Neobook — clinical reference

Policy
Procedure

Policy

Professional responsibility for the use of blood or blood products resides specifically with the doctor in charge of the patient.
Interns may fill out Western Province Blood Transfusion Service blood request forms with the approval of senior medical personnel. Exceptions may be made in the case of emergencies.
Where the responsibility for a patient’s care changes as a result of transfer to another ward/unit, the patient records must clearly indicate that previous orders for blood have been placed.
It is essential that the doctor’s orders for the giving of blood products and the transfusion details are recorded in writing, and kept in the patient’s file.
Should a patient receive a unit of blood, i.e. whole blood or red cell concentrate (packed red blood cells) or a blood product, e.g. fresh frozen plasma, platelet concentrate, cryoprecipitate or lyophilised plasma, the person infusing such blood or blood product must record the details of the transfusion in the patient’s medical record or the Blood and Blood Product Transfusion Record, where this form is available. The patient’s medical record includes the fluid chart or the anaesthetic record.
This information would be essential should there be a delayed untoward reaction to the blood or blood product or should the patient develop an infectious disease which could be possibly be attributed to the transfusion.
This policy applies to In-patients and to Out-patients.
CONSENT FOR BLOOD TRANSFUSION
1. Blood transfusion requires the explicit, informed consent of the patient.
2. In obtaining the informed consent for transfusion, the material risk of transmitted infection should be clearly explained to the patient, as well as indications for, and predicted benefits of the intervention.
3. The standard Consent to Medical Procedure form must be completed prior to the transfusion and/or procedure. The patient’s consent or refusal should be recorded in the block indicated for that purpose.
4. When a procedure is not contemplated, the Consent to Medical Procedure form must still be completed. “Blood Transfusion” must be recorded under the heading “Nature of Procedure”.
5. The consent remains valid as long as the nature of the treatment, the risk to the patient, and the indications for therapy do not change. (If, for example, the patient has an allergic reaction to blood on one occasion, then informed consent should be obtained for further transfusions, because the risk profile has changed, and the patient needs to be counselled about this).
6. If top-up transfusions are required for the same indication, the original consent remains valid.
7. For surgical procedures a new consent form should be completed for each separate surgical procedure.
8. In circumstances where the patient is not able to provide consent (e.g. life-threatening emergency, comatose patient, unaccompanied, patient under 12 years), the decision to proceed with transfusion should be made on clinical grounds alone, and documented in the patient’s file.

