Manual of Blood Transfusion Policies and Type: Policy

Procedures Register No: 04184

Status: Public

Developed in response to: CNST requirement for blood transfusion procedures

Improve governance
Contributes to CQC Outcome 4 NHSLA 1.4.7

Consulted With Post/Committee/Group Date

Dr Graham Philpott Consultant Anaesthetist, Trust Hospital Transfusion Group Lead 18/05/17
Dr Shereen Elshazly Consultant Haematologist with responsibility for Transfusion
Dr Ellie Makings Medical Director
Dr Tim Lightfoot Interim Divisional Director
Dr Ahmad Aziz Interim Divisional Director Emergency Care
Helen Clarke Governance Lead
Nick Sheppard Acting Blood Bank Manager
Tina Parker Transfusion Practitioner
Jodie Nightingill Haematology Nurse Specialist
Professionally Approved and also Dr Rowe Associate Chief Medical Officer 1/8/17
approved for Clinical EffectivenessBy Consultant in Intensive Care and Anaesthesia

Version Number 6.3

Issuing Directorate Cancer and Support Therapies
Ratified by: DRAG Chairmans Action
th
Ratified on: 9 July 2017
Executive Board Date September 2017
Implementation Date 30 August 2017
Next Review Date June 2020
Author/Contact for Information Nick Sheppard Acting Blood Bank Manager
Policy to be followed by (target staff) All grades of staff involved in the transfusion pathway
Distribution Method Intranet and Website
Related Trust Policies (to be read in Policies for the use of Medicines
conjunction with) Infection Control Policies
06065 Administration of anti-D for Rhesus (D) Negative patients in Maternity
04080 Consent to examination or treatment policy
07040 Management of pregnant women and postnatal patients refusing blood products
09100 Incident policy
13012 Major Haemorrhage policy
04080 Consent to examination or treatment policy
07072 Management of a patient reporting an antepartum haemorrhage
04234 Guideline for the management of a postpartum haemorrhage
16015 Special Requirements for Blood Transfusion policy
Document Review History
Version Authored/Reviewed by Issue Date
No
1.0 M Holden November 2004
2.1 M Holden January 2007
3.0 M Holden September 2009
4.0 M Holden July 2011
5.0 N M Sheppard 30 March 2015
5.1 N M Sheppard - Update to verbal consent with appendix 16, concessionary release form, 27 May 2015
transfusion reaction form and special requirement form,
5.2 N M Sheppard - Appendix 13 Special Blood Transfusion form updated to include known antibodies 13/11/2015
5.3 TJ Parker/ N M Sheppard/ December 2015
S Elshazly - Update to Training, Competency Assessments and Warfarin reversal
5.4 TJ Parker/N M Sheppard - Update terms of reference, appendix 8 East of England transfusion 7 June 2016
reaction guideline and Appendix 13 Special transfusion requirements
th
6.0 S Elshazly, N Sheppard, T Parker - Policy updated following review of NG 24 and NHSBT clinical 30 August 2017
indication codes
th
6.1 S Elshazly/ N Sheppard /T Parker - Update to NHSBT clinical indication codes, HEV requirement 5 July 2018
and updated EoE RTC MHP adults and children
th
6.2 Nick Sheppard/ T Parker - Clarification of recording prescription in section 21.3. Advice on dealing 10 December
with suspected bacterially infected units added in section 37. Apendix 7 updated with new 2018
transfusion reaction form. Competency 4 page 78 updated with ABO compatibility
st
6.3 Nick Sheppard/Tina Parker - Changes to PCC (Prothrombin Complex Concentrate) issue in the 21 June 2019
emergency situation. Update to the Adult Blood Component Authorisation Chart – to include NEWS
update
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 INDEX

