PC – Blood Component
Subject: Source: John Muir Health – Patient Care
Administration/ Transfusion
I. Purpose:
To provide guidelines for a safe, effective, delivery and administration of blood products in the hospital
and outpatient settings.
II. Definition:
Allogeneic Donor – donation of blood which is collected from volunteer donors without designating
specific recipients.
Autologous Donor – donation of blood for the donor’s own use; donor and recipient are the same
person.
Blood Transfusion – the transfer of blood or blood components directly into the vein of a patient. Only a
physician, registered nurse, or perfusionist may administer a blood transfusion.
Directed Donor – donation of blood which donors designate specific recipients for their donated blood
or blood components.
Unit Compatibility Label – crossmatch tag that is physically attached to the blood or blood component
unit by the transfusion service department.
Unit Label-Original product label generated at donor center at time of donation.
Transfusion Orders – form used to record physician prescribed injection of blood and blood
components into the recipient’s bloodstream; official legal document that is entered into
recipient’s medical record chart.
Transfusion Reaction Evaluation – form used in the investigation of an adverse response to a
transfusion.
Transfusion Record – slip/form that accompanies the component unit; official legal document that is
entered into recipient’s medical record documenting the transfusion(s).
Transfusion Service –provides the necessary testing and support to ensure appropriate and safe
transfusion of blood and blood components.
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III. Policy:
A. Responsibilities
See (Appendix – A) for responsibilities of staff involved in the process of blood administration.
B. Transfusion Consent or Refusal
1. Patients must sign the Whole Blood or Blood Products Transfusion Consent & Release from
Liability form prior to administration unless an emergency situation exists
(See policy: PC – Blood and Blood Product Transfusions Consent and Refusal)
C. Transfusion Order
1. Only a Licensed Independent Practitioner or Mid-Level Practitioner (NP, PA) may order the
transfusion of blood or blood components.
2. All transfusion orders must be requested using the appropriate Transfusion Order form.
(see policy: LAB-Processing Transfusion Order Forms TF- 7.0.576)
EXCEPTION: For Emergency Administration without pre-printed orders refer to:
Massive Transfusion Protocol (MTP)
(see policy: WC Trauma Policy Manual – Massive Transfusion Protocol)
Emergency Release Policy (Trauma)
3. When transfusion orders are written on blue physician order sheet, the following steps are taken:
a. Photocopy the blue physician order sheet to bring to blood bank
b. (Concord Only)
i. Attach photocopied order to Transfusion Order Form
ii. Document on Transfusion Order Form that consent has been verified
iii. Document on Transfusion Order Form most recent lab values if available.
iv. Enter Blood Band number on the bottom of the Transfusion Order Form (Concord
Campus, Walnut Creek outpatient/pre-op)
D. Sample Tube
Blood Samples can be drawn by the following trained personnel:
Lab Services
Lines Team RNs(Walnut Creek)
Outpatient Infusion Center RNs (Walnut Creek)
All RNs trained to draw blood samples (Concord )
1. The sample tube must contain the following minimum information.
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First and Last Name
Medical Record Number
Blood Band Number (Walnut Creek outpatient/pre-op, Concord Campus)
Employee ID number of person drawing the sample
Date and time sample was drawn
2. Inadequately/incorrectly labeled samples will NOT be accepted for testing.
E. Issue and Delivery of Blood and Blood Products for Transfusion
1. All blood and blood products will be issued with a Transfusion Record for each transfusion
episode.
A copy of the patient Transfusion Order form will be presented to the transfusion service staff at the
time blood and blood components are picked-up.
.
2. Blood and blood products may be transported from the transfusion service by hospital personnel
and/or adult volunteers.
a. Only one patient’s blood product may be transported at one time
b. If multiple units of blood products are issued for the same patient it must be transported in a
validated blood and blood component transport/storage container.
3. Blood components must be infused within 4 hours of leaving the Transfusion Service or
controlled storage container.
4. No more than 2 units of packed red cells will be administered through a single standard blood
administration filter set. The blood administration tubing filter set must be changed every 4
hours to prevent bacterial contamination.
F. Non-Administered Blood Components
1. All non-administered blood components shall be returned to the Transfusion Service for
disposition documentation if out of controlled storage for more than 30 minutes.
G. Normal Saline (0.9% Sodium Chloride) is the only IV solution that may be administered with or
added to blood products. Blood products may not be superimposed on any other existing IV.
