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Blood and Blood Products Standard 7: Blood and Blood Products The Victorian Department of Health is making this document freely available on the internet for health services to use and adapt to meet the National Safety and Quality Health Service Standards of the Australian Commission on Safety and Quality in Health Care. Each health service is responsible for all decisions on how to use this document at its health service and for any changes to the document. Health services need to review this document with respect to the local regulatory framework, processes and training requirements The author disclaims any warranties, whether expressed or implied, including any warranty as to the quality, accuracy, or suitability of this information for any particular purpose. The author and reviewers cannot be held responsible for the continued currency of the information, for any errors or omissions, and for any consequences arising there from. Published by Sector Performance, Quality and Rural Health, Victorian Government, Department of Health June 2014 Blood and Blood Products 1 Acknowledgements The Department of Health Victoria acknowledges the contribution of medical and health specialists, Victorian health services, and members of the National Safety and Quality Health Service Standards: Educational Resources Project project team, Steering Group and Advisory Committee. For the Blood and Blood Products module the Blood Matters Program, Department of Health, Victoria/ Australian Red Cross Blood Service, provided specialist advice. The Educational Resources Project Steering Group members comprised: Associate Professor Leanne Boyd, Steering Group Chair; Director of Education, Cabrini Education and Research Precinct, Cabrini Health Ms Madeleine Cosgrave, Project Manager Ms Susan Biggar, Senior Manager, Consumer Partnerships, Health Issues Centre Mr David Brown, Consumer representative Dr Jason Goh, Medical Administration Registrar - Cabrini Health Mr Matthew Johnson, Simulation Manager, Cabrini Education and Research Precinct, Cabrini Health Ms Tanya Warren, Educator, Cabrini Education and Research Precinct, Cabrini Health Ms Marg Way, Director, Clinical Governance, Alfred Health Mr Ben Witham, Senior Policy Officer, Quality and Safety, Department of Health Victoria The Educational Resources Project Advisory Committee members comprised: Associate Professor Leanne Boyd, Advisory Committee Chair; Director of Education, Cabrini Education and Research Precinct, Cabrini Health Ms Madeleine Cosgrave, Project Manager Ms Margaret Banks, Senior Program Director, Australian Commission on Safety and Quality in Health Care Ms Marrianne Beaty, Oral Health National Standards Advisor, Dental Health Services Victoria) Ms Susan Biggar, Senior Manager, Consumer Partnerships, Health Issues Centre Mr David Brown, Consumer representative Dr Jason Goh, Medical Administration Registrar, Cabrini Health Ms Catherine Harmer, Manager, Consumer Partnerships & Quality Standards, Department of Health, Victoria Ms Cindy Hawkins, Director, Monash Innovation and Quality, Monash Health Ms Karen James, Quality and Safety Manager, Hepburn Health Service Mr Matthew Johnson, Simulation Manager, Cabrini Health Ms Annette Penney, Director ,Quality and Risk, Goulburn Valley Health Ms Gayle Stone, Project Officer, Quality Programs, Commission for Hospital Improvement, Department of Health Victoria Ms Deb Sudano, Senior Policy Officer, Consumer Partnerships & Quality Standards , Department of Health Victoria Ms Tanya Warren, Educator, Cabrini Health Ms Marg Way, Director, Clinical Governance, Alfred Health Mr Ben Witham, Senior Policy Officer, Consumer Partnerships & Quality Standards, Department of Health Victoria Blood and Blood Products 2 Contents Blood and Blood Products 4 Introduction 4 Learning outcomes 4 National Standards 4 Aim of Standard 7 4 Policies and procedures 5 Background 5 Principles of blood and blood product safety 5 Use of blood and blood products 5 Prescriptions for transfusion 7 Sampling and testing 7 Administration of blood and blood products 7 Engaging with patients and carers 10 Documentation 11 Managing blood and blood product safety 12 Education and resources 12 Audit and evaluation 13 Reporting adverse events Error! Bookmark not defined. Summary 14 Glossary of Terms 15 Test Yourself 16 Answers 18 References 19 Blood and Blood Products 3 Blood and Blood Products Introduction This module relates to The National Safety and Quality Health Service (NSQHS) Standard 7: Blood and Blood Products. the level of care consumers should be able to expect from health services. Aim of Standard 7 The intention of Standard 7: Blood and Blood Products is to ensure safe, appropriate, effective and efficient blood management systems are in place and that patients and carers are engaged in decisions relating to their management. Standard 7 also relates to Standard 1: Governance for Safety and Quality in Health Service Organisations and Standard 2: Partnering with Consumers. The principles in these Standards are fundamental to all Standards and provide a framework for their implementation. ACSQHC, 2012 Learning outcomes On completion of this module, clinicians will be able to: 1. Describe the principles of patient blood management. 