6 TRANSFUSION PROCEDURES

The transfusion procedures described in this section have been approved for use in the University of Michigan Hospitals and Health Centers.

Patient care units may have specific patient care needs that require alterations in these policies and procedures.

Alternative Procedures

Alternative procedures must be approved by the Transfusion Committee of the University of Michigan Hospitals and Health Centers and must be available to patient care personnel.

Training and Competency Assessment

Personnel who participate in the administration of blood components must be trained on hire and annually in transfusion procedures and in recognition and management of adverse reactions.

Bedside identification is required prior to the start of a transfusion. 

Blood Product Administration Module (BPAM)

When barcode scanning is utilized in MiChart BPAM to verify the match between the blood product and the intended patient, the computer acts as the 2nd check for the identification verification.  Documentation of the transfusion should be fully recorded in MiChart

The following barcodes must be scanned:

• Patient wristband
• Donor unit number
• Product code
• Donor blood type
• Donor unit expiration

Manual Patient and Blood Product Verification

When MiChart BPAM is not used, the bedside identification is to be performed by qualified individuals such as a privileged provider and registered nurse, two registered nurses, or by a registered nurse and a licensed practical nurse.

Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) must complete the Blood Transfusion Course and pass the quiz offered with this education. LPNs must successfully complete the state-approved pharmacology course. LPNs having met this criterion can then check blood products and monitor the recipient of the product after the first 15 minutes of the transfusion.  The high risk of transfusions reactions during the first 15 minutes necessitate that an RN monitors the recipient of the product to provide any necessary intervention.

Non-physician transfusionists and anyone who assists in double checking the units (i.e. physician assistants, perfusion technicians, anesthesia allied health technicians, and emergency department technicians) must complete the "Blood Transfusion Policies" course and examination.

Equipment and Supplies

• All blood components must be filtered during administration.
• A blood component administration set containing an in-line blood filter is recommended. Either a "Y-Type" administration set or a single line set may be used.
• An add-on filter, such as a leukocyte reduction filter, may be used when the component was not leukocyte-reduced by the blood supplier.
• Because of the large number of filters available, the instructions for use on the package or on the product insert should be read to determine priming instructions and the maximum number of units that may be administered using the filter.

Intravenous Solutions

• Only isotonic saline (0.9%) is recommended for use with blood components.
• Other isotonic electrolyte solutions that have been approved by the FDA for this purpose may be used.
• Other commonly used intravenous solutions will cause varying degrees of difficulty when mixed with red cells. For example, 5% dextrose in water will hemolyze red cells. Intravenous solutions containing calcium, such as Lactated Ringer's solution, can cause clots to form in blood.
• Prior to blood transfusion, completely flush incompatible intravenous solutions and drugs from the blood administration set with isotonic saline.

Component Infusion Sets

Component and Platelet Administration sets with shorter tubing are available from the Materiel Service Center (MSC) section of Materiel Services.

Leukocyte-Reduction Filters

• With the exception of autologous units, the components stocked by the Blood Bank are leukocyte-reduced by the blood supplier.
• In rare circumstances, a beside leukocyte-reduction filters may be required.
• Granulocyte, hematopoetic progenitor cells, and mononuclear cell transfusions must NOT be administered through these white cell removal filters.
• Follow the priming instructions on the product package.

Pressure Infusion Devices

Follow the filter, port or catheter manufacturer’s instructions regarding the use of pressure infusion devices. The flow through some blood filters may be compromised and some catheters may cause catheter wall rupture if a pressure infusion device is used.

• Infusion pumps are available from the Patient Equipment section of Materiel Services.

• Equipment for transfusion must be used in accordance with the manufacturer's instructions for use and quality control of the instrument.

• Do not use equipment that does not have a current Biomedical Engineering tag indicating it has been tested for appropriate function and safety.

• Cuffs for pressure infusion may be used if care is taken not to exceed the designated pressure.


Blood Warmers

Blood warmers are available from the operating rooms.

Blood warmers may be used as long as the device has a temperature alarm and visible temperature monitor. Blood warming devices are most appropriate for massive and rapid blood replacement, such as exchange transfusion of the newborn.

Patient Instructions and Preparation

Blood Bank personnel will notify patient unit personnel by telephone when ordered blood is ready for transfusion.

