Blood Transfusion Policy (Adult)

Version 9

Name of responsible (ratifying) committee Hospital Transfusion Committee

Date ratified 22 April 2016

Document Manager (job title) Transfusion Practitioner

Date issued 26 May 2016

Review date 21 April 2019

Electronic location Clinical Policies Patient Identification Policy; Consent to Examination and Treatment Policy; Management of Adverse Incidents and Near Related Procedural Documents Misses; Management of Serious Incidents Requiring Investigations; Massive Haemorrhage Protocol; Blood; Platelets; Red Cells; Adverse Transfusion Reactions; Administration; Observations; Blood Components; Key Words (to aid with searching) Administration Sets; Plasma; Blood Transfusion; Blood Warmers; Jehovah’s Witnesses; Religious Beliefs; Training; In the case of hard copies of this policy the content can only be assured to be accurate on the date of issue marked on the document. For assurance that the most up to date policy is being used, staff should refer to the version held on the intranet

Version Tracking Version Date Brief Summary of Changes Author Ratified 9 22/04/2016 Title. Minor adjustments throughout. Indication Codes; Special K Heron/ Sue Requirements; Consent Sticker; Written Instruction and Chambers Observation Sheet; Flyer Information; Reaction Flow Chart. 8 26/10/2012 - J Hickey

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 1 of 31 CONTENTS

QUICK REFERENCE GUIDE...... 3

INTRODUCTION...... 5 PURPOSE...... 5 SCOPE...... 5 DEFINITIONS...... 6 DUTIES AND RESPONSIBILITIES...... 6 PROCESS...... 8 TRAINING REQUIREMENTS...... 14 REFERENCES AND ASSOCIATED DOCUMENTATION...... 26 EQUALITY IMPACT STATEMENT...... 26 MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS...... 27

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 2 of 31 QUICK REFERENCE GUIDE

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.

1. Obtaining consent for all transfusions is a Department of Health requirement and is the responsibility of the Clinician or Non-Medical Authoriser making the decision to transfuse. Do not forget the rights of the competent patient to refuse a transfusion or request an alternative treatment, if available. Transfusion Patient Information Leaflets are available and should be offered.

2. Transfusion written instruction (prescription) must include four patient identifiers: surname, first name, date of birth and NHS number (preferred) / Hospital / PAS (or ED number, unknown and gender for “unknown” patients), type of blood component, special requirements (e.g. CMV negative, irradiated, Hepatitis E (HEV) negative etc.), quantity to be given, duration and rate of infusion, name and signature of Clinician or Non-Medical Authoriser.

3. Only suitably trained registered practitioners can request blood and blood components. Request forms must contain the four markers of patient identification (PID) as above, together with the reason for transfusion, date and time required, name and signature of requesting Clinician or Non- Medical Authoriser, and the location.

4. Only suitably trained staff may take samples for group and screen and cross-matching. The sample must be taken into an EDTA (pink top) tube. These must be correctly labelled by hand, at the patients’ bedside, from the PID band with the four points of ID and they must be dated, timed and signed. All samples must be labelled by the staff member who took the sample.

5. When a cross-match is requested and the patient does not have a historical group recorded on the Apex computer system, the Transfusion Laboratory staff will request a second sample. This will NOT cause a delay in obtaining blood for the patient when blood is required urgently. The patient will receive group ‘O’ until the second sample has been verified.

6. All staff collecting blood and blood components must have initial training then annual revalidation. All staff are responsible for ensuring their training needs have been met.

7. Before collecting the blood or blood component, ensure your patient is ready to receive the transfusion and has the correct PID band in situ.

8. When collecting blood or blood components, staff must check the PID against the component label before scanning out of the issue fridge or signing for it from within the Transfusion Laboratory.

9. The PID must be checked against the component label and the PID band i.e. at the side of the patient before the transfusion is commenced. Do not connect any components unless you have checked all the details are correct yourself.

10. Transfusions must be given in clinical areas, where frequent visual and verbal contact may be maintained.

11. As a minimum per unit, the conscious patients’ temperature, pulse, respiratory rate (TPR), blood pressure (BP) and oxygen saturations (O2 Sats) must be checked before the start of the transfusion, 15 minutes following the start of the transfusion and again at the end of the unit. The unconscious patient requires, as a minimum per unit, TPR, BP and O2 Sats before the unit is started, every 15 minutes for the first hour, and hourly thereafter.

12. Patients should be encouraged to inform a member of staff if at any time during the transfusion they feel unwell (day case patient information leaflets to be given on discharge, available to order from Medical Illustration ref: 14/5879). Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 3 of 31 13. The same giving set used for a blood transfusion must NOT be subsequently used for administering fluids or different blood components.

14. Accurate documentation of the transfusion must be maintained. Any adverse reaction(s) or events should be communicated to the Transfusion Laboratory and/or to the Transfusion Practitioner (TP) and Transfusion Practice Educator (TPE).