2. Understand the requirements for safe administration of blood and blood products. 3. Discuss recognition and response to adverse effects during administration of blood or blood products. Standard 7 also relates to Standard 5: patient Identification and Procedure Matching Criteria to achieve Standard 7: Governance and systems for blood and blood products prescribing and clinical use Health service organisations have systems in place for the safe and appropriate prescribing and clinical use of blood and blood products. Documenting patient information 4. Discuss the documentation requirements in relation to transfusion of blood and blood products. The clinical workforce accurately records a patient’s blood and blood product transfusion history and indications for use of blood and blood products. 5. Describe the process for engaging patients and carers in the plan for treatment that includes blood or blood products. Managing blood and blood product safety National Standards The Australian Commission on Safety and Quality in Health Care (ACSQHC) developed the 10 NSQHS Standards to reduce the risk of patient harm and improve the quality of health service provision in Australia. The Standards focus on governance, consumer involvement and clinically related areas and provide a nationally consistent statement of Blood and Blood Products Health service organisations have systems in place to receive, store, transport and monitor wastage of blood and blood products safely and efficiently. Communicating with patients and carers Patients and carers are informed about the risks and benefits of using blood and blood products, and the available alternatives when a plan for treatment is developed. Table 1: Criteria to meet Standard 7 (ACSQHC, 2012) 4 Policies and procedures There are numerous policies, procedures and resources within health care services to assist you with the management of blood and blood products. It is important to access, read and adhere to systems, policies and procedures within your organisation in relation to blood and blood product safety. ACSQHC, 2012 adverse events must be recorded, reported and reviewed to identify areas for improvements in safety and quality Patients and carers should: o be Informed of the risks and benefits of using blood and blood products and the available alternatives o provide informed consent o be engaged in developing the plan for treatment with the opportunity to ask questions Background The transfusion of blood and blood products can lead to complications and adverse outcomes for patients. The risks associated with transfusion of blood and blood products usually fall into two categories: 1. Errors in procedure such as: ACSQHC, 2012; ANZSBT/RCNA 2011 Use of blood and blood products Blood and blood products should only be given when the expected benefits to the patient are likely to outweigh the potential risks. incorrect patient identification inaccurate blood sample labelling ACSQHC, 2012; Australian Red Cross Blood Service (the Blood Service) administration of blood or blood products to the wrong patient The blood and blood products covered by Standard 7 include: 2. Transfusion reactions. Australian Haemovigilance Report, 2010 Principles of blood and blood product safety Best practice guidelines in effective blood and blood product management outline the following key messages: systems must be in place to receive, store and transport blood and blood products safely and efficiently and to monitor wastage the decision to transfuse should be made balancing the potential benefits for the patient with the potential risks accurate documentation is required for all aspects of blood and blood product management Blood and Blood Products 1. Fresh blood products Red blood cells Platelets Fresh frozen plasma Cryoprecipitate Cryodepleted plasma 2. Plasma-derivatives and recombinant products albumin factor concentrates immunoglobulins, including immunoglobulin replacement therapy (e.g. IVIg) and hyperimmune globulins 5 PATIENT BLOOD MANAGEMENT Patient blood management is the management and preservation of the patient’s own blood. These strategies help to improve patient outcomes and reduce or avoid the need for a blood transfusion through: optimising the patient’s own blood volume (e.g. iron therapy to boost iron stores and haemoglobin) minimising the patient’s blood loss (e.g. careful surgical technique and managing medications) increasing tolerance of anaemia (oxygen therapy and specifying haemoglobin levels at which transfusion is required) The decision on whether to transfuse should be carefully considered. It should be made balancing the potential benefits for the patient with the potential risks and take into account