Exception: Normosol is acceptable within the trauma resuscitation setting.
H. No drugs of any kind may be added to blood products or blood tubing during transfusion.
1. In an emergency/ urgent situation, the blood transfusion may be stopped, and the initial
emergency/ urgent drugs administered through the port closest to the IV device with proper
flushing pre- and post-drug administration. If more drugs are to be given, a second line should
be started.
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2. For pre and post flushing, use 5 mL of saline for each flush into the port through which the
medication will be administered.
I. All adverse reactions to transfusions, including contamination of blood component or suspected
disease transmission will be reported to the Transfusion Service and the patient’s ordering
physician (See policy: JMH PC-Blood Transfusion Reaction)
J. All blood products received from Transfusion Service must be filtered using a Blood Administration
set. All red cell and platelet products are received leukoreduced from the donor center.
K. Patients transported to another department while receiving blood must be accompanied by an RN
and the receiving department must have an RN in attendance.
L. All compatibility labels attached to the blood/blood component bag must remain on the bag until
transfusion is completed.
IV. Procedure:
A. BLOOD PRODUCT ORDERS
A Transfusion Order Form must be used in non-emergent situations prior to ordering the blood
components in the computer system and prior to the administration of the blood components.
(see policy: LAB- Processing Transfusion Order forms TF- 7.0.576)
1. Blood component ordering:
a. The type of blood product and quantity should be ordered in the hospital information system
by the nursing unit. The transfusion service department will determine if a type and screen
needs to be ordered.
Concord Campus Only:
1. Type and Screen/Crossmatch orders:
a. The order for the Type and Screen/Crossmatch, or blood products are entered in the
hospital information system by the ordering physician, nursing, or unit secretary.
b. If the patient has previously received a blood band bracelet and additional products
are required within 72 hours of the initial Type and Screen/crossmatch order, enter product
request in the hospital information system.
3) At the end of each 72 hour period, a new Blood Band may be required. Clarification
with the Transfusion Service is necessary to determine if a new Blood Band and
crossmatch specimen is needed.
Exception:
Autologous units may be available for a longer period of time than allogeneic (regular)
units. Call Transfusion Service for timeline of availability of an autologous
crossmatch.
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c. Blood band bracelet:
1) Patients receiving blood and blood components must have a Blood Band bracelet
2) The Blood Band bracelet is placed on the patient by the person who drew the
specimen or directly witnessed the specimen collection.
Exception:
Pre-admit and Outpatient Blood band bracelets will be applied by the admitting nurse
after verifying the patient’s identity and comparing this information with the hospital
admission armband.
3) This band is to remain attached to the patient until a new Type and
Screen/Crossmatch is ordered or the patient is discharged, and should only be removed by
laboratory personnel or nursing, after consulting with transfusion service staff.
4) When a patient has multiple Blood Bands, call Transfusion Services for authorization
to remove a band.
5) If a circumstance arises which requires removal of the band, it must be applied
immediately to another extremity by the same individual that removed it.
6) The Blood Band must never be placed on structures such as the patient bed, since
this number is the most important method of identifying a unit of blood or blood component
with a specific patient.
d Second ABO/Rh (Blood Type)
National Patient Safety Goals require enhanced methods to verify correct patient
identification before blood transfusion. To improve patient safety, the Transfusion Service
has initiated a process in the hospital information system involving the collection of a second
specimen (second ABO/Rh) on transfusion candidates with no computer Blood Bank history
on file. This second sample must be collected at a different time than the first sample. (See
Transfusion Service Specimen Collection Policy and ABO/Rh Confirmation Specimen
Procedure)
B. PREPARING FOR TRANSFUSION
The Consent for Transfusion must be reviewed for completeness, patient signature and presence in
the patient chart prior to initiating the transfusion.
1. Ensure that patient has a patent IV prior to picking up the blood product. Connect IV to blood
administration set with Normal Saline (0.9% Sodium Chloride).
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a. Ideal catheter size for IV transfusion is 20-18 gauge.
b. A 22-gauge needle is the smallest acceptable gauge and may slow the infusion rate.
Walnut Creek Only
c. The Transfusion Service will split the blood unit in half, if using a small catheter and there is
concern over infusing the blood component longer than 4 hours.
