Maine Medical Center

MAINE MEDICAL CENTER Institutional Policy Manual Reviewed 2010

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Policy Title: Blood Component Administration - Adult/Pediatric

Policy Summary: It is the policy of Maine Medical Center to identify those individuals who have the authority to order and/or administer blood components at Maine Medical Center as well as to delineate procedure and policy to be followed to promotes the safe administration of these products

Policies: 1. Licensed Physicians, MMC Residents/Fellows, Nurse Practitioners, and Physician Assistants may order blood components. The ordering individual must provide documentation of the clinical indications for all transfusions. Patients should be monitored for the effect of the transfusion. If the transfusion had the desired effect, there should be an improvement in the patient’s functional status, laboratory value, or other parameter that was used to determine the need for the transfusion.

2. In addition to the above ordering individuals, registered nurses and clinical perfusionists may administer blood components with an appropriate prescription. These individuals are referred to as the “Transfusionist” in this policy.

3. All transfusions must be conducted in compliance with the MMC Institutional Policy entitled: “Informed Consent for Administration of Blood or Blood Components.”

4. Patient verification is done by two qualified personnel (in addition to those individuals delineated in policy statement #1, RN, LPN, CVAT, perfusionist) at the bedside, using the blood component, the Transfusion Administration Record, and an Institutionally accepted form of patient identification – most preferably, the patient ident-a-band. (Refer to Institutional Policy “Patient Identification”).

When using a two-person verification process, one individual conducting the identification verification must be the qualified tranfusionist who will administer the blood product to the patient. Outpatients who do not have an ident-a-band, will provide other positive identification, such as verbally stating their name and date of birth, comparing their outpatient/blue card or driver’s license with full name and date of birth.

5. Rate of infusion of blood components: The severity of an acute transfusion reaction (hemolytic, anaphylactic or bacterially contaminated unit) is

of 10 generally directly related to the volume of blood product infused. Therefore, an initial “test dose” is required as follows:

a. ADULT TEST DOSE – The first 25-50 ml of each blood component must be given slowly over 15 minutes with direct patient observation. b. PEDIATRIC TEST DOSE – As a suggested dose, 10% of the total volume of each blood component shall be administered slowly over 15 minutes with direct patient observation.

c. At the end of this period, if the patient’s condition and vital signs are satisfactory, the rate of infusion may be increased. The rate of the infusion is determined in conjunction with the physician’s order and the patient’s condition so as to complete the transfusion within four hours from the time the component left the Blood Bank (or is out of a Blood Bank approved refrigerator/cooler).

d. EXCEPTIONS:

The “test dose” procedure may be omitted if the risks of a slow rate of initial blood flow will outweigh the associated benefits (such as in an exsanguinating patient).

The “test dose” may not be possible in other certain situations such as with priming a cardiopulmonary bypass circuit.

6. The Transfusionist monitors the patient for potential transfusion reactions. Monitoring includes, but is not limited to:

a. The patient is educated as to the signs and symptoms of transfusion reactions to facilitate early recognition and minimize the adverse effects through early intervention. b. Vital signs (temperature, pulse, blood pressure, and respiration rate) must be assessed and documented within 15 minutes prior to starting the transfusion, at 15 minutes after the start of the transfusion, and within 30 minutes after completion of the transfusion. c. Direct visual observation is done for the first 15 minutes of the transfusion (during the test dose) and every 30 minutes for the remainder of the transfusion to detect and intervene if a transfusion reaction is suspected. Signs and symptoms of a reaction may include, but are not limited to; fever, chills, dyspnea, urticaria, hypotension, patient self reporting of feelings of impending doom, discomfort at infusion site, back pain, nausea, etc.

(Note: During Cardiopulmonary bypass it may be impossible to detect a transfusion reaction by routine vital signs such as: temperature, pulse, and respiration since these parameters are altered and controlled. The signs of a transfusion reaction during CPB would consist of a rapid fall in systolic blood

of 10 pressure [systolic BP <35 mmHg], a rapid severe fluid shift resulting in severe hypovolemia, and the presence of hives on the chest and neck.)

d. The patient remains in the patient care area for at least 30 minutes after completion of the transfusion.

7. Normal (0.9%) saline, Plasma-Lyte A, Normosol-R pH 7.4 (Abbott), and ABO- compatible plasma, are the only solutions which may be added to, or run in a line, with a blood product infusion. No other solutions or medications are to be added to blood components or the administration set.