any available alternative treatments. The Patient Blood Management Guidelines funded by the National Blood Authority outline indications for effective patient blood management in the following six modules: 1. critical bleeding and massive transfusion responsibility are responsible for obtaining and documenting informed consent. INFORMED CONSENT Informed consent means a conversation has occurred between the patient, carers and the prescriber about the risks, benefits and alternatives to transfusion. This conversation must occur prior to any transfusion of blood or blood products. As a result of this discussion the patient should be aware of: why a transfusion is being recommended the risks and benefits of transfusion alternative options the risks of refusing transfusion provided with information in a format that is understood The clinician needs to ensure that the patient understands this information. The patient and carer must also be given the opportunity to ask questions and have them answered. You should follow your organisation’s documented procedures in life-threatening situations where consent cannot be obtained. 2. peri operative 3. medical (including haematology and oncology) 4. critical care The status of Modules 5 and 6 is: 5. obstetric – due for to be released for public consultation June 2014 6. paediatric and neonatal – expected to be available in 2015 National Blood Authority (NBA), 2013 DOCTORS’ RESPONSIBILITIES Doctors should ensure that blood and blood products are given only when clearly indicated. Doctors and other clinicians with prescribing Blood and Blood Products INFORMED REFUSAL OF BLOOD AND BLOOD PRODUCTS All competent adults have the right to refuse transfusion of blood and blood product. There must be a conversation between patients, carers and prescribers to ensure understanding of the likely risks and results of refusing transfusion. The notes should include documentation of the refusal of transfusion and any agreed alternatives. Clinicians have a legal and moral duty to the patient to respect and act on the patient’s informed refusal, irrespective of the clinician’s personal beliefs and opinions. 6 The wishes of the patient must never be assumed. For example, for many Jehovah’s Witnesses, blood transfusion is forbidden, however there may be variation amongst individuals. The Jehovah’s Witnesses have set up Hospital Liaison Committees to assist clinicians. Further information can be found on the Office of the Public Advocate Victoria website: http://www.publicadvocate.vic.gov.au There are specific requirements for the transfusion of blood and blood products where parental consent is refused. Further information may be found in section 24 of the Human Tissue Act (Vic), 1982. Sampling and testing The patient’s identity must be positively confirmed at pre transfusion sample collection and before the administration of blood or blood products. To safely identify the patient you must, where possible: ask the patient to state their full name and date of birth confirm the patient’s identity using at least three approved identifiers All samples and specimens must be correctly labelled at the patient’s side with the patient’s: surname given name Prescriptions for transfusion date of birth Blood or blood products must be prescribed by a health professional accredited to prescribe blood products. UR number (if they are an inpatient) Consumers Health Forum of Australia, 2013; Medical Treatment Act 1988 The prescription must be recorded on the intravenous fluid or transfusion chart using appropriate and consistent terminology of the blood product to be administered. It must be legible and contain: patient identification details: family name, given name, gender, date of birth and unique patient identification number if available date and timing and urgency of the transfusion the route and rate of administration the number of units or dose of blood product to be given the product type and any special requirements(e.g. irradiation) The prescription should outline other relevant instructions such as the use of blood warmers and any medication required before or after the transfusion. Blood and Blood Products This information should be confirmed with the patient and matched to the identification band and the request form or cross match request slip. Administration of blood and blood products The Australian and New Zealand Society of Blood Transfusion (ANZSBT/RCNA) Guidelines for the Administration of Blood Products 2nd Edition (2011) provide clinicians with guidance on the safe administration and management of patients having blood or blood products as part of their medical treatment. PREPARATION Prior to collection of the blood or blood product for transfusion the following measures should be implemented. Prescription and informed consent Ensure that there is a valid prescription and that informed consent has been obtained. 