentation of the transfusion episode in the medical notes (ie indication quantity consent and outcome)
Explaining the risks and benefits of transfusion to the patient using a patient information leaflet
Taking blood samples for group and screen andor pre-transfusion testing
Taking appropriate action in the event of adverse effects
Completing in full all accompanying paperwork associated with the transfusion
In addition front line staff expected to give blood as part of their role eg anaesthetists intensivists emergency department doctors the administration of blood components and blood products which includes monitoring of patients during transfusion
47 Registered Nursing or Midwifery Staff
Ensure that they are aware of the policy and associated procedures
Completion of a competency based training package applicable to their role upon Induction and thereafter self-assessments every 3 years with the exception of blood Collection (see point 41 above)
Taking blood samples for group and screen andor pre-transfusion testing The collection of blood components and blood products The administration of blood components and blood products
The monitoring of patients during transfusion
Taking appropriate action in the event of adverse effects
Completing in full all accompanying paperwork associated with the transfusion
In addition for Designated Specialist Nurses Requesting blood components from Blood Bank in accordance with the Maximum Blood Ordering Schedule (MBOS)
In addition for those nurses that have completed their specialist nurse development pack for the authorisation of blood components for adult patients authorising the transfusion of red cells and platelets 471 Nurses under Preceptorship
Duties as for a registered nurse or midwife but for the administration of blood components and blood products work through the Blood Transfusion assessment pack (part A) before becoming the primary witness To be a secondary witness must have completed the calculations test as part of the Trusts IVI study day
Transfusion Policy Procedures and Guidelines
Page 6 of 14 Issue Date 15th November 2017
Review Date October 2020
48 Operating Department Practitioners
Ensure that they are aware of the policy and associated procedures
On behalf of a named Anaesthetist verbally request blood components from Blood Bank
The collection and administration of blood components and blood products
The monitoring of patients during transfusion
Taking appropriate action in the event of adverse effects
49 Health Care Assistants (Band 3)
Ensure that they are aware of the policy and associated procedures
Taking blood samples for group and screen
Collection of blood components and blood products from Blood Bank
Undertaking observations of patients pre during and post transfusion under the direct supervision of a registered practitioner
491 Health Care Assistants (Band 2)
Ensure that they are aware of the policy and associated procedures
Collection of blood components and blood products from Blood Bank
Undertaking observations of patients pre during and post transfusion under the direct supervision of a registered practitioner
410 Phlebotomists and Emergency Support Workers
Responsibilities are restricted within this policy to the taking of blood samples for group and save
411 Porters
Responsibilities are restricted within this policy to the collection of blood components and blood products from Blood Bank to Sherwood birthing unit and neonatal unit only
412 Student Nurses Medical Students
Shadowingobserving qualified colleagues No involvement in any aspect of blood transfusion unless under strict supervision by fully qualified staff
413 Agency Staff - Nursing
No involvement in any aspect of blood transfusion unless under strict supervision by fully qualified SFH NHS Trust staff or until they are deemed competent for that procedure
414 Bank Staff - Nursing
If a SFH NHS Trust employee then duties as above for their role
If a NON SFH NHS Trust employee no involvement in any aspect of blood transfusion unless under strict supervision by fully qualified SFH NHS Trust staff or until they are deemed competent for that procedure
415 Locum Medical Staff
If a SFH NHS Trust employee then duties as above for their role
If a non-SFH NHS Trust employee can be involved in blood transfusion if they can show evidence of completion within the last two years of-
1 The Trusts Induction Package 2 Completion of the modules listed in 46 above on the e-learning package
wwwlearnbloodtransfusionorguk in accordance with their role
Transfusion Policy Procedures and Guidelines
Page 7 of 14 Issue Date 15th November 2017
Review Date October 2020
416 Biomedical Scientists
Challenging the appropriateness of requests
Pre-transfusion testing
Issuing blood components and blood products
Investigating and reporting adverse events
417 Transfusion Practitioner
The identification and provision of transfusion training within the Trust
Investigate transfusion reactions or other clinical incidents relating to transfusion with the assistance of relevant staff according to the Trustrsquos incident reporting policy
Report any serious adverse transfusion events or reactions to the Medicines and Healthcare products Regulatory Agency (MHRA) andor the Serious Hazards of Transfusion (SHOT) reporting scheme
Duties as identified as a member of the Hospital Transfusion Committee and Team
5 NARRATIVE
As per the roles and responsibilities all staff caring for patients requiring transfusion services must refer to the relevant procedures and guidelines as listed within the appendices If in doubt seek senior advice or support from the Transfusion Practitioner
6 EVIDENCE BASE REFERENCES British Society for Haematology 2016 Guidelines for the use of platelet transfusions (httpwwwb-s-horgukguidelines) British Society for Haematology 2012 Pre transfusion compatibility procedures in blood transfusion laboratories (httpwwwb-s-horgukguidelines) British Society for Haematology 2004 Guidelines for the use of Fresh Frozen Plasma Cryoprecipitate and Cryosupernatant and 2007 Amendment to the Guidelines for the use of Fresh-Frozen Plasma Cryoprecipitate and Cryosupernatant (httpwwwb-s-horgukguidelines)
British Society for Haematology 2016 Transfusion for Fetuses Neonates and Older Children (httpwwwb-s-horgukguidelines) British Society for Haematology 2009 The administration of blood and blood components and 2012 Addendum to Administration of Blood Components (httpwwwb-s-horgukguidelines)
British Society for Haematology 2010 Use of irradiated blood components and 2012 Addendum to guidelines on the use of irradiated blood components (httpwwwb-s-horgukguidelines) British Society for Haematology 2012 Investigation and management of Acute Transfusion Reactions (httpwwwb-s-horgukguidelines) British Society for Haematology 2012 Management of Anaemia and Red Cell Transfusion in Adult Critically Ill Patients (httpwwwb-s-horgukguidelines)
Transfusion Policy Procedures and Guidelines
Page 8 of 14 Issue Date 15th November 2017
Review Date October 2020
British Society for Haematology 2012 Use of Anti-D Immunoglobulin for the prevention of Heamolytic Disease of the Fetus and Newborn (httpwwwb-s-horgukguidelines) British Society for Haematology 2016 Guideline for blood grouping and red cell antibody testing in pregnancy (httpwwwb-s-horgukguidelines)
British Society for Haematology 2015 Haematological management of Major Haemorrhage (httpwwwb-s-horgukguidelines) Guidelines on the management of massive blood loss BJH 2006 135(5) 634-41 Handbook of Transfusion Medicine 2013 5th Edition Blood Transfusion Services of the United Kingdom Ed D Norfolk
Health Service Circular 2007001 Better Blood Transfusion (Available at httpwwwtransfusionguidelinesorgukindexaspxPublication=BBT ) The Blood Safety and Quality Regulations 2005 (SI 200550) and amending regulations NPSA (2006) Right Patient Right Blood Safer Practice Notice 9th November 2006 No 14 (Available at httpwwwnpsanhsuknrlsalerts-and-directivesnotices) Serious Hazards of Transfusion Annual Report wwwshotukorg
7 EDUCATION AND TRAINING
A continuous programme of education exists in the Trust for all grades of staff Any additional training will be provided by the Transfusion Practitioner based on individual or departmental need
Appropriate competency-based training will be provided to nominated link trainers in each clinical area by the Transfusion Practitioner so that they can facilitate cascade training and competency assessments (Sampling and administration are self- assessments every 3 years following a one off observational assessment for sampling and for administration completion of the Trusts IVI pack or Grandparent rights document) Blood collection competency assessments are completed every 2 years
All training and assessments provided by the link trainers will be forwarded to the Transfusion Practitioner who together with any additional training or assessments that heshe performs will be recorded on the training database held by the training educational and developmental department
Transfusion Policy Procedures and Guidelines
Page 9 of 14 Issue Date 15th November 2017
Review Date October 2020
71 Competency Assessments
Staff Group
Obtaining a sample
Collection of blood components and products
Administration of blood components and blood products
Medical staff
Registered nurse (RN)
Registered midwife (RM)
ODP
HCA-Band 3
HCA ndashBand 2
Phlebotomist
Emergency Support workers
Porter
Students
Agency RNRM
Locum medics
Bank Staff
Biomedical Scientists
Medical Laboratory Assistants
Anaesthetists intensivists and emergency department doctors only
Competency assessment linked to their role
8 MONITORING COMPLIANCE NHSLA Standard
Method of Monitoring Timescale Lead
158a How blood samples are requested for pre-transfusion compatibility testing
A fully completed transfusion request form is completed by a member of the medical staff Data is collated from the Blood Transfusion Laboratory Information System regarding any request that fails to meet the minimal criteria as stated in Appendix 2 of this Policy
Monthly Quarterly
Chair of the Blood Transfusion Incident Review Group Chair of the Hospital Transfusion Committee
158b How transfusions are administered including patient identification
National Comparative audit Incident reporting
Every 3 years
Chair of the Hospital Transfusion Committee
158c Care of patients receiving a transfusion
National Comparative audit
Every 3 years
Chair of the Hospital Transfusion Committee
158d How the organisation trains staff in line with the training needs analysis
Records are kept by the Training Department of all transfusion related training courses who then report to staff line managers
Bi-Monthly Chair of the Hospital Transfusion Committee
Transfusion Policy Procedures and Guidelines
Page 10 of 14 Issue Date 15th November 2017
Review Date October 2020
158e How the organisation assesses the competency of all staff involved in the transfusion process
Completed assessments are held by the individual or in the clinical area Evidence of completion is sent to the Transfusion Practitioner to update the training database This information is shared with the Training Department
On -going Chair of the Hospital Transfusion Committee
How the organisation evidences non SFH locum medical staff training
Locum induction checklist held by rota co-ordinators
On-going Chair of the Hospital Transfusion Committee
158f How the organisation monitors compliance with all of the above
Reports go to the HTC Quarterly Chair of the Hospital Transfusion Committee
How the organisation monitors compliance with the Blood Safety and Quality Regulations
Compliance report to MHRA
Annually Chief Executive
How the organisations monitors compliance to achieve UKAS Accreditation to standard ISO 151892012
Inspections Every 2 years
Pathology Manager
9 CONSULTATION Contributors Communication Channel eg
11 meeting phone
Group committee meeting
Date
Consultant lead for Transfusion E mail 12072017
Consultant Haematologists E mail 12072017
Hospital Transfusion Committee Committee meeting Oct 2017
10 EQUALITY IMPACT ASSESSMENT (EIA) The Trust is committed to ensuring that none of its policies procedures and guidelines discriminate against individuals directly or indirectly on the basis of gender colour race nationality ethnic or national origins age sexual orientation marital status disability religion beliefs political affiliation trade union membership and social and employment status An EIA of this policyguideline was been conducted by the author using the EIA tool developed by the Diversity and Inclusivity Committee see below Equality Impact Assessment (EqIA) Form (please complete all sections) Guidance on how to complete an EIA Sample completed form
Name of servicepolicyprocedure being reviewed Trusts Transfusion Policy Procedures and Guidelines
New or existing servicepolicyprocedure Existing Policy
Date of Assessment November 2017
Transfusion Policy Procedures and Guidelines
Page 11 of 14 Issue Date 15th November 2017
Review Date October 2020
For the servicepolicyprocedure and its implementation answer the questions a ndash c below against each characteristic (if relevant consider breaking the policy or implementation down into areas)
Protected
Characteristic
a) Using data and supporting information what issues needs or barriers could the protected characteristic groupsrsquo experience For example are there any known health inequality or access issues to consider
b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics screening
c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality
The area of policy or its implementation being assessed
Race and Ethnicity None None None
Gender
None None None
Age
None None None
Religion Currently the policy does not address patients that refuse blood components based on their religion
The Policy for refusal of blood components and products is in the final stage of approval however Maternity do have a guideline for the management of women in pregnancy who decline blood and blood products
None
Disability
None None None
Sexuality
None None None
Pregnancy and Maternity
None None None
Gender Reassignment
None None None
Marriage and Civil Partnership
None None None
Socio-Economic Factors (ie living in
a poorer neighbourhood
social deprivation)
None None None
What consultation with protected characteristic groups including patient groups have you carried out Consultation has occurred with the local hospital Jehovahrsquos witness representatives
What data or information did you use in support of this EqIA
Transfusion Policy Procedures and Guidelines
Page 12 of 14 Issue Date 15th November 2017
Review Date October 2020
As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys questionnaires comments concerns complaints or compliments No
Level of impact From the information provided above and following EqIA guidance document please indicate the perceived level of impact Low Level of Impact For high or medium levels of impact please forward a copy of this form to the HR Secretaries for inclusion at the next Diversity and Inclusivity meeting
Name of Responsible Person undertaking this assessment Jane Walden-Specialist Transfusion Practitoner
Signature
Date 20112017
11 KEYWORDS Blood
12 APPENDICES As listed in contents table
Transfusion Policy Procedures and Guidelines
Page 13 of 14 Issue Date 15th November 2017
Review Date October 2020
Document control supporting information for this clinical document
Title
Transfusion Policy Procedures and Guidelines
Document category Clinical Policies and Guidelines
Reference
CGTRANS001
Version number
80
Approval
v Approved by
Approval Date
80 Hospital Transfusion Committee October 2017
Issue date
15th November 2017
Review date October 2020
Job title of author responsible for the document author name
Transfusion PractitionerJane Walden
Division amp Specialty Department Service responsible for reporting the status of the document
Diagnostic and Rehabilitation Haematology (Transfusion Services)
Document Sponsor
Medical Director
Date Equality Impact Assessment completed updated
As dated in relevant section of document
Superseded document(s) (Ref No Version number previous title if changed date issued ndash review date)
v70 Issued 8th April 2015 to August 2017
Version History and Practice Changes Amendments
Issue Date Version Comments (Section Change)
15-11-2017 70 41
46 and 415
47
471
6
7
Update to training and competency assessments
Update to e-learning modules for medical staff
Role of nurse authorisers
Preceptorship nurses and administration of blood
Update to references (change to British Society for Haematology from British Standard in Haematology
Changes to frequency of competency assessments addition of self-assessments
Transfusion Policy Procedures and Guidelines
Page 14 of 14 Issue Date 15th November 2017
Review Date October 2020
01-02-2015 70 415
471
60
Additional module ndash Safe Blood Sampling for Transfusion for locum medics
Nurses under preceptorship
Updated References
23-09-2014 62 Appendix 16 NEW Guideline for the transfusion of blood components in acute upper gastrointestinal bleeding
17-04-2014 61 41
46
Appendix 15
Appendix 6
Collection competency assessment to be undertaken every 2 years
Additional module ndash Safe Blood Sampling for Transfusion
New Appendix ndash Guidelines for the use of Human Albumin Solution
New table inserted ndash Transfusion reactions in adults nursing guidance
Distribution (Circulation)
This document will be accessible via the Trustrsquos intranet
Communication
Information regarding the initiation and subsequent updates of this document will be communicated via the earliest weekly Trust staff bulletin nursing bulletin and or other agreed communication method
Transfusion Policy Procedures and Guidelines
Page 3 of 14 Issue Date 15th November 2017
Review Date October 2020
1 INTRODUCTION A blood transfusion is a potentially hazardous procedure which should be given only when the clinical benefits to the patient outweigh the potential risks the most important of these being acute haemolytic reactions and transfusionndashtransmitted infections This policy aims to promote and support safe and appropriate transfusion practice and provide patients with information about transfusion therapy and its alternatives The policy covers all stages of the transfusion process and is supported by clinical guidelines and detailed procedures all of which comply with national guidelines and statutory requirements
2 SCOPE This clinical document applies to
Staff groups
