Trust Guideline

Document Sample
Trust Guideline Powered By Docstoc
					                                                                            AGENDA ITEM 10
                                                                              ENCLOSURE 7


Trust Guideline                 All Sites




     All healthcare professionals must exercise their own professional judgement when using
    guidelines. However any decision to vary from the guideline should be documented in the
        patient records to include the reason for variance and the subsequent action taken.


   Blood Transfusion Policy
   Lead Clinician                               Designation
   Sue Warner                                  Assistant Director of Clinical Services

   Lead Director                                Date seen by lead director
   Jane Pugh, Director of Clinical Services 16th February 2005
   and Nursing
   Provenance of guideline                                  See references

   Ratified by Clinical Quality Group

   Noted by the Healthcare Governance Committee

   This guideline should not be used after end of:




           THIS DOCUMENT MUST NOT BE PHOTOCOPIED
                If you require a copy for your department, please contact
                The Clinical Governance Co-ordinator on 01527 507052


   PLEASE NOTE THAT ALL CLINICAL GUIDELINES ARE AVAILABLE ON
   www.RandB-pct.nhs.uk




 PCT Board Meeting
 8 March 2005
                                                                              AGENDA ITEM 10
                                                                                ENCLOSURE 7


CONTRIBUTION LIST



Key individuals involved in developing the document
Name                                               Designation
Sue Warner                                         Assistant Director of Clinical Services
Cathy Greaves                                      Team Leader team 5 District nursing
Hilary Morgan                                      Blood Transfusion practitioner,
                                                   Worcestershire Acute Hospital trust
Paul Weaver                                        Blood Bank Manager, Alexandra Hospital




Circulated to the following individuals for comments
Name                                             Designation
Sue Lunec                                        PCT Pharmacy Advisor
Vicki Preece                                     Assistant Director of Nursing
Helen Vines                                      Ward Manager, POWCH
Lesley Way                                       Clinical Governance Facilitator
Jane Hipwell                                     District Nurse Team leader, team 10 Redditch
Chris Heath                                      G.P. St. John’s Surgery, Bromsgrove




PCT Board Meeting                              2
8 March 2005
                                                                AGENDA ITEM 10
                                                                  ENCLOSURE 7




                BLOOD TRANSFUSION POLICY
Blood transfusion are carried out both in the Princess of Wales Community
Hospital and in patients’ own homes within Redditch and Bromsgrove.

This Policy is intended to be cross referenced with:
   The PCT intravenous guidelines
   Worcestershire county infection control policy
   PCT consent to treatment policy.

This Policy and Guidelines are written in line with the Worcestershire Acute
Trust Policy and Guidelines for blood transfusions

Protocol 1: The decision to transfuse                          Page4
Protocol 2: Taking Blood for Cross-Matching                    Page 5
Protocol 3: Cross Matching of blood                            Page 5
Protocol 4: Prescribing Blood                                  Page 5
Protocol 5: Collecting blood from the blood bank and
             delivering it to the ward of department           Page6
Protocol 6: Receiving blood on to the ward or patient’s blood Page 7
Protocol 7: Preparing and informing the patient                Page 8
Protocol 8: Practical aspects of the transfusion process       Page 9
Protocol 9: Patient identity and blood unit check              Page 10
Protocol 10: The transfusion process                           Page 12
Protocol 11: Management and reporting of adverse effects       Page 13
Protocol 12: Post transfusion procedures                       Page 14
Protocol 13: Procedures to be followed in emergency situation Page 15
References                                                     Page 16
Appendix 1                                                     Page 17
Appendix 2                                                     Page 18




PCT Board Meeting                       3
8 March 2005
                                                                         AGENDA ITEM 10
                                                                           ENCLOSURE 7

PROTOCOL 1:            THE DECISION TO TRANSFUSE

1)       IDENTIFY THE NEED TO TRANSFUSE

        The hospital doctor or GP will identify the specific need to transfuse and
         documents this in the patient’s notes, together with the clinical objectives to be
         achieved by the transfusion.
        If the request is to “blood group and antibody screen” in anticipation of a
         possible transfusion, the same process should occur, with a further comment
         in the medical notes if a later decision to transfuse is made.