Informed Consent Updated 12/16/13

• Informed consent for blood transfusion is a process in which the patient is informed of the medical indications for the transfusion, the possible risks, the possible benefits, the alternatives, and the possible consequences of not receiving the transfusion.
• Informed consent  may be obtained by a privilidged prodvider, a nurse, or a physician extender who is knowledgeable about blood transfusion and the patient’s condition so as to be able to explain the elements of informed consent above. Refer to the institutional policy on informed consent UMH Policy on Informed consent 12/16/13 Informed Consent for Invasive Procedures and Treatments Involving Substantial Risk of an Adverse Outcome.
• The risks of transfusion, including adverse symptoms and alternatives to homologous (allogeneic) transfusion, must be discussed with the patient well before the transfusion. The booklet, Booklet Blood Transfusion your options describing transfusion options are available from Moore. This booklet should be provided to patients as early as possible before transfusion.
• The patient is then given a choice to accept or decline transfusion. Consent should be obtained sufficiently in advance of the transfusion that the patient can truly understand what is said and have sufficient time to make a choice.
• Consent should be documented in the medical chart.
• The form Blood transfusion consent form. is ( available on-line or from R. R. Donnelly).
• Refer to hospital policy about UMHHC Policy 62-10-001 on  Informed Consent  to determine length of duration for use of an informed consent.
• In emergency situations the privileged provider ordering the transfusion must make a reasonable judgment that the patient would accept the transfusion. Transfusion should not be delayed in a life-threatening situation if it is likely that the patient would agree to transfusion. After the event, the circumstances of the transfusion decision should be documented in the medical chart.

Refusal of Blood Transfusion

• The form "Patient’s Release Form for Refusal of Blood or Treatment" should be used to document the patient’s refusal of transfusion. The form is available on the Blood Bank web site.

Post Transfusion Instructions to the Patient

• Outpatients or patients who will be leaving the hospital within one week of transfusion should be given written instructions regarding delayed transfusion reactions.
• The patient handout "Post-Transfusion Instructions for the Patient" may be used for this purpose.
• Copies of this form are available from Moore order number 2201460.

Release and Transport of Blood Components

To reduce the potential for waste of the component, do the following before requesting that a blood component be issued from the Blood Bank:

Requesting blood components to be sent to the patient location

• Routine requests to issue blood components for inpatients and infusion-area outpatients (Taubman, Cancer Center, Canton, etc.) are requested using the electronic MiChart Send Blood Product Request. In some cases, an activation form is required before blood can be issued.
• Patients in the ED and OR should call Blood Bank to have blood issued.

Electronic or verbal requests must contain the following information in order for blood to be issued:

(4/28/15)

Packaging of Blood Components

Blood Bank will package the blood components based on the intended transport method. Multiple products may be issued to areas with blood refrigerators. Multiple products may be issued to areas without blood refrigerators when packaged appropriately for the component issued.

Picking up blood at the Blood Bank window

• Transport personnel must present to Blood Bank personnel written notification indicating following:
• Patient's name and MRN
• Blood component to pick up
• Number of components to pick up
•  
• Blood components will be released to physicians and registered nurses on the basis of an oral request stating this information.

• Patient care units Without a Blood Refrigerator: Only one unit of blood will be released at a time for a patient unless the patient has two intravenous lines in place that allow for the simultaneous administration of two components.

• Patient Care Units With a Blood Refrigerator: Multiple blood units will be released only to patient care units with monitored blood refrigerators

Transporting Blood Components

• Blood components should be promptly delivered to the patient location without delay.
• Blood components should remain in the packaging during delivery.
• Blood components sent via pneumatic tube should be promptly delivered to staff taking care of the patient. (4/28/15)

Receipt of Blood Components

The person receiving the blood being transported or opening the tube at the receiving location must immediately upon receipt

• Red Blood Cell and plasma components must be stored between 1 and 6 C and the temperature during transport cannot exceed 10 C. Refrigerated blood components will warm to above 10 C in approximately 30 minutes after removal from refrigeration.

• Platelets and Cryoprecipitate are stored at room temperature. These components may be used until the outdate time on the label.

• Consult with the Blood Bank if there is any question about the suitability or identification of a blood component.