Doctors nurses midwives operating department practitioners health care assistants health care support workers phlebotomists porters and laboratory staff
Clinical areas
All in-patient day case wards and outpatients within Sherwood Forest hospitals John Eastwood Hospice and Barlborough Treatment Centre Emergency department at Kings Mill and Minor injuries unit at Newark hospital
Patient groups
All patients within Sherwood Forest Hospitals and any organisation which commissions transfusion services from the Trust
Related Trust policies and guidelines andor other Trust documents
Anaphylaxis Policy
The Observations and Escalation Policy for Adult In-Patients
Hand Hygiene policy
Incident reporting policy and procedures
Policy and procedure for the positive identification of patients Policy for consent to examination treatment or care
3 DEFINITIONS ANDOR ABBREIVATIONS
Trust Sherwood Forest Hospitals NHS Foundation Trust
Staff All employees of the Trust including those managed by a third party organisation on behalf of the Trust
Patient All patients of Sherwood Forest Hospitals Foundation Trust and those of any organisation which commissions transfusion services from the Trust
Link Trainer Designated staff members within a clinical area who have received appropriate training and are subsequently responsible for the delivery of basic blood transfusion training to all clinical staff working within their own clinical environment
Blood Product Any therapeutic product derived from human blood or plasma donations
Transfusion Policy Procedures and Guidelines
Page 4 of 14 Issue Date 15th November 2017
Review Date October 2020
Blood Component A therapeutic primary constituent of human blood (red cells white cells platelets plasma and cryoprecipitate)
Autologous Blood Transfusion
Transfusion to an individual of blood collected from him or herself
4 ROLES AND RESPONSIBILITIES
41 ALL STAFF involved in any aspect of blood transfusion are responsible for-
Adhering to this policy and any attached transfusion procedures and guidelines
Maintaining and updating their knowledge and practice
Meeting the National blood transfusion committee requirements for training and assessments in blood transfusion by having a one off practical assessment for sample labelling and enough supervised administrations to be competent followed by self-assessment every 3 years and a competency assessment every 2 years for collection
Reporting transfusion reactions or other incidents related to transfusion
Gaining the appropriate lawful consent prior to undertaking any care or treatment for patients requiring the transfusion services If capacity is in doubt it must be assessed using the two stage test and where necessary care planned in a patientrsquos best interest Staff must also document the consent gained
42 Hospital Transfusion Committee
On behalf of the Trust Clinical Governance Committee have delegated responsibility to oversee develop and implement Trust policies procedures and guidelines relating to blood transfusion
Audit the practice of blood transfusion against the Trust policy and national guidelines focusing on critical points for patient safety and the appropriate use of blood
Identify and manage risk associated with blood transfusion by reporting quarterly to the Trustrsquos Clinical Governance Committee
Review the transfusion policy related procedures and guidelines as required to ascertain changes additions or deletions deemed necessary due to changes in local national or international guidance
43 Hospital Transfusion team
Assists in the implementation of the Hospital Transfusion Committeersquos objectives
44 Service Directors and Heads of Nursing
Ensure that the policy and attached procedures are available to staff
Ensure that the policy and attached procedures are adhered to
45 Line Managers
Ensure that staff involved in the blood transfusion process are informed of the transfusion policy
Ensure staff are competent through appropriate training to follow guidelines and procedures to ensure that the right blood is given to the right patient at the right time
Time facilitation for the delivery of transfusion training by the designated link trainer(s) within their area
Investigate clinical incidents relating to transfusion which occur in their clinical area or involve a member of their staff according to the Trusts Incident Reporting policy
Transfusion Policy Procedures and Guidelines
Page 5 of 14 Issue Date 15th November 2017
Review Date October 2020
46 Medical Staff
Ensure that they are aware of the policy and associated procedures
Completion every two years of the following modules on the e-learning package wwwlearnbloodtransfusionorguk
Safe Transfusion Practice Blood components and indications for use Consent for Transfusion Acute Transfusion Reactions Safe Blood Sampling for Transfusion Video Anti-D clinical module (Obstetricians and Gynaecologists ONLY) Learn Cell Salvage (Anaesthetists and Surgeons ONLY)
If working with Paediactric patients must complete the above but Safe Transfusion Practice is replaced by -Safe Transfusion Practice for Paediatrics
The prescription of blood (including autologous) blood components and blood products
Requesting blood components and blood products from Blood Bank
Documentation of the transfusion episode in the medical notes (ie indication quantity consent and outcome)
Explaining the risks and benefits of transfusion to the patient using a patient information leaflet
Taking blood samples for group and screen andor pre-transfusion testing
Taking appropriate action in the event of adverse effects
Completing in full all accompanying paperwork associated with the transfusion
In addition front line staff expected to give blood as part of their role eg anaesthetists intensivists emergency department doctors the administration of blood components and blood products which includes monitoring of patients during transfusion
47 Registered Nursing or Midwifery Staff
Ensure that they are aware of the policy and associated procedures
Completion of a competency based training package applicable to their role upon Induction and thereafter self-assessments every 3 years with the exception of blood Collection (see point 41 above)
Taking blood samples for group and screen andor pre-transfusion testing The collection of blood components and blood products The administration of blood components and blood products
The monitoring of patients during transfusion
Taking appropriate action in the event of adverse effects
Completing in full all accompanying paperwork associated with the transfusion
In addition for Designated Specialist Nurses Requesting blood components from Blood Bank in accordance with the Maximum Blood Ordering Schedule (MBOS)
In addition for those nurses that have completed their specialist nurse development pack for the authorisation of blood components for adult patients authorising the transfusion of red cells and platelets 471 Nurses under Preceptorship
Duties as for a registered nurse or midwife but for the administration of blood components and blood products work through the Blood Transfusion assessment pack (part A) before becoming the primary witness To be a secondary witness must have completed the calculations test as part of the Trusts IVI study day
Transfusion Policy Procedures and Guidelines
Page 6 of 14 Issue Date 15th November 2017
Review Date October 2020
48 Operating Department Practitioners
Ensure that they are aware of the policy and associated procedures
On behalf of a named Anaesthetist verbally request blood components from Blood Bank
The collection and administration of blood components and blood products
The monitoring of patients during transfusion
Taking appropriate action in the event of adverse effects
49 Health Care Assistants (Band 3)
Ensure that they are aware of the policy and associated procedures
Taking blood samples for group and screen
Collection of blood components and blood products from Blood Bank
Undertaking observations of patients pre during and post transfusion under the direct supervision of a registered practitioner
491 Health Care Assistants (Band 2)
Ensure that they are aware of the policy and associated procedures
Collection of blood components and blood products from Blood Bank
Undertaking observations of patients pre during and post transfusion under the direct supervision of a registered practitioner
410 Phlebotomists and Emergency Support Workers
Responsibilities are restricted within this policy to the taking of blood samples for group and save
411 Porters
Responsibilities are restricted within this policy to the collection of blood components and blood products from Blood Bank to Sherwood birthing unit and neonatal unit only
412 Student Nurses Medical Students
Shadowingobserving qualified colleagues No involvement in any aspect of blood transfusion unless under strict supervision by fully qualified staff
413 Agency Staff - Nursing
No involvement in any aspect of blood transfusion unless under strict supervision by fully qualified SFH NHS Trust staff or until they are deemed competent for that procedure
414 Bank Staff - Nursing
If a SFH NHS Trust employee then duties as above for their role
If a NON SFH NHS Trust employee no involvement in any aspect of blood transfusion unless under strict supervision by fully qualified SFH NHS Trust staff or until they are deemed competent for that procedure
415 Locum Medical Staff
If a SFH NHS Trust employee then duties as above for their role
If a non-SFH NHS Trust employee can be involved in blood transfusion if they can show evidence of completion within the last two years of-
1 The Trusts Induction Package 2 Completion of the modules listed in 46 above on the e-learning package
wwwlearnbloodtransfusionorguk in accordance with their role
Transfusion Policy Procedures and Guidelines
Page 7 of 14 Issue Date 15th November 2017
Review Date October 2020
416 Biomedical Scientists
Challenging the appropriateness of requests
Pre-transfusion testing
Issuing blood components and blood products
Investigating and reporting adverse events
417 Transfusion Practitioner
The identification and provision of transfusion training within the Trust
Investigate transfusion reactions or other clinical incidents relating to transfusion with the assistance of relevant staff according to the Trustrsquos incident reporting policy
Report any serious adverse transfusion events or reactions to the Medicines and Healthcare products Regulatory Agency (MHRA) andor the Serious Hazards of Transfusion (SHOT) reporting scheme
Duties as identified as a member of the Hospital Transfusion Committee and Team
5 NARRATIVE
As per the roles and responsibilities all staff caring for patients requiring transfusion services must refer to the relevant procedures and guidelines as listed within the appendices If in doubt seek senior advice or support from the Transfusion Practitioner
6 EVIDENCE BASE REFERENCES British Society for Haematology 2016 Guidelines for the use of platelet transfusions (httpwwwb-s-horgukguidelines) British Society for Haematology 2012 Pre transfusion compatibility procedures in blood transfusion laboratories (httpwwwb-s-horgukguidelines) British Society for Haematology 2004 Guidelines for the use of Fresh Frozen Plasma Cryoprecipitate and Cryosupernatant and 2007 Amendment to the Guidelines for the use of Fresh-Frozen Plasma Cryoprecipitate and Cryosupernatant (httpwwwb-s-horgukguidelines)
British Society for Haematology 2016 Transfusion for Fetuses Neonates and Older Children (httpwwwb-s-horgukguidelines) British Society for Haematology 2009 The administration of blood and blood components and 2012 Addendum to Administration of Blood Components (httpwwwb-s-horgukguidelines)
British Society for Haematology 2010 Use of irradiated blood components and 2012 Addendum to guidelines on the use of irradiated blood components (httpwwwb-s-horgukguidelines) British Society for Haematology 2012 Investigation and management of Acute Transfusion Reactions (httpwwwb-s-horgukguidelines) British Society for Haematology 2012 Management of Anaemia and Red Cell Transfusion in Adult Critically Ill Patients (httpwwwb-s-horgukguidelines)
Transfusion Policy Procedures and Guidelines
Page 8 of 14 Issue Date 15th November 2017
Review Date October 2020
British Society for Haematology 2012 Use of Anti-D Immunoglobulin for the prevention of Heamolytic Disease of the Fetus and Newborn (httpwwwb-s-horgukguidelines) British Society for Haematology 2016 Guideline for blood grouping and red cell antibody testing in pregnancy (httpwwwb-s-horgukguidelines)
British Society for Haematology 2015 Haematological management of Major Haemorrhage (httpwwwb-s-horgukguidelines) Guidelines on the management of massive blood loss BJH 2006 135(5) 634-41 Handbook of Transfusion Medicine 2013 5th Edition Blood Transfusion Services of the United Kingdom Ed D Norfolk
Health Service Circular 2007001 Better Blood Transfusion (Available at httpwwwtransfusionguidelinesorgukindexaspxPublication=BBT ) The Blood Safety and Quality Regulations 2005 (SI 200550) and amending regulations NPSA (2006) Right Patient Right Blood Safer Practice Notice 9th November 2006 No 14 (Available at httpwwwnpsanhsuknrlsalerts-and-directivesnotices) Serious Hazards of Transfusion Annual Report wwwshotukorg
7 EDUCATION AND TRAINING
A continuous programme of education exists in the Trust for all grades of staff Any additional training will be provided by the Transfusion Practitioner based on individual or departmental need
Appropriate competency-based training will be provided to nominated link trainers in each clinical area by the Transfusion Practitioner so that they can facilitate cascade training and competency assessments (Sampling and administration are self- assessments every 3 years following a one off observational assessment for sampling and for administration completion of the Trusts IVI pack or Grandparent rights document) Blood collection competency assessments are completed every 2 years
All training and assessments provided by the link trainers will be forwarded to the Transfusion Practitioner who together with any additional training or assessments that heshe performs will be recorded on the training database held by the training educational and developmental department
Transfusion Policy Procedures and Guidelines
Page 9 of 14 Issue Date 15th November 2017
Review Date October 2020
71 Competency Assessments
Staff Group
Obtaining a sample
Collection of blood components and products
Administration of blood components and blood products
Medical staff
Registered nurse (RN)
Registered midwife (RM)
ODP
HCA-Band 3
HCA ndashBand 2
Phlebotomist
Emergency Support workers
Porter
Students
Agency RNRM
Locum medics
Bank Staff
Biomedical Scientists
Medical Laboratory Assistants
Anaesthetists intensivists and emergency department doctors only
Competency assessment linked to their role
8 MONITORING COMPLIANCE NHSLA Standard
Method of Monitoring Timescale Lead
158a How blood samples are requested for pre-transfusion compatibility testing
A fully completed transfusion request form is completed by a member of the medical staff Data is collated from the Blood Transfusion Laboratory Information System regarding any request that fails to meet the minimal criteria as stated in Appendix 2 of this Policy
Monthly Quarterly
Chair of the Blood Transfusion Incident Review Group Chair of the Hospital Transfusion Committee
158b How transfusions are administered including patient identification
National Comparative audit Incident reporting
Every 3 years
Chair of the Hospital Transfusion Committee
158c Care of patients receiving a transfusion
National Comparative audit
Every 3 years
Chair of the Hospital Transfusion Committee
158d How the organisation trains staff in line with the training needs analysis
Records are kept by the Training Department of all transfusion related training courses who then report to staff line managers
Bi-Monthly Chair of the Hospital Transfusion Committee
Transfusion Policy Procedures and Guidelines
Page 10 of 14 Issue Date 15th November 2017
Review Date October 2020
158e How the organisation assesses the competency of all staff involved in the transfusion process
Completed assessments are held by the individual or in the clinical area Evidence of completion is sent to the Transfusion Practitioner to update the training database This information is shared with the Training Department
On -going Chair of the Hospital Transfusion Committee
How the organisation evidences non SFH locum medical staff training
Locum induction checklist held by rota co-ordinators
On-going Chair of the Hospital Transfusion Committee
158f How the organisation monitors compliance with all of the above
Reports go to the HTC Quarterly Chair of the Hospital Transfusion Committee
How the organisation monitors compliance with the Blood Safety and Quality Regulations
Compliance report to MHRA
Annually Chief Executive
How the organisations monitors compliance to achieve UKAS Accreditation to standard ISO 151892012
Inspections Every 2 years
Pathology Manager
9 CONSULTATION Contributors Communication Channel eg
11 meeting phone
Group committee meeting
Date
Consultant lead for Transfusion E mail 12072017
Consultant Haematologists E mail 12072017
Hospital Transfusion Committee Committee meeting Oct 2017
10 EQUALITY IMPACT ASSESSMENT (EIA) The Trust is committed to ensuring that none of its policies procedures and guidelines discriminate against individuals directly or indirectly on the basis of gender colour race nationality ethnic or national origins age sexual orientation marital status disability religion beliefs political affiliation trade union membership and social and employment status An EIA of this policyguideline was been conducted by the author using the EIA tool developed by the Diversity and Inclusivity Committee see below Equality Impact Assessment (EqIA) Form (please complete all sections) Guidance on how to complete an EIA Sample completed form
Name of servicepolicyprocedure being reviewed Trusts Transfusion Policy Procedures and Guidelines
New or existing servicepolicyprocedure Existing Policy
Date of Assessment November 2017
Transfusion Policy Procedures and Guidelines
Page 11 of 14 Issue Date 15th November 2017
Review Date October 2020
For the servicepolicyprocedure and its implementation answer the questions a ndash c below against each characteristic (if relevant consider breaking the policy or implementation down into areas)
Protected
Characteristic