2)       COMPLETE A TRANSFUSION REQUEST FORM

The blood transfusion request form will indicate the following information:

        The location of the patient
        The number and type of blood product and the time and date they are required
        If possible, details of the patient’s past obstetric and transfusion history (this
         information is essential if there are abnormal pre-transfusion blood results)
        The patient’s diagnosis
        The reason for the request
        Any special blood requirements e.g. certain types of patient need gamma
         irradiated blood.
        The requesting doctor will sign the request form and give their bleep number
         of mobile phone number.

3)       TELEPHONE TRANSFUSION REQUESTS

     
     If a “blood group and antibody screen” request is subsequently converted to a
     request for blood to be cross-matched, it is acceptable to do this by telephone
     call to the Blood Bank but all of the above information should be supplied.
   A record of any telephoned request for urgent cross-match or blood group
     analysis will be competed by the person receiving the call in Blood Bank,
     including the name and position of the person making the request.
AUDIT

Standard                                            Percentage          Clinical
                                                    Compliance          Exceptions
All essential patient identification details are    100%                None
completed on the blood transfusion request
card

The doctor responsible for the patient’s care  100%                     None
will document in the notes why the transfusion
was indicated, the date, and the number and
type of blood components used.
(See also “post transfusion” for documentation
of outcome)



PCT Board Meeting                             4
8 March 2005
                                                                            AGENDA ITEM 10
                                                                              ENCLOSURE 7

PROTOCOL 2:            TAKING BLOOD FOR CROSS-MATCHING

The blood sample tube must be labelled clearly with the following information and
signed by the person taking the sample. The tube will be labelled immediately
after the sample has been taken and before leaving the patient.

1.       IDENTIFY THE PATIENT – COMMUNITY HOSPITAL

Before blood is taken the patient’s identification wristband must be in place and must
contain the minimum essential information for patient identification, i.e.

            Surname
            First name
            Gender
            Date of birth
            NHS or hospital Identification number

         If the wristband needs to be removed it is the responsibility of the person
         removing it to ensure that it is replaced.

2. IDENTIFY THE PATIENT - PATIENT’S OWN HOME

         For patients in their own homes, where a wristband is not worn, three methods
         of identification must be established, e.g. name, date of birth and address.
         Blood transfusions in the community will only be carried out on patients who
         have had a full assessment and are found to be lucid and able to give detailed
         personal information

PROTOCOL 3:            CROSS MATCHING OF BLOOD

The following procedures for blood transfusion (Worcestershire Acute Hospitals) will
be adhered to:

        National Blood Service orders – SOP BT22 (appendix one)
        Action to take if a sample tube is improperly or inadequately labelled SOP BT3
         (appendix 2)

Standard operating procedures are kept in the Blood Transfusion Department of the
Alexandra hospital, Redditch.


PROTOCOL 4:            PRESCRIBING BLOOD

1)       RESPONSIBILITY FOR PRESCRIBING

            The prescription of blood is the responsibility of a doctor.




PCT Board Meeting                             5
8 March 2005
                                                                       AGENDA ITEM 10
                                                                         ENCLOSURE 7

2)      THE PRESCRIPTION CHART

          Prescriptions for blood will be prescribed on sheets for intravenous
           infusions.
         The blood transfusion prescription sheet must contain all of the essential
           patient identification information
               o Surname
               o First name
               o Date of birth
               o Patient identification number, Hospital or NHS number
     The prescription will specify
         The type of blood component to be administered including any special
           requirements e.g. irradiated blood
         The quantity to be given
         The duration of the transfusion
         Any special instructions e.g., for diuretic
         Any drugs to be given at the same time as a unit of blood must be
           separately prescribed on the medicines chart

3)      DOCUMENTATION

           The doctor will indicate in the patient’s medical notes why the transfusion
            was indicated, the date and the number and type of blood components
            used (see also “post transfusion” documentation for documentation of
            outcome and any adverse events)
AUDIT

Standard                                         Percentage         Clinical
                                                 compliance         Exceptions
The blood prescription sheet will contain        100%               None
minimum essential patient identification
details
A drug chart will always be used to prescribe 100%                  None
drugs to be given concurrently with blood



PROTOCOL 5:           COLLECTING BLOOD FROM THE BLOOD BANK AND
                      DELIVERING IT TO THE WARD, DEPARTMENT OR
                      PATIENT’S HOME

1)      TRAINING

           Staff collecting blood from the Blood Bank in the Acute Trust may be from
            a variety of professional backgrounds, e.g. nursing and medical staff but
            only staff who have received specific local training will do so. The training
            package used is the Worcestershire Acute Hospital, Assessment record for




PCT Board Meeting                           6
8 March 2005
                                                                     AGENDA ITEM 10
                                                                       ENCLOSURE 7

         nurses involved in blood transfusion, which was developed in line with The
         better blood Transfusion HSC 2002/009. They will have an annual update.