1. Purpose
2. Scope of document
3 Staff training
4. Information on blood and blood components
5. Introduction to the blood transfusion process
6. Standards for a safe transfusion
7. Sources of danger
8. Procedure of collecting blood samples for cross-matching and blood grouping
8.2 The request
8.17 The sample
9. Major Haemorrhage in adults and children
10. Red Cell products
11. Platelet products
12. Fresh Frozen Plasma
13. Cryoprecipitate
14. Human albumin solutions
15. Plasma derivatives including PCC (Beriplex)
16. Granulocyte transfusions
17. Maximum blood ordering schedule
18. Collection of blood from blood banks
19. Procedure for return to the blood bank
20. Labelling of non- blood bank refrigerators in clinical areas
21. Process of administering blood and blood products pre-transfusion information
22. The procedure of transfusing of blood or blood components
23. Use of blood warmers
24. Informing the patient - consent
25. Refusal of a blood transfusion
26. Children
26.1 Pre-transfusion testing for neonates and infants within the first four months
27. Small volume transfusions for infants less than four months
28. Large volume or exchange transfusions (which exceeds baby’s blood volume)
29. Use of irradiated products for routine transfusions in infants and neonates
30. Granulocyte transfusions for infants and neonates
31. Blood and blood components for congenital immuno-deficiencies in infants and children
32. Acute leukaemia in infants and children
33. Administration of Desferrioxamine Mesylate
34. Clinical Indications for the use of Fresh Frozen Plasma (FFP)
35. Administration of Prophylactic Anti-D Immunoglobulin
36. Alternatives to Transfusion
37. Transfusion Reactions
38. Breach event reporting and adverse reactions and events of transfusion
39. Reporting to MHRA via Serious Adverse Blood reactions and Events (SABRE) and Serious
Hazards of Transfusion (SHOT)
40. Autologous Transfusion
41. Directed Donations
42. Transportation of blood and blood products
43. Audit and Monitoring
44. References
45. Statutory requirements

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Appendices

Appendix 1 The Hospital Transfusion Group

Appendix 2 The Hospital Transfusion Team

Appendix 3 Indications for the use of red cells

Appendix 4 Indications for the use of platelets

Appendix 5 Indications for the use of fresh frozen plasma and cryoprecipitate

Appendix 6 Procedure for administering blood and blood products

Appendix 7 Blood transfusion reaction form

Appendix 8 East of England guideline on investigation of transfusion reactions

Appendix 9 Summary of acute and delayed complications of transfusion

Appendix 10 Blood transfusion competencies

Appendix 11 Concessionary Release Form

Appendix 12 Audit and monitoring assessment tool

Appendix 13a Special Blood Transfusion Requirements Form

Appendix 13b Request for the Removal of Special Requirements - Blood Products

Appendix 14 Flow chart for Major Haemorrhage in adults

Appendix 15 Flow chart for Major Haemorrhage in children

Appendix 16 The adult blood products transfusion chart (verbal consent)

Appendix 17 NHSBT Portfolio of Blood Components and Guidance for their Clinical Use

Appendix 18 Doctor’s self assessment statement - competency one

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1 Purpose

1.1 To provide guidance for staff actively involved in the transfusion pathway on the
management of the transfusion process: in order to reduce the risk of an adverse event or
transfusion reaction.

1.2 This policy has been written to meet the needs of the Trust and to meet the standards
required by:
 NHS Litigation Authority (NHSLA)
 EU Blood Directive 2002/98/EC monitored by the Medicines and Healthcare products
Regulatory Agency (MHRA)
 Current guidelines from the British Committee Standards for Haematology (BSH).

2 Scope

2.1 The scope of the document is to provide information on the transfusion pathway of all
patients requiring a transfusion of blood or blood components for Trust staff.

2.2 The Mid Essex Hospitals Services NHS Trust (MEHT) is committed to provision that is fair,
accessible and meets the needs of all individuals.

2.3 The Trust Hospital Transfusion Group (HTG) meets to co-ordinate the varying interests of all
parties involved in the transfusion policies and procedures to ensure the safe and appropriate
use of products.

Refer to Appendix 1 for terms of reference, role and membership of the group.

2.4 The Hospital Transfusion Team (HTT) meets to review untoward incidents, develop
transfusion related policies and to ensure service provision.

Refer to Appendix 2 for terms of reference, role and membership of the HTT.

3 Staff Training

3.1 Mandatory Staff Training

3.2 All staff, appropriate to their grade and training needs analysis, must attend Mandatory blood
transfusion training sessions

Staff Role Mandatory Comp 1 Comp 2 Comp 3 Comp 4

Doctors √ √* X X X
Anaesthetists √ √ X X √
Registered √ √* √ √** √
Midwives
Registered √ √* √ √** √
Nurses
ODP √ √* √ √** X
HCA/HCSW √ √* X X X
Porters √ X X √** X
Phlebotomists √ √ X X X
* staff who are trained to take samples of blood
** staff who collect components from the laboratory/use blood track

3.3 All clinical staff in the transfusion process will be required to complete further two yearly
mandatory training. Qualified nursing and midwifery staff must complete a knowledge test
4
 and achieve at least 80% to be compliant with mandatory training. This can be completed as
part of the e-learning module or face to face learning.

3.4 Staff can be offered training sessions on-line as part of e-learning, mandatory training days
organised by the Training and Developent Team or face to face training session with the
Transfusion Practitioner.