a) Using data and supporting information what issues needs or barriers could the protected characteristic groupsrsquo experience For example are there any known health inequality or access issues to consider
b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics screening
c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality
The area of policy or its implementation being assessed
Race and Ethnicity None None None
Gender
None None None
Age
None None None
Religion Currently the policy does not address patients that refuse blood components based on their religion
The Policy for refusal of blood components and products is in the final stage of approval however Maternity do have a guideline for the management of women in pregnancy who decline blood and blood products
None
Disability
None None None
Sexuality
None None None
Pregnancy and Maternity
None None None
Gender Reassignment
None None None
Marriage and Civil Partnership
None None None
Socio-Economic Factors (ie living in
a poorer neighbourhood
social deprivation)
None None None
What consultation with protected characteristic groups including patient groups have you carried out Consultation has occurred with the local hospital Jehovahrsquos witness representatives
What data or information did you use in support of this EqIA
Transfusion Policy Procedures and Guidelines
Page 12 of 14 Issue Date 15th November 2017
Review Date October 2020
As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys questionnaires comments concerns complaints or compliments No
Level of impact From the information provided above and following EqIA guidance document please indicate the perceived level of impact Low Level of Impact For high or medium levels of impact please forward a copy of this form to the HR Secretaries for inclusion at the next Diversity and Inclusivity meeting
Name of Responsible Person undertaking this assessment Jane Walden-Specialist Transfusion Practitoner
Signature
Date 20112017
11 KEYWORDS Blood
12 APPENDICES As listed in contents table
Transfusion Policy Procedures and Guidelines
Page 13 of 14 Issue Date 15th November 2017
Review Date October 2020
Document control supporting information for this clinical document
Title
Transfusion Policy Procedures and Guidelines
Document category Clinical Policies and Guidelines
Reference
CGTRANS001
Version number
80
Approval
v Approved by
Approval Date
80 Hospital Transfusion Committee October 2017
Issue date
15th November 2017
Review date October 2020
Job title of author responsible for the document author name
Transfusion PractitionerJane Walden
Division amp Specialty Department Service responsible for reporting the status of the document
Diagnostic and Rehabilitation Haematology (Transfusion Services)
Document Sponsor
Medical Director
Date Equality Impact Assessment completed updated
As dated in relevant section of document
Superseded document(s) (Ref No Version number previous title if changed date issued ndash review date)
v70 Issued 8th April 2015 to August 2017
Version History and Practice Changes Amendments
Issue Date Version Comments (Section Change)
15-11-2017 70 41
46 and 415
47
471
6
7
Update to training and competency assessments
Update to e-learning modules for medical staff
Role of nurse authorisers
Preceptorship nurses and administration of blood
Update to references (change to British Society for Haematology from British Standard in Haematology
Changes to frequency of competency assessments addition of self-assessments
Transfusion Policy Procedures and Guidelines
Page 14 of 14 Issue Date 15th November 2017
Review Date October 2020
01-02-2015 70 415
471
60
Additional module ndash Safe Blood Sampling for Transfusion for locum medics
Nurses under preceptorship
Updated References
23-09-2014 62 Appendix 16 NEW Guideline for the transfusion of blood components in acute upper gastrointestinal bleeding
17-04-2014 61 41
46
Appendix 15
Appendix 6
Collection competency assessment to be undertaken every 2 years
Additional module ndash Safe Blood Sampling for Transfusion
New Appendix ndash Guidelines for the use of Human Albumin Solution
New table inserted ndash Transfusion reactions in adults nursing guidance
Distribution (Circulation)
This document will be accessible via the Trustrsquos intranet
Communication
Information regarding the initiation and subsequent updates of this document will be communicated via the earliest weekly Trust staff bulletin nursing bulletin and or other agreed communication method
Transfusion Policy Procedures and Guidelines
Page 4 of 14 Issue Date 15th November 2017
Review Date October 2020
Blood Component A therapeutic primary constituent of human blood (red cells white cells platelets plasma and cryoprecipitate)
Autologous Blood Transfusion
Transfusion to an individual of blood collected from him or herself
4 ROLES AND RESPONSIBILITIES
41 ALL STAFF involved in any aspect of blood transfusion are responsible for-
Adhering to this policy and any attached transfusion procedures and guidelines
Maintaining and updating their knowledge and practice
Meeting the National blood transfusion committee requirements for training and assessments in blood transfusion by having a one off practical assessment for sample labelling and enough supervised administrations to be competent followed by self-assessment every 3 years and a competency assessment every 2 years for collection
Reporting transfusion reactions or other incidents related to transfusion
Gaining the appropriate lawful consent prior to undertaking any care or treatment for patients requiring the transfusion services If capacity is in doubt it must be assessed using the two stage test and where necessary care planned in a patientrsquos best interest Staff must also document the consent gained
42 Hospital Transfusion Committee
On behalf of the Trust Clinical Governance Committee have delegated responsibility to oversee develop and implement Trust policies procedures and guidelines relating to blood transfusion
Audit the practice of blood transfusion against the Trust policy and national guidelines focusing on critical points for patient safety and the appropriate use of blood
Identify and manage risk associated with blood transfusion by reporting quarterly to the Trustrsquos Clinical Governance Committee
Review the transfusion policy related procedures and guidelines as required to ascertain changes additions or deletions deemed necessary due to changes in local national or international guidance
43 Hospital Transfusion team
Assists in the implementation of the Hospital Transfusion Committeersquos objectives
44 Service Directors and Heads of Nursing
Ensure that the policy and attached procedures are available to staff
Ensure that the policy and attached procedures are adhered to
45 Line Managers
Ensure that staff involved in the blood transfusion process are informed of the transfusion policy
Ensure staff are competent through appropriate training to follow guidelines and procedures to ensure that the right blood is given to the right patient at the right time
Time facilitation for the delivery of transfusion training by the designated link trainer(s) within their area
Investigate clinical incidents relating to transfusion which occur in their clinical area or involve a member of their staff according to the Trusts Incident Reporting policy
Transfusion Policy Procedures and Guidelines
Page 5 of 14 Issue Date 15th November 2017
Review Date October 2020
46 Medical Staff
Ensure that they are aware of the policy and associated procedures
Completion every two years of the following modules on the e-learning package wwwlearnbloodtransfusionorguk
Safe Transfusion Practice Blood components and indications for use Consent for Transfusion Acute Transfusion Reactions Safe Blood Sampling for Transfusion Video Anti-D clinical module (Obstetricians and Gynaecologists ONLY) Learn Cell Salvage (Anaesthetists and Surgeons ONLY)
If working with Paediactric patients must complete the above but Safe Transfusion Practice is replaced by -Safe Transfusion Practice for Paediatrics
The prescription of blood (including autologous) blood components and blood products
Requesting blood components and blood products from Blood Bank
Documentation of the transfusion episode in the medical notes (ie indication quantity consent and outcome)
Explaining the risks and benefits of transfusion to the patient using a patient information leaflet
Taking blood samples for group and screen andor pre-transfusion testing
Taking appropriate action in the event of adverse effects
Completing in full all accompanying paperwork associated with the transfusion
In addition front line staff expected to give blood as part of their role eg anaesthetists intensivists emergency department doctors the administration of blood components and blood products which includes monitoring of patients during transfusion
47 Registered Nursing or Midwifery Staff
Ensure that they are aware of the policy and associated procedures
Completion of a competency based training package applicable to their role upon Induction and thereafter self-assessments every 3 years with the exception of blood Collection (see point 41 above)
Taking blood samples for group and screen andor pre-transfusion testing The collection of blood components and blood products The administration of blood components and blood products
The monitoring of patients during transfusion
Taking appropriate action in the event of adverse effects
Completing in full all accompanying paperwork associated with the transfusion
In addition for Designated Specialist Nurses Requesting blood components from Blood Bank in accordance with the Maximum Blood Ordering Schedule (MBOS)
In addition for those nurses that have completed their specialist nurse development pack for the authorisation of blood components for adult patients authorising the transfusion of red cells and platelets 471 Nurses under Preceptorship
Duties as for a registered nurse or midwife but for the administration of blood components and blood products work through the Blood Transfusion assessment pack (part A) before becoming the primary witness To be a secondary witness must have completed the calculations test as part of the Trusts IVI study day
Transfusion Policy Procedures and Guidelines
Page 6 of 14 Issue Date 15th November 2017
Review Date October 2020
48 Operating Department Practitioners
Ensure that they are aware of the policy and associated procedures
On behalf of a named Anaesthetist verbally request blood components from Blood Bank
The collection and administration of blood components and blood products
The monitoring of patients during transfusion
Taking appropriate action in the event of adverse effects
49 Health Care Assistants (Band 3)
Ensure that they are aware of the policy and associated procedures
Taking blood samples for group and screen
Collection of blood components and blood products from Blood Bank
Undertaking observations of patients pre during and post transfusion under the direct supervision of a registered practitioner
491 Health Care Assistants (Band 2)
Ensure that they are aware of the policy and associated procedures
Collection of blood components and blood products from Blood Bank
Undertaking observations of patients pre during and post transfusion under the direct supervision of a registered practitioner
410 Phlebotomists and Emergency Support Workers
Responsibilities are restricted within this policy to the taking of blood samples for group and save
411 Porters
Responsibilities are restricted within this policy to the collection of blood components and blood products from Blood Bank to Sherwood birthing unit and neonatal unit only
412 Student Nurses Medical Students
Shadowingobserving qualified colleagues No involvement in any aspect of blood transfusion unless under strict supervision by fully qualified staff
413 Agency Staff - Nursing
No involvement in any aspect of blood transfusion unless under strict supervision by fully qualified SFH NHS Trust staff or until they are deemed competent for that procedure
414 Bank Staff - Nursing
If a SFH NHS Trust employee then duties as above for their role
If a NON SFH NHS Trust employee no involvement in any aspect of blood transfusion unless under strict supervision by fully qualified SFH NHS Trust staff or until they are deemed competent for that procedure
415 Locum Medical Staff
If a SFH NHS Trust employee then duties as above for their role
If a non-SFH NHS Trust employee can be involved in blood transfusion if they can show evidence of completion within the last two years of-
1 The Trusts Induction Package 2 Completion of the modules listed in 46 above on the e-learning package
wwwlearnbloodtransfusionorguk in accordance with their role
Transfusion Policy Procedures and Guidelines
Page 7 of 14 Issue Date 15th November 2017
Review Date October 2020
416 Biomedical Scientists
Challenging the appropriateness of requests
Pre-transfusion testing
Issuing blood components and blood products
Investigating and reporting adverse events
417 Transfusion Practitioner
The identification and provision of transfusion training within the Trust
Investigate transfusion reactions or other clinical incidents relating to transfusion with the assistance of relevant staff according to the Trustrsquos incident reporting policy
Report any serious adverse transfusion events or reactions to the Medicines and Healthcare products Regulatory Agency (MHRA) andor the Serious Hazards of Transfusion (SHOT) reporting scheme
Duties as identified as a member of the Hospital Transfusion Committee and Team
5 NARRATIVE
As per the roles and responsibilities all staff caring for patients requiring transfusion services must refer to the relevant procedures and guidelines as listed within the appendices If in doubt seek senior advice or support from the Transfusion Practitioner
6 EVIDENCE BASE REFERENCES British Society for Haematology 2016 Guidelines for the use of platelet transfusions (httpwwwb-s-horgukguidelines) British Society for Haematology 2012 Pre transfusion compatibility procedures in blood transfusion laboratories (httpwwwb-s-horgukguidelines) British Society for Haematology 2004 Guidelines for the use of Fresh Frozen Plasma Cryoprecipitate and Cryosupernatant and 2007 Amendment to the Guidelines for the use of Fresh-Frozen Plasma Cryoprecipitate and Cryosupernatant (httpwwwb-s-horgukguidelines)
British Society for Haematology 2016 Transfusion for Fetuses Neonates and Older Children (httpwwwb-s-horgukguidelines) British Society for Haematology 2009 The administration of blood and blood components and 2012 Addendum to Administration of Blood Components (httpwwwb-s-horgukguidelines)
British Society for Haematology 2010 Use of irradiated blood components and 2012 Addendum to guidelines on the use of irradiated blood components (httpwwwb-s-horgukguidelines) British Society for Haematology 2012 Investigation and management of Acute Transfusion Reactions (httpwwwb-s-horgukguidelines) British Society for Haematology 2012 Management of Anaemia and Red Cell Transfusion in Adult Critically Ill Patients (httpwwwb-s-horgukguidelines)
Transfusion Policy Procedures and Guidelines
Page 8 of 14 Issue Date 15th November 2017
Review Date October 2020
British Society for Haematology 2012 Use of Anti-D Immunoglobulin for the prevention of Heamolytic Disease of the Fetus and Newborn (httpwwwb-s-horgukguidelines) British Society for Haematology 2016 Guideline for blood grouping and red cell antibody testing in pregnancy (httpwwwb-s-horgukguidelines)
British Society for Haematology 2015 Haematological management of Major Haemorrhage (httpwwwb-s-horgukguidelines) Guidelines on the management of massive blood loss BJH 2006 135(5) 634-41 Handbook of Transfusion Medicine 2013 5th Edition Blood Transfusion Services of the United Kingdom Ed D Norfolk
Health Service Circular 2007001 Better Blood Transfusion (Available at httpwwwtransfusionguidelinesorgukindexaspxPublication=BBT ) The Blood Safety and Quality Regulations 2005 (SI 200550) and amending regulations NPSA (2006) Right Patient Right Blood Safer Practice Notice 9th November 2006 No 14 (Available at httpwwwnpsanhsuknrlsalerts-and-directivesnotices) Serious Hazards of Transfusion Annual Report wwwshotukorg
7 EDUCATION AND TRAINING
A continuous programme of education exists in the Trust for all grades of staff Any additional training will be provided by the Transfusion Practitioner based on individual or departmental need
Appropriate competency-based training will be provided to nominated link trainers in each clinical area by the Transfusion Practitioner so that they can facilitate cascade training and competency assessments (Sampling and administration are self- assessments every 3 years following a one off observational assessment for sampling and for administration completion of the Trusts IVI pack or Grandparent rights document) Blood collection competency assessments are completed every 2 years
All training and assessments provided by the link trainers will be forwarded to the Transfusion Practitioner who together with any additional training or assessments that heshe performs will be recorded on the training database held by the training educational and developmental department
Transfusion Policy Procedures and Guidelines
Page 9 of 14 Issue Date 15th November 2017
Review Date October 2020
71 Competency Assessments
Staff Group
Obtaining a sample
Collection of blood components and products
Administration of blood components and blood products
Medical staff
Registered nurse (RN)
Registered midwife (RM)
ODP
HCA-Band 3
HCA ndashBand 2
Phlebotomist
Emergency Support workers
Porter
Students
Agency RNRM
Locum medics
Bank Staff
Biomedical Scientists
Medical Laboratory Assistants
Anaesthetists intensivists and emergency department doctors only
Competency assessment linked to their role
8 MONITORING COMPLIANCE NHSLA Standard
Method of Monitoring Timescale Lead
158a How blood samples are requested for pre-transfusion compatibility testing
A fully completed transfusion request form is completed by a member of the medical staff Data is collated from the Blood Transfusion Laboratory Information System regarding any request that fails to meet the minimal criteria as stated in Appendix 2 of this Policy
Monthly Quarterly
Chair of the Blood Transfusion Incident Review Group Chair of the Hospital Transfusion Committee
158b How transfusions are administered including patient identification
National Comparative audit Incident reporting
Every 3 years
Chair of the Hospital Transfusion Committee
158c Care of patients receiving a transfusion
National Comparative audit