2)   PATIENT IDENTIFICATION

        The person collecting the blood will have with them either the blood
         collecting form, completed with minimum patient identification data, or
         another means of exact patient identification, including;
             o Surname
             o First name
             o Date of birth
             o Patient identification number
        Blood may be collected by suitably trained porters. Ward staff may
         telephone such a porter with a request to collect blood, and will in these
         circumstances give the following details to the porter:
             o Patient’s name
             o Patient’s identification number
             o Patient’s location
             o Type and blood product and number of units required

3)   DELIVERY OF BLOOD TO THE WARD OR DEPARTMENT

        If the person collecting the blood unit from the blood bank is not a qualified
         medical practitioner or registered nurse, then that person will ensure, upon
         reaching the ward or patient’s home, that the blood unit is handed over to
         the nurse in charge.


PROTOCOL 6:         RECEIVING BLOOD ON TO THE WARD OR PATIENT’S
HOME

1)
        When blood is delivered to a ward or patient’s home the nurse in charge
         will check that the correct blood has been delivered and inspect the unit of
         blood for any defect
        The patient should have been assessed recently by a doctor and deemed
         fit for transfusion. If there is doubt about this then medical confirmation
         should be sought from the doctor who has prescribed the blood


2)   CARE OF BLOOD PRIOR TO TRANSFUSION

        Transfusion will begin as soon as possible after delivery of the blood unit
        “There is a risk of bacterial proliferation when blood components are kept
         at ambient temperatures. For this reason a blood component transfusion
         must be started within 30 minutes of removing the pack from refrigeration,
         and be completed with 5 hours of starting the transfusion” (McClelland,
         1996)



PCT Board Meeting                         7
8 March 2005
                                                                         AGENDA ITEM 10
                                                                           ENCLOSURE 7

            If the unit has been out of the refrigerator for more that 30 minutes without
             starting transfusion and if there is no prospect of the imminent transfusion,
             the Blood Bank must be informed and the blood returned to the blood
             bank.
            Blood which is being transported in transfer cool boxes (supplied by the
             haematology laboratory) can be stored for up to 4 hours in the cool box
             after removal from the blood refrigerator.
            Blood must not be stored in ward refrigerators or patient’s own
             refrigerator under any circumstances.

AUDIT

Standard                                            Percentage          Clinical
                                                    Compliance          Exceptions
No unit of blood will still be in the process of    100%                None
transfusion more 5hrs after its removal from
the Blood Bank refrigerator


PROTOCOL 7:            PREPARING AND INFORMING THE PATIENT

See also the PCT Trust “Consent to Treatment” Policy for procedure for obtaining
informed consent

1.       PATIENT INFORMATION

            Explanation of the possible need for transfusion should be given to all
             patients from whom a cross-match sample of blood is taken.
            The information leaflet “Receiving a blood transfusion” (National Blood
             Service) is available Lickey and Cottage wards and District Nursing team
             five based at POWCH and a copy should be given to all patients who may
             require transfusion. ( further copies can be obtained from the NBS hospital
             liaison team tel: 01865 440042
             or online at www.blood.co.uk/pdfdocs/blood.transfusion.pdf
            Patients should be informed of the indication for transfusion and its risks
             and benefits, and have the right to refuse it.


2.       CONSENT FOR TRANSFUSION

        It is important that patients should give informed consent for any transfusion
         episode and a signed consent is required.

3.       PATIENT LOCATION FOR TRANSFUSION

        The patient should be situated in an area of the ward where they can be
         readily observed.




PCT Board Meeting                             8
8 March 2005
                                                                         AGENDA ITEM 10
                                                                           ENCLOSURE 7

        For patients in their own homes, the equipment required for blood transfusion,
         including an anaphylactic shock pack, should be delivered in advance of the
         transfusion.