3.5 Staff involved in a serious incident relating to blood transfusion must not be involved in the
blood transfusion process until they have repeated their mandatory training and if applicable
the appropriate competency assessment.

3.6 If a ward/department does not have staff who have achieved their mandatory or
competency training requirements, it is the responsibility of the Nurse in Charge to contact
the Lead Nurse for the specialty to arrange for staff who have achieved the expected level
of competence and mandatory training to check the blood product for the patient

3.7 Staff who fail the knowledge test will be allowed a second attempt (with different questions).
If they fail again they will need to complete the online e-learning module of blood transfusion
training, and complete the on-line tests. If they fail this, they will be referred to their line
manager to decide the next actions. If this person has other failings it may be appropriate to
manage them under the Capability Policy ref 04012.

3.8 Competency assessments

3.9 It is not mandatory for staff to be involved in the blood transfusion process, but those who
are, must pass the appropriate competency (appendix 10).

3.10 These are one off assessments, unless the person is involved in a blood transfusion incident,
or they/their manager feels that they require further input/training.

3.11 Medical students are not authorised to collect samples of blood for blood grouping and cross-
matching.

3.12 A medical student must not, in any circumstances, request or prescribe blood or blood
components for transfusion

3.13 Competency assessments can be completed by the ward manager with responsibility for the
staff member, if the ward manager has completed their own competency and is up to date
with mandatory blood transfusion training.

3.14 Staff who have not completed the appropriate training to the level required for their role
must not take part in the transfusion process

3.15 Competency 1, Sample taking: All staff that collect a venous sample of blood for testing for
the purposes of blood transfusion.

3.16 Nursing and Midwifery staff who satisfy the Nursing Midwifery Council (NMC) requirements
and who have completed appropriate local MEHT training, may collect, label and sign
samples for group and cross-matching purposes.

3.17 Nursing staff can complete request forms if they have attended a ‘Special Requirement’
training session (usually pre-assessment nurses).

3.18 Doctors may complete a self assessment statement in regard to their role in taking samples
of blood for transfusion pruposes, or can sign the statement to state they are not part of this
role (appendix 18).
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3.19 Competency 2, arranging the collection of blood: All staff who organise the receipt of blood
and blood products from the blood transfusion department will undergo training and be
assessed by observation or skills test.

3.20 Competency 3, collection of blood compoenents: All staff that collect blood and blood
products from the blood bank must undergo training and be assessed by observation or skills
test. Staff working within the Broomfield site must also receive training and have access to
the current electronic system for tracking blood and blood products, e.g. Blood Track.

3.21 Competency 4, administration of blood. All staff who prepare to administer, and administer
blood and blood components to patients must undergo training and be assessed by
observation or skills test.

3.22 Ward managers are informed by the Transfusion Practitioner of the ward/department
compliance for both mandatory training and competency assessments on a quarterly basis.

4. Information on Blood and Blood Components

4.1 All donors undertake screening prior to donation to exclude any donor whose blood may
have the potential to harm the patient or to prevent possible harm to the donor during
donating.

4.2 Approximately 470ml of whole blood is donated at each session, which can be up to three
times a year.

4.3 In the UK, every donation is tested to determine:

ABO & D group
Irregular red cell antibodies
Hepatitis B
Hepatitis C
Hepatitis E (from 10/4/17)
Human Immunodeficiency virus 1 and 2,
Human T- cell lymphotropic virus
Syphilis

In special circumstances blood may be tested for:

Malaria
West Nile Virus
Trypanosoma cruzi antibodies

4.4 Persons at risk of Creutzfeldt-Jacob disease (vCJD) are excluded from donation. Whilst all
donations are leucodepleted as a precaution against vCJD, there is currently no test that
can be used routinely to identify donors with vCJD.

4.5 Special requirements for blood transfusion, means that the donated unit needs an extra test
or process to make it safe for a particular patient, for example patients that have Hodgkins
Lymphoma will require irradiated blood components. It is the Doctor’s responsibility for
ensuring that the Blood Transfusion Department are informed of any special requirement a
patient has.

4.6 Transfusion associated graft versus host disease (TA-GVHD) is the most frequent cause of
transfusion-associated death (SHOT 2002). Patients at risk of TA-GVHD should be given
gamma irradiated red cells according to current guidelines.

4.7 If irradiated products are required contact the Blood Transfusion Department as soon as 6
 possible.

4.8 If this is the first occurrence or there has been a change in the patients special requirements
complete a Special Blood Transfusion Requirements Form (Appendix 13).

