Download Blood Tranfusion Policy - Portsmouth Hospitals NHS Trust

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
Related Procedural Documents
Patient Identification Policy; Consent to Examination and
Treatment Policy; Management of Adverse Incidents and Near
Misses; Management of Serious Incidents Requiring
Investigations; Massive Haemorrhage Protocol;
Key Words (to aid with searching)
Blood; Platelets; Red Cells; Adverse Transfusion Reactions;
Administration;
Observations;
Blood
Components;
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
Ratified
Brief Summary of Changes
Author
9
22/04/2016
Title. Minor adjustments throughout. Indication Codes; Special
Requirements; Consent Sticker; Written Instruction and
Observation Sheet; Flyer Information; Reaction Flow Chart.
K Heron/ Sue
Chambers
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 30
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 30
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 NonMedical 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 30
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 30
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.
2. 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
3. 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 30
4. 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
5. DUTIES AND RESPONSIBILITIES
(A) 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 30
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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
(B) 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
(C) 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
(D) 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
(E) 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 30
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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
(F) 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
(G) 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
(H) 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
6. 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
(A) 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 30
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
That any patient may have valid personal reasons or beliefs for not wishing to have a
transfusion
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
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
The patient should be provided with information about alternatives to transfusion, including
autologous transfusion, where appropriate
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)
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
o
o
o
o
o
o
For guidance regarding religious or personal beliefs refer to the Trust’s Guideline on
the Care of Patients Who Wish to Decline Transfusions.
(B) Requesting Blood and Blood Components
For Emergency Issue of Blood or activation of the Massive Haemorrhage Protocol call
4444
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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 30

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

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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
(C) 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
(D) Blood Sampling
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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
(E) Written Instruction and Observation Sheet (prescription) (appendix iii)

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:
Blood Transfusion Policy
Version: 9
Date of Issue: 26 May 2016
Review Date: 21 April 2019 (unless requirements change)
Page 10 of 30
o
o
o
o
o
o
o
o
Completed patient identifiers (addressograph label)
Patients body weight
Confirmation of consent and whether information leaflets were offered and accepted
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)
Each unit must be written individually
The duration or rate of transfusion
Date to be transfused
Name and signature of Clinician or Non-medical Authoriser
(F) 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
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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 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
(G) 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
Blood Transfusion Policy
Version: 9
Date of Issue: 26 May 2016
Review Date: 21 April 2019 (unless requirements change)
Page 11 of 30

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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
Red Cells*
Type of set
Blood giving set with integral
170-200 micron filter
Platelets*
Blood giving set with integral
170-200 micron filter
Fresh Frozen Plasma*
Blood giving set with integral
(FFP)
170-200 micron filter
Cryoprecipitate*
Blood giving set with integral
170-200 micron filter
*Fresh giving sets should be used with a different component. Do not
components as clotting may occur
Change Set after
12 hours or 4 units of blood
(whichever comes first)
After each unit
At the end of the
administration
At the end of the
administration
use the same set for different
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)
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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
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
Blood Transfusion Policy
Version: 9
Date of Issue: 26 May 2016
Review Date: 21 April 2019 (unless requirements change)
Page 12 of 30
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
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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
(H) Observations Required for the Transfusion
Conscious Patients
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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
(I) Transfusing at Night

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
(J) Documentation
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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
Blood Transfusion Policy
Version: 9
Date of Issue: 26 May 2016
Review Date: 21 April 2019 (unless requirements change)
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



‘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
7. 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 angiooedema 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
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:
Blood Transfusion Policy
Version: 9
Date of Issue: 26 May 2016
Review Date: 21 April 2019 (unless requirements change)
Page 14 of 30


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
8. RAPID INFUSIONS AND BLOOD WARMERS


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
Blood Transfusion Policy
Version: 9
Date of Issue: 26 May 2016
Review Date: 21 April 2019 (unless requirements change)
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9. 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
10. 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
11. TRAINING REQUIREMENTS