7 Venous access and equipment You must make sure that intravenous access is both patent (open and unobstructed) and of the correct size and location to support transfusion. Blood and blood products must be transfused using the appropriate administration sets and infusion devices which should be specified in your organisation’s procedures or guidelines. Indications for the use of rapid infusion sets and blood warmers may also be found in your organisations procedures or guidelines and as specified by the prescriber. ANZSBT/RCNA 2011 Location and timing of transfusion Transfusion should only take place when there are adequate numbers of trained staff available to observe and monitor the patient. This should include two staff to perform the blood product and patient identity checks at the patient’s side. There should also be access to emergency medical support. Transfusion should occur as soon as the product is delivered to the clinical area. Overnight and out-of-hours transfusion should be avoided unless clinically indicated. Priming administration sets TRANSFUSION Priming of the set may be done with 0.9% sodium chloride or the blood product. At completion of the transfusion, blood administration sets may be flushed with 0.9% sodium chloride, however, there is no evidence to suggest that this is of benefit between units, except to keep the vein open if there is delay. The final check at the patient’s side is a vital step in preventing transfusion error and should occur immediately prior to commencing the transfusion. Staff must be vigilant to ensure that the right blood is administered to the right patient. Platelets must not be transfused through a blood administration set which has been used for red cells, as red cell debris may trap infused platelets. The exception to this is during massive transfusion when platelets and plasma may need to be transfused through the same administration set. The patient’s identity must be confirmed by asking the patient to state name, DOB, and ensure these accurately match the ID band and the product compatibility slip immediately prior to the administration of blood or blood products. ANZSBT/RCNA 2011 Medications Pre-medication (if required) should be administered with enough time to take effect. Medication must not be added to the blood or blood product at any time. The administration set should not be used to administer medications prior to or during transfusion as they may interact with the product or additives in the blood product, e.g. anticoagulants. These should be noted in the health service’s policy ANZSBT/RCNA 2011 Blood and Blood Products ANZSBT/RCNA 2011 Positive identification of the patient Matching to the prescription The prescription or order must be available and confirmed at the patient’s side immediately before the transfusion commences. The blood product checking procedure must ensure the following: the patient details attached to the product match the patient who will receive the transfusion the blood product type is the same on the prescription, product and laboratory compatibility label (including any special requirements, e.g. irradiation) 8 the blood group on the blood product and the laboratory compatibility label matches the blood group of the patient transfusion is not to go ahead, the red blood cells must be returned to controlled storage conditions, within 30 minutes to prevent wastage. the blood product has not passed its crossmatch or product expiry date Duration of transfusion The integrity of the blood product is confirmed by excluding: any leaks any evidence of haemolysis, unusual discoloration or cloudiness the presence of any large clots If any discrepancy is found during the checking process at the patient’s side, the blood product must not be used and should be returned to the transfusion service provider. If there are no discrepancies, the blood product must be spiked immediately, by one of the clinicians involved in the identification and matching process. The commencement time must be documented on the appropriate paperwork or in the clinical record. ANZSBT/RCNA 2011 Observation and monitoring As a baseline, the vital signs of the patient must be measured and recorded prior to each transfusion. This includes temperature, pulse, blood pressure and respiration rate (T,BP,P,R). The patient must be closely observed for the first 15 minutes after commencement of each unit to identify any adverse effects. This should include patient observation and measurement of (T,BP,P,R). . Patient monitoring should continue throughout the transfusion. A final set of observations should be taken after the transfusion is complete. All observations must be recorded in the patient’s medical record. All transfusions should be completed within 4 hours of commencement of the transfusion or 4 ½ hours from release from storage. Transfusions should start slowly, where clinically appropriate. After 15 minutes, the transfusion can be increased to the specified rate as long as there are no signs of adverse reaction. The rate will depend on the context, age and clinical status of the patient. Recognising