8. Prior to transfusion, blood components may be stored only in Blood Bank approved refrigerators and/or coolers and are labeled as such. (Refer to Institutional Policy, “Blood Component Storage and Return – Adult/Pediatric”)

9. The transfusion must be completed within four (4) hours of the component leaving the Blood Bank or a Blood Bank approved refrigerator or cooler. The component cannot be returned to the Blood Bank if it has been out of the Blood Bank controlled environment or approved storage container for more than 30 minutes. (Refer to Institutional Policy, “Blood Component Storage and Return – Adult/Pediatric” )

10. Blood administration tubing sets are changed at a minimum of every four (4) hours to minimize bacterial overgrowth. A standard (170 – 260 micron) clot filter must be used with all transfusions (except for Autologous Peripheral Blood Stem Cells). Blood components sent from the Blood Bank in a syringe are pre-filtered by the Blood Bank. These syringes do not require additional clot filtration at the bedside.

11. If any amount of blood has been infused into the patient, the Transfusion Administration Record must be completed and placed in the patient’s medical record. In the event of a transfusion reaction, a copy of the front side of the Transfusion Administration Record is sent or faxed (662-4700) to the Blood Bank.

12. Manufacturer’s guidelines will be followed in the use of positive-pressure electronic infusion devices, external compression devices and blood warmers for blood and/or blood component administration.

13. Uncrossmatched blood components may be transfused in an emergency situation with a physician’s prescription. (Refer to Institutional policy: “Blood Emergency Release of Uncrossmatched Blood.”) 14. Documentation: The following items must be documented in the patient’s medical record as follows:

of 10 - The Clinical Indication for the transfusion: May document in the electronic medical record, Transfusion Administration Record (TAR), or Progress Notes. - The two-person verification of identification of both the patient and the blood component: Must use TAR. - Vital Signs (15 minutes prior to start, 15 minutes after start, and 30 minutes after finishing the transfusion: May use TAR or patient flowsheet. - Start and finish time of the transfusion: May use TAR or patient flowsheet. - Transfusion reactions: Must use MMC Transfusion Reaction Report form.

Definitions: TAR = Transfusion Administration Record Patient flowsheet = anesthesia record, the dialysis flowsheet, intensive care flowsheet, cardiopulmonary bypass record

Guidelines:

1. ALL BLOOD COMPONENTS:

a. If the patient is ambulatory, instruct the patient to stay on the nursing unit during transfusion. Coordinate procedures with other departments, if possible, to allow uninterrupted time on the unit during transfusions. b. If possible, allow at least 5 – 10 minutes to elapse between successive units of blood. c. Outpatients are instructed about whom to call should a delayed reaction be suspected. d. Prior to spiking the component, mix it thoroughly using a gentle rolling motion. e. The Abbott PLUM pump may be of clinical benefit to patients (especially small pediatric patients) when precise control of the rate and volume is desired.

2. RED BLOOD CELLS (RBC’s):

a. ABO compatibility is as follows:  Group A patient receives A or O RBC’s  Group B patient receives B or O RBC’s  Group O patient receives only Group O RBC’s  Group AB patient receives Group AB, A, B, or O RBC’s

b. Rh compatibility is as follows:  Rh-positive patients may receive Rh-positive or Rh-negative RBC’s  Rh-negative patients should only receive Rh-negative RBC’s In certain situations (extremely low Blood Bank inventory of Rh-negative units) Rh- positive RBC’s may be given with approval of the patient’s physician and the Medical Director of the Blood Bank.

of 10 c. After the test dose, a unit of red blood cells is usually administered over 1.5 to 3 hours unless there are patient contraindications. Transfusions MUST be completed within 4 hours of the component leaving the Blood Bank. With advance notice, the Blood Bank can divide a unit into aliquots for patients requiring slow infusions (greater than 4 hours).

3. FRESH FROZEN PLASMA (FFP):

a. Fresh frozen plasma contains ABO antibodies, and should therefore be ABO compatible with the recipient’s red blood cells, especially when the component is to be transfused to infants. The compatibility of plasma is opposite to the compatibility of Red Blood Cells, as follows:

 Group A patient receives A or AB FFP  Group B patient receives B or AB FFP  Group AB patient receives only AB FFP  Group O patient receives O, A, B, or AB FFP

b. Rh compatibility is not an issue since plasma contains no red blood cells.

c. After the test dose, a unit of plasma is usually completely transfused within two hours. Transfusions MUST be completed within 4 hours of the component leaving the Blood Bank.

4. PLATELETS:

a. For infants – donor plasma in platelets should be ABO compatible with the recipient’s red blood cells. Refer to fresh frozen plasma guideline.

For adults – donor plasma in platelets need not be ABO compatible with recipient’s red blood cells.

b. Rh-positive patients may receive Rh-positive or Rh-negative platelets. Rh-negative patients should preferentially receive Rh-negative platelets, because platelets may contain some RBC’s. Occasionally, Rh-positive platelets are given to Rh-negative patients. The Transfusionist caring for the patient will be notified by the Blood Bank if the patient is a candidate for Rh Immune Globulin administration. Rh Immune Globulin must be administered within 72 hours of the transfusion. (Refer to Institutional policy: “RhoGam Administration.”)