Special Labels

• When blood is released for transfusion under unusual circumstances a special notation will be indicated on the Transfusion Record Form.
• This information will often suggest to physicians and nurses that particular caution must be exercised during transfusion, and that the blood transfusion should be terminated at the first sign of an untoward reaction.
• Personnel initiating the transfusion who have questions concerning the significance of this information should contact the Blood Bank.

IMMEDIATELY PRIOR TO BLOOD TRANSFUSION

Pretransfusion Vital Sign Documentation

• To provide a baseline, record the patient's blood pressure, pulse, respirations and temperature in the chart or on the transfusion record form

If a patient is febrile, consideration should be given to postponement of blood transfusion, since the fever may mask the development of a febrile reaction to the blood component itself.

• Verify physician's orders for transfusion and any that any pretransfusion medications have been administered

• Perform bedside verification of patient and component Using the

• labels on the bag,

• the Transfusion Record Form and

• the patients attached positive patient identifier.


Two qualified individuals must

These steps must never be bypassed.

DO NOT START the transfusion if there is any discrepancy.

Contact the Blood Bank.

Initiating the Transfusion

• Immediately before transfusion, mix the unit of blood thoroughly by gentle inversion.
• Follow the manufacturer's instruction for the use of special filters and ancillary devices. Additional administration instructions for selected components are printed at the end of this chapter and are available upon request from the Blood Bank.
• If any part of the unit is transfused, the unit is considered transfused.

Flow Rates

During the Transfusion Document

See Chapter 7 for details concerning the signs and symptoms of a transfusion reaction.

If the patient has a preexisting fever

The need for transfusion must be balanced with the risk of transfusion. Contact the patient’s physician to determine if pretransfusion medications should be administered.

If a patient is being transported with blood hanging

Patients should not be transported with blood components infusing unless accompanied by a clinician who can monitor and respond to a potential reaction. Additionally, the receiving clinic/area must have a clinician who can manage a patient while they are receiving blood components.

Medications

• Do not add medications directly to a unit of blood during transfusion.
• Medications that can be administered "IV Push" may be administered by stopping the transfusion, clearing the line at the medication injection site with 5-10 mL of normal saline, administering the medication, reflushing the line with saline and restarting the transfusion.

Units entered and not transfused

If a unit of blood or a blood component has been entered for any reason by personnel not working in the Blood Bank, and the unit has not been transfused

• Record on the transfusion Record Form the volume transfused as "NONE"

• Indicate the disposition of the unit "Discarded on patient unit" and sign and date the notation.

• Return the Transfusion Record Form to the Blood Bank


If Components Are No Longer Needed

To avoid unnecessary waste of blood resources, notify the Blood Bank staff immediately if components are no longer needed for a patient, as the component may be suitable for transfusion to another patient. Return any unneeded units to the blood bank.

At the Termination of an Uncomplicated Transfusion

After the completion of each uncomplicated transfusion, the responsible physician or nurse should verify that the "Transfusers Must Complete" section of the Transfusion Record Form

is complete, including

• date and time transfusion was stopped
• volume of blood infused
• Check the box documenting the presence/absence of a transfusion reaction.

Discontinue the isotonic saline solution used to initiate the transfusion after the completion of the transfusion unless specifically ordered.

Document the patient's response to the transfusion in the patient's medical record.

If a Transfusion Reaction is Suspected

• Stop the transfusion
• Maintain the IV.
• Save the bag and attached tubing and refer to Chapter 7 for additional instructions.

Disposal of Blood Bags If No Reaction is Suspected

Discard empty blood bags with attached blood infusion sets on the patient unit in a biohazard waste container such as a red bag.

Transfusion Record Form Distribution

Following completion of the form, the white copy of this form should be retained in the patient unit for attachment to the patient's chart; the pink copy of the form must be returned to the Blood Bank in hospital mail.

SPECIAL INSTRUCTIONS FOR HEMATOPOIETIC PROGENITOR CELL (HPC) INFUSION

Autologous stem cells are the patient's own stem cells that are harvested from the marrow or peripheral blood and then cryopreserved.

Allogeneic Bone Marrow is fresh stem cells taken from a donor's bone marrow. Allogeneic stem cells are taken from the peripheral blood by apheresis. After collection these cells may be cryopreserved.