Every 3 years
Chair of the Hospital Transfusion Committee
158d How the organisation trains staff in line with the training needs analysis
Records are kept by the Training Department of all transfusion related training courses who then report to staff line managers
Bi-Monthly Chair of the Hospital Transfusion Committee
Transfusion Policy Procedures and Guidelines
Page 10 of 14 Issue Date 15th November 2017
Review Date October 2020
158e How the organisation assesses the competency of all staff involved in the transfusion process
Completed assessments are held by the individual or in the clinical area Evidence of completion is sent to the Transfusion Practitioner to update the training database This information is shared with the Training Department
On -going Chair of the Hospital Transfusion Committee
How the organisation evidences non SFH locum medical staff training
Locum induction checklist held by rota co-ordinators
On-going Chair of the Hospital Transfusion Committee
158f How the organisation monitors compliance with all of the above
Reports go to the HTC Quarterly Chair of the Hospital Transfusion Committee
How the organisation monitors compliance with the Blood Safety and Quality Regulations
Compliance report to MHRA
Annually Chief Executive
How the organisations monitors compliance to achieve UKAS Accreditation to standard ISO 151892012
Inspections Every 2 years
Pathology Manager
9 CONSULTATION Contributors Communication Channel eg
11 meeting phone
Group committee meeting
Date
Consultant lead for Transfusion E mail 12072017
Consultant Haematologists E mail 12072017
Hospital Transfusion Committee Committee meeting Oct 2017
10 EQUALITY IMPACT ASSESSMENT (EIA) The Trust is committed to ensuring that none of its policies procedures and guidelines discriminate against individuals directly or indirectly on the basis of gender colour race nationality ethnic or national origins age sexual orientation marital status disability religion beliefs political affiliation trade union membership and social and employment status An EIA of this policyguideline was been conducted by the author using the EIA tool developed by the Diversity and Inclusivity Committee see below Equality Impact Assessment (EqIA) Form (please complete all sections) Guidance on how to complete an EIA Sample completed form
Name of servicepolicyprocedure being reviewed Trusts Transfusion Policy Procedures and Guidelines
New or existing servicepolicyprocedure Existing Policy
Date of Assessment November 2017
Transfusion Policy Procedures and Guidelines
Page 11 of 14 Issue Date 15th November 2017
Review Date October 2020
For the servicepolicyprocedure and its implementation answer the questions a ndash c below against each characteristic (if relevant consider breaking the policy or implementation down into areas)
Protected
Characteristic
a) Using data and supporting information what issues needs or barriers could the protected characteristic groupsrsquo experience For example are there any known health inequality or access issues to consider
b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics screening
c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality
The area of policy or its implementation being assessed
Race and Ethnicity None None None
Gender
None None None
Age
None None None
Religion Currently the policy does not address patients that refuse blood components based on their religion
The Policy for refusal of blood components and products is in the final stage of approval however Maternity do have a guideline for the management of women in pregnancy who decline blood and blood products
None
Disability
None None None
Sexuality
None None None
Pregnancy and Maternity
None None None
Gender Reassignment
None None None
Marriage and Civil Partnership
None None None
Socio-Economic Factors (ie living in
a poorer neighbourhood
social deprivation)
None None None
What consultation with protected characteristic groups including patient groups have you carried out Consultation has occurred with the local hospital Jehovahrsquos witness representatives
What data or information did you use in support of this EqIA
Transfusion Policy Procedures and Guidelines
Page 12 of 14 Issue Date 15th November 2017
Review Date October 2020
As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys questionnaires comments concerns complaints or compliments No
Level of impact From the information provided above and following EqIA guidance document please indicate the perceived level of impact Low Level of Impact For high or medium levels of impact please forward a copy of this form to the HR Secretaries for inclusion at the next Diversity and Inclusivity meeting
Name of Responsible Person undertaking this assessment Jane Walden-Specialist Transfusion Practitoner
Signature
Date 20112017
11 KEYWORDS Blood
12 APPENDICES As listed in contents table
Transfusion Policy Procedures and Guidelines
Page 13 of 14 Issue Date 15th November 2017
Review Date October 2020
Document control supporting information for this clinical document
Title
Transfusion Policy Procedures and Guidelines
Document category Clinical Policies and Guidelines
Reference
CGTRANS001
Version number
80
Approval
v Approved by
Approval Date
80 Hospital Transfusion Committee October 2017
Issue date
15th November 2017
Review date October 2020
Job title of author responsible for the document author name
Transfusion PractitionerJane Walden
Division amp Specialty Department Service responsible for reporting the status of the document
Diagnostic and Rehabilitation Haematology (Transfusion Services)
Document Sponsor
Medical Director
Date Equality Impact Assessment completed updated
As dated in relevant section of document
Superseded document(s) (Ref No Version number previous title if changed date issued ndash review date)
v70 Issued 8th April 2015 to August 2017
Version History and Practice Changes Amendments
Issue Date Version Comments (Section Change)
15-11-2017 70 41
46 and 415
47
471
6
7
Update to training and competency assessments
Update to e-learning modules for medical staff
Role of nurse authorisers
Preceptorship nurses and administration of blood
Update to references (change to British Society for Haematology from British Standard in Haematology
Changes to frequency of competency assessments addition of self-assessments
Transfusion Policy Procedures and Guidelines
Page 14 of 14 Issue Date 15th November 2017
Review Date October 2020
01-02-2015 70 415
471
60
Additional module ndash Safe Blood Sampling for Transfusion for locum medics
Nurses under preceptorship
Updated References
23-09-2014 62 Appendix 16 NEW Guideline for the transfusion of blood components in acute upper gastrointestinal bleeding
17-04-2014 61 41
46
Appendix 15
Appendix 6
Collection competency assessment to be undertaken every 2 years
Additional module ndash Safe Blood Sampling for Transfusion
New Appendix ndash Guidelines for the use of Human Albumin Solution
New table inserted ndash Transfusion reactions in adults nursing guidance
Distribution (Circulation)
This document will be accessible via the Trustrsquos intranet
Communication
Information regarding the initiation and subsequent updates of this document will be communicated via the earliest weekly Trust staff bulletin nursing bulletin and or other agreed communication method
Transfusion Policy Procedures and Guidelines
Page 5 of 14 Issue Date 15th November 2017
Review Date October 2020
46 Medical Staff
Ensure that they are aware of the policy and associated procedures
Completion every two years of the following modules on the e-learning package wwwlearnbloodtransfusionorguk
Safe Transfusion Practice Blood components and indications for use Consent for Transfusion Acute Transfusion Reactions Safe Blood Sampling for Transfusion Video Anti-D clinical module (Obstetricians and Gynaecologists ONLY) Learn Cell Salvage (Anaesthetists and Surgeons ONLY)
If working with Paediactric patients must complete the above but Safe Transfusion Practice is replaced by -Safe Transfusion Practice for Paediatrics
The prescription of blood (including autologous) blood components and blood products
Requesting blood components and blood products from Blood Bank
Documentation of the transfusion episode in the medical notes (ie indication quantity consent and outcome)
Explaining the risks and benefits of transfusion to the patient using a patient information leaflet
Taking blood samples for group and screen andor pre-transfusion testing
Taking appropriate action in the event of adverse effects
Completing in full all accompanying paperwork associated with the transfusion
In addition front line staff expected to give blood as part of their role eg anaesthetists intensivists emergency department doctors the administration of blood components and blood products which includes monitoring of patients during transfusion
47 Registered Nursing or Midwifery Staff
Ensure that they are aware of the policy and associated procedures
Completion of a competency based training package applicable to their role upon Induction and thereafter self-assessments every 3 years with the exception of blood Collection (see point 41 above)
Taking blood samples for group and screen andor pre-transfusion testing The collection of blood components and blood products The administration of blood components and blood products
The monitoring of patients during transfusion
Taking appropriate action in the event of adverse effects
Completing in full all accompanying paperwork associated with the transfusion
In addition for Designated Specialist Nurses Requesting blood components from Blood Bank in accordance with the Maximum Blood Ordering Schedule (MBOS)
In addition for those nurses that have completed their specialist nurse development pack for the authorisation of blood components for adult patients authorising the transfusion of red cells and platelets 471 Nurses under Preceptorship
Duties as for a registered nurse or midwife but for the administration of blood components and blood products work through the Blood Transfusion assessment pack (part A) before becoming the primary witness To be a secondary witness must have completed the calculations test as part of the Trusts IVI study day
Transfusion Policy Procedures and Guidelines
Page 6 of 14 Issue Date 15th November 2017
Review Date October 2020
48 Operating Department Practitioners
Ensure that they are aware of the policy and associated procedures
On behalf of a named Anaesthetist verbally request blood components from Blood Bank
The collection and administration of blood components and blood products
The monitoring of patients during transfusion
Taking appropriate action in the event of adverse effects
49 Health Care Assistants (Band 3)
Ensure that they are aware of the policy and associated procedures
Taking blood samples for group and screen
Collection of blood components and blood products from Blood Bank
Undertaking observations of patients pre during and post transfusion under the direct supervision of a registered practitioner
491 Health Care Assistants (Band 2)
Ensure that they are aware of the policy and associated procedures
Collection of blood components and blood products from Blood Bank
Undertaking observations of patients pre during and post transfusion under the direct supervision of a registered practitioner
410 Phlebotomists and Emergency Support Workers
Responsibilities are restricted within this policy to the taking of blood samples for group and save
411 Porters
Responsibilities are restricted within this policy to the collection of blood components and blood products from Blood Bank to Sherwood birthing unit and neonatal unit only
412 Student Nurses Medical Students
Shadowingobserving qualified colleagues No involvement in any aspect of blood transfusion unless under strict supervision by fully qualified staff
413 Agency Staff - Nursing
No involvement in any aspect of blood transfusion unless under strict supervision by fully qualified SFH NHS Trust staff or until they are deemed competent for that procedure
414 Bank Staff - Nursing
If a SFH NHS Trust employee then duties as above for their role
If a NON SFH NHS Trust employee no involvement in any aspect of blood transfusion unless under strict supervision by fully qualified SFH NHS Trust staff or until they are deemed competent for that procedure
415 Locum Medical Staff
If a SFH NHS Trust employee then duties as above for their role
If a non-SFH NHS Trust employee can be involved in blood transfusion if they can show evidence of completion within the last two years of-
1 The Trusts Induction Package 2 Completion of the modules listed in 46 above on the e-learning package
wwwlearnbloodtransfusionorguk in accordance with their role
Transfusion Policy Procedures and Guidelines
Page 7 of 14 Issue Date 15th November 2017
Review Date October 2020
416 Biomedical Scientists
Challenging the appropriateness of requests
Pre-transfusion testing
Issuing blood components and blood products
Investigating and reporting adverse events
417 Transfusion Practitioner
The identification and provision of transfusion training within the Trust
Investigate transfusion reactions or other clinical incidents relating to transfusion with the assistance of relevant staff according to the Trustrsquos incident reporting policy
Report any serious adverse transfusion events or reactions to the Medicines and Healthcare products Regulatory Agency (MHRA) andor the Serious Hazards of Transfusion (SHOT) reporting scheme
Duties as identified as a member of the Hospital Transfusion Committee and Team
5 NARRATIVE
As per the roles and responsibilities all staff caring for patients requiring transfusion services must refer to the relevant procedures and guidelines as listed within the appendices If in doubt seek senior advice or support from the Transfusion Practitioner
6 EVIDENCE BASE REFERENCES British Society for Haematology 2016 Guidelines for the use of platelet transfusions (httpwwwb-s-horgukguidelines) British Society for Haematology 2012 Pre transfusion compatibility procedures in blood transfusion laboratories (httpwwwb-s-horgukguidelines) British Society for Haematology 2004 Guidelines for the use of Fresh Frozen Plasma Cryoprecipitate and Cryosupernatant and 2007 Amendment to the Guidelines for the use of Fresh-Frozen Plasma Cryoprecipitate and Cryosupernatant (httpwwwb-s-horgukguidelines)
British Society for Haematology 2016 Transfusion for Fetuses Neonates and Older Children (httpwwwb-s-horgukguidelines) British Society for Haematology 2009 The administration of blood and blood components and 2012 Addendum to Administration of Blood Components (httpwwwb-s-horgukguidelines)
British Society for Haematology 2010 Use of irradiated blood components and 2012 Addendum to guidelines on the use of irradiated blood components (httpwwwb-s-horgukguidelines) British Society for Haematology 2012 Investigation and management of Acute Transfusion Reactions (httpwwwb-s-horgukguidelines) British Society for Haematology 2012 Management of Anaemia and Red Cell Transfusion in Adult Critically Ill Patients (httpwwwb-s-horgukguidelines)
Transfusion Policy Procedures and Guidelines
Page 8 of 14 Issue Date 15th November 2017
Review Date October 2020
British Society for Haematology 2012 Use of Anti-D Immunoglobulin for the prevention of Heamolytic Disease of the Fetus and Newborn (httpwwwb-s-horgukguidelines) British Society for Haematology 2016 Guideline for blood grouping and red cell antibody testing in pregnancy (httpwwwb-s-horgukguidelines)
British Society for Haematology 2015 Haematological management of Major Haemorrhage (httpwwwb-s-horgukguidelines) Guidelines on the management of massive blood loss BJH 2006 135(5) 634-41 Handbook of Transfusion Medicine 2013 5th Edition Blood Transfusion Services of the United Kingdom Ed D Norfolk
Health Service Circular 2007001 Better Blood Transfusion (Available at httpwwwtransfusionguidelinesorgukindexaspxPublication=BBT ) The Blood Safety and Quality Regulations 2005 (SI 200550) and amending regulations NPSA (2006) Right Patient Right Blood Safer Practice Notice 9th November 2006 No 14 (Available at httpwwwnpsanhsuknrlsalerts-and-directivesnotices) Serious Hazards of Transfusion Annual Report wwwshotukorg
7 EDUCATION AND TRAINING
A continuous programme of education exists in the Trust for all grades of staff Any additional training will be provided by the Transfusion Practitioner based on individual or departmental need
Appropriate competency-based training will be provided to nominated link trainers in each clinical area by the Transfusion Practitioner so that they can facilitate cascade training and competency assessments (Sampling and administration are self- assessments every 3 years following a one off observational assessment for sampling and for administration completion of the Trusts IVI pack or Grandparent rights document) Blood collection competency assessments are completed every 2 years
All training and assessments provided by the link trainers will be forwarded to the Transfusion Practitioner who together with any additional training or assessments that heshe performs will be recorded on the training database held by the training educational and developmental department
Transfusion Policy Procedures and Guidelines
Page 9 of 14 Issue Date 15th November 2017
Review Date October 2020
71 Competency Assessments
Staff Group
Obtaining a sample
Collection of blood components and products
Administration of blood components and blood products
Medical staff
Registered nurse (RN)
Registered midwife (RM)
ODP
HCA-Band 3
HCA ndashBand 2
Phlebotomist
Emergency Support workers
Porter
Students
Agency RNRM
Locum medics
Bank Staff
Biomedical Scientists
Medical Laboratory Assistants
Anaesthetists intensivists and emergency department doctors only
Competency assessment linked to their role
8 MONITORING COMPLIANCE NHSLA Standard
Method of Monitoring Timescale Lead
158a How blood samples are requested for pre-transfusion compatibility testing
A fully completed transfusion request form is completed by a member of the medical staff Data is collated from the Blood Transfusion Laboratory Information System regarding any request that fails to meet the minimal criteria as stated in Appendix 2 of this Policy
Monthly Quarterly
Chair of the Blood Transfusion Incident Review Group Chair of the Hospital Transfusion Committee
158b How transfusions are administered including patient identification
National Comparative audit Incident reporting
Every 3 years
Chair of the Hospital Transfusion Committee