and responding to adverse events Prior to commencement of the transfusion, patients and any carers who are present, should be educated regarding potential adverse effects. They should be advised to report any effects to staff during or after the transfusion. The management of a transfusion reaction is dependent upon the type and severity of the reaction. Severe transfusion reactions such as haemolytic or septic events can occur within minutes of commencement and require urgent treatment. The most common sign of an adverse transfusion reaction is a rise in the patient’s temperature. This may be due to the transfusion or as a result of the patient’s underlying illness. A rise in temperature should prompt stopping the transfusion and a clinical assessment of the patient. You should refer to your organisation’s policies and procedures for managing and reporting transfusion reactions. Inform your blood supplier/pathology service and return any unused portion of the blood product for follow-up testing. Transfusion of red blood cells should be commenced within 30 minutes of the product being released from controlled storage. If for some reason this has not occurred, and the Blood and Blood Products 9 Immediately report the reaction to the transfusion service provider, who will advise on return of the implicated product and administration set, and any further blood or urine samples needed from the patient Signs Localised rash/itching and/or isolated temperature rise < 1.5 °C Monitor and record the patient’s temperature, pulse, respiration and blood pressure Record the volume and colour or any urine passed (looking for evidence of haemoglobinuria The following lists some common signs of transfusion reactions and suggested actions should signs and symptoms develop. Mild transfusion reactions Suggested actions STOP the transfusion Maintain IV access Monitor and record the patient’s temperature and vital signs Repeat all identity checks of the patient and blood pack. Contact medical staff immediately for further instructions and to review patient. Moderate to severe reactions Signs Any of the following could be considered signs of a moderate to severe transfusion reaction: Temperature >1.5 °C above baseline Hypotension/shock OR hypertension Tachycardia Tachypnoea, wheeze, stridor Rigors or chills Nausea, vomiting or pain (local, chest, back) Required actions If a moderate or severe transfusion reaction is suspected the following steps MUST be undertaken: STOP the transfusion immediately and seek urgent medical advice; Medical Emergency Team (MET) support may be required depending on the specific clinical situation Repeat all clerical and identity checks of the patient and blood pack Blood and Blood Products ANZSBT/RCNA 2011 All adverse events including transfusion reactions should be reported to the nurse/midwife in charge, the attending medical officer and be documented in the clinical record. They should also be reported on your organisation’s risk or incident management system, pathology provider/ the Blood Service. It is very important to notify the lab/ Blood Service as there may be other associated blood components implicated and these could potentially be a risk for other patients. Many blood components are made from a single donation and if there is a reaction to one of the components then others could also be at risk. This is often overlooked. Further information on the recognition and management of transfusion reactions is available in the guidelines (ANZSBT/RCNA 2011). The NBA is developing a chart to assist clinicians in the recognition and management of adverse transfusion reactions. Reporting adverse events All adverse events including transfusion reactions should be reported to the nurse/midwife in charge, the attending medical officer and be documented in the clinical record. They should also be reported on your organisation’s Risk or Incident Management System and to state or national systems. It is important to report outside the organisation as this is where trends or clusters of events can be detected. 10 Patients and carers should be fully informed of any adverse events and the organisation’s open disclosure processes implemented. This collaboration enables an opportunity for patients, carers and clinicians to share information which may impact on the effectiveness of the plan. Information trends can then be used to inform quality improvement activities such as system, policy, protocol and equipment improvements and education and training activities. Health care professionals should consider the following in order to encourage patients to be involved in their own care: ACSQHC, 2012 The NBA has developed reporting and governance frameworks for the National Haemovigilance program for Australia. It reports on serious transfusion related adverse events occurring in public and private hospitals. Relevant adverse events should also be reported to the: the Blood Service pathology service providerState Haemovigilance Incident Reporting