15. Blood or blood components must NOT be stored in a ward domestic or drug fridge UNDER ANY CIRCUMSTANCE.

16. Routine transfusions can be administered overnight, providing the environment is conducive to safe practice enabling close monitoring of the patient and all observations to be carried out and recorded as per this policy. However, if the transfusion could safely wait until the day time then this would be preferable. Transfusions must take place overnight if the patient is bleeding.

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 4 of 31 1. INTRODUCTION

Appropriate transfusion is an essential support to many medical treatments and can be lifesaving. There are many risks to the patient, including acute haemolytic reactions and transfusion transmitted infections. Incidents affecting the safety of transfusion are highlighted through the Serious Hazards of Transfusion (SHOT) haemovigilance scheme. This scheme has shown that avoidable, serious hazards of transfusion continue to occur in Trusts throughout the UK, the most frequent factor being human error. Out of 3017 total incidents, 77.8% were caused by human error (often multiple errors). There has been little progress in the last decade (Annual SHOT Report, 2014)

Stringent procedures must be followed to ensure that the correct blood is always given and that any adverse reactions are dealt with promptly and efficiently.

Procedures for requesting, writing up and the administration of blood and blood components, as well as the management of any complications support this clinical policy on transfusion. Procedures for the documentation of transfusions in nursing, medical and laboratory records are also provided, including the procedure for the reporting of any adverse reactions or events occurring in relation to transfusions.

This clinical policy has been revised to clarify terminology, incorporating core standards in transfusion practice in adult patients.

Neonatal Intensive Care patients are one of the most transfused groups and because of their potential normal life expectancy they are more susceptible to the long-term effects of transfusion. Particular care and attention must be given to neonates and children to minimise blood component use. See local departmental PHT policy for neonatal and paediatric practice.

This policy reflects the Blood Safety and Quality Regulations (BSQR) 2005, current NICE guidelines and BCSH recommendations.

1. PURPOSE

The purpose of this policy is to:

 Provide a clear framework and guidance for safe transfusion practice, throughout Portsmouth Hospitals NHS Trust (the Trust)

 Ensure a consistent approach to the requesting, writing up, handling and administration of blood and blood components throughout the Trust

 Ensure that all members of staff involved at any stage of the process of transfusing blood and blood components are aware of their role and the legal aspects of this practice

2. SCOPE

This policy applies to all staff involved in the requesting, sampling, prescribing, storing, collecting, transporting and administering of human blood and blood components, including those who work in Primary Care Trusts supplied with blood/blood components from the Trust Transfusion Laboratory.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain on going patient and staff safety’

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 5 of 31 3. DEFINITIONS

Transfusion: blood or any of its components used to correct or treat a clinical abnormality

Blood component: red cells, fresh frozen plasma (FFP), Octaplas®, cryoprecipitate, and platelet concentrate

Blood Product: any drug which is manufactured using human blood components

Patient Blood Management (PBM): a standard of care that focuses on measures to reduce or avoid the need for transfusion if possible. If a transfusion is needed, the aim is to ensure that the patients are only given what they really need and that the transfusion is given safely

Cold chain: the legal requirements to monitor transport and storage conditions of blood, from donor to recipient

Maximum Surgical Blood Ordering Schedule (MSBOS): the Trust’s agreed maximum number of cross-matched units or group and screen testing requirements for surgical procedures

Medicines and Healthcare Products Regulatory Agency (MHRA): An executive agency which aims to enhance and safeguard the health of the public by ensuring that medicines and medical devices work and are acceptably safe

Serious Adverse Blood Reactions and Events (SABRE): the MHRA reporting scheme to which serious adverse reactions and events related to blood components / products are reported

Serious Hazards of Transfusion (SHOT): the United Kingdoms’ independent, professionally-led haemovigilance scheme, responsible for recording and monitoring all blood component adverse events and reactions

Serious Incidents Requiring Investigation (SIRI): Trust system for investigating Amber or Red incidents and events

4. DUTIES AND RESPONSIBILITIES

5. The Hospital Transfusion Committee (HTC)

The HTC includes members of the Hospital Transfusion Team and representatives from all clinical areas where blood and blood components are administered.

Responsible for:  Overseeing all aspects of transfusion practice  Promoting good transfusion practice based on national guidelines through the provision of a robust framework to communicate information and advice  Arranging for audits of blood and blood component usage to be carried out, in line with local and national requirements and receiving and reviewing the reports of those audits  Making recommendations to address any issues highlighted by the reports and monitoring the implementation of the actions  Receiving quarterly reports from the Hospital Transfusion Team regarding the trends and themes from adverse incidents, including any variance from this policy and for recommending any actions to address the variance  Reviewing all SHOT submissions and ensure the root causes are identified and all necessary action taken to prevent a recurrence  Monitoring the implementation of actions arising from the investigation of SIRI Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 6 of 31  Receiving the results of all audits associated with the transfusion process and developing any required action plans to address the identified issues  Undertaking regular review of this policy and recommending any changes as highlighted by audits or adverse incidents  Ensuring any risks associated with the transfusion process are assessed and escalated to the Trust Risk Register  Acting as a forum to discuss advancements in transfusion practice, including PBM and reviewing and amending practices and policies in the light of those advancements  Providing, through the Chair, an annual report on all aspects of transfusion practice, to the Governance and Quality Committee

6. Hospital Transfusion Team (HTT)

The HTT includes the Clinical Lead for Transfusion, Transfusion Laboratory manager (TLM), Transfusion Laboratory Seniors, Transfusion Practitioner (TP) and Transfusion Practice Educator (TPE).