158c Care of patients receiving a transfusion
National Comparative audit
Every 3 years
Chair of the Hospital Transfusion Committee
158d How the organisation trains staff in line with the training needs analysis
Records are kept by the Training Department of all transfusion related training courses who then report to staff line managers
Bi-Monthly Chair of the Hospital Transfusion Committee
Transfusion Policy Procedures and Guidelines
Page 10 of 14 Issue Date 15th November 2017
Review Date October 2020
158e How the organisation assesses the competency of all staff involved in the transfusion process
Completed assessments are held by the individual or in the clinical area Evidence of completion is sent to the Transfusion Practitioner to update the training database This information is shared with the Training Department
On -going Chair of the Hospital Transfusion Committee
How the organisation evidences non SFH locum medical staff training
Locum induction checklist held by rota co-ordinators
On-going Chair of the Hospital Transfusion Committee
158f How the organisation monitors compliance with all of the above
Reports go to the HTC Quarterly Chair of the Hospital Transfusion Committee
How the organisation monitors compliance with the Blood Safety and Quality Regulations
Compliance report to MHRA
Annually Chief Executive
How the organisations monitors compliance to achieve UKAS Accreditation to standard ISO 151892012
Inspections Every 2 years
Pathology Manager
9 CONSULTATION Contributors Communication Channel eg
11 meeting phone
Group committee meeting
Date
Consultant lead for Transfusion E mail 12072017
Consultant Haematologists E mail 12072017
Hospital Transfusion Committee Committee meeting Oct 2017
10 EQUALITY IMPACT ASSESSMENT (EIA) The Trust is committed to ensuring that none of its policies procedures and guidelines discriminate against individuals directly or indirectly on the basis of gender colour race nationality ethnic or national origins age sexual orientation marital status disability religion beliefs political affiliation trade union membership and social and employment status An EIA of this policyguideline was been conducted by the author using the EIA tool developed by the Diversity and Inclusivity Committee see below Equality Impact Assessment (EqIA) Form (please complete all sections) Guidance on how to complete an EIA Sample completed form
Name of servicepolicyprocedure being reviewed Trusts Transfusion Policy Procedures and Guidelines
New or existing servicepolicyprocedure Existing Policy
Date of Assessment November 2017
Transfusion Policy Procedures and Guidelines
Page 11 of 14 Issue Date 15th November 2017
Review Date October 2020
For the servicepolicyprocedure and its implementation answer the questions a ndash c below against each characteristic (if relevant consider breaking the policy or implementation down into areas)
Protected
Characteristic
a) Using data and supporting information what issues needs or barriers could the protected characteristic groupsrsquo experience For example are there any known health inequality or access issues to consider
b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics screening
c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality
The area of policy or its implementation being assessed
Race and Ethnicity None None None
Gender
None None None
Age
None None None
Religion Currently the policy does not address patients that refuse blood components based on their religion
The Policy for refusal of blood components and products is in the final stage of approval however Maternity do have a guideline for the management of women in pregnancy who decline blood and blood products
None
Disability
None None None
Sexuality
None None None
Pregnancy and Maternity
None None None
Gender Reassignment
None None None
Marriage and Civil Partnership
None None None
Socio-Economic Factors (ie living in
a poorer neighbourhood
social deprivation)
None None None
What consultation with protected characteristic groups including patient groups have you carried out Consultation has occurred with the local hospital Jehovahrsquos witness representatives
What data or information did you use in support of this EqIA
Transfusion Policy Procedures and Guidelines
Page 12 of 14 Issue Date 15th November 2017
Review Date October 2020
As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys questionnaires comments concerns complaints or compliments No
Level of impact From the information provided above and following EqIA guidance document please indicate the perceived level of impact Low Level of Impact For high or medium levels of impact please forward a copy of this form to the HR Secretaries for inclusion at the next Diversity and Inclusivity meeting
Name of Responsible Person undertaking this assessment Jane Walden-Specialist Transfusion Practitoner
Signature
Date 20112017
11 KEYWORDS Blood
12 APPENDICES As listed in contents table
Transfusion Policy Procedures and Guidelines
Page 13 of 14 Issue Date 15th November 2017
Review Date October 2020
Document control supporting information for this clinical document
Title
Transfusion Policy Procedures and Guidelines
Document category Clinical Policies and Guidelines
Reference
CGTRANS001
Version number
80
Approval
v Approved by
Approval Date
80 Hospital Transfusion Committee October 2017
Issue date
15th November 2017
Review date October 2020
Job title of author responsible for the document author name
Transfusion PractitionerJane Walden
Division amp Specialty Department Service responsible for reporting the status of the document
Diagnostic and Rehabilitation Haematology (Transfusion Services)
Document Sponsor
Medical Director
Date Equality Impact Assessment completed updated
As dated in relevant section of document
Superseded document(s) (Ref No Version number previous title if changed date issued ndash review date)
v70 Issued 8th April 2015 to August 2017
Version History and Practice Changes Amendments
Issue Date Version Comments (Section Change)
15-11-2017 70 41
46 and 415
47
471
6
7
Update to training and competency assessments
Update to e-learning modules for medical staff
Role of nurse authorisers
Preceptorship nurses and administration of blood
Update to references (change to British Society for Haematology from British Standard in Haematology
Changes to frequency of competency assessments addition of self-assessments
Transfusion Policy Procedures and Guidelines
Page 14 of 14 Issue Date 15th November 2017
Review Date October 2020
01-02-2015 70 415
471
60
Additional module ndash Safe Blood Sampling for Transfusion for locum medics
Nurses under preceptorship
Updated References
23-09-2014 62 Appendix 16 NEW Guideline for the transfusion of blood components in acute upper gastrointestinal bleeding
17-04-2014 61 41
46
Appendix 15
Appendix 6
Collection competency assessment to be undertaken every 2 years
Additional module ndash Safe Blood Sampling for Transfusion
New Appendix ndash Guidelines for the use of Human Albumin Solution
New table inserted ndash Transfusion reactions in adults nursing guidance
Distribution (Circulation)
This document will be accessible via the Trustrsquos intranet
Communication
Information regarding the initiation and subsequent updates of this document will be communicated via the earliest weekly Trust staff bulletin nursing bulletin and or other agreed communication method
Transfusion Policy Procedures and Guidelines
Page 6 of 14 Issue Date 15th November 2017
Review Date October 2020
48 Operating Department Practitioners
Ensure that they are aware of the policy and associated procedures
On behalf of a named Anaesthetist verbally request blood components from Blood Bank
The collection and administration of blood components and blood products
The monitoring of patients during transfusion
Taking appropriate action in the event of adverse effects
49 Health Care Assistants (Band 3)
Ensure that they are aware of the policy and associated procedures
Taking blood samples for group and screen
Collection of blood components and blood products from Blood Bank
Undertaking observations of patients pre during and post transfusion under the direct supervision of a registered practitioner
491 Health Care Assistants (Band 2)
Ensure that they are aware of the policy and associated procedures
Collection of blood components and blood products from Blood Bank
Undertaking observations of patients pre during and post transfusion under the direct supervision of a registered practitioner
410 Phlebotomists and Emergency Support Workers
Responsibilities are restricted within this policy to the taking of blood samples for group and save
411 Porters
Responsibilities are restricted within this policy to the collection of blood components and blood products from Blood Bank to Sherwood birthing unit and neonatal unit only
412 Student Nurses Medical Students
Shadowingobserving qualified colleagues No involvement in any aspect of blood transfusion unless under strict supervision by fully qualified staff
413 Agency Staff - Nursing
No involvement in any aspect of blood transfusion unless under strict supervision by fully qualified SFH NHS Trust staff or until they are deemed competent for that procedure
414 Bank Staff - Nursing
If a SFH NHS Trust employee then duties as above for their role
If a NON SFH NHS Trust employee no involvement in any aspect of blood transfusion unless under strict supervision by fully qualified SFH NHS Trust staff or until they are deemed competent for that procedure
415 Locum Medical Staff
If a SFH NHS Trust employee then duties as above for their role
If a non-SFH NHS Trust employee can be involved in blood transfusion if they can show evidence of completion within the last two years of-
1 The Trusts Induction Package 2 Completion of the modules listed in 46 above on the e-learning package
wwwlearnbloodtransfusionorguk in accordance with their role
Transfusion Policy Procedures and Guidelines
Page 7 of 14 Issue Date 15th November 2017
Review Date October 2020
416 Biomedical Scientists
Challenging the appropriateness of requests
Pre-transfusion testing
Issuing blood components and blood products
Investigating and reporting adverse events
417 Transfusion Practitioner
The identification and provision of transfusion training within the Trust
Investigate transfusion reactions or other clinical incidents relating to transfusion with the assistance of relevant staff according to the Trustrsquos incident reporting policy
Report any serious adverse transfusion events or reactions to the Medicines and Healthcare products Regulatory Agency (MHRA) andor the Serious Hazards of Transfusion (SHOT) reporting scheme
Duties as identified as a member of the Hospital Transfusion Committee and Team
5 NARRATIVE
As per the roles and responsibilities all staff caring for patients requiring transfusion services must refer to the relevant procedures and guidelines as listed within the appendices If in doubt seek senior advice or support from the Transfusion Practitioner
6 EVIDENCE BASE REFERENCES British Society for Haematology 2016 Guidelines for the use of platelet transfusions (httpwwwb-s-horgukguidelines) British Society for Haematology 2012 Pre transfusion compatibility procedures in blood transfusion laboratories (httpwwwb-s-horgukguidelines) British Society for Haematology 2004 Guidelines for the use of Fresh Frozen Plasma Cryoprecipitate and Cryosupernatant and 2007 Amendment to the Guidelines for the use of Fresh-Frozen Plasma Cryoprecipitate and Cryosupernatant (httpwwwb-s-horgukguidelines)
British Society for Haematology 2016 Transfusion for Fetuses Neonates and Older Children (httpwwwb-s-horgukguidelines) British Society for Haematology 2009 The administration of blood and blood components and 2012 Addendum to Administration of Blood Components (httpwwwb-s-horgukguidelines)
British Society for Haematology 2010 Use of irradiated blood components and 2012 Addendum to guidelines on the use of irradiated blood components (httpwwwb-s-horgukguidelines) British Society for Haematology 2012 Investigation and management of Acute Transfusion Reactions (httpwwwb-s-horgukguidelines) British Society for Haematology 2012 Management of Anaemia and Red Cell Transfusion in Adult Critically Ill Patients (httpwwwb-s-horgukguidelines)
Transfusion Policy Procedures and Guidelines
Page 8 of 14 Issue Date 15th November 2017
Review Date October 2020
British Society for Haematology 2012 Use of Anti-D Immunoglobulin for the prevention of Heamolytic Disease of the Fetus and Newborn (httpwwwb-s-horgukguidelines) British Society for Haematology 2016 Guideline for blood grouping and red cell antibody testing in pregnancy (httpwwwb-s-horgukguidelines)
British Society for Haematology 2015 Haematological management of Major Haemorrhage (httpwwwb-s-horgukguidelines) Guidelines on the management of massive blood loss BJH 2006 135(5) 634-41 Handbook of Transfusion Medicine 2013 5th Edition Blood Transfusion Services of the United Kingdom Ed D Norfolk
Health Service Circular 2007001 Better Blood Transfusion (Available at httpwwwtransfusionguidelinesorgukindexaspxPublication=BBT ) The Blood Safety and Quality Regulations 2005 (SI 200550) and amending regulations NPSA (2006) Right Patient Right Blood Safer Practice Notice 9th November 2006 No 14 (Available at httpwwwnpsanhsuknrlsalerts-and-directivesnotices) Serious Hazards of Transfusion Annual Report wwwshotukorg
7 EDUCATION AND TRAINING
A continuous programme of education exists in the Trust for all grades of staff Any additional training will be provided by the Transfusion Practitioner based on individual or departmental need
Appropriate competency-based training will be provided to nominated link trainers in each clinical area by the Transfusion Practitioner so that they can facilitate cascade training and competency assessments (Sampling and administration are self- assessments every 3 years following a one off observational assessment for sampling and for administration completion of the Trusts IVI pack or Grandparent rights document) Blood collection competency assessments are completed every 2 years
All training and assessments provided by the link trainers will be forwarded to the Transfusion Practitioner who together with any additional training or assessments that heshe performs will be recorded on the training database held by the training educational and developmental department
Transfusion Policy Procedures and Guidelines
Page 9 of 14 Issue Date 15th November 2017
Review Date October 2020
71 Competency Assessments
Staff Group
Obtaining a sample
Collection of blood components and products
Administration of blood components and blood products
Medical staff
Registered nurse (RN)
Registered midwife (RM)
ODP
HCA-Band 3
HCA ndashBand 2
Phlebotomist
Emergency Support workers
Porter
Students
Agency RNRM
Locum medics
Bank Staff
Biomedical Scientists
Medical Laboratory Assistants
Anaesthetists intensivists and emergency department doctors only
Competency assessment linked to their role
8 MONITORING COMPLIANCE NHSLA Standard
Method of Monitoring Timescale Lead
158a How blood samples are requested for pre-transfusion compatibility testing
A fully completed transfusion request form is completed by a member of the medical staff Data is collated from the Blood Transfusion Laboratory Information System regarding any request that fails to meet the minimal criteria as stated in Appendix 2 of this Policy
Monthly Quarterly
Chair of the Blood Transfusion Incident Review Group Chair of the Hospital Transfusion Committee
158b How transfusions are administered including patient identification
National Comparative audit Incident reporting
Every 3 years
Chair of the Hospital Transfusion Committee
158c Care of patients receiving a transfusion
National Comparative audit
Every 3 years
Chair of the Hospital Transfusion Committee
158d How the organisation trains staff in line with the training needs analysis
Records are kept by the Training Department of all transfusion related training courses who then report to staff line managers
Bi-Monthly Chair of the Hospital Transfusion Committee
Transfusion Policy Procedures and Guidelines
Page 10 of 14 Issue Date 15th November 2017
Review Date October 2020
158e How the organisation assesses the competency of all staff involved in the transfusion process
Completed assessments are held by the individual or in the clinical area Evidence of completion is sent to the Transfusion Practitioner to update the training database This information is shared with the Training Department
On -going Chair of the Hospital Transfusion Committee
How the organisation evidences non SFH locum medical staff training
Locum induction checklist held by rota co-ordinators
On-going Chair of the Hospital Transfusion Committee
158f How the organisation monitors compliance with all of the above
Reports go to the HTC Quarterly Chair of the Hospital Transfusion Committee
How the organisation monitors compliance with the Blood Safety and Quality Regulations
Compliance report to MHRA
Annually Chief Executive
How the organisations monitors compliance to achieve UKAS Accreditation to standard ISO 151892012
Inspections Every 2 years
Pathology Manager
9 CONSULTATION Contributors Communication Channel eg
11 meeting phone
Group committee meeting
Date
Consultant lead for Transfusion E mail 12072017
Consultant Haematologists E mail 12072017
Hospital Transfusion Committee Committee meeting Oct 2017
10 EQUALITY IMPACT ASSESSMENT (EIA) The Trust is committed to ensuring that none of its policies procedures and guidelines discriminate against individuals directly or indirectly on the basis of gender colour race nationality ethnic or national origins age sexual orientation marital status disability religion beliefs political affiliation trade union membership and social and employment status An EIA of this policyguideline was been conducted by the author using the EIA tool developed by the Diversity and Inclusivity Committee see below Equality Impact Assessment (EqIA) Form (please complete all sections) Guidance on how to complete an EIA Sample completed form
Name of servicepolicyprocedure being reviewed Trusts Transfusion Policy Procedures and Guidelines
New or existing servicepolicyprocedure Existing Policy
Date of Assessment November 2017
Transfusion Policy Procedures and Guidelines
Page 11 of 14 Issue Date 15th November 2017
Review Date October 2020
For the servicepolicyprocedure and its implementation answer the questions a ndash c below against each characteristic (if relevant consider breaking the policy or implementation down into areas)
