A charge nurse is observing a newly hired nurse who is preparing to administer a blood transfusion

Refer to EMR tip sheet for further information

Nursing competence

It is recommended that all nurses at RCH providing care to children receiving blood transfusions have completed the blood transfusion competency package.  You can access the package through your Nursing Competence workbook.

Patient preparation

The patient should be ready for transfusion prior to picking up blood from the blood bank. eg appropriate IV access, consent completed, pre-medication administered if required. 
For any non-emergency transfusion the patient/parents should have had the benefits/risks of transfusion discussed and an opportunity to have any questions answered.  Consent for transfusion should then be documented on a blood transfusion consent form. 

For further information and for parent and patient information see:  Consent and Consumer Information Guideline

This  video shows the correct blood administration process which should be followed. 

Issue of blood products from the blood bank

The safe transfusion of blood and blood products requires strict adherence to patient identification processes during all steps in the transfusion chain, including collecting the product from blood bank. Blood bank scientists must know they are issuing to the correct patient and require complete patient identification. This includes:

• full name
• date of birth
• MRN

The blood bank release form contains all required patient identification. During EMR downtime use the green blood bank release card and attach a patient identification label.

Blood products are issued from blood bank in 2 ways:

1. Pneumatic Transport System (PTS)
   • suitable for fresh blood products only (i.e. red blood cells, platelets, FFP, cryoprecipitate)
   • Note: batched blood products (i.e. IVIg, albumin, clotting factors) cannot be sent via PTS.
2. Pick-up from blood bank
   • the only option available for batched blood products but also suitable for fresh blood products
   • the staff member must present with the blood bank release form at the time of collection - do not send the blood bank release form in the PTS separately.
     

Blood products should only be released in EMR and retrieved from blood bank when the transfusion is ready to commence. This ensures appropriate storage of blood products. Blood products must not be stored in ward areas or domestic fridges.

Fresh blood products must be commenced within 30 minutes of leaving the blood bank. If circumstances change the fresh blood product must be returned to blood bank for storage.

This does not apply to albumin products. Albumin can be kept at room temperature for a maximum of 24 hours. If the requirement for albumin changes, it should be returned to blood bank at the earliest convenience.

Blood Box

The blood box provides a validated, short term (up to 4 hours) storage for red cells at the point of care. It has a timer attached.

The blood box can be requested for patients who are at risk of critical bleeding and red cells are required to be at the bedside “just in case”. Select the blood box in the prepare section of the red cell order.

Examples of patients who may need a blood box are as follows:

• Emergency Department
  • Trauma or bleeding where red blood cell transfusion may be needed. The blood box can be issued prior to patient arrival
• Rosella
  • Chest opening/closing on the ward
  • ECLS cannulation/decannulation
  • Surgical procedure on the ward
• Theatre
  • Re-do sternotomy
  • Cardiac surgery
  • Craniofacial surgery
• Butterfly
  • Surgical procedure on the ward

Discuss patients who fall outside of these pre-approved circumstances with the on-call haematologist.

Keep the lid closed at all times to maintain an environment cool enough to keep the RBC’s at a temperature to minimize bacterial growth. The lid may be opened to quickly inspect the contents but should otherwise remain closed. 

Do not place any equipment or other blood products inside the blood box.

A maximum of 2 units of RBCs will be placed inside the box. Do not place the blood box near a heater or in a refrigerator.

If the timer alerts, return the blood box to blood bank. If red cells are still required these may be ordered again.

Release form

When ready to transfuse the blood product:

• In ‘flowsheets’ select the ‘blood’ tab
• Select ‘release transfusion report’
• Select the ‘release’ hyperlink for the blood product you wish to transfuse

This will print a release form to the nearest printer. Complete all fields including your name, clinical area, PTS number (if applicable) and phone number. This will allow prompt communication from blood bank when the blood product is ready.

For general wards, release will be limited to the following quantities at a time:

• (1) unit of red blood cells
• (4) units of platelets (or one pooled or apheresis bag)
• (2) units of FFP
• (5) units of cryoprecipitate

Special arrangements are available to the Emergency Department, ICU, NICU and Operating Suites for release of greater quantities. 

Pretransfusion check

Safe transfusion requires a final patient identity check at the patient bedside before blood administration. This is vital to ensure the right blood is given to the right patient.

Two clinicians must independently complete the patient and blood product identification check at the bedside. By electronically signing the blood administration flowsheet checks in EMR they indicate they have correctly completed this process. 

• At the bedside, if possible ask the patient or parent/guardian to state full name and birth.
• Check these details match exactly on and include the MRN:
  1. Identification band
  2. Blood product tag attached to blood product
  3. EMR order
     
• In EMR:
  • Complete pre-transfusion documentation
  • Open the blood administration flowsheet by clicking on ‘Action’
  • Select the IV line you will use for the transfusion
    1.Scan the patient’s identification band
    2.Scan the unit number
    3.Scan the registration number on the blood product tag attached to the blood product
    4.Scan the product code on the blood product under the product description
    5.Scan blood type. Ensure this is compatible with patient blood type.
  • Green thumb and ‘ready’ appears if all details match
• Check the order to ensure the following:
  • Transfusion consent present
  • Previous alert for transfusion reaction
  • Clinical notes- premedication on MAR
  • Transfusion indication relevant
  • Type of blood product ordered matches blood product provided
  • Duration per unit/transfusion is specified and appropriate
  • Dose to be transfused (mls or units)
  • Modifications or specialised blood products (e.g. irradiation, CMV negative, cryodepleted, IgA negative, HLA matched, washed, phenotype matched)
• Check the blood product:
  • Expiry date
  • Modifications or specialised blood products (e.g. irradiation, CMV negative, cryodepleted, IgA negative, HLA matched, washed, phenotype matched)
  • Integrity of the blood product
• Enter all other required information in EMR including the rate of transfusion, date and time commenced.
• Co-sign to indicate the 2nd user has independently completed the above checks  
  

If the blood product is removed from the bedside after the patient identification check is complete, the whole checking process must be repeated. This includes blood products removed from the bedside for priming of circuits. 

Spike the unit only after all checks listed above are completed. The person spiking the unit must be one of the clinicians undertaking the patient and blood product identification check. 1

Prime blood administration set at the bedside. 

IMPORTANT

If there is any discrepancy between the blood product, patient details & pack tag/label or if you
are concerned about the appearance of the product DO NOT TRANSFUSE.  Report to Blood Bank immediately: extension 55829

Care and monitoring of transfused patients

Patients receiving transfusion should be monitored for symptoms/signs of potential complications of transfusion.

Vital signs for fresh blood products (temperature, pulse, respirations, blood pressure, oxygen saturations and site observations) should be measured and recorded

• before the start of each transfusion
• 15 minutes after commencement of each pack
• hourly until conclusion
• at the completion of transfusion
• 4 hourly in the 24 hours following transfusion

This is a minimum requirement. Some clinical areas may require more frequent observations particularly in unstable or unconscious patients.

Patients should be directly observed during the first 15 minutes of transfusion as some life-threatening reactions may occur after the infusion of only a small amount of blood. Where possible, patients and families should be informed of possible symptoms of a transfusion reaction and should inform staff immediately if they feel unwell during transfusion.

For information about observation requirements for fractionated blood products, refer to the product page.