2. If using Abbott Plum or Hospira “Smart Pump” infusion pump for blood component
administration:
a. Prime the primary IV Plumset tubing with Normal Saline (0.9% Sodium Chloride) solution and
insert into the infusion device.
b. Prime the Blood Administration tubing with Normal Saline (0.9% Sodium Chloride) solution.
c. Connect the transfusion tubing to the secondary infusion port.
d. Program the infusion pump for the desired delivery rate and volume, selecting “blood” from
the Clinical Care Area if using the Smart Pump.
Note: When using the infusion pump for transfusions, two bags of Normal Saline (0.9%
Sodium Chloride) solution are required (one for transfusion tubing and one for pump tubing)
e. After acquiring the blood product from the Transfusion Service, the blood component will be
connected to the second piercing pin on the Y-tubing (on the secondary blood administration
tubing).
f. RN obtains baseline VS, including temperature, prior to picking up the component, but within
30 minutes of starting the transfusion.
g. Pre-medicate the patient, if ordered by the physician.
C. ISSUE, COLLECTION, DELIVERY OF BLOOD AND BLOOD PRODUCTS
1. All blood products will be issued with a Transfusion Record for each transfusion episode.
2. A copy of the completed Transfusion Order form will be presented to Transfusion Service staff at
the time of blood or blood component issue.
o In-Patients Transfusions
o Out-Patients Transfusions
o Pre-operative
NOTE: For Walnut Creek Outpatient’s and all Concord Campus patients
If the patient is not wearing the Blood Band number at the time of transfusion or admission, the
nursing personnel are to contact the Transfusion Services, who will draw a new specimen for
confirmation.
a. Nursing personnel/adult volunteer will bring a copy of the Transfusion Order Form as a “pick-
up” slip for the blood component.
Transfusion Order Form must contain the following:
First and Last Name
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Medical Record Number
Blood Band Number (Walnut Creek outpatient/pre-op, Concord Campus)
Blood Component Ordered
b. Transfusion Services
1) Confirms that the ordered component and patient information is on the Transfusion
Order Form.
2) Selects blood component with shortest expiration date and scans barcode for product
code and unit number into the computer.
3) Visually inspect the unit for evidence of bacterial growth or other abnormal appearance.
4) Verifies with transporter the following:
a. The transporter will read to the Transfusion Service staff from the Transfusion Record
Patient Name
Patient Medical Record Number
Patient ABO/Rh Type
Blood Band Number (if applicable)
Unit ABO/Rh type
Unit Number
Unit Expiration Date
b. The Transfusion Service staff will verify from the unit compatibility label.
Patient name
Patient medical record Number
Patient ABO/Rh Type
Blood Band Number (if applicable)
c. The Transfusion Service staff will verify from the “unit label.”
Unit ABO/Rh Type
Unit Number
Unit Expiration Date
d. The Transfusion Service staff will verbally re-confirm the unit number to the
transporter.
5) The Transfusion Service and the transporter will sign, date and time the Transfusion
Record.
6) The blood component issue will be completed in the computer by Transfusion Service.
7) The transporter shall immediately deliver all issued blood or blood components to the
receiving patient’s clinical area.
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8) If the transfusion cannot be initiated promptly, the blood or blood component MUST be
returned to the Transfusion Service within 30 minutes for storage.
Exception: Blood or blood components issued in validated blood transport containers
shall be kept in the controlled storage container until transfusion or until expiration of
storage container coolant.
a. ALL NON ADMINISTERED blood and blood components shall be returned to the
Transfusion Service for disposition documentation if out of controlled storage for more
than 30 minutes.
D. ADMINISTRATION OF BLOOD AND BLOOD PRODUCTS
1. The RN shall take the baseline vital signs within 30 minutes prior to the start of transfusion.
2. At the bedside prior to transfusion, an RN and another licensed(MD/RN/LVN) or appropriately
certified person (Perfusionist) will verify the following:
Physicians Order for transfusion
Consent for Transfusion is completed, contains patient signature and is present in the
chart.
Patient’s Identification Wristband for:
First and Last Name
Medical Record Number
Blood Band Number (All Concord Campus patients and WC outpatient/pre-op
only)
Unit Compatibility Label
Unit Number
ABO/Rh Type
Expiration date
Compatibility
Unit Label
Unit Number
ABO/Rh
Expiration date
3. Transfusionist and RN/MD/LVN/Perfusionist will sign the Transfusion Record to confirm that the
above information is correct.