Responsible for:  Meeting weekly to discuss current issues and incidents  Addressing and monitoring any outstanding corrective and preventative actions  Informing the decision-making process for new initiatives  Ensuring the HTC is informed of any required audits  Reporting quarterly to the HTC  The review and development of policies and guidelines

7. Clinical Lead for Transfusion

Responsible for:  Acting as the main point of contact for medical staff, including GP’s, requiring information, advice and guidance on transfusion issues  Submission of clinical information to NHSBT to aid investigation of serious adverse transfusion reactions, in conjunction with TP and TPE

8. TLM

Responsible for:  Ensuring the Transfusion Laboratory complies with the legislation as set down in the Blood and Safety Quality Regulations (BSQR 2005) and the statutory requirements of the Department of Health to ensure patient and staff safety  Submission of reports to SABRE and/or SHOT, in conjunction with the TP and TPE  The investigation of all adverse incidents and near misses associated with any aspect of transfusion, in conjunction with the TP, TPE and Laboratory Seniors

9. TP and TPE

Responsible for:  Submission of reports to SHOT and/or SABRE, in conjunction with the TLM and Laboratory Seniors  The investigation of all adverse clinical incidents and near misses associated with any aspect of transfusion

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 7 of 31  Provide the HTC with quarterly reports on all aspects of transfusion practice, including adverse events  Facilitate education and training for all relevant clinical staff groups  Participate in local and national audits and feedback results to HTT and HTC  Maintain and update relevant clinical policies  Provide advice and support on transfusion matters to clinical staff

10. Clinicians Including Non-Medical Authorisers

Responsible for:  The decision to transfuse in conjunction with NHSBT indication codes (appendix i)  Ensuring any special requirements are met  The consent process including the reasons for the transfusion, the risks and benefits, their right to refuse and the documentation of this  Where practical, informing patients of alternatives to transfusion

11. All Ward and Line Managers

Responsible for:  Being aware of this policy and associated policies and guidelines  Releasing staff for training  Integrating compliance into the Knowledge and Skills Framework (KSF) and Annual Performance and Development Appraisals (APDR) for all their staff  Ensuring appropriate evidence of compliance is gained during the APDR process  Ensure their staff are aware of and understand this policy and comply with its content  Communicating any concerns regarding staff compliance with this policy to the TP/TPE

12. All Staff Involved in the Processes Associated with Transfusion

Responsible for:  Attending training relevant to their role in the process  Comply with this policy at a level commensurate with their involvement  Report all adverse incidents and near misses to TP/TPE

13. PROCESS

Note: whilst the same principles apply to all patients regardless of age, there are some very specific issues which relate to neonates and paediatrics, see local PHT departmental guidelines. For renal patients see speciality guidelines and policies, WRTS Blood Administration: Adults on Haemodialysis/Haemofiltration

14. Consent

 Obtaining consent for a transfusion is a Department of Health requirement and it is the responsibility of the prescribing Clinician or Non-Medical Authoriser to obtain and document that consent in accordance with Trust Policy and provide written information (leaflets available from TP and TPE). If the patient is unable to provide consent, this must also be documented in the notes. Refer to the Trust ‘Consent to Examination and Treatment Policy’. In order to

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 8 of 31 facilitate the documentation of consent, stickers are available from Medical Illustration and may be used, complete and place in notes (appendix ii)

 Where practical, patients should be informed of the reasons for the transfusion, the potential risks and benefits involved. They should also be informed of their right to refuse the transfusion but must then be advised of the risks of doing so

 All staff, but particularly those taking consent must be aware:

o Of the beliefs of the Jehovah’s Witness in relation to receiving any blood component and medical alternatives, which may be applicable o That any patient may have valid personal reasons or beliefs for not wishing to have a transfusion o That each patient has the right to be treated with respect and staff must be sensitive to their individual needs, acknowledging their values, beliefs and cultural background o That an individual patient may accept different treatments such as dialysis, cardiopulmonary bypass, organ transplants, and non-blood replacement fluids of plasma derivatives, iron therapy and cell salvage o The patient should be provided with information about alternatives to transfusion, including autologous transfusion, where appropriate o In circumstances where a patient lacks the capacity to consent and it is an emergency or urgent situation, treatment can be provided on the basis of ‘best interests’. There is a patient information leaflet available for patients who have received an unexpected blood transfusion (obtain from TP and TPE) o In elective situations the healthcare professional seeking consent must consider whether the patient has put in place a valid and applicable Advanced Directive, which covers the refusal of a transfusion. Further guidance can be obtained from the Trust’s Legal Services Manager

For guidance regarding religious or personal beliefs refer to the Trust’s Guideline on the Care of Patients Who Wish to Decline Transfusions.