Protected
Characteristic
a) Using data and supporting information what issues needs or barriers could the protected characteristic groupsrsquo experience For example are there any known health inequality or access issues to consider
b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics screening
c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality
The area of policy or its implementation being assessed
Race and Ethnicity None None None
Gender
None None None
Age
None None None
Religion Currently the policy does not address patients that refuse blood components based on their religion
The Policy for refusal of blood components and products is in the final stage of approval however Maternity do have a guideline for the management of women in pregnancy who decline blood and blood products
None
Disability
None None None
Sexuality
None None None
Pregnancy and Maternity
None None None
Gender Reassignment
None None None
Marriage and Civil Partnership
None None None
Socio-Economic Factors (ie living in
a poorer neighbourhood
social deprivation)
None None None
What consultation with protected characteristic groups including patient groups have you carried out Consultation has occurred with the local hospital Jehovahrsquos witness representatives
What data or information did you use in support of this EqIA
Transfusion Policy Procedures and Guidelines
Page 12 of 14 Issue Date 15th November 2017
Review Date October 2020
As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys questionnaires comments concerns complaints or compliments No
Level of impact From the information provided above and following EqIA guidance document please indicate the perceived level of impact Low Level of Impact For high or medium levels of impact please forward a copy of this form to the HR Secretaries for inclusion at the next Diversity and Inclusivity meeting
Name of Responsible Person undertaking this assessment Jane Walden-Specialist Transfusion Practitoner
Signature
Date 20112017
11 KEYWORDS Blood
12 APPENDICES As listed in contents table
Transfusion Policy Procedures and Guidelines
Page 13 of 14 Issue Date 15th November 2017
Review Date October 2020
Document control supporting information for this clinical document
Title
Transfusion Policy Procedures and Guidelines
Document category Clinical Policies and Guidelines
Reference
CGTRANS001
Version number
80
Approval
v Approved by
Approval Date
80 Hospital Transfusion Committee October 2017
Issue date
15th November 2017
Review date October 2020
Job title of author responsible for the document author name
Transfusion PractitionerJane Walden
Division amp Specialty Department Service responsible for reporting the status of the document
Diagnostic and Rehabilitation Haematology (Transfusion Services)
Document Sponsor
Medical Director
Date Equality Impact Assessment completed updated
As dated in relevant section of document
Superseded document(s) (Ref No Version number previous title if changed date issued ndash review date)
v70 Issued 8th April 2015 to August 2017
Version History and Practice Changes Amendments
Issue Date Version Comments (Section Change)
15-11-2017 70 41
46 and 415
47
471
6
7
Update to training and competency assessments
Update to e-learning modules for medical staff
Role of nurse authorisers
Preceptorship nurses and administration of blood
Update to references (change to British Society for Haematology from British Standard in Haematology
Changes to frequency of competency assessments addition of self-assessments
Transfusion Policy Procedures and Guidelines
Page 14 of 14 Issue Date 15th November 2017
Review Date October 2020
01-02-2015 70 415
471
60
Additional module ndash Safe Blood Sampling for Transfusion for locum medics
Nurses under preceptorship
Updated References
23-09-2014 62 Appendix 16 NEW Guideline for the transfusion of blood components in acute upper gastrointestinal bleeding
17-04-2014 61 41
46
Appendix 15
Appendix 6
Collection competency assessment to be undertaken every 2 years
Additional module ndash Safe Blood Sampling for Transfusion
New Appendix ndash Guidelines for the use of Human Albumin Solution
New table inserted ndash Transfusion reactions in adults nursing guidance
Distribution (Circulation)
This document will be accessible via the Trustrsquos intranet
Communication
Information regarding the initiation and subsequent updates of this document will be communicated via the earliest weekly Trust staff bulletin nursing bulletin and or other agreed communication method
Transfusion Policy Procedures and Guidelines
Page 7 of 14 Issue Date 15th November 2017
Review Date October 2020
416 Biomedical Scientists
Challenging the appropriateness of requests
Pre-transfusion testing
Issuing blood components and blood products
Investigating and reporting adverse events
417 Transfusion Practitioner
The identification and provision of transfusion training within the Trust
Investigate transfusion reactions or other clinical incidents relating to transfusion with the assistance of relevant staff according to the Trustrsquos incident reporting policy
Report any serious adverse transfusion events or reactions to the Medicines and Healthcare products Regulatory Agency (MHRA) andor the Serious Hazards of Transfusion (SHOT) reporting scheme
Duties as identified as a member of the Hospital Transfusion Committee and Team
5 NARRATIVE
As per the roles and responsibilities all staff caring for patients requiring transfusion services must refer to the relevant procedures and guidelines as listed within the appendices If in doubt seek senior advice or support from the Transfusion Practitioner
6 EVIDENCE BASE REFERENCES British Society for Haematology 2016 Guidelines for the use of platelet transfusions (httpwwwb-s-horgukguidelines) British Society for Haematology 2012 Pre transfusion compatibility procedures in blood transfusion laboratories (httpwwwb-s-horgukguidelines) British Society for Haematology 2004 Guidelines for the use of Fresh Frozen Plasma Cryoprecipitate and Cryosupernatant and 2007 Amendment to the Guidelines for the use of Fresh-Frozen Plasma Cryoprecipitate and Cryosupernatant (httpwwwb-s-horgukguidelines)
British Society for Haematology 2016 Transfusion for Fetuses Neonates and Older Children (httpwwwb-s-horgukguidelines) British Society for Haematology 2009 The administration of blood and blood components and 2012 Addendum to Administration of Blood Components (httpwwwb-s-horgukguidelines)
British Society for Haematology 2010 Use of irradiated blood components and 2012 Addendum to guidelines on the use of irradiated blood components (httpwwwb-s-horgukguidelines) British Society for Haematology 2012 Investigation and management of Acute Transfusion Reactions (httpwwwb-s-horgukguidelines) British Society for Haematology 2012 Management of Anaemia and Red Cell Transfusion in Adult Critically Ill Patients (httpwwwb-s-horgukguidelines)
Transfusion Policy Procedures and Guidelines
Page 8 of 14 Issue Date 15th November 2017
Review Date October 2020
British Society for Haematology 2012 Use of Anti-D Immunoglobulin for the prevention of Heamolytic Disease of the Fetus and Newborn (httpwwwb-s-horgukguidelines) British Society for Haematology 2016 Guideline for blood grouping and red cell antibody testing in pregnancy (httpwwwb-s-horgukguidelines)
British Society for Haematology 2015 Haematological management of Major Haemorrhage (httpwwwb-s-horgukguidelines) Guidelines on the management of massive blood loss BJH 2006 135(5) 634-41 Handbook of Transfusion Medicine 2013 5th Edition Blood Transfusion Services of the United Kingdom Ed D Norfolk
Health Service Circular 2007001 Better Blood Transfusion (Available at httpwwwtransfusionguidelinesorgukindexaspxPublication=BBT ) The Blood Safety and Quality Regulations 2005 (SI 200550) and amending regulations NPSA (2006) Right Patient Right Blood Safer Practice Notice 9th November 2006 No 14 (Available at httpwwwnpsanhsuknrlsalerts-and-directivesnotices) Serious Hazards of Transfusion Annual Report wwwshotukorg
7 EDUCATION AND TRAINING
A continuous programme of education exists in the Trust for all grades of staff Any additional training will be provided by the Transfusion Practitioner based on individual or departmental need
Appropriate competency-based training will be provided to nominated link trainers in each clinical area by the Transfusion Practitioner so that they can facilitate cascade training and competency assessments (Sampling and administration are self- assessments every 3 years following a one off observational assessment for sampling and for administration completion of the Trusts IVI pack or Grandparent rights document) Blood collection competency assessments are completed every 2 years
All training and assessments provided by the link trainers will be forwarded to the Transfusion Practitioner who together with any additional training or assessments that heshe performs will be recorded on the training database held by the training educational and developmental department
Transfusion Policy Procedures and Guidelines
Page 9 of 14 Issue Date 15th November 2017
Review Date October 2020
71 Competency Assessments
Staff Group
Obtaining a sample
Collection of blood components and products
Administration of blood components and blood products
Medical staff
Registered nurse (RN)
Registered midwife (RM)
ODP
HCA-Band 3
HCA ndashBand 2
Phlebotomist
Emergency Support workers
Porter
Students
Agency RNRM
Locum medics
Bank Staff
Biomedical Scientists
Medical Laboratory Assistants
Anaesthetists intensivists and emergency department doctors only
Competency assessment linked to their role
8 MONITORING COMPLIANCE NHSLA Standard
Method of Monitoring Timescale Lead
158a How blood samples are requested for pre-transfusion compatibility testing
A fully completed transfusion request form is completed by a member of the medical staff Data is collated from the Blood Transfusion Laboratory Information System regarding any request that fails to meet the minimal criteria as stated in Appendix 2 of this Policy
Monthly Quarterly
Chair of the Blood Transfusion Incident Review Group Chair of the Hospital Transfusion Committee
158b How transfusions are administered including patient identification
National Comparative audit Incident reporting
Every 3 years
Chair of the Hospital Transfusion Committee
158c Care of patients receiving a transfusion
National Comparative audit
Every 3 years
Chair of the Hospital Transfusion Committee
158d How the organisation trains staff in line with the training needs analysis
Records are kept by the Training Department of all transfusion related training courses who then report to staff line managers
Bi-Monthly Chair of the Hospital Transfusion Committee
Transfusion Policy Procedures and Guidelines
Page 10 of 14 Issue Date 15th November 2017
Review Date October 2020
158e How the organisation assesses the competency of all staff involved in the transfusion process
Completed assessments are held by the individual or in the clinical area Evidence of completion is sent to the Transfusion Practitioner to update the training database This information is shared with the Training Department
On -going Chair of the Hospital Transfusion Committee
How the organisation evidences non SFH locum medical staff training
Locum induction checklist held by rota co-ordinators
On-going Chair of the Hospital Transfusion Committee
158f How the organisation monitors compliance with all of the above
Reports go to the HTC Quarterly Chair of the Hospital Transfusion Committee
How the organisation monitors compliance with the Blood Safety and Quality Regulations
Compliance report to MHRA
Annually Chief Executive
How the organisations monitors compliance to achieve UKAS Accreditation to standard ISO 151892012
Inspections Every 2 years
Pathology Manager
9 CONSULTATION Contributors Communication Channel eg
11 meeting phone
Group committee meeting
Date
Consultant lead for Transfusion E mail 12072017
Consultant Haematologists E mail 12072017
Hospital Transfusion Committee Committee meeting Oct 2017
10 EQUALITY IMPACT ASSESSMENT (EIA) The Trust is committed to ensuring that none of its policies procedures and guidelines discriminate against individuals directly or indirectly on the basis of gender colour race nationality ethnic or national origins age sexual orientation marital status disability religion beliefs political affiliation trade union membership and social and employment status An EIA of this policyguideline was been conducted by the author using the EIA tool developed by the Diversity and Inclusivity Committee see below Equality Impact Assessment (EqIA) Form (please complete all sections) Guidance on how to complete an EIA Sample completed form
Name of servicepolicyprocedure being reviewed Trusts Transfusion Policy Procedures and Guidelines
New or existing servicepolicyprocedure Existing Policy
Date of Assessment November 2017
Transfusion Policy Procedures and Guidelines
Page 11 of 14 Issue Date 15th November 2017
Review Date October 2020
For the servicepolicyprocedure and its implementation answer the questions a ndash c below against each characteristic (if relevant consider breaking the policy or implementation down into areas)
Protected
Characteristic
a) Using data and supporting information what issues needs or barriers could the protected characteristic groupsrsquo experience For example are there any known health inequality or access issues to consider
b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics screening
c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality
The area of policy or its implementation being assessed
Race and Ethnicity None None None
Gender
None None None
Age
None None None
Religion Currently the policy does not address patients that refuse blood components based on their religion
The Policy for refusal of blood components and products is in the final stage of approval however Maternity do have a guideline for the management of women in pregnancy who decline blood and blood products
None
Disability
None None None
Sexuality
None None None
Pregnancy and Maternity
None None None
Gender Reassignment
None None None
Marriage and Civil Partnership
None None None
Socio-Economic Factors (ie living in
a poorer neighbourhood
social deprivation)
None None None
What consultation with protected characteristic groups including patient groups have you carried out Consultation has occurred with the local hospital Jehovahrsquos witness representatives
What data or information did you use in support of this EqIA
Transfusion Policy Procedures and Guidelines
Page 12 of 14 Issue Date 15th November 2017
Review Date October 2020
As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys questionnaires comments concerns complaints or compliments No
Level of impact From the information provided above and following EqIA guidance document please indicate the perceived level of impact Low Level of Impact For high or medium levels of impact please forward a copy of this form to the HR Secretaries for inclusion at the next Diversity and Inclusivity meeting
Name of Responsible Person undertaking this assessment Jane Walden-Specialist Transfusion Practitoner
Signature
Date 20112017
11 KEYWORDS Blood
12 APPENDICES As listed in contents table
Transfusion Policy Procedures and Guidelines
Page 13 of 14 Issue Date 15th November 2017
Review Date October 2020
Document control supporting information for this clinical document
Title
Transfusion Policy Procedures and Guidelines
Document category Clinical Policies and Guidelines
Reference
CGTRANS001
Version number
80
Approval
v Approved by
Approval Date
80 Hospital Transfusion Committee October 2017
Issue date
15th November 2017
Review date October 2020
Job title of author responsible for the document author name
Transfusion PractitionerJane Walden
Division amp Specialty Department Service responsible for reporting the status of the document
Diagnostic and Rehabilitation Haematology (Transfusion Services)
Document Sponsor
Medical Director
Date Equality Impact Assessment completed updated
As dated in relevant section of document
Superseded document(s) (Ref No Version number previous title if changed date issued ndash review date)
v70 Issued 8th April 2015 to August 2017
Version History and Practice Changes Amendments
Issue Date Version Comments (Section Change)
15-11-2017 70 41
46 and 415
47
471
6
7
Update to training and competency assessments
Update to e-learning modules for medical staff
Role of nurse authorisers
Preceptorship nurses and administration of blood
Update to references (change to British Society for Haematology from British Standard in Haematology
Changes to frequency of competency assessments addition of self-assessments
Transfusion Policy Procedures and Guidelines
Page 14 of 14 Issue Date 15th November 2017
Review Date October 2020
01-02-2015 70 415
471
60
Additional module ndash Safe Blood Sampling for Transfusion for locum medics
Nurses under preceptorship
Updated References
23-09-2014 62 Appendix 16 NEW Guideline for the transfusion of blood components in acute upper gastrointestinal bleeding
17-04-2014 61 41
46
Appendix 15
Appendix 6
Collection competency assessment to be undertaken every 2 years
Additional module ndash Safe Blood Sampling for Transfusion
New Appendix ndash Guidelines for the use of Human Albumin Solution
New table inserted ndash Transfusion reactions in adults nursing guidance
Distribution (Circulation)
This document will be accessible via the Trustrsquos intranet
Communication
Information regarding the initiation and subsequent updates of this document will be communicated via the earliest weekly Trust staff bulletin nursing bulletin and or other agreed communication method
Transfusion Policy Procedures and Guidelines
Page 8 of 14 Issue Date 15th November 2017
Review Date October 2020
British Society for Haematology 2012 Use of Anti-D Immunoglobulin for the prevention of Heamolytic Disease of the Fetus and Newborn (httpwwwb-s-horgukguidelines) British Society for Haematology 2016 Guideline for blood grouping and red cell antibody testing in pregnancy (httpwwwb-s-horgukguidelines)
British Society for Haematology 2015 Haematological management of Major Haemorrhage (httpwwwb-s-horgukguidelines) Guidelines on the management of massive blood loss BJH 2006 135(5) 634-41 Handbook of Transfusion Medicine 2013 5th Edition Blood Transfusion Services of the United Kingdom Ed D Norfolk
