Transfusion Procedure #
Safe Transfusion Practice is the goal of the multidisciplinary team members involved in transfusion medicine.
The skills and expertise of the health care team members are key in providing the patient with an uneventful therapeutic intervention such as a blood transfusion.
These same skills and expertise are also required to identify when there has been a deviation in process, or when an unusual event such as a transfusion reaction has occurred and how to respond to such an event.
There are several essential steps for safe transfusion practice and the nurse or physician involved should be fully aware of the elements of each step.
Procedures can vary for different hospitals or agencies, so consult your policy and procedure manuals or contact your Blood Transfusion Service for local information.
Physician’s Order #
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As with any medically prescribed procedure, a Physician’s Order is required to initiate the process. Some hospitals have implemented a pre-printed order form specific to transfusion that includes all of the information necessary to transfuse safely.
This pertinent information may also be required by the blood transfusion service in order to request or prepare the product. The clinical indication for the transfusion should be noted in the Physician’s Order or history form.
The Physician’s Order must specify:
- The patient’s first and last names and unique identifier number
- The date, time, and duration of the transfusion
- The amount and type of blood, blood components or other related products to be transfused
- The sequence in which multiple components are to be transfused
- Any modifications to the component, such as irradiation or washing
- Special transfusion requirements
- The use of a blood warmer or rapid infusion device, except in specialty areas where there is an established hospital policy and procedure
- Any pre- and post-transfusion medication orders related to the transfusion
The procedure for processing a physician’s order and the time required to obtain the products will vary so consult your procedure manual or contact your Blood Transfusion Service.
Informed Consent #
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“Informed Consent” is a legal term for the granting of permission by a patient to allow a medical procedure, after receiving complete information on the benefits, risks and alternatives of the proposed treatment or procedure, usually by the attending physician or surgeon.
The informed consent of a patient is mandatory in many hospitals for the transfusion of all blood and blood products, such as red cells including autologous blood, plasma, platelets, and cryoprecipitate.
Responsibility for obtaining informed consent rests with the physician most responsible for the patient, usually the ordering physician, and cannot be delegated. Ideally the discussion between physician and patient will occur prior to the planned surgery or on admission to hospital, and consent, or possibly refusal of consent, is documented at the time of the discussion.
Although policy directives and the method of documentation of informed consent can vary from one hospital to another, the elements of informed consent remain consistent. First, the physician must provide relevant information to the patient, including
- a description of the blood product or component,
- the benefits of the treatment,
- the risks of the treatment,
- and any and all alternatives to the treatment, including their benefits and risks
Informed consent includes an opportunity for questions and clarification, to ensure that the patient understands the information provided and is able to make a knowledgeable decision based upon complete information. The patient then agrees or refuses to give consent and the appropriate documentation is completed.
In emergency situations, informed consent is not required for blood transfusions:
- when treatment is necessary to preserve a patient’s life and continuing health,
- and it is not reasonably possible to obtain consent,
- and there is no substitute decision maker,
- and there is no evidence of advance directive.
In the case of minors, the Infants Act should prevail.
The registered nurse will ensure documentation of informed consent for blood or blood products is complete as per hospital policy before administering any product, or will ensure that the emergency response has been initiated. In the event there is no documentation of a discussion and / or the patient disclaims knowledge or understanding of the intended transfusion, the registered nurse will notify the physician and should not initiate an elective transfusion until the situation has been resolved.
Specimen Collection #
The transfusion process begins with the collection of a specimen, which involves both accurate identification of the patient and correct labeling of the specimen.
Without exception, every patient must be uniquely and positively identified using an identification band or equivalent. Whenever possible, as a final identification check, the patient should be asked to spell his or her name and state date of birth.
“Catherine, C-A-T-H-E-R-I-N-E. ; Hammil, H-A-M-M-I-L.” “June 7, 1980”
Specimens obtained for the purpose of Blood Grouping and Screening must be labeled in the presence of the patient, at the time of draw. It is essential that the information is accurate and correct on the patient identification band or equivalent, the requisition, and the label. This reduces the risk of a hemolytic reaction due to mislabeling at the time of collection. This kind of error cannot be detected during the laboratory screening process unless there is a pre-existing blood grouping on the patient file.
If you encounter a problem in meeting this standard in your clinical area, consult with your Blood Transfusion Service and establish an alternative process that will ensure proper identification and meet the standards necessary to ensure a safe transfusion.
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Transporting Blood Products (within hospital) #
The first step in initiating the transfusion is to check the patient chart and verify:
- the physician’s order
- informed consent, and
- completed ABO/Rh screening (if available)
When the physician’s order and informed consent are complete and current, and when the patient is prepared for the transfusion, the product may be obtained.
Blood and blood components or other related products must be requested or acquired from the Blood Transfusion Service or hospital lab immediately prior to initiation of the transfusion. Again, procedures will vary so familiarize yourself with your hospital policy and length of time required to receive blood products.