(A) Requesting Blood and Blood Components

For Emergency Issue of Blood or activation of the Massive Haemorrhage Protocol call 4444

 Only suitably trained registered Clinicians and Non-Medical Authorisers can request blood and blood components  Request forms must contain the four PID markers as per Trust policy and include the date and time blood and blood components are required, contact number, name and signature of the requesting Clinician or Non-Medical Authoriser, and clinical details. The request may be refused if the form is not completed appropriately  The request form should clearly state any special blood requirements e.g. CMV negative, irradiated or Hepatitis E (HEV) negative blood and details of antibody history  For patients who cannot supply the relevant information, the name and date of birth can be verified by the patients’ family, carer, guardian or other representative  Requests for blood and blood components will not be processed if the sample is inadequately labelled as per Trust Policy (i.e. must have the four points of PID, be dated, timed and signed, with no amendments and be legible)

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 9 of 31  Unidentified patients are usually admitted via the ED department. In these circumstances the request form and the sample must be labelled with the identity status of unknown male/female and ED number (all transfusion samples must be by hand)  If the unidentified patient is a young person and may have been born after 1st January 1996, this must be made known to the Transfusion Laboratory so appropriate components can be issued, until the actual date of birth is confirmed  For non urgent requests the Transfusion Laboratory usually require 48 hours notice to prepare blood and blood components. If required earlier than 48 hours, please call the Transfusion Laboratory on ext. 6539 to discuss the request  Where antibodies are identified, selection of blood may take longer as complex cross-matches may require referral to NHSBT in Bristol for testing and the sourcing of antigen negative blood from other NHSBT sites  Requests for blood components (e.g. platelets) must be made by calling the Transfusion Laboratory, ext. 6539, ensuring any special requirements are communicated. The approval of a haematologist is required to ensure appropriate usage, with the exception of DCCQ and NICU. All verbal requests must be followed up with an ICE request

Refer to Drug Therapy Guidelines:  Use of Platelets No 138.02  Use of FFP and Cryoprecipitate No 72.03  Use of Octaplas® No 161.00

(B)Requests for Elective Surgery

 Patients who are scheduled for elective surgery must have a group and antibody screen performed at least 48 hours prior to enable any detected antibodies to be catered for  Elective surgery should not be cancelled because of non availability of a group and antibody screen. Suitable units will be made available in the event of an emergency

(C)Blood Sampling

 Only suitably trained and competent staff may perform phlebotomy for group and antibody screen and cross-matching  All blood samples must be taken in accordance with Trust Policy (refer to Blood Sampling Policy (Adults)  The sample must be taken into an EDTA (pink top) tube and immediately labelled at the side of the patient by the staff member who took the sample. The sample must be labelled appropriately, as detailed above  Pre labelled tubes and addressograph labels MUST NOT be used

 When a cross-match is requested and the patient does not have a historical group recorded on the Apex computer system, the Transfusion Laboratory staff will request a second sample. This will NOT cause a delay in obtaining blood for the patient when blood is required urgently. The patient will receive group ‘O’ until the second sample has been verified

(D)Written Instruction and Observation Sheet (prescription) (appendix iii)

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 10 of 31  Before the collection of blood from the issue fridge, or blood and blood components from the Transfusion Laboratory, staff must check that a written instruction has been correctly and fully completed. This must include:

o Completed patient identifiers (addressograph label)

o Patients body weight

o Confirmation of consent and whether information leaflets were offered and accepted

o Blood, must be written as ‘packed red cells’, or blood component to be transfused, plus any special requirements (e.g. CMV negative, irradiated, HEV negative)

o Each unit must be written individually

o The duration or rate of transfusion

o Date to be transfused

o Name and signature of Clinician or Non-medical Authoriser

(E) Collection from the Blood Issue Fridge and the Transfusion Laboratory

 It is a statutory requirement that all staff collecting blood and blood components must have initial training and maintain their access by annual revalidation when asked to do so

Only suitably trained, competent and validated staff may collect blood and blood components

The member of staff should:

 Check the patient details on their identity band, notes and written instruction are correct

Remember: No Identity Band, No Transfusion

 Ensure there is a suitable, patent cannula for the transfusion – Flush the line prior to collecting  Ensure your patient is ready and has consented to having the transfusion. Allow time to discuss and alleviate any anxieties  Take official written confirmation of the patient’s identity to the issue fridge or Transfusion Laboratory. This must contain the four points of PID which matches the patient identity band  For the issue fridge, swipe their validated ID card to gain access Note: it is a disciplinary offence to use someone else’s card  Select the unit required and confirm the details on the blood compatibility label with the written confirmation of the patient’s identity  Scan the unit as demonstrated during training, ensuring the unit number appears on the screen  Only one unit per patient should be removed at a time  Take the unit directly to the clinical area in which it is needed in the red bag provided, make no diversions Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 11 of 31  Blood should be either started on the patient or returned to the Transfusion Laboratory within 30 minutes of removal from cold storage  In an emergency, massive haemorrhage situation, a cold box will be issued by the Transfusion Laboratory staff. This allows one hour for the blood to be either started on the patient or returned to the Transfusion Laboratory  Start the transfusion immediately on return to the clinical area, do not leave to ‘warm up’