4.9 It is especially important to do this where patients have shared care with other hospitals.
Where there is shared care ensure all parties are aware of the requirements. Failure to do
this may results in life threatening TA-GVHD.

4.10 For more information on special requirements for blood transfusion please refer to the
Special Requirements for Blood Transfusion policy ref 16015.

4.11 Section 130 of the 1968 Medicines Act and amended by the Section 25 of the Blood Safety
and Quality Regulations 2005 (SI 2005). Blood and Blood Components (Red Cells,
Platelets, Fresh Frozen Plasma and Cryoprecipitate) are excluded from a legal definition of
medicinal products and therefore cannot be “prescribed” by any practitioner. The usual
terminology is therefore authoriation of blood products, however, in this policy the
authorisation of blood is referred to as the prescription.

5 Introduction to the blood transfusion process

5.1 Correctly used, blood and blood products can save lives and provide clinical benefit to many
patients.

5.2 The consequences to the patient of receiving incompatible blood may be serious and include,
shock due to intravascular haemolysis, cessation of renal blood circulation and death. This is
largely preventable if the following recommendations are always followed.

5.3 The consequences of mistakes made during the collection of blood samples for transfusion
may be serious. Whilst a compatible transfusion may help to save a patient’s life, an
incompatible transfusion may kill.

5.4 Transfusion should only be used when the benefits outweigh the risks and all alternatives to
blood transfusion have been considered.

5.5 Laboratory measures are not the sole deciding factor for a transfusion.

5.6 The decision to transfuse should be based on clinical assessment underpinned by clinical
guidelines.

6 Standards for a safe transfusion

6.1 Current transfusion guidelines should be adhered to at all times. This includes appropriate
documentation of clinical observations and ensuring traceability of products to ensure
compliance with MHRA requirements.

6.2 The reason for transfusing each patient must be clearly documented in the patient’s notes.

6.3 For planned surgery, the arrangements for pre-operative assessment should permit
correction of medically treatable deficiencies, for example iron deficiency, prior to surgery.

6.4 Offer oral iron before and after surgery to patients with iron-deficiency anaemia where
appropriate.

6.5 Consider intravenous iron before or after surgery for patients who:
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  Have iron-deficiency anaemia and cannot tolerate or absorb oral iron, or are unable to
adhere to oral iron treatment
 Are diagnosed with a functional iron deficiency
 Are diagnosed with iron deficiency anaemia, and the interval between diagnosis of anaemia
and surgery is predicted to be too short for oral iron to be effective.

6.6 For the management of anaemia in patients with chronic kidney disease, see NICE guideline
on anaemia management in chronic kidney disease.

6.7 All patients receiving a transfusion must wear a wristband at all times clearly showing the
patients first name, last name, date of birth, hospital number, NHS Number and gender.

6.8 Patients should be monitored during a transfusion in accordance with current MEHT/
National guidelines (appendix 6).

6.9 When a patient is discharged from hospital following a blood transfusion they should be
advised to contact their General Practitioner (GP) if they feel they have any side effects they
believe to be related to the transfusion, within 3-7 days of the transfusion. E.g. new pyrexia
or new rash.

6.10 Documentation of transfusion should be highlighted in the patients’ discharge summary.

7 Sources of danger

7.1 The main sources for danger which will lead to an adverse transfusion event are:

 Supplying the wrong sample to the laboratory for compatibility testing – wrong blood in
tube incident
 Failure to supply clinical information, particularly in regard to previous transfusions,
pregnancies, blood grouping and special transfusion requirements
 Use of a single common name (e.g. Smith) on forms and labels, leading to muddling of
patients, specimens and blood units.
 Error in laboratory cross-matching tests
 Mis-labelling of blood units
 Transfusing the wrong patient
 Leaving blood at room temperature before use, longer than the 30 minutes, thus
encouraging bacterial growth
 Heating blood in hot water prior to transfusion or storing in non-approved blood banks
causing cell disintegration

7.2 Data from all serious adverse transfusion reactions and events will be reported to the MHRA
via Serious Adverse Blood Reactions and Events (SABRE) and Serious Hazards of
Transfusion (SHOT).

7.3 Transfusion should only occur following receipt of all paperwork/samples in accordance with
this policy. In the rare event that transfusion is required and all elements of this process are
not completed or cannot be fulfilled, blood may be issued under concession following
completion of a Concessionary Release form (appendix 11). Its use however should be
restricted to occasions where, for example, it is not possible to provide Kell negative units to
a female of child bearing age. It must not be used to allow release of products where
incorrectly labelled forms and samples have been received or where there has been a failure
to send a sample to confirm the patient’s blood group.