Health Service Circular 2007001 Better Blood Transfusion (Available at httpwwwtransfusionguidelinesorgukindexaspxPublication=BBT ) The Blood Safety and Quality Regulations 2005 (SI 200550) and amending regulations NPSA (2006) Right Patient Right Blood Safer Practice Notice 9th November 2006 No 14 (Available at httpwwwnpsanhsuknrlsalerts-and-directivesnotices) Serious Hazards of Transfusion Annual Report wwwshotukorg
7 EDUCATION AND TRAINING
A continuous programme of education exists in the Trust for all grades of staff Any additional training will be provided by the Transfusion Practitioner based on individual or departmental need
Appropriate competency-based training will be provided to nominated link trainers in each clinical area by the Transfusion Practitioner so that they can facilitate cascade training and competency assessments (Sampling and administration are self- assessments every 3 years following a one off observational assessment for sampling and for administration completion of the Trusts IVI pack or Grandparent rights document) Blood collection competency assessments are completed every 2 years
All training and assessments provided by the link trainers will be forwarded to the Transfusion Practitioner who together with any additional training or assessments that heshe performs will be recorded on the training database held by the training educational and developmental department
Transfusion Policy Procedures and Guidelines
Page 9 of 14 Issue Date 15th November 2017
Review Date October 2020
71 Competency Assessments
Staff Group
Obtaining a sample
Collection of blood components and products
Administration of blood components and blood products
Medical staff
Registered nurse (RN)
Registered midwife (RM)
ODP
HCA-Band 3
HCA ndashBand 2
Phlebotomist
Emergency Support workers
Porter
Students
Agency RNRM
Locum medics
Bank Staff
Biomedical Scientists
Medical Laboratory Assistants
Anaesthetists intensivists and emergency department doctors only
Competency assessment linked to their role
8 MONITORING COMPLIANCE NHSLA Standard
Method of Monitoring Timescale Lead
158a How blood samples are requested for pre-transfusion compatibility testing
A fully completed transfusion request form is completed by a member of the medical staff Data is collated from the Blood Transfusion Laboratory Information System regarding any request that fails to meet the minimal criteria as stated in Appendix 2 of this Policy
Monthly Quarterly
Chair of the Blood Transfusion Incident Review Group Chair of the Hospital Transfusion Committee
158b How transfusions are administered including patient identification
National Comparative audit Incident reporting
Every 3 years
Chair of the Hospital Transfusion Committee
158c Care of patients receiving a transfusion
National Comparative audit
Every 3 years
Chair of the Hospital Transfusion Committee
158d How the organisation trains staff in line with the training needs analysis
Records are kept by the Training Department of all transfusion related training courses who then report to staff line managers
Bi-Monthly Chair of the Hospital Transfusion Committee
Transfusion Policy Procedures and Guidelines
Page 10 of 14 Issue Date 15th November 2017
Review Date October 2020
158e How the organisation assesses the competency of all staff involved in the transfusion process
Completed assessments are held by the individual or in the clinical area Evidence of completion is sent to the Transfusion Practitioner to update the training database This information is shared with the Training Department
On -going Chair of the Hospital Transfusion Committee
How the organisation evidences non SFH locum medical staff training
Locum induction checklist held by rota co-ordinators
On-going Chair of the Hospital Transfusion Committee
158f How the organisation monitors compliance with all of the above
Reports go to the HTC Quarterly Chair of the Hospital Transfusion Committee
How the organisation monitors compliance with the Blood Safety and Quality Regulations
Compliance report to MHRA
Annually Chief Executive
How the organisations monitors compliance to achieve UKAS Accreditation to standard ISO 151892012
Inspections Every 2 years
Pathology Manager
9 CONSULTATION Contributors Communication Channel eg
11 meeting phone
Group committee meeting
Date
Consultant lead for Transfusion E mail 12072017
Consultant Haematologists E mail 12072017
Hospital Transfusion Committee Committee meeting Oct 2017
10 EQUALITY IMPACT ASSESSMENT (EIA) The Trust is committed to ensuring that none of its policies procedures and guidelines discriminate against individuals directly or indirectly on the basis of gender colour race nationality ethnic or national origins age sexual orientation marital status disability religion beliefs political affiliation trade union membership and social and employment status An EIA of this policyguideline was been conducted by the author using the EIA tool developed by the Diversity and Inclusivity Committee see below Equality Impact Assessment (EqIA) Form (please complete all sections) Guidance on how to complete an EIA Sample completed form
Name of servicepolicyprocedure being reviewed Trusts Transfusion Policy Procedures and Guidelines
New or existing servicepolicyprocedure Existing Policy
Date of Assessment November 2017
Transfusion Policy Procedures and Guidelines
Page 11 of 14 Issue Date 15th November 2017
Review Date October 2020
For the servicepolicyprocedure and its implementation answer the questions a ndash c below against each characteristic (if relevant consider breaking the policy or implementation down into areas)
Protected
Characteristic
a) Using data and supporting information what issues needs or barriers could the protected characteristic groupsrsquo experience For example are there any known health inequality or access issues to consider
b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics screening
c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality
The area of policy or its implementation being assessed
Race and Ethnicity None None None
Gender
None None None
Age
None None None
Religion Currently the policy does not address patients that refuse blood components based on their religion
The Policy for refusal of blood components and products is in the final stage of approval however Maternity do have a guideline for the management of women in pregnancy who decline blood and blood products
None
Disability
None None None
Sexuality
None None None
Pregnancy and Maternity
None None None
Gender Reassignment
None None None
Marriage and Civil Partnership
None None None
Socio-Economic Factors (ie living in
a poorer neighbourhood
social deprivation)
None None None
What consultation with protected characteristic groups including patient groups have you carried out Consultation has occurred with the local hospital Jehovahrsquos witness representatives
What data or information did you use in support of this EqIA
Transfusion Policy Procedures and Guidelines
Page 12 of 14 Issue Date 15th November 2017
Review Date October 2020
As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys questionnaires comments concerns complaints or compliments No
Level of impact From the information provided above and following EqIA guidance document please indicate the perceived level of impact Low Level of Impact For high or medium levels of impact please forward a copy of this form to the HR Secretaries for inclusion at the next Diversity and Inclusivity meeting
Name of Responsible Person undertaking this assessment Jane Walden-Specialist Transfusion Practitoner
Signature
Date 20112017
11 KEYWORDS Blood
12 APPENDICES As listed in contents table
Transfusion Policy Procedures and Guidelines
Page 13 of 14 Issue Date 15th November 2017
Review Date October 2020
Document control supporting information for this clinical document
Title
Transfusion Policy Procedures and Guidelines
Document category Clinical Policies and Guidelines
Reference
CGTRANS001
Version number
80
Approval
v Approved by
Approval Date
80 Hospital Transfusion Committee October 2017
Issue date
15th November 2017
Review date October 2020
Job title of author responsible for the document author name
Transfusion PractitionerJane Walden
Division amp Specialty Department Service responsible for reporting the status of the document
Diagnostic and Rehabilitation Haematology (Transfusion Services)
Document Sponsor
Medical Director
Date Equality Impact Assessment completed updated
As dated in relevant section of document
Superseded document(s) (Ref No Version number previous title if changed date issued ndash review date)
v70 Issued 8th April 2015 to August 2017
Version History and Practice Changes Amendments
Issue Date Version Comments (Section Change)
15-11-2017 70 41
46 and 415
47
471
6
7
Update to training and competency assessments
Update to e-learning modules for medical staff
Role of nurse authorisers
Preceptorship nurses and administration of blood
Update to references (change to British Society for Haematology from British Standard in Haematology
Changes to frequency of competency assessments addition of self-assessments
Transfusion Policy Procedures and Guidelines
Page 14 of 14 Issue Date 15th November 2017
Review Date October 2020
01-02-2015 70 415
471
60
Additional module ndash Safe Blood Sampling for Transfusion for locum medics
Nurses under preceptorship
Updated References
23-09-2014 62 Appendix 16 NEW Guideline for the transfusion of blood components in acute upper gastrointestinal bleeding
17-04-2014 61 41
46
Appendix 15
Appendix 6
Collection competency assessment to be undertaken every 2 years
Additional module ndash Safe Blood Sampling for Transfusion
New Appendix ndash Guidelines for the use of Human Albumin Solution
New table inserted ndash Transfusion reactions in adults nursing guidance
Distribution (Circulation)
This document will be accessible via the Trustrsquos intranet
Communication
Information regarding the initiation and subsequent updates of this document will be communicated via the earliest weekly Trust staff bulletin nursing bulletin and or other agreed communication method
Transfusion Policy Procedures and Guidelines
Page 9 of 14 Issue Date 15th November 2017
Review Date October 2020
71 Competency Assessments
Staff Group
Obtaining a sample
Collection of blood components and products
Administration of blood components and blood products
Medical staff
Registered nurse (RN)
Registered midwife (RM)
ODP
HCA-Band 3
HCA ndashBand 2
Phlebotomist
Emergency Support workers
Porter
Students
Agency RNRM
Locum medics
Bank Staff
Biomedical Scientists
Medical Laboratory Assistants
Anaesthetists intensivists and emergency department doctors only
Competency assessment linked to their role
8 MONITORING COMPLIANCE NHSLA Standard
Method of Monitoring Timescale Lead
158a How blood samples are requested for pre-transfusion compatibility testing
A fully completed transfusion request form is completed by a member of the medical staff Data is collated from the Blood Transfusion Laboratory Information System regarding any request that fails to meet the minimal criteria as stated in Appendix 2 of this Policy
Monthly Quarterly
Chair of the Blood Transfusion Incident Review Group Chair of the Hospital Transfusion Committee
158b How transfusions are administered including patient identification
National Comparative audit Incident reporting
Every 3 years
Chair of the Hospital Transfusion Committee
158c Care of patients receiving a transfusion
National Comparative audit
Every 3 years
Chair of the Hospital Transfusion Committee
158d How the organisation trains staff in line with the training needs analysis
Records are kept by the Training Department of all transfusion related training courses who then report to staff line managers
Bi-Monthly Chair of the Hospital Transfusion Committee
Transfusion Policy Procedures and Guidelines
Page 10 of 14 Issue Date 15th November 2017
Review Date October 2020
158e How the organisation assesses the competency of all staff involved in the transfusion process
Completed assessments are held by the individual or in the clinical area Evidence of completion is sent to the Transfusion Practitioner to update the training database This information is shared with the Training Department
On -going Chair of the Hospital Transfusion Committee
How the organisation evidences non SFH locum medical staff training
Locum induction checklist held by rota co-ordinators
On-going Chair of the Hospital Transfusion Committee
158f How the organisation monitors compliance with all of the above
Reports go to the HTC Quarterly Chair of the Hospital Transfusion Committee
How the organisation monitors compliance with the Blood Safety and Quality Regulations
Compliance report to MHRA
Annually Chief Executive
How the organisations monitors compliance to achieve UKAS Accreditation to standard ISO 151892012
Inspections Every 2 years
Pathology Manager
9 CONSULTATION Contributors Communication Channel eg
11 meeting phone
Group committee meeting
Date
Consultant lead for Transfusion E mail 12072017
Consultant Haematologists E mail 12072017
Hospital Transfusion Committee Committee meeting Oct 2017
10 EQUALITY IMPACT ASSESSMENT (EIA) The Trust is committed to ensuring that none of its policies procedures and guidelines discriminate against individuals directly or indirectly on the basis of gender colour race nationality ethnic or national origins age sexual orientation marital status disability religion beliefs political affiliation trade union membership and social and employment status An EIA of this policyguideline was been conducted by the author using the EIA tool developed by the Diversity and Inclusivity Committee see below Equality Impact Assessment (EqIA) Form (please complete all sections) Guidance on how to complete an EIA Sample completed form
Name of servicepolicyprocedure being reviewed Trusts Transfusion Policy Procedures and Guidelines
New or existing servicepolicyprocedure Existing Policy
Date of Assessment November 2017
Transfusion Policy Procedures and Guidelines
Page 11 of 14 Issue Date 15th November 2017
Review Date October 2020
For the servicepolicyprocedure and its implementation answer the questions a ndash c below against each characteristic (if relevant consider breaking the policy or implementation down into areas)
Protected
Characteristic
a) Using data and supporting information what issues needs or barriers could the protected characteristic groupsrsquo experience For example are there any known health inequality or access issues to consider
b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics screening
c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality
The area of policy or its implementation being assessed
Race and Ethnicity None None None
Gender
None None None
Age
None None None
Religion Currently the policy does not address patients that refuse blood components based on their religion
The Policy for refusal of blood components and products is in the final stage of approval however Maternity do have a guideline for the management of women in pregnancy who decline blood and blood products
None
Disability
None None None
Sexuality
None None None
Pregnancy and Maternity
None None None
Gender Reassignment
None None None
Marriage and Civil Partnership
None None None
Socio-Economic Factors (ie living in
a poorer neighbourhood
social deprivation)
None None None
What consultation with protected characteristic groups including patient groups have you carried out Consultation has occurred with the local hospital Jehovahrsquos witness representatives
What data or information did you use in support of this EqIA
Transfusion Policy Procedures and Guidelines
Page 12 of 14 Issue Date 15th November 2017
Review Date October 2020
As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys questionnaires comments concerns complaints or compliments No
Level of impact From the information provided above and following EqIA guidance document please indicate the perceived level of impact Low Level of Impact For high or medium levels of impact please forward a copy of this form to the HR Secretaries for inclusion at the next Diversity and Inclusivity meeting
Name of Responsible Person undertaking this assessment Jane Walden-Specialist Transfusion Practitoner
Signature
Date 20112017
11 KEYWORDS Blood
12 APPENDICES As listed in contents table
Transfusion Policy Procedures and Guidelines
Page 13 of 14 Issue Date 15th November 2017
Review Date October 2020
Document control supporting information for this clinical document
Title
Transfusion Policy Procedures and Guidelines
Document category Clinical Policies and Guidelines
Reference
CGTRANS001
Version number
80
Approval
v Approved by
Approval Date
80 Hospital Transfusion Committee October 2017
Issue date
15th November 2017
Review date October 2020
Job title of author responsible for the document author name
Transfusion PractitionerJane Walden
Division amp Specialty Department Service responsible for reporting the status of the document
Diagnostic and Rehabilitation Haematology (Transfusion Services)
Document Sponsor
Medical Director
Date Equality Impact Assessment completed updated
As dated in relevant section of document
Superseded document(s) (Ref No Version number previous title if changed date issued ndash review date)
v70 Issued 8th April 2015 to August 2017
Version History and Practice Changes Amendments
Issue Date Version Comments (Section Change)
15-11-2017 70 41
46 and 415
47
471
6
7
Update to training and competency assessments
Update to e-learning modules for medical staff
Role of nurse authorisers
Preceptorship nurses and administration of blood
Update to references (change to British Society for Haematology from British Standard in Haematology
Changes to frequency of competency assessments addition of self-assessments
Transfusion Policy Procedures and Guidelines
Page 14 of 14 Issue Date 15th November 2017
Review Date October 2020
01-02-2015 70 415
471
60
Additional module ndash Safe Blood Sampling for Transfusion for locum medics
Nurses under preceptorship
Updated References
23-09-2014 62 Appendix 16 NEW Guideline for the transfusion of blood components in acute upper gastrointestinal bleeding
17-04-2014 61 41
46
Appendix 15
Appendix 6
Collection competency assessment to be undertaken every 2 years
Additional module ndash Safe Blood Sampling for Transfusion
New Appendix ndash Guidelines for the use of Human Albumin Solution
New table inserted ndash Transfusion reactions in adults nursing guidance
Distribution (Circulation)
This document will be accessible via the Trustrsquos intranet
Communication