Blood and blood components must NEVER be stored in a ward fridge

(F) Administration of Blood and Blood Components

 To administer and/or check blood and blood components the staff member must be a Registered Practitioner and suitably trained (firstly completed their IV competency) and have their blood awareness competency signed to level two  Transfusions must be administered in the clinical area, where frequent visual and verbal (where possible) contact can be maintained  Blood and blood components can be administered peripherally or centrally, a Y connector must NOT be used. No other fluids must be administered at the same time into the same peripheral cannula. However, if a patient has a double lumen central/PICC line with distal and proximal ports, different fluids can be administered at the same time  No other drugs or fluid can be mixed with blood and blood components under any circumstances  The correct giving set must be used for the appropriate blood component and its availability must be confirmed prior to collecting the component. This will prevent any unnecessary delay in starting the transfusion

Type of Component Type of set Change Set after Red Cells* Blood giving set with integral 12 hours or 4 units of blood 170-200 micron filter (whichever comes first) Platelets* Blood giving set with integral After each unit 170-200 micron filter Fresh Frozen Plasma* Blood giving set with integral At the end of the (FFP) 170-200 micron filter administration Cryoprecipitate* Blood giving set with integral At the end of the 170-200 micron filter administration *Fresh giving sets should be used with a different component. Do not use the same set for different components as clotting may occur

Be pragmatic during an emergency / massive haemorrhage situation

 Blood: must be administered within a maximum of four hours from leaving cold storage. Slow infusion promotes bacterial growth in the unit. Two hours is suitable for most patients however, those patients with underlying cardiac or respiratory conditions may require the transfusion to be given over three hours

Be aware of the volume being infused – remember the risk of TACO (Transfusion Associated Circulatory Overload) (Information Flyers appendix iv)

 Platelets: Start immediately once received into the clinical area and administer over 30 minutes  FFP/Cryoprecipitate: Start immediately once received into the clinical area and administer ‘stat’, maximum 30 minutes  Octaplas®: As for FFP/Cryoprecipitate  Volumetric pumps should be used with the appropriate administration set

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 12 of 31  To reduce the risk of transfusion errors, remote checking of the unit away from the patient is unacceptable and unsafe. Positive identification of the patient at the bedside is essential and mandatory  Ensure that all patient identity markers correspond (blood or blood component label, PID band and all other paperwork and documentation) any discrepancies, DO NOT TRANSFUSE  When a patient is conscious and able to communicate, it is recommended that a single Registered Practitioner should check the unit with patient at the bedside. The Registered Practitioner must ask the patient to state their surname, first name and date of birth  When a patient is unconscious or unable to communicate it is required that two registered practitioners check the unit, independently, at the bedside. If required another member of staff or relative/carer can confirm the patient’s identity  In the event of an “unknown” patient, the PID band, which will include the ED No, unknown male/female should be used for checking purposes

Refer to Patient Identification Policy

Remember: No Identity Band – No Transfusion

Any discrepancies – DO NOT transfuse, contact the Transfusion Laboratory and return the unit immediately

 The Registered Practitioner(s) must also check the expiry date (and time) of the blood or blood component and ensure the donor group number and the blood group on the bag corresponds to the printed Transfusion Laboratory label. Handwritten amendments to PID are NOT permitted  No unit of blood or blood component should be left unattended or stored in the clinical area

(G)Observations Required for the Transfusion

Conscious Patients

 Record the patient’s temperature, pulse, respirations (TPR), blood pressure (BP) and oxygen saturations (O² Sats) prior to (collection) starting the transfusion  Ask the patient to report if they are feeling unwell in any way during the transfusion  Repeat and record the patients TPR, BP and O² Sats within 15 minutes. This is the crucial time, as severe reactions frequently occur during this time  Observe the patient regularly throughout the transfusion  The recording of further observations and the regularity of those is dependent on the patient’s underlying condition or if the patient becomes unwell, or shows signs and symptoms of a reaction  Repeat and record the patients TPR, BP and O² Sats at the end of the unit  Regular visual observations of skin colour and cannula site must be undertaken  Fluid balance should recorded on the ‘fluid balance’ chart

Unconscious Patients

In addition to the observations for a conscious patient:

 Repeat the TPR, BP and O² Sats every 15 minutes for the first hour and hourly thereafter if patient stable

(H)Transfusing at Night

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 13 of 31  Routine transfusions can be administered overnight, providing the environment is conducive to safe practice enabling close monitoring of the patient and all observations to be carried out and recorded as per this policy. However, if the transfusion could safely wait until the following morning, then this would be preferable