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8 Procedure for collecting blood samples for cross-matching and blood grouping

Staff group Completion of Completion of Antenatal

request form request form Cross- request
G&S match forms
Doctors √ √ √
Registered Midwives √ x √
Registered Nurses x x x
Pre-assessment nurses who have √ x x
completed Special requirement training

8.1 The request

8.2 The procedure for collection of samples for cross-matching and blood grouping, is designed
to safeguard all involved in Blood Transfusion work, including laboratory blood bank staff,
medical, maternity and nursing staff, the person collecting the sample and the patient.

8.3 The person completing and signing the top section of the form is held responsible for
ensuring all these sections are completed and for the accuracy of the information given.

8.4 Check for any previous laboratory records, special instructions advised, for example
sending extra samples where antibody specificities make it difficult to find compatible blood
and any special transfusion requirements. When patients are found to have antibodies NHS
blood and Transplant (NHSBT) send them an antibody card, so if the antibody has been
previously detected the patient should be aware of this. Those with a newly detected
antibody will be informed by NHSBT, via the patient’s General Practitioner.

8.5 It is the responsibility of the clinician responsible for the patient to advise the laboratory of any
special transfusion requirements the patient has.

8.6 Ask the patient for any relevant details, such as previous pregnancies, earlier transfusions,
knowledge of any special requirements such as irradiated blood or red cell antibodies
present and relevant drug treatments.

8.7 If blood or blood products are required a time and date required must be entered on the
request form.

8.8 Doctors can make verbal requests for blood components if there is a valid sample,
laboratory staff have been empowered to question requests to ensure patients do not
receive unnecessary transfusions. Therefore staff making these requests need to know the
current haemoglobin/platelet count when maing these requests (in the non-bleeding
patient).

8.9 It is recognised that on occasion, midwives need to request and send samples to the
laboratory urgently. They should notify the Blood Transfusion, Haematology or Biochemistry
Departments or appropriate BMS on call if outside normal working hours.

8.10 Transfusion requests will only be acted on if samples are fully labelled and all sections of the
request form are completed.

8.11 If the request form or sample is partially labelled/demographic details missing or unsigned,
the sample will be discarded and the ward/clinical team advised - irrespective of the clinical
pressure.

8.12 MEHT follows BSH guidelines which recommend that prior to the issue of blood products
9
 the patients group is checked on a separate sample collected on a different occasion and
where the patient has been identified separately. It should be noted that for some patients
the laboratory may have historical records on their Laboratory Information Management
System (LIMS).
o Historical record present – require one sample to confirm group & any antibodies
present
o No historical record, two separate blood samples are required, taken by two different
staff members, at separate times.

8.13 For all urgent requests and requests for products other than red cells and prophylactic
anti-D the Blood Transfusion Department should be contacted by telephone or if ouside
normal working hours by contacting the Biomedical Scientist (BMS) on call for
Haematology.

8.14 Laboratory staff are instructed not to accept any substitutes. In all non-urgent cases for
blood grouping and cross-matching, testing needs to be ordered a minimum of 48 hours in
advance.

8.15 Requests for blood and blood products at short notice must be discussed with the
laboratory at the direct instruction and responsibility of the person medically in charge of
the patient at that time.

8.16 Where blood is required in an emergency and samples have not been correctly labelled or
there are discrepancies in information given, making the samples unsuitable for testing, the
following groups of products will be issued as Emergency blood:

Red cells Group O D Negative Kell negative (if over the age of 60 or male
group O D Positive blood may be used depending on supply)
FFP Group AB
Cryoprecipitate Group A (High titre negative)
Platelets Group A D Negative (High titre negative). If over the age of 60 or
male group A D Positive may be used depending on supply

8.17 The Sample

8.18 The procedure for the collection of blood samples.

8.19 For adults and older children use only blood group and cross-match request forms and
bottles (blue top). Paediatric/neonatal samples can be taken in a haematology tube (red
top) but must still have the correct identifiers and the sample takers signature to be able to
accept the sample.

8.20 The first section of the request form (demographics, special requirements and transfusion
history) should be completed by the Doctor or Midwife (NMC nurses who have completed
the special requirement training); details should be copied from the patient’s notes.

 Take the request form to the patient.

 Ask the patient to confirm their full name and date of birth (check spelling of name).
 Check the details on the form against the patient’s wristband.
 Stay at the patient’s bedside and complete the sample with handwritten details including
date, patient’s first name, last name, date of birth, registration/hospital number, NHS number,
gender and location.
 Sign the sample
 Complete and sign the sections of the request form relating to the sample collection.