The Blood Transfusion Service or laboratory, as part of its accreditation process, is responsible for ensuring that established industry practice standards are met for such procedures as:
- receiving
- processing
- storing
- issuing and transporting
- documenting
If blood accompanies a patient from another hospital, it must not be opened. The blood must be delivered immediately to the Blood Transfusion Service for inspection.
A product may be issued, transported, returned to the Blood Transfusion Service and re-issued, sometimes several times, before it is transfused. Therefore, for the purpose of quality assurance, established procedures, based on the guidelines, must be followed.
Often these procedures will extend beyond the lab into the clinical areas, for example, the storage of blood products in a monitored satellite refrigerator.
The lab or Blood Transfusion Service standards require that monitoring procedures, such as documenting the temperature readings or changing the graph charts, are completed. The transportation of blood products usually involves other members of the health care team such as a hospital porter, nurse and sometimes even the physician.
In some instances, hospital policy may permit the use of a specialized pneumatic tube system. It is important that everyone involved in handling blood and blood components recognize that established guidelines must be followed to ensure the quality of the product.
Policies should clearly define:
- who may sign out products from the Blood Transfusion Service and transport them to the patient’s location
- acceptable timeframes for blood and blood products to be in transit
- acceptable timeframes from the issuance of blood and blood products by the Blood Transfusion Service until the time the transfusion is completed
- Appropriate handling and storage procedures
Blood products must be transported to the patient location and initiated within 30 minutes of issuance, or stored appropriately in a monitored satellite refrigerator or approved storage container. For example, in situations where appropriate storage is not provided, red cells must be discarded if returned to the lab after 30 minutes.
Consult your lab manual or Blood Transfusion Service for information regarding transporting procedures and documentation required within your hospital.
Patient Identification #
Once it is established that the product is available and that the transfusion can proceed, initiate or assess IV site access with normal saline, or in the case of IVIG, 5% dextrose and water. Blood or blood components should be administered through a needle gauge large enough to allow appropriate flow rates and avoid cell damage. Products must be transfused within 4 hours of the time of issue. Medication cannot be added to blood products or to the blood administration set. Pre-medications must be administered through regular IV tubing and the access line cleared of medication prior to the initiation of the blood product.
When the required blood product is received at the patient’s location, all documentation must be completely verified. This process is identical, regardless of whether it involves one or two transfusion-trained staff members. Specific guidelines for one or two person procedures should be in your hospital manual.
At this time it is important to check the appearance of the unit for clots, clumps, or discolouration, including black or purple colour of the red cell mass, and the integrity of the seals. If you have any concerns, consult your blood transfusion service.
Accurate patient identification requires the patient chart, the patient identification band, the labeled blood products, and any other documentation issued by the lab or Blood Transfusion Service. This process should be done without interruption.
First, compare the information on the relevant documentation from the Blood Transfusion Service with the patient chart, verifying the patient’s name, unique identifying number, and the physician’s order. Then compare the information on the documentation from the Blood Transfusion Service with the product identification label and attached blood product tag.
Verify:
- The patient’s name and unique identification number
- The type of component
- Any special requirements
- The Component Serial Number
- Expiry date, and
- ABO/Rh, when applicable
The final and most important step in the identification process is completed in the presence of the patient immediately prior to the transfusion.
Compare the patient’s full name and unique identifier number using:
- the patient identification band or equivalent
- the blood product label and attached tag
- any other relevant documentation from the Blood Transfusion Service
Whenever possible, have the patient spell both first and last names and state his or her date of birth.
“Catherine, C-A-T-H-E-R-I-N-E ; Hammil,H-A-M-M-I-L.” ; “June 7, 1980”
In the event of any discrepancy or inaccuracy in any information, do not proceed. Contact the lab or blood transfusion service immediately for resolution and direction.
Initiating and Terminating the Transfusion #
Immediately prior to transfusion, obtain baseline vital signs including blood pressure, temperature, pulse and respiration. For patients identified at risk for circulatory overload such as the elderly or pediatric populations, conduct a cardiovascular assessment. Assess also for existing clinical manifestations that maybe confused with a transfusion reaction such as rash, fever, back pain or shortness of breath.
The bag of Normal Saline and IV tubing must remain ready in case a transfusion reaction occurs. Unless otherwise stated in a physician’s order or
hospital policy, blood and blood components must be transfused through a standard sterile, pyrogen–free transfusion set, that has a filter, usually 170—260 microns, designed to retain particles that could potentially be harmful to the patient.
Filter tubing used for the administration of blood, blood components and other products for transfusion must be changed every four hours or after two to four units of blood, whichever comes first. Also note that it’s recommended that filter tubing sets be changed
between the administration of different blood components. Only after final verification, and when all information is accurate and the patient’s vital signs have been obtained, should the blood container be spiked. When priming the blood set, for maximum efficiency of the filter, ensure the filter is completely covered with the blood product.