4. Start the transfusion.
The first 25-50 ml should be given slowly (approximately 15 minutes) and monitored closely,
except during urgent replacement of blood volume.
a. If reaction occurs, stop the transfusion and notify the physician immediately (see
transfusion reaction evaluation policy/procedure).
b. If physician orders transfusion to be stopped, notify Transfusion Service.
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5. If the transfusion is well tolerated, increase the rate of infusion to the specified rate in the
physician’s order.
6. RN will obtain vital signs, reassess the patient’s condition and document the findings at the
following intervals:
Baseline (within 30 minutes of start of transfusion)
15 minutes after start of transfusion
Hourly from start of transfusion during transfusion
Within 60 minutes after completion of transfusion
Exception- special patient populations i.e.: perioperative or critically ill patients will often have
vital signs assessed at more frequent intervals. For multiple emergent transfusions, vital signs
are to be documented within the electronic medical record or on the Trauma Flow Sheet.
7. For multiple units of blood products given in succession, follow guidelines as stated above in
steps 2 through 6.
a. Discard the bag in the red biohazard waste container.
Outpatient’s only
1. Keep the IV line open until patient is ready for discharge.
2. Prior to discharge, verbal and written instructions to the patient or a responsible caregiver
outlining possible adverse events and the appropriate action to take if such symptoms are
noted.
E. DOCUMENTATION
1. Transfusion Record
a) Verify all sections of the Transfusion Record are complete.
b) Document the following:
Vital signs
Temperature
Pulse
Respiration
Blood Pressure
SpO2
c) Place the form in the patient’s medical record.
Exception: For multiple emergent transfusions, vital signs are to be documented in the
electronic medical record or on the Trauma Flow Sheet
2. Patient Electronic Medical Record
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Transfusion start and completion times
Type of blood product and total volume infused
Total volume of normal saline infused
Any complications or serious adverse events
Transfusion vital signs that occur during routine vital sign assessment should be
entered in the electronic record in addition to the Transfusion record.
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Reference / Regulations: Applies To:
Supersedes:
Sponsor Title:
Record of Additional Approval Body / Date
Admin OLT Board
MEC-WC SLT
MEC-CC
Origination Date: Review Dates: Revision Dates:
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Appendix – A
Responsibilities
A. All Staff
1. It is the responsibility of all staff involved in the transfusion process, from the taking of, ordering
of and transfusion of blood and blood products to ensure that they are aware of their
responsibilities as stated in this policy.
2. Annual training for staff regarding the transfusion of blood and blood products within John Muir
Health is provided by John Muir Health.
B. Registered Nurses
1. It is the responsibility of the transfusionist to ensure that the correct patient is identified.
2. It is the responsibility of the transfusionist to verify that the patient has been informed of the
procedure by a medical practitioner and that the Blood Transfusion Consent Form has been
signed.
3. Are responsible for the monitoring of the patients condition throughout the blood transfusion
procedure.
4. The maintenance of the blood transfusion documentation during the procedure is the
responsibility of qualified nurses.
5. Are responsible for being confident and competent to identify signs and symptoms of a
possible transfusion reaction.
6. Registered nurses have a professional responsibility to ensure that they have received
adequate training to perform a blood transfusion and that they have received annual
mandatory update sessions prior to administering blood or blood components.
C. Licensed Independent Practitioners/Mid-level Practitioner (NP, PA)
1. It is the responsibility of a Licensed Independent Practitioners to assess the need for and
make the decision to ‘prescribe’ a blood transfusion as a form of treatment.
2. Licensed Independent Practitioners are the person responsible for prescribing the blood to
be transfused. 3. The information regarding the benefits and risks of blood transfusion should
be explained to the patient by the Licensed Independent Practitioners. They should also
gain consent from the patient to perform a blood transfusion.
Appendix – B
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Product Information
A. Leukoreduced Packed Red Blood Cells
1. Packed red blood cells shall not hang for more than 4 hours and must be completely
infused within 4 hours of leaving the Transfusion Service controlled storage unit or
validated blood and blood component transport/ storage container.
2. All non-administered packed red blood cells shall be returned to the Transfusion Service for
disposition documentation if out of controlled storage for more than 30 minutes.
3. No more than 2 units of packed red blood cells shall be administered through a single
standard blood administration filter set. The blood administration filter set must be changed
every 4 hours.
4. A standard 170-260 micron clot filter must be used with all non-neonatal transfusions.
a. Neonatal (Walnut Creek Campus Only):
1) Syringe aliquots are filtered in the Blood Bank prior to issue.