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8.21 If the sample is received unlabelled or a pre-printed data label used on the sample, the
sample will be discarded, and the ward/department informed. These incidents will be
reported via Datixweb.

8.22 It is the responsibility of the person collecting the samples for transfusion purposes to ensure
beyond all doubt, the identity of the patient. Should the patient be unconscious or
identification unreliable, the patient’s identity should be regarded as unknown. In these cases
samples should be labelled as Unknown Male/Female and given a unique registration
number.

8.23 Registered nurses, midwives and doctors may collect samples of blood for blood
transfuson, therefore medical studentsand student nurses/midwives are not authorised to
collect samples of blood for blood grouping and cross-match. Nealth Care Assistants can
take samples for transfusion if they are compliant with mandatory training and competency
assessment completed/passed.

8.24 Samples must be labelled at the bedside immediately after collection. Do not pre-label
samples or label samples from more than one patient at the same time. Pre-printed sticky
labels are not acceptable.

8.25 The person signing the form confirming they have taken the sample is responsible for
ensuring the details on the request form match the patients wristband and are confirmed
verbally by the patient and for ensuring the sample is labelled correctly.

8.26 Whenever a plasma substitute is used, always take a sample for blood grouping
beforehand. Plasma substitutes of this kind may interfere with the accuracy of grouping and
cross-matching.

8.27 Samples have a limited validity, if the patient has had a recent red cell transfusion or
recent pregnancy then the sample should be collected from the patient adhering to the
following guidelines:
 Patient transfused or pregnant (any stage) in the last 3 months, sample valid up to 72
hours
 Patient not transfused or pregnant in the last 3 months sample valid for 7 days

8.28 Many patients already have historical groups on the Local Information Management
System (LIMS) system and only one further sample is required. Where no historical group
is available two samples are required that have been collected on separate occasions by
two different people, with the patient being fully identified on each occasion.

8.29 MEHT does not currently recommend a set period of time between collections of these
samples. Where it is suspected that the samples have been collected together, for example
where the time of collection is the same on both samples they will be treated as one
sample and one will be discarded.

8.30 Fill the appropriate EDTA (Ethylene diamine tetracetic acid) bottle to the line. At least 6ml of
blood should be sent. If smaller amounts are received only a group and save will be
performed and no plasma will be available to be held for cross-matching purposes. If there
is insufficient sample for cross-matching purposes, then the ward will be informed.

8.30 Laboratory staff check each sample/form against historical records, and check the previous
data system (Legacy) to determine if there are previous records to ensure any previously
detected antibodies are reviewed.

8.32 Samples and forms must have four points of identification present. However, if five or more
points of identification are used, all of them have to be correct to be able to process the
11
 sample. E.g if the first name, last name, date of birth, registration number and NHS
number are all used, but one is incorrect, the sample will be discarded.

8.33 Staff cannot delegate taking of blood transfusion samples to others, i.e. a medical student
cannot be asked to take samples for transfusion with the registered practitioner taking
responsibility for this. Samples must be taken by trained and competency assessed staff as
per the Trust policy.

8.34 A zero tolerance policy is in place for errors for both the transfusion request and the sample.

9 Major Haemorrhage in adults and children refer to the Major Haemorrhage policy 13012

9.1 Major Haemorrhage in adults is defined as:

• The loss of approximately 40% of total blood volume or
• Four litres in 24 hours or
• Two litres in three hours or
• Greater than 150ml/min.

Major Haemorrhage in children is defined as:

• >80 ml/kg loss in 24 hours
• >40ml/kg loss in 3 hours
• >3ml/kg loss/minute

9.2 For information on Major Haemorrhage refer to the policy, 13012, and Major Haemorrhage
Management - Appendices 14 and 15 for flow diagrams.

9.3 Seek senior clinical help and request Major Haemorrhage packs 1 (primary) and 2
(secondary) as appropriate.

9.4 Summary:

 Summon senior help

 Assess ABC
 Obtain IV access
 Resuscitate
 Give blood
 Prevent coagulopathy
 Maintain stability
 Get more help to stop bleeding

9.5 Requesting blood in an emergency situation

9.6 Information for Clinical Staff

 Electronic issue 5-10 minutes, two separate samples on record, no history of antibodies,
transfusion or pregnancy since last samples
 Full cross match 40 minutes if the analyser detects antibodies then a full manual cross match
takes place – another 40 minutes
 Group specific, if the situation determines that waiting for a full cross match would negatively
impact on the patient, the most senior Doctor caring for the patient at that time takes
responsibility for asking for group specific blood products.