After the test dose, platelets may be transfused rapidly over 30 – 60 minutes at a rate the patient can tolerate. Transfusions MUST be completed within 4 hours of the component leaving the Blood Bank.

of 10 5. CRYOPRECIPITATE:

a. When possible, ABO-compatible cryoprecipitate should be used. ABO compatibility is the same as that for Fresh Frozen Plasma. b. Rh compatibility is not an issue since Cryoprecipitate contain no red blood cells. c. After the test dose, Cryoprecipitate can be transfused rapidly; usually the entire dose can be transfused within 30 – 60 minutes. Transfusions MUST be completed within 4 hours of the component leaving the Blood Bank.

Procedures:

1. For RBC transfusions: check the electronic medical record (Lab Retrieval) to ensure that a current Type and Screen result is available on the patient. Specimens are considered to be current if they are less than three days old, or if the patient is enrolled in the Extended Specimen Program (ESP). If the T & S is current and if the screen is “negative”, send for RBC’s as needed (units will generally be available within ten minutes). If either of these two conditions is not met, call the Blood Bank (662-2121) for further assistance.

2. FFP and Cryoprecipitate need to be thawed. Notify the Blood Bank by phone (662-2121) thirty minutes in advance of the need for these components.

3. Verify patient IV access. The gauge of the IV needle is determined by practice, desired rate of infusion, and patient comfort.

Patient Suggested Needle Gauge

Adult 18 – 20 gauge Pediatric (1 – 8 years of age) 20 – 24 gauge Infants (<1 year or <10 Kg) 24 gauge

4. Patient Safety: Make sure the request for blood is on the correct patient! Obtain blood component from the Blood Bank. Blood component is transported via the Translogic Tube System by entering a transport request using SCM; go to Orders, choose Blood Bank, then Transport Blood Products.

a. If the Translogic Tube is down, the Blood Bank will call CSD to deliver the blood component once the transport order is received.

b. If electronic medical records are down, send an index card to the Blood Bank, which bears the patient’s name label and both the type and amount of component needed. If no label is available, legibly hand write the patient’s full

of 10 name (spelled correctly) and MMC identification number and components requested.

c. Procurement of Blood to the Operating Room (OR):

- Blood products may be requested to be sent to the OR by: - Submitting a blood product request form to the Blood Bank. This form must include: *Patient name label *Date and time *Type and amount of blood component needed *OR Room Number *Destination (send to the OR room or the OR Blood refrigerator)

Send completed form to Blood Bank (via pneumatic tube or Orderly).

- Blood Bank will call OR when product available. - Blood product and form are sent to the OR (via pneumatic tube or transport person). - Blood component is delivered to specified destination (OR refrigerator or OR room. If component is placed in the OR refrigerator, the transport person will notify the OR room of the blood availability by giving the Blood Product request form to the RN in charge of the patient’s OR room.

5. STAT order for blood component: enter STAT order in SCM and call Blood Bank (662-2121) to notify of STAT order and to determine how this will be delivered to the patient care area. Blood Bank will send bloos product via pneumatic tube unless instructed otherwise. If CSD is unable to pickup and deliver, nursing unit personnel may need to do the pickup. 6. Red Blood Cells and Platelets are typically received in the patient care area within 15 minutes of the request. FFP and Cryoprecipitate may take up to 30 minutes. Contact the Blood Bank to determine the reason for any delays. 7. The patient is educated to self-report the signs and symptoms of transfusion reactions so as to facilitate early recognition and minimize the adverse effects through early intervention. These may include fever, chills, hives, dyspnea, hypotension, unusual bleeding, pain at infusion site, low back pain, nausea, and sense of impending doom. Fever may result from a benign reaction, or may be the first expression of a fatal hemolytic transfusion reaction or the infusion of a bacterially contaminated blood product. 8. Patients on infection control precautions will have the blood component sealed in a clear plastic bag prior to entering the patient room. The blood component bag will remain protected from touch contamination while encased in the plastic bag. The Transfusion Administration Record does not enter the room. 9. Patient verification is the single most important patient safety issue of the transfusion. This verification is performed by two qualified personnel (physician,

of 10 RN, LPN, CVAT, perfusionist). When using a two-person verification process, one individual conducting the identification verification must be the qualified tranfusionist who will administer the blood product to the patient. Verification is performed at the bedside, using the following information.

a. Confirm the patient’s identity by asking the patient to state full name when able. b. Compare the patient’s ident-a-band with the upper right hand corner of the Transfusion Administration Record for:

1. Patient’s Name 2. Patient’s eight digit Medical Record Number

NOTE: The Medical Record Number is the FIRST eight digits of the twelve digit number on the wristband. The last four digits represent the encounter number. Example: 123456780001.