Transfusions must take place overnight if the patient is bleeding

(I) Documentation

 It should be documented in the patient’s medical notes the reason for the transfusion and where the patient is able, that a conversation has taken place between the prescribing Clinician or Non-medical Authoriser and the patient about the risks and benefits associated with transfusion  The reason for the transfusion  The component type, amount administered and any adverse effects  ‘Fix to Patients Notes’ traceability labels should be filled in appropriately and placed on side two of the prescription (appendix iii)  ‘ Return to Blood Bank’ traceability labels should be filled in appropriately with date, time, name and signature of administrator and returned to the Transfusion Laboratory in the envelope provided  After administration of the emergency ‘O’ negative units, the label returned MUST be completed with the details of the patient who received the unit, in addition to the information stated above  Once the transfusion episode is completed, the prescription should be filed in the medical notes in the appropriate date area of the history sheets

2. MANAGEMENT OF ADVERSE TRANSFUSION REACTIONS (Flow chart, appendix v; Table of common complications associated with transfusion of a blood component, appendix vi)

(A) Acute Transfusion Reactions (ATRs)

 Present within 24 hours of transfusion and vary in severity from mild febrile to allergic reactions to life threatening events. They include: o Febrile non-haemolytic transfusion reactions – usually clinically mild o Allergic transfusion reactions – ranging from mild urticarial to life-threatening angio- oedema or anaphylaxis o Acute haemolytic transfusion reactions – e.g. ABO incompatibility o Bacterial contamination of blood unit – range from mild pyrexial reactions to rapidly lethal septic shock depending on species o Transfusion-associated circulatory overload (TACO) o Transfusion-associated acute lung injury (TRALI)

Patients with severe reactions can deteriorate very quickly with hypotension, respiratory distress, collapse and possible death

 Possible features of an acute transfusion reaction, which may include, but are not limited to: o Patient in distress o Restlessness/ behavioural changes o Pyrexia o Chills o Rigors o Tachycardia o Hyper/hypotension o Flushing/pallor Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 14 of 31 o Headache o Pain at or near transfusion cannula site o Urticaria o Anaphylaxis o Pain (bone, muscle, chest, abdominal, loin, back) o Dyspnoea o Respiratory distress o Nausea/vomiting o General malaise o Haemoglobinuria/haematuria o Collapse

(B)Suspected Minor Reaction

 Pyrexia of < 2º C from baseline and/or pruritus or rash WITHOUT other features:  The transfusion can be slowed down and continued with direct observation and possible treatment with oral paracetamol (adult dose 500-1000mg) and/or antihistamine (adult dose of chlorphenamine 10mg IV). If hydrocortisone is required the standard dose for an adult is 100mg by slow IV injection  If transfusion is discontinued follow suspected transfusion reaction process as below

(C)Suspected Moderate/Severe Reaction

 Pyrexia of > 2º C from baseline and/or chills, rigors, tachycardia, hyper/hypotension, urticaria, anaphylaxis, chest/back/abdominal/bone pain, dyspnoea, respiratory distress, nausea/vomiting, haemoglobinuria/haematuria, collapse  Stop the transfusion, call for medical assistance, check PID and unit compatibility label, maintain venous access, resuscitate and treat symptoms  Return implicated unit bag, with giving set, and any previous transfusion unit bags that have been used in this episode to the Transfusion Laboratory  Complete suspected transfusion reaction form as fully as possible (available only from the Transfusion Laboratory) and return promptly to the Transfusion Laboratory

(D)Documentation of ATRs/Incidents

 All transfusion (including ‘near miss’) incidents must be reported on the Trust’s ‘Safety Learning Event’ DATIX system (accessible from desktop icon)  TP/TPE will be alerted to transfusion related incidents entered onto DATIX. They will ensure correct process has been followed  Any ‘wrong blood component in patient’ or other major incident must be recorded as a SIRI and fully investigated in accordance with Trust Policy. Inform TP/TPE ASAP  Document clearly and concisely in patient’s notes  All ATR’s and any other adverse incidents will be discussed by the HTT and reported quarterly to the HTC

(E) SHOT/ SABRE Reporting

 Moderate/severe ATR will be reported to SHOT/SABRE as required to by the TP/TPE  SHOT suggest that TACO and TRALI are under reported. Therefore any suspicion of these, contact the TP (Monday – Friday 0800-1600) and the on-call Haematologist via the Trust switchboard

3. RAPID INFUSIONS AND BLOOD WARMERS

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 15 of 31  The routine warming of blood is not necessary  Warming the blood increases the risk of bacterial growth, so should not be used except in the following circumstances: o Massive haemorrhage where level one infusers are used o Neonates/Infants requiring exchange transfusion o Patients who have clinically significant cold agglutinin antibodies o Patients who are hypothermic or at risk of becoming hypothermic due to complicated or prolonged surgery

 If a blood warmer is required, this must only be done using a specifically designed commercial device, with a visible thermometer and audible alarm which ensures the blood is not warmed over 410C