9.7 Emergency O D Negative units of blood are available in the Maternity blood bank and main
ward blood bank in Pathology Reception for immediate use. Caution should be used when
taking these units as they cannot be guaranteed to be the best product available for every 12
 scenario, particularly when patients are known to have red cell antibodies. They should only
be used where failure to give blood may result in death.

9.8 Should the blood be required from the laboratory before the cross-matching has been
completed, the units can only be issued on the authority of the medical officer directly in
charge of the case.

9.9 The paperwork will state that this blood is issued as suitable for the patient but un-
crossmatched. The risk of issuing a unit that is not fully compatible must be balanced against
the risk of delaying the transfusion.

9.10 Blood may be issued electronically (computer issued) if the patient has two identical groups
on samples collected on different occasions and a negative red cell antibody screen on both
samples with no historical evidence of the presence of red cell antibodies, recent transfusion
or pregnancy. These blood units can be made available within 5-10 minutes of the request.

9.11 In an emergency, blood may be issued directly to a sub-bank (e.g. theatre or maternity) from
the Blood Transfusion Department. Transfusion staff will note the name of the person
assuming responsibility for the safe keeping of the blood, and its return to the holding blood
bank, if not used. Where BloodTrack is in use units should be tracked electronically.

9.12 Emergency O D negative blood units are held on the main Broomfield site in two blood
banks:
 Two units O D negative unit in Pathology reception blood bank (suitable for adults
and children)
 Two adult units O D negative in Labur ward blood bank (suitable for adults and
children)
 One neonatal unit O D negative in Labour ward blood bank (donated <10days)

9.13 These units can be collected at any time for emergency use. It is important, if there is an
emergency admission, that the laboratory is sent a sample for the issue of further units if
required.

9.14 If the blood is used, the Blood Bank Record form should be returned to the blood transfusion
department.

9.15 Inform Laboratory staff that O D negative blood has been removed/used.

9.16 Some external sites have stock of O D negative units, Braintree Community Hospital and
Baddow Village Hospital. These are only to be used in the emergency situation.

9.17 When blood is returned to the holding blood bank, the record of the blood removed should be
placed on the clip provided, after recording the signature, date and time of the person
returning the unit. Where BloodTrack is in use units should be tracked electronically.

9.18 If blood is returned without the correct paperwork to prove that the cold chain pathway has
been maintained, it will be discarded.

10. The products

13
10.1 Red cell products

10.1 Information for clinical staff

 Red cell units must not be stored in a domestic, pharmacy or ward fridge.
 Red cell units expire at midnight of the date shown on the blood pack (if not completed at
this point the transfusion of the expired unit must be stopped).
 A unit of red cells must be transfused within 4 hours of removal from the blood bank
 Red cell units must be compatible with the recipient ABO and D type.
 They must be infused through a blood administration set
 Blood administration set must be changed after 12 hours if a continuous red cell
transfusion is given, if a different blood product is transfused or if the ABO group of the
next unit differs, for example where units of different groups are issued due to the
presence of unusual red cell antibodies.
 If the transfusion is to be given via an infusion pump, the blood must still be given via a
blood administration set suitable for that device.
 If another fluid is given before or following a red cell transfusion then the giving set must
be changed.
 Patients who have received treatment with purine analogues e.g. fludurabine or drugs
such as alemtuzumab or bendamustine should have irradiated blood products as should
all Hodgkins lymphoma patients or infants who have received an intrauterine transfusion.
See Special Requirements Policy 16015 for more information.
 Check the pack for colour, clots, leakages from ports or seals before transfusing.
 For non urgent transfusion national recommendations are to transfuse one unit and then
review the patient before transfusing further units in order to reduce the possibility of
transfusion associated acute circulatory overload (TACO).
 See Appendix 3 for the guidelines for indications of use for red cells.

10.2 Information for laboratory staff

 Red cell units must be stored at a temperature between 2-60C in a specially designated
and monitored blood bank i.e. not a domestic, pharmacy or ward fridge.
 Pregnant patients and the very young (under 4 months of age) should receive units that
have been tested and found to be negative for CMV (cytomegalovirus) unless there is a
clinical need and it is not possible to await their delivery from the National Health Service
Blood and Transplant (NHSBT). See also current SaBTO guidelines.
 Patients who react to plasma may benefit from the use of platelets suspended in Platelet
Storage Medium (PSM).
 Patients who react to plasma may benefit from the use of washed red cells.
 Patients with anti-IgA antibodies may benefit from the use of products from IgA deficient
donors.