AUDIT

Standard                                     Percentage             Clinical
                                             Compliance             Exceptions
All patients, or their parent/carers,        100%                   None
receiving blood transfusion, will be
aware of the indications for transfusion,
its risks and benefits and their right to
refuse


PROTOCOL 8:            PRACTICAL ASPECTS OF THE TRANSFUSION PROCESS

1)       CANNULATION FOR BLOOD TRANSFUSION

        Only staff trained and competent in cannulation should insert intravenous
         cannulae (see PCT Intravenous infusion policy)
        If the patient identification wristband needs to be removed prior to cannulation,
         it is the responsibility of the person removing it to ensure that it is replaced
        There is no minimum or maximum size of cannula for transfusion; the cannula
         chosen will depend on the size of the vein and the speed the blood is to be
         transfused

2)       GIVING SETS FOR TRANSFUSION

        Blood will be transfused through a sterile giving set designed for the purpose.
         Additional filters will not be required.
        Priming the line: the line will be primed with the blood or blood product itself,
         or the amount of 0.9% normal saline required to prime the line
        Platelets will not be put through giving sets through which blood has already
         been transfused
        Each giving set must only be used for a maximum of 12 hours
        On completion of the transfusion the giving set must be flushed with 0.9%
         normal saline, in sufficient amount only to clear the line of blood, after which
         the giving set will be discarded.

3)       BLOOD WARMING

        The decision to warm blood is the responsibility of the doctor
        Blood will only be warmed using a specifically designed commercial device
         with a visible thermometer and audible warning
        Blood warming devices will only be operated by personnel who have received
         training in their use.




PCT Board Meeting                             9
8 March 2005
                                                                        AGENDA ITEM 10
                                                                          ENCLOSURE 7

4)       INFUSION PUMPS

        Electronic infusion pumps may damage blood cells and will not be used for the
         administration of red cells unless the manufacturer has verified them to be
         safe for this purpose.

5)       DRUGS WILL NOT BE ADDED TO BLOOD UNDER ANY
         CIRCUMSTANCES


PROTOCOL 9:           PATIENT IDENTITY AND BLOOD UNIT CHECK

1)       THE PATIENT WRISTBAND

        The patients undergoing blood transfusion in the hospital setting will have an
         identification wristband in place.
        If the wristband needs to be removed it is the responsibility of the person
         removing it to ensure that it is replaced.

2)       THE UNIT OF BLOOD TO BE TRANSFERRED

        The unit of blood must be inspected with special attention to
          The integrity of the pack: check for leaks at the port or seams
          Evidence of haemolysis in the plasma and at the interface between red
            cells and plasma
          Evidence of unusual discolouration or turbidity
          The presence of clots

If there is evidence of the above, the unit will not be transferred and the hospital
blood bank will be informed

        If the blood unit pack is accidentally punctured during the setting up procedure
         or not transfused for any other reason, the blood bank will be informed as
         soon as practicable

3)       CHECK THE PATIENT’S IDENTIFY AGAINST THE BLOOD UNIT DETAILS

        The patient identity and blood unit check will be carried out by a suitably
         qualified person, with a second appropriately trained person acting as checker
        This check will always be done in the presence of the patient who is to receive
         the transfusion
        The procedure for patient check is as follows:
                   Positively identify the patient through questioning. The surname,
                     first name and date of birth should be verified in all patients who
                     are judged capable of giving a reliable response
                   Check that the details on the patient’s identification wristband
                     match those on the request form. The following details must be




PCT Board Meeting                           10
8 March 2005
                                                                         AGENDA ITEM 10
                                                                           ENCLOSURE 7

                    checked

                      1.   Surname
                      2.   First name
                      3.   Date of birth
                      4.   Patient Identification Number

   The above details must be found to be identical on
        The patient’s identification wristband
        Blood bank slip
        The compatibility label attached to the blood pack
        The prescription

   The blood group and the blood unit number as they appear on the blood unit,
    must be identical to those on the blood bank slip. If they are not, the unit will not
    be transfused and the blood transfusion department will be informed.
   If the blood group of the unit and the patient are not identical, there will be a
    comment from the blood bank on the blood bank slip to indicate compatibility, or a
    sticky label on the blood pack. If there is no such comment or label then the unit
    will not be transfused and the blood transfusion department will be informed.
   The unit of blood will be checked to ensure it has not passed its expiry date. If it
    has passed its expiry date the unit will not be transfused and the blood
    transfusion department will be informed.