 The device must be monitored and validated every twelve months. Blood warmers are extremely dangerous if they malfunction

4. STORAGE

 Blood is only to be stored in a purpose built, fully validated and alarmed fridge at between 2 and 60C, in accordance with BSQR (2005). This prevents the risk of bacterial growth. Note: The alarm is connected to the Hospital switchboard to alert of any malfunction  Blood must NEVER be stored in a ward/departmental drug or food fridge  As stated previously: Blood should be either started on the patient or returned to the issue fridge/Transfusion Laboratory within 30 minutes of removal from cold storage  In an emergency, massive haemorrhage situation, a cold box will be issued by the Transfusion Laboratory staff. This allows one hour for the blood to be either started on the patient or returned to the Transfusion Laboratory  Cross-matched blood units are normally available in the issue fridge for up to 48hrs, depending on the time the sample is taken. If they are not used within this time they are withdrawn and taken back to the Transfusion Laboratory and put into stock.  All units not transfused for any reason must be returned to the issue fridge/Transfusion Laboratory  Blood components must be transfused as soon as possible following removal from the Transfusion Laboratory to ensure they are at optimum quality. All unused units must be returned to the Transfusion Laboratory. These components must never be stored at ward/departmental level

5. TRANSPORTATION TO OTHER SITES

 Only staff who have received GMP (Good Manufacturing Practice) training may transport blood and blood components to other sites  Blood and blood components must only be transported between sites in a validated, sealed cold box, specifically designed for this purpose  The staff member packing the blood/blood components must record the date and time it was placed into the box, together with the end storage time or the time the contents must be returned to the Transfusion Laboratory  On receipt of the cold box at the destination, a suitably trained member of staff must sign the paperwork to acknowledge the maintenance of ‘cold chain’, the time of arrival and that the correct blood/blood component has arrived. This must be faxed to the Transfusion Laboratory on the number provided  Any discrepancies must be reported immediately to the sending Transfusion Laboratory. Under no circumstances must this blood/blood component be used without seeking advice

6. TRAINING REQUIREMENTS

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 16 of 31  Transfusion training forms part of the Trust’s Essential Skills and Training Requirements. This is included in the mandatory Corporate Induction and Essential Skills Updates  Staff must attend a classroom based, face-to-face ‘Blood Awareness Update’ every two years  This training is recorded on the individuals ESR (Electronic Staff Record) and is indicated on the Matrix when training is due  The Learning and Development Team provide a monthly heat map to each CSC (Clinical Service Centre), to enable the monitoring compliance  Compliance is further monitored through the CSC performance reviews with the Executive Team  As part of the Knowledge and Skills Framework (KSF) there is a Trust Competency for preparing and administering blood or blood components. Staff must be assessed by a level three assessor and have this signed to level two

15. REFERENCES AND ASSOCIATED DOCUMENTATION

Annual SHOT Report, 2014 PHT Neonatal / Paediatric Guidelines Blood Safety and Quality Regulations (BSQR) 2005 NICE Guidelines (NG24) November 2015 BCSH Guidelines PHT Speciality Guidelines and Policies, WRTS Blood Administration: Adults on Haemodialysis/Haemofiltration PHT Consent to Examination and Treatment Policy PHT Blood Sampling Policy (Adults) Guideline on the Care of Patients Who Wish to Decline Transfusions PHT Drug Therapy Guidelines:Use of Platelets No 138.02 Use of FFP and Cryoprecipitate No 72.03 Use of Octaplas® No 161.00

16. EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly

Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace. Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do. We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Respect and dignity Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 17 of 31 Quality of care Working together Efficiency

This policy should be read and implemented with the Trust Values in mind at all times.

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 18 of 31 17. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

This document will be monitored to ensure it is effective and to assurance compliance.

Minimum Lead Tool Frequency of Reporting arrangements Lead(s) for acting on requirement to be Report of Recommendations monitored Compliance 100% transfusion Phlebotomy Audit against Annually Policy audit report to: Chair of HTC samples taken and trainer blood  HTC labeled correctly sampling policy Requests for Transfusion Audit Annually Policy audit report to: Chair of HTC transfusion to be Practitioner  HTC made appropriately Process for Transfusion Audit Annually Policy audit report to: Chair of HTC administration of all Practitioner ID bands/  HTC transfusions including patient observations/ identification documentation /review of adverse events 100% of patients Transfusion Trending of Quarterly Policy audit report to: Chair of HTC receiving Practitioner Safety  HTC transfusions have Learning appropriate care events 100% of staff Transfusion ESR records 2 yearly Policy audit report to: Chair of HTC involved in the Practitioner held by  HTC transfusion process Learning and are competent Development and signed competency Transfusion Transfusion All inspections Annually Policy audit report to: Chair of HTC laboratory retains Laboratory from outside  HTC compliance with Manager agencies regulatory bodies

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 19 of 31 APPENDIX i

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 20 of 31 APPENDIX ii

Available to order from Medical Illustration

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 21 of 31 APPENDIX iii

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 22 of 31 Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 23 of 31 APPENDIX iv