Information regarding the initiation and subsequent updates of this document will be communicated via the earliest weekly Trust staff bulletin nursing bulletin and or other agreed communication method
Transfusion Policy Procedures and Guidelines
Page 10 of 14 Issue Date 15th November 2017
Review Date October 2020
158e How the organisation assesses the competency of all staff involved in the transfusion process
Completed assessments are held by the individual or in the clinical area Evidence of completion is sent to the Transfusion Practitioner to update the training database This information is shared with the Training Department
On -going Chair of the Hospital Transfusion Committee
How the organisation evidences non SFH locum medical staff training
Locum induction checklist held by rota co-ordinators
On-going Chair of the Hospital Transfusion Committee
158f How the organisation monitors compliance with all of the above
Reports go to the HTC Quarterly Chair of the Hospital Transfusion Committee
How the organisation monitors compliance with the Blood Safety and Quality Regulations
Compliance report to MHRA
Annually Chief Executive
How the organisations monitors compliance to achieve UKAS Accreditation to standard ISO 151892012
Inspections Every 2 years
Pathology Manager
9 CONSULTATION Contributors Communication Channel eg
11 meeting phone
Group committee meeting
Date
Consultant lead for Transfusion E mail 12072017
Consultant Haematologists E mail 12072017
Hospital Transfusion Committee Committee meeting Oct 2017
10 EQUALITY IMPACT ASSESSMENT (EIA) The Trust is committed to ensuring that none of its policies procedures and guidelines discriminate against individuals directly or indirectly on the basis of gender colour race nationality ethnic or national origins age sexual orientation marital status disability religion beliefs political affiliation trade union membership and social and employment status An EIA of this policyguideline was been conducted by the author using the EIA tool developed by the Diversity and Inclusivity Committee see below Equality Impact Assessment (EqIA) Form (please complete all sections) Guidance on how to complete an EIA Sample completed form
Name of servicepolicyprocedure being reviewed Trusts Transfusion Policy Procedures and Guidelines
New or existing servicepolicyprocedure Existing Policy
Date of Assessment November 2017
Transfusion Policy Procedures and Guidelines
Page 11 of 14 Issue Date 15th November 2017
Review Date October 2020
For the servicepolicyprocedure and its implementation answer the questions a ndash c below against each characteristic (if relevant consider breaking the policy or implementation down into areas)
Protected
Characteristic
a) Using data and supporting information what issues needs or barriers could the protected characteristic groupsrsquo experience For example are there any known health inequality or access issues to consider
b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics screening
c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality
The area of policy or its implementation being assessed
Race and Ethnicity None None None
Gender
None None None
Age
None None None
Religion Currently the policy does not address patients that refuse blood components based on their religion
The Policy for refusal of blood components and products is in the final stage of approval however Maternity do have a guideline for the management of women in pregnancy who decline blood and blood products
None
Disability
None None None
Sexuality
None None None
Pregnancy and Maternity
None None None
Gender Reassignment
None None None
Marriage and Civil Partnership
None None None
Socio-Economic Factors (ie living in
a poorer neighbourhood
social deprivation)
None None None
What consultation with protected characteristic groups including patient groups have you carried out Consultation has occurred with the local hospital Jehovahrsquos witness representatives
What data or information did you use in support of this EqIA
Transfusion Policy Procedures and Guidelines
Page 12 of 14 Issue Date 15th November 2017
Review Date October 2020
As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys questionnaires comments concerns complaints or compliments No
Level of impact From the information provided above and following EqIA guidance document please indicate the perceived level of impact Low Level of Impact For high or medium levels of impact please forward a copy of this form to the HR Secretaries for inclusion at the next Diversity and Inclusivity meeting
Name of Responsible Person undertaking this assessment Jane Walden-Specialist Transfusion Practitoner
Signature
Date 20112017
11 KEYWORDS Blood
12 APPENDICES As listed in contents table
Transfusion Policy Procedures and Guidelines
Page 13 of 14 Issue Date 15th November 2017
Review Date October 2020
Document control supporting information for this clinical document
Title
Transfusion Policy Procedures and Guidelines
Document category Clinical Policies and Guidelines
Reference
CGTRANS001
Version number
80
Approval
v Approved by
Approval Date
80 Hospital Transfusion Committee October 2017
Issue date
15th November 2017
Review date October 2020
Job title of author responsible for the document author name
Transfusion PractitionerJane Walden
Division amp Specialty Department Service responsible for reporting the status of the document
Diagnostic and Rehabilitation Haematology (Transfusion Services)
Document Sponsor
Medical Director
Date Equality Impact Assessment completed updated
As dated in relevant section of document
Superseded document(s) (Ref No Version number previous title if changed date issued ndash review date)
v70 Issued 8th April 2015 to August 2017
Version History and Practice Changes Amendments
Issue Date Version Comments (Section Change)
15-11-2017 70 41
46 and 415
47
471
6
7
Update to training and competency assessments
Update to e-learning modules for medical staff
Role of nurse authorisers
Preceptorship nurses and administration of blood
Update to references (change to British Society for Haematology from British Standard in Haematology
Changes to frequency of competency assessments addition of self-assessments
Transfusion Policy Procedures and Guidelines
Page 14 of 14 Issue Date 15th November 2017
Review Date October 2020
01-02-2015 70 415
471
60
Additional module ndash Safe Blood Sampling for Transfusion for locum medics
Nurses under preceptorship
Updated References
23-09-2014 62 Appendix 16 NEW Guideline for the transfusion of blood components in acute upper gastrointestinal bleeding
17-04-2014 61 41
46
Appendix 15
Appendix 6
Collection competency assessment to be undertaken every 2 years
Additional module ndash Safe Blood Sampling for Transfusion
New Appendix ndash Guidelines for the use of Human Albumin Solution
New table inserted ndash Transfusion reactions in adults nursing guidance
Distribution (Circulation)
This document will be accessible via the Trustrsquos intranet
Communication
Information regarding the initiation and subsequent updates of this document will be communicated via the earliest weekly Trust staff bulletin nursing bulletin and or other agreed communication method
Transfusion Policy Procedures and Guidelines
Page 11 of 14 Issue Date 15th November 2017
Review Date October 2020
For the servicepolicyprocedure and its implementation answer the questions a ndash c below against each characteristic (if relevant consider breaking the policy or implementation down into areas)
Protected
Characteristic
a) Using data and supporting information what issues needs or barriers could the protected characteristic groupsrsquo experience For example are there any known health inequality or access issues to consider
b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics screening
c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality
The area of policy or its implementation being assessed
Race and Ethnicity None None None
Gender
None None None
Age
None None None
Religion Currently the policy does not address patients that refuse blood components based on their religion
The Policy for refusal of blood components and products is in the final stage of approval however Maternity do have a guideline for the management of women in pregnancy who decline blood and blood products
None
Disability
None None None
Sexuality
None None None
Pregnancy and Maternity
None None None
Gender Reassignment
None None None
Marriage and Civil Partnership
None None None
Socio-Economic Factors (ie living in
a poorer neighbourhood
social deprivation)
None None None
What consultation with protected characteristic groups including patient groups have you carried out Consultation has occurred with the local hospital Jehovahrsquos witness representatives
What data or information did you use in support of this EqIA
Transfusion Policy Procedures and Guidelines
Page 12 of 14 Issue Date 15th November 2017
Review Date October 2020
As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys questionnaires comments concerns complaints or compliments No
Level of impact From the information provided above and following EqIA guidance document please indicate the perceived level of impact Low Level of Impact For high or medium levels of impact please forward a copy of this form to the HR Secretaries for inclusion at the next Diversity and Inclusivity meeting
Name of Responsible Person undertaking this assessment Jane Walden-Specialist Transfusion Practitoner
Signature
Date 20112017
11 KEYWORDS Blood
12 APPENDICES As listed in contents table
Transfusion Policy Procedures and Guidelines
Page 13 of 14 Issue Date 15th November 2017
Review Date October 2020
Document control supporting information for this clinical document
Title
Transfusion Policy Procedures and Guidelines
Document category Clinical Policies and Guidelines
Reference
CGTRANS001
Version number
80
Approval
v Approved by
Approval Date
80 Hospital Transfusion Committee October 2017
Issue date
15th November 2017
Review date October 2020
Job title of author responsible for the document author name
Transfusion PractitionerJane Walden
Division amp Specialty Department Service responsible for reporting the status of the document
Diagnostic and Rehabilitation Haematology (Transfusion Services)
Document Sponsor
Medical Director
Date Equality Impact Assessment completed updated
As dated in relevant section of document
Superseded document(s) (Ref No Version number previous title if changed date issued ndash review date)
v70 Issued 8th April 2015 to August 2017
Version History and Practice Changes Amendments
Issue Date Version Comments (Section Change)
15-11-2017 70 41
46 and 415
47
471
6
7
Update to training and competency assessments
Update to e-learning modules for medical staff
Role of nurse authorisers
Preceptorship nurses and administration of blood
Update to references (change to British Society for Haematology from British Standard in Haematology
Changes to frequency of competency assessments addition of self-assessments
Transfusion Policy Procedures and Guidelines
Page 14 of 14 Issue Date 15th November 2017
Review Date October 2020
01-02-2015 70 415
471
60
Additional module ndash Safe Blood Sampling for Transfusion for locum medics
Nurses under preceptorship
Updated References
23-09-2014 62 Appendix 16 NEW Guideline for the transfusion of blood components in acute upper gastrointestinal bleeding
17-04-2014 61 41
46
Appendix 15
Appendix 6
Collection competency assessment to be undertaken every 2 years
Additional module ndash Safe Blood Sampling for Transfusion
New Appendix ndash Guidelines for the use of Human Albumin Solution
New table inserted ndash Transfusion reactions in adults nursing guidance
Distribution (Circulation)
This document will be accessible via the Trustrsquos intranet
Communication
Information regarding the initiation and subsequent updates of this document will be communicated via the earliest weekly Trust staff bulletin nursing bulletin and or other agreed communication method
Transfusion Policy Procedures and Guidelines
Page 12 of 14 Issue Date 15th November 2017
Review Date October 2020
As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys questionnaires comments concerns complaints or compliments No
Level of impact From the information provided above and following EqIA guidance document please indicate the perceived level of impact Low Level of Impact For high or medium levels of impact please forward a copy of this form to the HR Secretaries for inclusion at the next Diversity and Inclusivity meeting
Name of Responsible Person undertaking this assessment Jane Walden-Specialist Transfusion Practitoner
Signature
Date 20112017
11 KEYWORDS Blood
12 APPENDICES As listed in contents table
Transfusion Policy Procedures and Guidelines
Page 13 of 14 Issue Date 15th November 2017
Review Date October 2020
Document control supporting information for this clinical document
Title
Transfusion Policy Procedures and Guidelines
Document category Clinical Policies and Guidelines
Reference
CGTRANS001
Version number
80
Approval
v Approved by
Approval Date
80 Hospital Transfusion Committee October 2017
Issue date
15th November 2017
Review date October 2020
Job title of author responsible for the document author name
Transfusion PractitionerJane Walden
Division amp Specialty Department Service responsible for reporting the status of the document
Diagnostic and Rehabilitation Haematology (Transfusion Services)
Document Sponsor
Medical Director
Date Equality Impact Assessment completed updated
As dated in relevant section of document
Superseded document(s) (Ref No Version number previous title if changed date issued ndash review date)
v70 Issued 8th April 2015 to August 2017
Version History and Practice Changes Amendments
Issue Date Version Comments (Section Change)
15-11-2017 70 41
46 and 415
47
471
6
7
Update to training and competency assessments
Update to e-learning modules for medical staff
Role of nurse authorisers
Preceptorship nurses and administration of blood
Update to references (change to British Society for Haematology from British Standard in Haematology
Changes to frequency of competency assessments addition of self-assessments
Transfusion Policy Procedures and Guidelines
Page 14 of 14 Issue Date 15th November 2017
Review Date October 2020
01-02-2015 70 415
471
60
Additional module ndash Safe Blood Sampling for Transfusion for locum medics
Nurses under preceptorship
Updated References
23-09-2014 62 Appendix 16 NEW Guideline for the transfusion of blood components in acute upper gastrointestinal bleeding
17-04-2014 61 41
46
Appendix 15
Appendix 6
Collection competency assessment to be undertaken every 2 years
Additional module ndash Safe Blood Sampling for Transfusion
New Appendix ndash Guidelines for the use of Human Albumin Solution
New table inserted ndash Transfusion reactions in adults nursing guidance
Distribution (Circulation)
This document will be accessible via the Trustrsquos intranet
Communication
Information regarding the initiation and subsequent updates of this document will be communicated via the earliest weekly Trust staff bulletin nursing bulletin and or other agreed communication method
Transfusion Policy Procedures and Guidelines
Page 13 of 14 Issue Date 15th November 2017
Review Date October 2020
Document control supporting information for this clinical document
Title
Transfusion Policy Procedures and Guidelines
Document category Clinical Policies and Guidelines
Reference
CGTRANS001
Version number
80
Approval
v Approved by
Approval Date
80 Hospital Transfusion Committee October 2017
Issue date
15th November 2017
Review date October 2020
Job title of author responsible for the document author name
Transfusion PractitionerJane Walden
Division amp Specialty Department Service responsible for reporting the status of the document
Diagnostic and Rehabilitation Haematology (Transfusion Services)
Document Sponsor
Medical Director
Date Equality Impact Assessment completed updated
As dated in relevant section of document
Superseded document(s) (Ref No Version number previous title if changed date issued ndash review date)
v70 Issued 8th April 2015 to August 2017
Version History and Practice Changes Amendments
Issue Date Version Comments (Section Change)
15-11-2017 70 41
46 and 415
47
471
6
7
Update to training and competency assessments
Update to e-learning modules for medical staff
Role of nurse authorisers
Preceptorship nurses and administration of blood
Update to references (change to British Society for Haematology from British Standard in Haematology
Changes to frequency of competency assessments addition of self-assessments
Transfusion Policy Procedures and Guidelines
Page 14 of 14 Issue Date 15th November 2017
Review Date October 2020
01-02-2015 70 415
471
60
Additional module ndash Safe Blood Sampling for Transfusion for locum medics
Nurses under preceptorship
Updated References
23-09-2014 62 Appendix 16 NEW Guideline for the transfusion of blood components in acute upper gastrointestinal bleeding
17-04-2014 61 41
46
Appendix 15
Appendix 6
Collection competency assessment to be undertaken every 2 years
Additional module ndash Safe Blood Sampling for Transfusion
New Appendix ndash Guidelines for the use of Human Albumin Solution
New table inserted ndash Transfusion reactions in adults nursing guidance
Distribution (Circulation)
This document will be accessible via the Trustrsquos intranet
Communication
Information regarding the initiation and subsequent updates of this document will be communicated via the earliest weekly Trust staff bulletin nursing bulletin and or other agreed communication method
Transfusion Policy Procedures and Guidelines
Page 14 of 14 Issue Date 15th November 2017
Review Date October 2020
01-02-2015 70 415
471
60
Additional module ndash Safe Blood Sampling for Transfusion for locum medics
Nurses under preceptorship
Updated References
23-09-2014 62 Appendix 16 NEW Guideline for the transfusion of blood components in acute upper gastrointestinal bleeding
17-04-2014 61 41
46
Appendix 15
Appendix 6
Collection competency assessment to be undertaken every 2 years
Additional module ndash Safe Blood Sampling for Transfusion
New Appendix ndash Guidelines for the use of Human Albumin Solution
New table inserted ndash Transfusion reactions in adults nursing guidance
Distribution (Circulation)
This document will be accessible via the Trustrsquos intranet
Communication
Information regarding the initiation and subsequent updates of this document will be communicated via the earliest weekly Trust staff bulletin nursing bulletin and or other agreed communication method