   The unit of blood will be checked for any special requirements against the
    prescription sheet, e.g. irradiated blood. If there is any inconsistency the unit will
    not be transfused and the blood transfusion department will be informed.

   The blood bank slip will be signed by both persons carrying out the patient check
    and the time and date of commencement of the unit entered (to verify checking of
    the unit).

   The blood prescription sheet will be signed by both persons carrying out the
    patient check and the time and date of commencement of the unit entered (to
    verify completion of the prescription).

AUDIT

Standard                                         Percentage           Clinical
                                                 Compliance           Exceptions
Blood to be transfused will be checked in        100%                 None
the presence of the patient who is to
receive it




PCT Board Meeting                           11
8 March 2005
                                                                        AGENDA ITEM 10
                                                                          ENCLOSURE 7

PROTOCOL 10;           THE TRANSFUSION PROCESS

1)       GENERAL CONSIDERATIONS

        The blood bank slip will be readily available close to the patient throughout the
         transfusion, for example by being clipped to the observations chart
        Transfusion of red cells should be commenced within 30 minutes of removal
         from the blood bank refrigerator, and for each unit transfusion should be
         competed within 5 hours
        Only one unit of blood will be removed from the blood bank refrigerator at a
         time, unless extremely rapid transfusion of large quantities of blood is
         anticipated
        Blood and blood components are viewed as medications for administration
         purposes (British Committee for Standards in Haematology, 1999)
        DRUGS WILL NOT BE ADDED TO BLOOD UNDER ANY
         CIRCUMSTANCES

2)       CARE AND MONITORING OF TRANSFUSED PATIENTS

            Severe reaction to transfusion is most likely to occur within the first
             15 minutes of the start of each unit. The patient will be closely
             observed during this period
            The patient (or the patient’s carer) will be informed of possible adverse
             effects of the transfusion and the importance of reporting to clinical staff
             immediately any shivering, rash, flushing, shortness or breathe or pain in
             the extremities or loins
            Observations relating to the transfusion will be recorded separately from
             other observations and clearly dated.
            The start and finish times of each unit transfused will be recorded on the
             observations chart.
            Observations of temperature, pulse and blood pressure will be recorded
             before the start of each unit of blood or blood component and at the end of
             the transfusion episode (i.e., when all planned units have been transfused)
            Temperature and pulse will be measured and recorded 15 minutes after
             the start of each unit being transfused.
            No further observations need be recorded during the transfusion process
             unless the patient shows the following signs of adverse reaction or appears
             unwell. Special attention will be paid during the first 15 or 20 minutes of
             transfusion, observing for hypertension, haemoglobinuria or oliguria
            If a severe transfusion reaction occurs to a patient in their own home then
             the patient should be transferred to hospital by emergency ambulance
             (999)
            The cannula site should be checked frequently




PCT Board Meeting                           12
8 March 2005
                                                                      AGENDA ITEM 10
                                                                        ENCLOSURE 7

AUDIT

Standard                                     Percentage            Clinical
                                             Compliance            Exception
The blood bank slip will be readily          100%                  None
available during the transfusion process
Observations of temperature, pulse and       100%                  None
respirations, relating to the blood
transfusion, will be recorded separately
from other patient observations
Temperature, pulse and blood pressure        100%                  NONE
are recorded before each unit
commences, and 15 minutes after to the
start of each unit


PROTOCOL 11:          MANAGEMENT AND REPORTING OF ADVERSE EFECTS

1.       TYPES OF TRANSFUSION REACTIOON AND ACTION TO BE TAKEN

a)       HAEMOLYTIC REACTIONS

A severe reaction is evidenced by one or more of the following symptoms and signs

        Agitation
        Pain in abdomen, flank, chest or venepuncture site
        Flushing
        Fever (greater than 38.5oC)
        Hypertension
        Haemoglobinuria
        Non productive cough
        Breathlessness

If a severe reaction is suspected:

        Stop the treatment
        Seek urgent medical advice
        Take down the blood giving set and replace with saline 0.9% to be run slowly
         to maintain venous access
        Keep the blood giving set and blood unit
        Take temperature, pulse and blood pressure readings immediately and
         continue at frequent intervals
        Record the volume and colour of all urine passed
        Return the unit of blood that was being transfused to the hospital blood bank
         and collect any blood samples requested by them without delay.

b)       SIMPLE FEBRILE REACTIONS




PCT Board Meeting                          13
8 March 2005
                                                                         AGENDA ITEM 10
                                                                           ENCLOSURE 7

            If adverse reaction symptoms are mild, a rise in temperature of less than
             1.5oC, and occur after the first 20 minutes of the transfusion, slow the
             transfusion and give an anti-pyretic as required and prescribed.

c)       ALLERGIC REACTIONS TO PLASMA COMPONENTS

            The commonest such reaction is urticaria, which is usually mild and may
             be treated by giving an antihistamine (eg cholorpheniramine 10mg iv to an
             adult). Patients prone to such reactions may be given an oral
             antihistamine before subsequent transfusions.
          Rarely, severe anaphylactic reactions occur, usually in patients who are
             almost completely deficient in IgA (about 1 in 1000 of the normal
             population) and who may have anti-IgA antibodies. Such reactions
             should be treated by stopping the transfusion and giving adrenaline
             (1ml of 1:1000 sc or im, or 10mls 1:10000 iv) and hydrocortisone (100
             – 200mg iv)
          In the patient’s own home, 1ml of adrenaline 1:1000 sc will be given

2.       REPORTING ADVERSE EVENTS

            If a transfusion reaction is suspected, whether mild or severe, the doctor
             will be contacted immediately
            All serious transfusion reactions must be recorded in the patient’s notes
            The blood bank must be informed of all serious transfusion reactions
            In all cases of adverse reaction to blood transfusion a clinical incident form
             must be completed
            All cases of adverse reaction will be subjected to individual case review

PROTOCOL 12:           POST TRANSFUSION PROCEDURES

1)       DOCUMENTATION

        When the transfusion is complete the blood bank slip will be fixed into the
         patient’s records on a separate section reserved only for blood bank slips.
        The sheet used for prescribing the blood or blood product will be filed in the
         patient’s records
        The sheet containing the nursing observations during the transfusion will be
         filed in the patient’s records
        The doctor will indicate in the patient’s medical notes why the transfusion was
         indicated, the date, the number and type of blood components used, whether
         the desired result was achieved, whether there were any adverse effects and
         the action taken.
        The nursing care plan will be preserved in the patient’s notes along with an
         evaluation of the plan indicating whether or not the transfusion was safely
         completed. There should also be, if relevant, a description of any adverse
         reactions and the action taken by the nurse.




PCT Board Meeting                            14
8 March 2005
                                                                         AGENDA ITEM 10
                                                                           ENCLOSURE 7




2)       DISPOSAL OF THE USED BLOOD PACK

        Prior to disposal the empty blood pack will be kept in the clinical area for 24
         hours in case it is required for bacteriological investigation
        The empty blood pack will be sealed with a suitably sized spigot, or attached
         blue plug, and placed in a bag marked with the date.
        After 24 hours the pack can be disposed of as clinical waste, see hospital
         policy for disposing of clinical waste

AUDIT

Standard                                    Percentage            Clinical
                                            compliance            Exceptions
The doctor responsible for the              100%                  None
patient’s care will document in the
notes why the transfusion was
indicated, the date, the number and
type of blood components used,
whether the desired result was
achieved and any adverse effects
A blood transfusion care plan is used       100%                  None



PROTOCOL 13:   PROCEDURES TO BE FOLLOWED WHEN BLOOD
TRANSFUSION IS REQUIRED URGENTLY.

1)       REQUESTING BLOOD FROM BLOOD BANK

Telephone requests

The following information must be provided

        Patient’s surname, first name, identification number and date of birth
        Location
        Number and type of blood components required including special
         requirements
        The reason for the request
        The time and date the blood is required




PCT Board Meeting                           15
8 March 2005
                                                                     AGENDA ITEM 10
                                                                       ENCLOSURE 7




References


Department of Health (1999) Better blood transfusion. London: DH Management
executive letter 1999 (9)

Gray.A and Illingworth J Right blood, right patient, right time (2004), RCN guidance
for improving transfusion practice. London. Royal College of Nursing.