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 24 of 31 Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 25 of 31 APPENDIX v

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 26 of 31 APPENDIX vi

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 27 of 31 Common Complications Associated with Transfusion of a Blood Component Problem Likely Cause Timing of Severity Management and Event Prevention (A) Acute Event

Intravascular Major ABO Almost Potentially fatal 10% Mortality Haemolysis incompatibility immediately Check for DIC and renal following start failure of transfusion Maintain BP and renal perfusion Contact: On-call Haematologist, T P, Transfusion Laboratory Initiate RED Safety Learning Event report (Datix) TACO Rapidly infused, large Occurs usually Potentially fatal Accurate assessment of (Transfusion volume infusions or within 2 - 6 patients at risk of TACO Associated high TACO risk hours of Careful attention to fluid Circulatory patients transfusion balance Overload) Consider appropriateness of transfusion Consider rate of transfusion and diuretic cover Initiate AMBER Safety Learning Event report (Datix) TRALI Leucocyte Antibodies During or within Potentially fatal Manage as for ARDS refer (Transfusion in donor blood 6 hours of to Critical Care Team Related Acute transfusion – Chest X-Ray – shows Lung Injury) RARE but can bilateral pulmonary be confused infiltrates with ARDS Initiate AMBER Safety (Acute Learning Event report Respiratory (Datix) Distress Syndrome) TAD (Transfusion Transfusion of donor Respiratory Potentially fatal Assess respiratory distress Associated blood and patient co- distress within CXR Dyspnoea) morbidities 24 hours of Oxygen saturations and transfusion and ABG’s no other Initiate Safety Learning associated Event report (Datix) grade cause appropriately Anaphylaxis IgA Antibodies in Immediate Potentially fatal Maintain ABC’s and follow donor or recipient Anaphylaxis Policy Initiate Safety Learning Event report (Datix) grade appropriately Septic Shock Bacterial During Potentially fatal Manage septicemia contamination transfusion Initiate Safety Learning Event report (Datix) grade appropriately Febrile, Non- Anti-leucocyte Up to several Unpleasant but Treat with Anti-pyretic (e.g.

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 28 of 31 haemolytic antibodies hours post not usually life Paracetamol 1g) transfusion threatening Initiate Safety Learning Event report (Datix) grade appropriately Urticaria IgE Antibodies in During Unpleasant but Treat or prevent with donor blood transfusion not usually life Antihistamine (Oral or IV) threatening Initiate Safety Learning Event report (Datix) grade appropriately (B) Delayed Event

Delayed IgG Antibodies to 2 – 26 days Not usually life Poor response to haemolytic donor blood post transfusion threatening transfusion reaction Jaundice Send samples for investigation Review transfusion needs TA-GvHD Donor lymphocytes Extremely rare Usually fatal None seen in the last 10 (Transfusion up to 30 days years following leucocyte Associated Graft following depletion Versus Host transfusion Irradiated blood to ‘at risk’ Disease) groups Post Transfusion Recipient antibodies 5 – 12 days Rare but Contact Bloodbank to Purpura (PTP) against HPA system post transfusion treatable arrange patient investigation at platelet laboratory Post Transfusion Infected donor blood Post transfusion Rare Depends on virus Viral Infection Seek specialist medical advice Iron overload Multi-transfused Occurs either Rare but Use iron chelation therapy patients with single treatable if or venesection episode of diagnosed Monitor LFT’s and cardiac multi-units or enzymes long term Consider cardiac scans transfusion therapies

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 29 of 31

Equality Impact Screening Tool

To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval for service and policy changes/amendments.

Stage 1 - Screening

Title of Procedural Document: Transfusion Policy (Adult)

Date of Assessment 22/04/2016 Responsible Hospital Transfusion Department Committee Name of person K Heron Job Title TP completing S Chambers TPE assessment Does the policy/function affect one group less or more favourably than another on the basis of : Yes/No Comments  Age No  Disability No Learning disability; physical disability; sensory impairment and/or mental health problems e.g. dementia  Ethnic Origin (including gypsies and travellers) No  Gender reassignment No  Pregnancy or Maternity No  Race No  Sex No  Religion and Belief No  Sexual Orientation No If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2

More Information can be found be following the link below www.legislation.gov.uk/ukpga/2010/15/contents

Stage 2 – Full Impact Assessment What is the impact Level of Mitigating Actions Responsible

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 30 of 31 Impact (what needs to be done to minimise / Officer remove the impact)

Monitoring of Actions The monitoring of actions to mitigate any impact will be undertaken at the appropriate level

Specialty Procedural Document: Specialty Governance Committee Clinical Service Centre Procedural Document: Clinical Service Centre Governance Committee Corporate Procedural Document: Relevant Corporate Committee

All actions will be further monitored as part of reporting schedule to the Equality and Diversity Committee

Blood Transfusion Policy Version: 9 Date of Issue: 26 May 2016 Review Date: 21 April 2019 (unless requirements change) Page 31 of 31