Procedure

THE ORDERING OF BLOOD
1. The administration of blood products must be meticulously recorded on the patient’s fluid chart, or the anaesthetic record or on the Blood and Blood Product Transfusion Record and be kept in the in-patient record.
2. The doctor who orders a transfusion of blood or blood products must write the order under “DOCTOR’S INSTRUCTION” on the fluid balance chart or on the anaesthetic record or on the Blood and Blood Product Transfusion Record and date it.
3. The same procedure applies to In-patients and Out-patients receiving blood or blood products. Out-patients receiving any blood products must have the blood products prescribed and recorded on the patient record.
THE TAKING OF BLOOD SAMPLES FOR COMPATIBILITY TESTING
1. The blood sample may be collected by a doctor or registered nurse; however, only a doctor may fill out the Western Province Blood Transfusion Service blood request form.
2. The blood request form must be clearly filled in and signed by the medical practitioner, with the doctor’s name printed legibly in brackets underneath.
3. The following four steps in this procedure must be meticulously observed:
  1. The patient must be accurately identified.
  2. The blood request form must be legibly completed.
  3. The following information must be indicated on the blood request form and the blood tube:-
    - The patient’s full name
    - The patient’s folder number
    - The date of collection
    - Both the hospital and the ward
    - The name of the requesting doctor
  4. The following information must be indicated on the blood request form:
    - The time when the blood is required.
    - The cost centre stamp (where available).
4. The form and matching tube are sent to the Blood Bank where, on completion and certification that the samples from the patient and the unit of blood are compatible, the blood will be issued. The sample from the patient is retained for two weeks.
THE ADMINISTRATION OF BLOOD OR BLOOD PRODUCTS
1. The Blood Bank will not inform the person who ordered the blood or blood products that the products are ready for collection. The person who ordered the blood products must enquire telephonically whether the blood or blood products are ready for collection and arrange for the collection thereof from the Blood Bank.
2. The release of an ordered blood product to a nurse or porter has no medico-legal implication and their signatures are only needed for auditing purposes to document that the item has been received from the Blood Bank.
3. On receipt of the blood or blood products in the ward, the doctor must check the units against the Western Province Blood Transfusion Service request protocol. The hamper must remain closed in order that unused units are maintained at an optimum temperature.
4. A doctor or registered nurse working under the doctor’s legal authority, is legally entitled to administer these products; however, overall responsibility for the transfusion lies with the doctor.
5. Prior to starting the transfusion, the blood unit and the patient must be verified by a medical practitioner and a registered nurse, or by two registered nurses. This process must be repeated for each unit of blood to ensure that the correct unit will be given for the correct patient.
6. Every time a new unit of blood/blood product is put up/administered the following steps must be followed.
  1. The patient’s name and number must be checked against the wrist identification bracelet.
  2. The serial number of the unit must be checked against the donor ID/serial number on the Western Province Blood Transfusion Service blood issue form which accompanies the blood hamper.
  3. The details of the blood/blood product must be entered in the Fluid chart or in the anaesthetic record or in the Blood and Blood Product Transfusion Record.
    1. The type of product must be indicated.
    2. The serial/donor ID number of blood/blood product being administered must be noted in the appropriate space, or the bar code sticker on the reverse of the blood unit can be removed and placed in the appropriate space.
    3. The time the unit was commenced must be noted in the appropriate space.
    4. The name of the doctor or registered nurse who checked and commenced the unit must be clearly printed and signed.
7. The above steps must be repeated for each unit that the patient receives.
8. On completion of the blood transfusion the empty bags with the labels intact must be returned to the Blood Bank, where they are retained for a period of two weeks before being discarded.
9. All other intravenous fluids administered before, after, or in between units of blood, must be entered on the fluid balance chart or anaesthetic record as usual. Only blood products administered to the patient must be entered on the Blood and Blood Product Transfusion Record, in instances where this specific form is used.
10. It is only necessary for the nursing staff to record the volume of blood or blood products received by the patient on the fluid balance chart. When appropriate this information will be entered on the anaesthetic record.
MONITORING THE PATIENT
1. Baseline observations of vital signs should be recorded prior to commencing the transfusion.
2. The patient is then observed closely for the first 30 minutes of the transfusion to detect any untoward reaction, and to ensure that the desired rate of transfusion is maintained.
3. In cases of major blood loss, ideally the CVP, pulse, BP respiratory rate and urinary output should be monitored every 15 minutes throughout the transfusion.
4. In less severe cases the recipient’s vital signs should be checked every half hour after the initial 30-minute observation.
5. Patients at risk for circulatory overload should be observed for 12-24 hours after transfusion.
IN THE EVENT OF A TRANSFUSION REACTION OR ANY INCORRECT PROCEDURE (e.g. blood given to the wrong patient or wrong blood to the right patient)
- In the event of a reaction following the administration of blood or any incorrect procedure, the transfusion must be stopped immediately and the doctor informed.
  1. The blood bag must be sealed with the stopper provided and sent to the Blood Bank by the doctor or the registered nurse.
  2. The particular unit and preferably all other unused packs if possible must be returned, together with the used infusion sets.
  3. In addition, 1 EDTA tube and 2 cross-matched tubes must be immediately drawn from the patient, clearly labelled and sent to the Blood Bank.
  4. The untoward reaction or incorrect procedure report (see attached) is completed jointly by the doctor and the registered nurse responsible for the patient, and sent immediately to the Blood Bank. This information must be copied to the Manager: Medical Services responsible for blood management.
  5. Full details of the reaction or incorrect procedure must be recorded in the patient care notes and a GSH adverse incident form must also be completed.
  6. Adverse blood reactions and incidents will be monitored and reviewed by the Blood User’s Committee.
IN THE CASE OF EXTREME EMERGENCIES
1. In an extreme emergency, blood or blood products may be infused into a patient without pre-transfusion compatibility testing, at the discretion of the Doctor.
2. All standard procedures must, however, be resumed at the earliest opportunity during or after such resuscitation has commenced.
FURTHER DETAILS
- Further details can be viewed IN “CLINICAL GUIDELINES FOR THE USE OF BLOOD PRODUCTS IN SOUTH AFRICA”. This valuable booklet provides further information regarding products available and provides indications for the use of blood products as well as details regarding the risks of blood transfusion and transfusion reactions. A surgical blood ordering schedule is also provided. This booklet produced by the South African Blood Transfusion Services is available free of charge on request. Please contact Policy and Documentation (ext. 3261 or 3405) for the latest edition.