McClelland DBL (2001) Handbook of Transfusion Medicine. London, The Stationary
Office www.transfusionguidelines.org.uk

Nursing and Midwifery Council, (2004) Guidelines for the administration of medicines.
London. www.nmc-uk.org

Serious Hazards of transfusions (2003) Annual report 2001-2002. Manchester:
SHOT ISBN 0 9532 789 5 6 www.shotuk.org.

Worcestershire Acute Hospitals NHS Trust: Assessment record for Nurses involved
in Blood transfusion




February 2005




PCT Board Meeting                         16
8 March 2005
                                                                           AGENDA ITEM 10
                                                                             ENCLOSURE 7

                                                                                APPENDIX 1

                   BLOODBANK – ALEXANDRA HOSPITAL
                        STANDARD OPERATING PROCEDURE

                                       NBS ORDERS

Orders from the National Blood Transfusion Service Birmingham should be
faxed to 0121 253 4039 after phoning 0121 253 4037 to obtain an order number,
which is entered onto the order form

For routine round deliveries, ie will arrive before 1 pm the same day, the BTS would prefer to
receive the order the night before, and only additions to the order placed before 10.30 the
following day. Remember to give the driver anything to take back such as antenatal samples.

Monday am: Assess blood stocks after de-reservation and place order before 10.30 am.

Tuesday – Friday: Assess blood stocks and place order at the end of the working day. Look
at blood due to be de-reserved the following morning, and see if it is safe to de-reserve by
checking the haemoglobin level. Take into account blood required for the following day.

The following morning, assess blood usage during the previous night and make an additional
order if necessary, after de-reserving blood for that day.

If this is not possible, de-reserve and assess stocks in the morning and place the whole order
before 10.30 am.

Ad-hoc or urgent deliveries: Obtain an order number by phone, and fax the order with any
specified time required written in the comments section. Consider if a “blue light” delivery is
required.

Ask for an estimated delivery time. The driver will find out of hours access through the AE
Department, or swipe card entry into the lab area.

Keep the original fax request to show what has been ordered, file away when the order has
been received and checked for accuracy.

Check the box for extras such as antenatal reports or reagents.

Blood is booked into the computer using STK routine

Emergency BTS telephone number is 0121 471 5119.

Emergency BTS fax number is 0121 471 5123




PCT Board Meeting                             17
8 March 2005
                                                                            AGENDA ITEM 10
                                                                              ENCLOSURE 7

                                                                                   APPENDIX 2

                   BLOOD BANK – ALEXANDRA HOSPITAL
                         STANDARD OPERATING PROCEDURE

                                  SPECIMEN RECEPTION

Specimens should be EDTA or a plain tube depending on the test required.

All PID on the specimen must be handwritten and contain full name, date of birth and unique
10 digit hospital number/AE number. Where there is no number, eg GP patient, an address is
acceptable. The request form should have the same PID, and state patient location, clinician
and reason for request with dates for any blood products required.

For patients with no other details, eg trauma in AE, and AE number is essential.

If the specimen is in a plain tube, allow the blood to clot fully.

Centrifuge the specimen and separate as follows – serum/plasma into a labelled Z5, 2–3% cell
suspension in PBS saline into a plastic tube. A unique lab number is given to each, along the
request form and original bottle.

A full group and screen with possible panels or crossmatch, requires 3 mls blood, and the
serum/plasma should be free from haemolysis.

If the specimen fails to meet the acceptance criteria, the requesting doctor should be informed,
a repeat sample asked for, and a report issued. Request forms with missing information can
be returned for completion.

The request is booked in using REQ. Generally a crossmatch request is not booked in to the
computer, so that a written report of group and antibody screen can be issued the same day.

When booking in hospital numbers the computer will accept 8 numbers, so if a prefix 5550,
4440 or 7770 is present, use the last two numbers (50, 40 or 70) followed by 6 numbers.

Casualty numbers are prefixed AE followed by 6 numbers, omitting the number after the
dash.




PCT Board Meeting                               18
8 March 2005

				
DOCUMENT INFO