Begin the transfusion slowly and remain with the patient for the first 5 minutes. The recommended initial rate for adults is no more than 25 mL in the first 15 minutes.
For pediatric patients rates vary with product. For red blood cells, 5% of the total volume ordered within the first 15 minutes, then increase to 2-5 mL per kg per hour or as tolerated. For platelets, 5% of the total volume ordered within the first 5 minutes, then one unit run over 30 minutes to a maximum of four hours. For plasma, 5% of the total volume ordered within the first 5 minutes, then 1 – 2 mL per minute.
Explain the possible side effects to the patient and advise him or her to report any symptoms such as shortness of breath, fever, itching or chills.
After 15 minutes, vital signs are taken again. Assessing and identifying a transfusion reaction is the responsibility of the registered nurse or physician administering the transfusion. Monitoring and documenting vital signs 15 minutes after initiation and a least hourly throughout the procedure is essential. The infusion rate may be increased after 15 minutes, but only in the absence of any adverse symptoms. Products should be transfused according to the physician’s order and within 4 hours of issue from the lab or blood transfusion service or removal from a satellite refrigerator.
The transfusion process must be documented on the patient record. At this time, record:
- the type of blood or blood component,
- the unit or lot number,
- the time the transfusion was initiated,
- the transfusion rate,
- the patient’s initial response to the transfusion, and
- the patient’s vital signs.
Although it is not required to clear the tubing between units, upon completion of the transfusion it is necessary to clear the blood administration set of the blood product.
This can be accomplished by infusing a maximum of 50mLs of Normal Saline or in the case of IVIG, use 5% Dextrose and Water and administer slowly through the existing blood administration set. Once the 50mL bag is empty, complete the patient’s vital signs and observe for any symptoms of a transfusion reaction. Re-establish IV infusion as previously ordered, or discontinue the intravenous site if the patient is clinically stable.
Discard the empty blood product bag and blood administration set into a hazardous waste container.
Documentation of the transfusion must now be completed on the patient record, and must include:
- The time the transfusion was completed,
- The final volume transfused,
- Patient response since the initial entry, and
- The patient’s vital signs
If the transfusion was interrupted for any reason, the time of interruption and re-initiation must also be recorded.
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Nursing Procedures #
During the monitoring process, the patient should be observed for any symptoms of an adverse transfusion reaction. Hives and itching could indicate a minor allergic reaction.
A minor febrile reaction could be characterized by:
- nausea and vomiting
- chills and/or minor rigors
- anxiety
- fever, defined as an increase in baseline temperature of more than 1 degree Celsius.
Major, and potentially serious, transfusion reactions are characterized by, but not limited to, one or more of these symptoms:
- unexpected bleeding
- heat and/or pain at the IV site
- shortness of breath
- nausea and vomiting
- bilateral pulmonary edema
- facial and/or tongue swelling
- shock
- chest pain
- back pain
- red or brown urine
- fever, again a temperature increase of more than a 1 degree from the pre-transfusion baseline
- headache
- jaundice
- wheezing
- flushing
- rigors and/or severe chills
- anxiety
All reactions should be managed according to established hospital policies and procedures, If any of these symptoms, minor or major, occur:
- First, stop the transfusion immediately, and disconnect the blood set from the IV site.
- Run Normal Saline to keep the vein open.
- Verify patient identification with the blood product and requisition.
- Take vital signs as indicated in hospital policies and procedures.
Notify the attending physician and the Transfusion Service immediately, and follow instructions.
- Complete the Transfusion Reaction Report Form, identifying all patient and blood product information, symptoms, and transfusion information. It is very important that all relevant information is reported accurately and quickly to your hospital Transfusion Service.
If the reaction consists only of hives and/or itching – that is, a minor allergic reaction:
- No blood or urine specimen is required.
- With appropriate medication and frequent monitoring of vital signs, the transfusion may be restarted at a slower rate.
For ALL other transfusion reactions:
- Follow hospital procedures or contact the lab for appropriate specimen collection requirements for post transfusion blood and urine samples.
- Monitor the patient’s renal function by obtaining the first voided urine.
- Be sure to indicate on all specimens, report forms, and requisitions being sent to the laboratory that they are “post-transfusion” specimens.
- Return the entire transfusion set-up, including tubing and previously completed blood product containers, to Transfusion Service as soon as possible.
Closing
The standardized guidelines and educational material presented have been developed as a component of a hospital based transfusion safety program to assist nurses and the health care team in the provision of quality transfusion therapy.
Section Two of this program provides more detailed information on adverse reactions, including:
- types of transfusion reactions
- the causes of those reactions
- the signs and symptoms of reactions,
- the action required as per patient care guidelines.