2) Units for exchange transfusion will be filtered at the bedside using the standard filter.
1. Walnut Creek Campus Only:
a. Red Blood Cell units that need to be transfused for longer than 4 hours can be
split/divided in half by transfusion service personnel upon physician order request
B. Platelet Pheresis
1. Platelet pheresis comes from one random donor and is equal to 6-10 single-donor platelet
units
2. No more than 2 units of platelet pheresis should be administered through a standard blood
administration filter set. The blood administration filter set must be changed every 4 hours.
3. All platelet products shall be stored at room temperature (20-24°C) with constant agitation.
3. All non-administered platelets shall be returned to the Transfusion Service for disposition
documentation if out of controlled storage for more than 30 minutes.
C. Frozen Plasma/ fresh Frozen Plasma/ Thawed Plasma
1. Plasma shall not hang for more than 4 hours and must be completely infused within 4 hours
of leaving the Transfusion Service controlled storage unit or validated blood and blood
component transport/ storage container.
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2. No more than 2 units of plasma should be administered through a standard blood
administration filter set. The blood administration filter set must be changed every 4 hours.
3. Frozen Plasma is stored frozen in the Transfusion Service department and is thawed
immediately before use.
a. Order units 40 minutes prior to infusion to allow for thawing.
b. Frozen Plasma expires 24 hours after it is thawed.
4. Depending on the required blood type, Thawed Plasma is generally readily available.
Thawed Plasma has a 5-day expiration date.
5. All non-administered plasma shall be returned to the Transfusion Service for disposition
documentation if out of controlled storage for more than 30 minutes.
D. Cryoprecipitate/ Pre-pooled Cryoprecipitate
1. Pre-pooled Cryoprecipitate contains 5 single donor units.
A normal adult dose is (2)-pre-pooled Cryoprecipitates.
2. Random Cryoprecipitates will only be given if pre-pooled units are not available.
A normal adult dose is 6-10 Random Cryoprecipitates.
3. Cryoprecipitate is stored frozen in the Transfusion Service department and is thawed
immediately before use.
a. Order units 40 minutes prior to infusion to allow for thawing.
b. Cryoprecipitate expires in 4 or 6 hours after it is thawed.
4. Cryoprecipitate shall be kept at room temperature after being thawed.
4. All non-administered Cryoprecipitate shall be returned to the Transfusion Service for
disposition documentation if out of controlled storage for more than 30 minutes.
5. Cryoprecipitate should be administered through a standard blood administration filter set.
The blood administration filter set must be changed every 4 hours.
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Sample Times
1. The Transfusion Service Department will make every attempt to complete cell
crossmatches and component preparation in a timely manner.
2. Turnaround times for the testing of samples in the Transfusion Service will be as follows:
a. STAT orders for crossmatch of cellular components will be completed:
1) Within 45 minutes of accession, if needed unit is in stock and Type and Screen is
run consecutively and found to be negative.
2) Within 60 minutes of arrival of the component from the donor center, if unit is not in
stock and Type and Screen is run consecutively and found to be negative.
3) Within 15 minutes of accession, if unit is in stock and Type and Screen has been
previously performed and found to be negative.
4) Within 30 minutes of arrival from the donor center, if unit is not in stock and if Type
and Screen has been previously performed and found to be negative.
b. STAT orders for frozen products will be completed:
If there is an ABO/Rh blood type on file:
1) Within 45 minutes* of accession for Frozen Plasma (FFP, FP24) or Cryoprecipitate
(pre-pooled Cryo5, pooled single units) and no breakage occurs.
2) Within 15 minutes* of accession if Thawed Plasma is available.
Note: If no ABO/Rh blood type is on file, add an additional 30 minutes
c. STAT orders for Platelet components will be completed:
1) Within 15 minutes of accession if the needed unit is in stock
2) Within 15 minutes of arrival from the donor center if the needed unit is not in stock
d. Routine orders for crossmatch or set up of components for same day transfusion will be
completed within 4 hours of accession or arrival of unit from the donor center.
e. Routine orders for Type and Screen on outpatients or pre-op patients will be completed
within 24 hours of scheduled admission
f. Crossmatch of cellular components for patients demonstrating significant IgG antibodies
will be completed as quickly as possible, depending on specificity of the antibody(ies)
and availability of antigen negative units. Patients’ physician will be notified of any
delay of more than 4 hours in obtaining blood.
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