Scheme (Serious Transfusion Incident Reporting=STIR) the service’s risk management tool the product manufacturer You should refer to your organisation’s policies and procedures regarding reporting of these adverse events. ensuring a conversation takes place between the clinician and the patient or carer about the specific transfusion, including risks, benefits and alternatives ensuring the patient understands and agrees to the transfusion and document informed consent in the clinical record explaining the need for repetitive identification explaining the patient’s role in safe care, including their ability to raise concerns with the heath care team providing relevant, easy to understand information about transfusion offering information in languages other than English and not assuming literacy Patients and carers should be encouraged to ask questions and take part in discussions and decisions about their care. Reporting criteria and further information is available at the: Blood Matters at: http://www.health.vic.gov.au/bloodmatter s/stir.htm National Blood Authority at: www.blood.gov.au Engaging with patients and carers Patients and carers should be educated about the benefits and risks of transfusion of blood and blood products. They must be involved in the development of a plan for care. This plan should identify the reasons for transfusion of blood products and outline any treatment alternatives. Blood and Blood Products ACSQHC, 2012 Documentation It is important to ensure accurate and comprehensive documentation in the clinical record in relation to all aspects of the transfusion of blood and blood products. This information should include: a record of the conversation between the patient, carer and prescriber resulting in consent to, or refusal of, the transfusion indications for transfusion or administration of the blood product 11 known medical conditions and transfusion history the prescription, laboratory compatibility report and product details including identification number, type and volume administered time of transfusion commencement and completion evidence of patient observations during transfusion patient response to the transfusion including occurrence and management of any adverse events The details of any transfusion of blood or blood products should also routinely appear in discharge documentation to inform future decision making and treatment. According to the Australian Standard (AS 3864 1997) Medical Refrigeration Equipment - For the Storage of Blood and Blood Products: red blood cells must only be stored in temperature-controlled and monitored, dedicated blood refrigerators and not in ward or domestic refrigerators all other blood products must be stored according to their specific requirements ANZSBT/RCNA, 2011 Before collecting any blood product from controlled storage, clinical staff and the patient must be adequately prepared to commence the transfusion process without delay. You must comply with your organisation’s procedures to accurately identify and record blood product removal from storage. ACSQHC, 2012 ACSQHC, 2012 Managing blood and blood product safety Management of blood and blood products refers to handling, transport, and storage (including inventory management). Inadequate product stores can potentially put patients at risk. Alternatively, storing too much blood can deplete products held by the supplier to insufficient levels, increase the age of blood at transfusion and increase wastage. Health care organisations must have systems and processes in place to ensure that blood and blood products are ordered, stored and handled appropriately. This is critical to maintain the quality and integrity of the product and to minimise wastage. Education and resources Clinical and relevant ancillary staff should be aware of the requirements for safe and appropriate storage of blood and blood products. Education is also required regarding: consent and refusal processes appropriate clinical use of blood and blood products safe transfusion administration practices documentation requirements for all aspects of blood and blood product management recognition and reporting of adverse events These systems should ensure the adequate supply of products to meet clinical needs and minimise the requirement to discard products. Blood and Blood Products 12 RESOURCES FOR STAFF There are considerable education and training resources available to guide organisations and clinicians in blood and blood product safety. These are available at the following sites: Australian Red Cross Blood Service at: www.transfusion.com.au RESOURCES FOR PATIENTS Patient information resources from the following sites may be adapted to suit a health service’s requirements: Blood transfusion: Have all your questions been answered and Frequently asked questions about blood transfusion (2012) at: http://docs.health.vic.gov.au/docs/doc/Bl ood-transfusion:-Have-all-your-questionsbeen-answered- Blood Matters Program Victorian Department of Health at: http://www.health.vic.gov.au/bloodmatter s Blood Safe e-learning at: https://www.bloodsafelearning.org.au Blood Matters at: National Blood Authority at: www.blood.gov.au National Blood Authority at: NBA inventory management guidelines at: www.blood.gov.au/sites/default/files/doc uments/nba-inventory-managementguidelines.pdf Other Australian State Jurisdictional Blood The Australian and New Zealand Society of Blood Transfusion (ANZSBT) Guidelines for the Administration of Blood Products 2nd Edition at: http://www.anzsbt.org.au/publications/do cuments/ANZSBT_Guidelines_Administrati on_Blood_Products_2ndEd_Dec_2011_Hy perlinks.pdf ANZSBT Guidelines for Pretransfusion Testing 4th Edition at: http://www.anzsbt.org.au/publications/do cuments/ANZSBTguide_Nov02b.pdf Other Australian State Jurisdictional Blood Programs, e.g. NSW Blood Watch, SA Blood Safe www.health.vic.gov/bloodmatters www.blood.gov.au Programs, e.g. NSW Blood Watch, SA Blood Safe The Australian Red Cross Blood Service Patient website at: www.mytransfusion.com Audit and evaluation You may be required to participate in audit activities which could include examination of: patient clinical records informed consent documentation transfusion records The purpose of audit is to measure compliance with policies and protocols and to monitor the frequency and severity of adverse events in relation to blood and blood products. This information can be used to improve practice. A range of audit tools can be found on the Blood Matters website: http://www.health.vic.gov.au/bloodmatters/tools/da ta-collection.htm Blood and Blood Products 13 Summary Blood and blood product safety is the focus of Standard 7 in the National Safety and Quality Health Service Standards. The key messages are: 1. The risks associated with transfusion of blood and blood products usually fall into two categories: Errors in procedure such as: o incorrect patient identification o inaccurate blood sample labelling o administration of incorrect blood or blood products, or to the wrong patient Transfusion reactions 2. Patient blood management practices should be employed to manage and preserve the patient’s own blood. These strategies help to improve patient outcomes and reduce or avoid the need for a blood transfusion. 3. The decision to transfuse should be made balancing the potential benefits for the patient with the potential risks. or blood product is administered to the right patient. 8. Transfusion should only take place when there are adequate numbers of trained staff available to observe and monitor the patient. 9. The patient must be closely observed for the first 15 minutes after commencement of each unit and monitored throughout the transfusion, to identify any adverse effects. 10. Systems must be in place to receive, store, transport blood and blood products safely and efficiently and monitor wastage. 11. Accurate documentation is required for all aspects of blood management. 12. All adverse events should be reported to the clinicians in charge and be documented in the clinical record. They should also be reported on your organisation’s risk management system, pathology provider/ the Blood Service. It is very important to notify the lab/ Blood Service as many blood components are made from a single donation, and if there is a reaction to one of the components then others could also be at risk. 4. Patients and carers should: be informed of the risks and benefits of using blood and blood products and available alternatives provide informed consent be engaged in developing the plan for treatment 5. Informed consent means a conversation has taken place between the patient, carer and prescriber about the risks, benefits and any alternatives to transfusion. 6. Correct patient identification at ALL points in the transfusion chain is vital to ensure patient safety in transfusion 7. The final check at the patient’s side is a vital step in preventing transfusion error. Staff must be vigilant to ensure that the right blood Blood and Blood Products 14 Glossary of Terms BLOODNET Australia’s national blood ICT system enabling online ordering, receipting, dating and inventory management of blood and blood products. TRANSFUSION The administration of all blood and blood products regardless of their route of administration including fresh blood components such as: ACSQHC, 2012 red blood cells HAEMOVIGILANCE Defined by the International Haemovigilance Network as ‘a set of surveillance procedures covering the whole transfusion chain (from the collection of blood and its components to the follow-up of recipients), intended to collect and assess information on unexpected or undesirable effects resulting from the therapeutic use of labile blood products, and to prevent their occurrence or recurrence’. platelets fresh frozen plasma cryoprecipitate cryodepleted plasma ACSQHC, 2012 INFORMED CONSENT Informed consent is a legal procedure undertaken to ensure that a patient understands the implications of treatment, in this case, transfusion of blood and