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
Blood Transfusion Policy
Version: 9
Date of Issue: 26 May 2016
Review Date: 21 April 2019 (unless requirements change)
Page 16 of 30
12. 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
13. 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
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 17 of 30
14. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
This document will be monitored to ensure it is effective and to assurance compliance.
Minimum
requirement to be
monitored
Lead
Tool
Frequency of
Report of
Compliance
100% transfusion
samples taken and
labeled correctly
Phlebotomy
trainer
Audit against
blood
sampling
policy
Annually
Requests for
transfusion to be
made appropriately
Transfusion
Practitioner
Audit
Annually
Process for
administration of all
transfusions
including patient
identification
Transfusion
Practitioner
Audit
ID bands/
observations/
documentation
/review of
adverse
events
Annually
100% of patients
receiving
transfusions have
appropriate care
Transfusion
Practitioner
Trending of
Safety
Learning
events
Quarterly
100% of staff
involved in the
transfusion process
are competent
Transfusion
Practitioner
ESR records
held by
Learning and
Development
and signed
competency
2 yearly
Transfusion
laboratory retains
compliance with
regulatory bodies
Transfusion
Laboratory
Manager
All inspections
from outside
agencies
Annually
Reporting arrangements
Policy audit report to:

Blood Transfusion Policy
Version: 9
Date of Issue: 26 May 2016
Review Date: 21 April 2019 (unless requirements change)
Chair of HTC
HTC
Policy audit report to:

Chair of HTC
HTC
Policy audit report to:

Chair of HTC
HTC
Policy audit report to:

Chair of HTC
HTC
Policy audit report to:

Chair of HTC
HTC
Policy audit report to:

Lead(s) for acting on
Recommendations
HTC
Page 18 of 30
Chair of HTC
APPENDIX i
Blood Transfusion Policy
Version: 9
Date of Issue: 26 May 2016
Review Date: 21 April 2019 (unless requirements change)
Page 19 of 30
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 20 of 30
APPENDIX iii
Blood Transfusion Policy
Version: 9
Date of Issue: 26 May 2016
Review Date: 21 April 2019 (unless requirements change)
Page 21 of 30
Blood Transfusion Policy
Version: 9
Date of Issue: 26 May 2016
Review Date: 21 April 2019 (unless requirements change)
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APPENDIX iv
Blood Transfusion Policy
Version: 9
Date of Issue: 26 May 2016
Review Date: 21 April 2019 (unless requirements change)
Page 23 of 30
Blood Transfusion Policy
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Date of Issue: 26 May 2016
Review Date: 21 April 2019 (unless requirements change)
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APPENDIX v
Blood Transfusion Policy
Version: 9
Date of Issue: 26 May 2016
Review Date: 21 April 2019 (unless requirements change)
Page 25 of 30
Blood Transfusion Policy
Version: 9
Date of Issue: 26 May 2016
Review Date: 21 April 2019 (unless requirements change)
Page 26 of 30
APPENDIX vi
Common Complications Associated with Transfusion of a Blood Component
Problem
(A)
Likely Cause
Timing of
Event
Severity
Management and
Prevention
Acute Event
Intravascular
Haemolysis
Major ABO
incompatibility
Almost
immediately
following start
of transfusion
Potentially fatal
TACO
(Transfusion
Associated
Circulatory
Overload)
Rapidly infused, large
volume infusions or
high TACO risk
patients
Occurs usually
within 2 - 6
hours of
transfusion
Potentially fatal
TRALI
(Transfusion
Related Acute
Lung Injury)
Leucocyte Antibodies
in donor blood
Potentially fatal
TAD (Transfusion
Associated
Dyspnoea)
Transfusion of donor
blood and patient comorbidities
Anaphylaxis
IgA Antibodies in
donor or recipient
During or within
6 hours of
transfusion –
RARE but can
be confused
with ARDS
(Acute
Respiratory
Distress
Syndrome)
Respiratory
distress within
24 hours of
transfusion and
no other
associated
cause
Immediate
Septic Shock
Bacterial
contamination
During
transfusion
Potentially fatal
Potentially fatal
Potentially fatal
Blood Transfusion Policy
Version: 9
Date of Issue: 26 May 2016
Review Date: 21 April 2019 (unless requirements change)
10% Mortality
Check for DIC and renal
failure
Maintain BP and renal
perfusion
Contact: On-call
Haematologist, T P,
Transfusion Laboratory
Initiate RED Safety
Learning Event report
(Datix)
Accurate assessment of
patients at risk of TACO
Careful attention to fluid
balance
Consider appropriateness
of transfusion
Consider rate of transfusion
and diuretic cover
Initiate AMBER Safety
Learning Event report
(Datix)
Manage as for ARDS refer
to Critical Care Team
Chest X-Ray – shows
bilateral pulmonary
infiltrates
Initiate AMBER Safety
Learning Event report
(Datix)
Assess respiratory distress
CXR
Oxygen saturations and
ABG’s
Initiate Safety Learning
Event report (Datix) grade
appropriately
Maintain ABC’s and follow
Anaphylaxis Policy
Initiate Safety Learning
Event report (Datix) grade
appropriately
Manage septicemia
Initiate Safety Learning
Event report (Datix) grade
appropriately
Page 27 of 30
Febrile, Nonhaemolytic
Anti-leucocyte
antibodies
Up to several
hours post
transfusion
Unpleasant but
not usually life
threatening
Urticaria
IgE Antibodies in
donor blood
During
transfusion
Unpleasant but
not usually life
threatening
(B)
Treat with Anti-pyretic (e.g.
Paracetamol 1g)
Initiate Safety Learning
Event report (Datix) grade
appropriately
Treat or prevent with
Antihistamine (Oral or IV)
Initiate Safety Learning
Event report (Datix)
grade appropriately
Delayed Event
Delayed
haemolytic
reaction
IgG Antibodies to
donor blood
2 – 26 days
post transfusion
Not usually life
threatening
TA-GvHD
(Transfusion
Associated Graft
Versus Host
Disease)
Post Transfusion
Purpura (PTP)
Donor lymphocytes
Extremely rare
up to 30 days
following
transfusion
Usually fatal
Recipient antibodies
against HPA system
5 – 12 days
post transfusion
Rare but
treatable
Post Transfusion
Viral Infection
Infected donor blood
Post transfusion Rare
Iron overload
Multi-transfused
patients
Occurs either
with single
episode of
multi-units or
long term
transfusion
therapies
Rare but
treatable if
diagnosed
Blood Transfusion Policy
Version: 9
Date of Issue: 26 May 2016
Review Date: 21 April 2019 (unless requirements change)
Poor response to
transfusion
Jaundice
Send samples for
investigation
Review transfusion needs
None seen in the last 10
years following leucocyte
depletion
Irradiated blood to ‘at risk’
groups
Contact Bloodbank to
arrange patient
investigation at platelet
laboratory
Depends on virus
Seek specialist medical
advice
Use iron chelation therapy
or venesection
Monitor LFT’s and cardiac
enzymes
Consider cardiac scans
Page 28 of 30
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
Department
Name of person
completing
assessment
K Heron
S Chambers
Job Title
Hospital Transfusion
Committee
TP
TPE
Does the policy/function affect one group less or more favourably than another on the basis
of :
Yes/No
 Age
No
 Disability
Learning disability; physical disability; sensory
impairment and/or mental health problems e.g.
dementia
No
 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
Comments
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
(what needs to be done to minimise /
Blood Transfusion Policy
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Date of Issue: 26 May 2016
Review Date: 21 April 2019 (unless requirements change)
Page 29 of 30
Impact
remove the impact)
Officer
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)
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