NOTE: This eight digit MRN is to be matched with the LAST eight digits of the “Pt ID” on the Transfusion Administration Record. Example: (30014) A12345678.

c. Make sure that the following information on the Transfusion Administration Record matches the information on the blood component label: 1. Blood component name 2. ABO blood group of both patient and donor. For compatibility see Guidelines 2 through 5. 3. Rh factor of both patient and donor. For compatibility see Guidelines 2 through 5. 4. Component identification number on BOTH the white label and original component label. 5. Expiration date.

ALL DATA MUST MATCH PRIOR TO INITIATING TRANSFUSION OF THE BLOOD COMPONENT. IF YOU FIND ANY DISCREPANCIES OR HAVE ANY QUESTIONS, CALL THE BLOOD BANK AT (662-2121).

10. Both verifying personnel must legibly sign the Transfusion Administration Record immediately after checking patient and blood component information.

11. Verify patient’s understanding to notify the Transfusionist of any signs/symptoms of a reaction.

12. Administer the test dose, monitor vital signs and for transfusion reactions.

13. Complete documentation as outlined previously in this policy, #14 Documentation, above.

of 10 14. Place completed Transfusion Administration Record in the patient’s medical record.

15. Chart the administration of blood product (and any saline).

16. Discard the blood component bag (or syringe) and tubing in a red biohazard bag (unless there is a transfusion reaction – see below).

17. If a transfusion reaction ensues:

a. Stop the infusion immediately to limit the amount of blood infused. b. All reactions should be treated as potentially life-threatening situations as follows: (1) Keep the IV line open with infusion of normal saline (0.9% sodium chloride). Use a new administration set and start another bag of normal saline at a keep-open rate. (2) Notify the physician immediately. (3) Examine the labels on the blood containers and all the other records to determine if there has been an error in identifying the patient or the blood. (4) Notify the Blood Bank (662-2121) of a possible reaction. (5) If the potential for a severe acute transfusion reaction (hemolytic transfusion reaction, bacterially contaminated unit or anaphylaxis) can be excluded, the physician may prescribe restart of transfusion. This must be indicated on the Transfusion Reaction Form. The patient must be closely monitored for the duration of such a transfusion. (6) If a severe reaction cannot be excluded, proceed to (7). (7) Document the complication in the patient’s medical record (using a Transfusion Reaction Form). Document the date/time of termination of transfusion on the Transfusion Administration Record. (8) Keep tubing attached to the blood component bag. Cap the tubing with a sterile plug (do not send a needle on the tubing to the Blood Bank). Put blood component bag in a sealed plastic bag for transport to the Blood Bank. (Units removed from a precaution room will require that the tubing be removed, with careful handling of the blood product bag to prevent touch contamination. Request a Coupler plug from the Blood Bank to seal the blood container.) (9) As soon as possible, forward the following items:

To the Blood Bank:  a new, properly labeled blood specimen -7 ml pink-top (EDTA) tube-avoid hemolysis;  the blood container (whether or not it still contains blood);  the attached administration set (if appropriate);

of 10  the completed Transfusion Reaction Form;  a copy or fax (662-4700) of the front side of the Transfusion Administration Record

To the Laboratory:  send first voided urine immediately for occult blood. Enter electronic medical record protocol order for transfusion reaction urine.

After evaluation of this material, the Transfusion Reaction Form will be returned to the nursing unit to be placed in the patient’s medical record.

Definitions: N/A ______References: 1. Administration of Blood and Components. AABB Technical Manual, 16th edition, 2008. 2. AABB, Standards for Blood Banks and Transfusion Services, 26th edition, 2009. 3. American Red Cross, Circular of Information for the Use of Human Blood and Blood Components 4. Transfusion Therapy: Nursing Implications, Clinical Journal of Oncology Nursing 1997, v1 p.61-72 5. National Blood Resource Education Program’s Nursing Education Working Group. (1991). Transfusion Nursing: Trends and Practices for the 90’s. Choosing Blood Components and Equipment. American Journal of Nursing. 91(6): 42-52. 8/72 6. Package inserts: Normosol-R, Plasma-Lyte A

Original Date: 10/2000 Review Date(s): 6/2006, 1/2008, 10/2010 Approval Committee(s) and Dates: MMC Transfusion Committee: 2/2008 Institutional Policy Review Committee: 11/2010

Sponsoring Director: ______Date: ______Blood Bank Medical Director

VP/AVP Approval: ______Date: ______