blood products. Informed consent is given after a dialogue has occurred between the patient (and carers) and doctor about the risks, benefits and any alternatives to transfusion. As a result of this discussion the patient should: know why a transfusion is being recommended Plasma derivatives and recombinant products like: albumin immunoglobulins, including immunoglobulin replacement therapy and hyperimmune globulins cclotting factors ACSQHC, 2012 TRANSFUSION GOVERNANCE GROUP The group responsible for overseeing the Transfusion Quality Improvement System. This may be a dedicated transfusion committee or an agenda item on a quality committee. ACSQHC, 2012 TRANSFUSION QUALITY IMPROVEMENT SYSTEM be aware of the risks and benefits be aware of any alternatives have had an opportunity to ask questions and have them answered give consent for the transfusion A cycle of activities to review current practice relating to transfusion practice, assess risks, identify opportunities for improvement, implement practice improvement and measure the results. ACSQHC, 2012 ACSQHC, 2013 Blood and Blood Products 15 Test Yourself True or False? 1. Any discrepancy that is found in the transfusion checking process; such as loss of product integrity (e.g. clots in the bag), incorrect labelling (e.g. discrepancy in the DOB or spelling of name) or the, can still be administered if instructed by the treating Medical Officer. True or False (please circle) 2. Patient blood management refers to the preservation of patients’ own blood, improving the tolerance of anaemia, to reduce or avoid the need for a blood transfusion. True or False 3. In life threatening situations, where consent cannot be obtained, you should follow your organisation’s procedures. True or False 4. To safely identify your patient pre transfusion, you need to use at least two approved identifiers. True or False 5. The final check that takes place should be at the patient’s bedside, immediately prior to spiking the blood product. True or False 6. Medications can be added to blood and blood products. True or False 7. Baseline observations should be taken once the transfusion has commenced. True or False 8. Red blood cells should begin transfusion within 30 minutes of the product being released from controlled storage. True or False Blood and Blood Products 16 9. The transfusion should run over a maximum of 6 hours to maintain the quality of the blood product. True or False 10. The blood products and patient identity checks should be performed at the patient side immediately prior to transfusion. True or False 11. The most common sign of an adverse transfusion reaction is a rise in the patient’s temperature. True or False 12. Red blood cells must only be stored in temperature-controlled, dedicated blood refrigerators and not in ward or domestic refrigerators. True or False Blood and Blood Products 17 Answers 1. False – the blood product should not be administered, and should be returned to the transfusion service provider. 2. True. 3. True. 4. False – at least three approved identifiers must be used. 5. True. 6. False – medications should not be added to blood and blood products. 7. False – baseline observations should be taken prior to transfusion commencement and 15 minutes into the transfusion and the patient should be observed closely. 8. True. 9. False – The transfusion should be run over maximum 4 hours. 10. False – at least 2 staff members should complete the blood products and patient identity checks at the patient’s side. 11. True. 12. True. Blood and Blood Products 18 References Australian Red Cross Blood Service Transfusion - http://www.transfusion.com.au/ Australian and New Zealand Society of Blood Transfusion Ltd and Royal College of Nursing Australia. (2011). Guidelines For the Administration of Blood Components, 2nd Edition. Sydney, 2011. Australian Commission on Safety and Quality in Health Care (2012). Safety and Quality Improvement Guide Standard 7: Blood and Blood Products. Sydney: Commonwealth of Australia Australian Commission on Safety and Quality in Health Care (2013). Blood and Blood Products, Standard 7: Fact Sheet. ACSQHC, Sydney Blood Matters Home - http://www.health.vic.gov.au/bloodmatters/index.htm BloodSafe Home – Welcome to BloodSafe eLearning Australia. 2012. Accessed at www.bloodsafelearning.org.au/node/9 Consumers Health Forum of Australia. (2013). Informed Consent in Healthcare: An Issues Paper. Accessed at: https://www.chf.org.au/pdfs/chf/Informed-Consent-Issues-Paper.pdf Medical Treatment Act 1988 (Enduring Power of Attorney) National Blood Authority. Australian Haemovigilance Report 2010, A Report by the National Blood Authority Haemovigilance Advisory Committee. Canberra: National Blood Authority, 2010. National Blood Authority. Patient Blood Management Guidelines: Module 1 Critical Bleeding Massive Transfusion. NBA, 2011. National Blood Authority.(2012). Patient Blood Management Guidelines: Module 2 Perioperative. Blood and Blood Products 19 Blood and Blood Products 20