11 Platelet products

11.1 Information for Clinical Staff

 Platelet units must be transfused through an administration filter supplied by the Blood
Transfusion Department. Normal blood giving sets may be used but will result in a loss of
the product due to dead volume in the set.
 A new filter must be used for each dose of platelets transfused.
 Platelet units must never by stored in the refrigerator.
 Normally each unit of platelets should be transfused within 30 minutes.
 Paediatric platelets are also available. These have a smaller volume, are always collected
by apheresis techniques and are prescribed in mls/kg.
 Volume of platelets required is 10-20 ml/kg for children less than 15 kg and a single
apheresis unit for children over 15 kg.
 Infusion of platelets for children should be10-20 ml/kg/hr. 14
  Platelet doses are ordered on a named patient basis from the National Blood and
Transplant Service (NHSBT) as and when required.
 Platelet units expire at midnight on the date shown on donor bag.
 Always check the pack for leaks at the ports and seams. Examine for unusual colour or
turbidity which might suggest bacterial contamination.
 Patients who have received treatment with purine analogues e.g. fludurabine or drugs
such as alemtuzumab or bendamustine should have irradiated blood products as should
all Hodgkins Lymphoma patients or infants who have received an intrauterine
transfusion. See the Special requirements policy 16015 for more information.
 A single dose platelet transfusion is recommended in non-urgent situations and should
be sufficient to increment the platelet count 20-40x109/l.
 Where patients repeatedly do not receive a suitable increment following platelet
transfusion, the use of HLA matched platelets should be considered.
 See Appendix 4 for the guidelines for indications of use for platelets.

11.2 Information for Laboratory staff

 Platelets are supplied as one adult therapeutic dose (ATD).
 Pooled, approximately 300ml of plasma; platelet count approximately 310x109
 Apheresis, approximately 200 ml of plasma; platelet count approximately 280x10 9
 Paediatric platelets are also available. These have a smaller volume, are always
collected by apheresis techniques.
 Apheresis platelets are prepared from a single donor, normally 3 adult doses may be
prepared from one donation.
 Each pooled platelet concentrate is prepared from four units of whole blood to
produce a single pooled dose.
 Storage temperature for platelets is 220C on an agitator and have a shelf life of 5-
7 days depending on production method. Storage facilities are only available within
the Blood Transfusion Department.
 A greater platelet recovery is obtained if ABO compatible platelets are transfused.
 Patients born after 1/1/1996 must preferentially be given apheresis platelets unless
these are unavailable and the clinical requirement is such that it is not possible to
await their delivery from NHSBT.
 Pregnant patients and the very young (under 4 months of age) should receive units
that have been tested and found to be negative for CMV, unless there is a clinical
need and it is not possible to await their delivery from NHSBT. See also current
SaBTO guidelines.
 Patients who react to plasma may benefit from the use of platelets suspended in
PSM (Platelet Storage Medium).
 Patients with anti-IgA antibodies may benefit from the use of platelet products from
IgA deficient donors.

12 Fresh frozen plasma (FFP)

12.1 Information for Clinical Staff

Please Note FFP is not approved for warfarin reversal

 Volume in each donation is approximately 150-300ml. Usual requirement is 10-15ml/Kg

body weight.
 It takes 30 minutes to defrost fresh frozen plasma ready for use and should then be
transfused immediately, as the effects of coagulation proteins decline over time.
Consequently requests are not prepared in advance of requirement.
 Fresh frozen plasma must be infused through a blood administration set.
 If the transfusion is to be given via an infusion pump, the plasma must still be given via a
blood administration set suitable for that device.
15
  Check the pack for leakages at the ports and seams. Look for unexpected flocculation or
discolouration.
 Anaphylaxis is a greater risk with rapid infusion of FFP.
 Only consider fresh frozen plasma transfusion for patients with clinically significant
bleeding but without major haemorrhage if they have abnormal coagulation test results
(for example, prothombin time ratio or activated partial thromboplastin time ratio above
1.5).
 Do not offer fresh frozen plasma to correct abnormal coagulation in patients who:
o are not bleeding (unless they are having invasive procedures or surgery with a
risk of clinically significant bleeding).
o need reversal of a vitamin K antagonist.
 Consider prophylactic fresh frozen plasma transfusions for patients with abnormal
coagulation who are having invasive procedures or surgery with a risk of clinically
significant bleeding.
 Reassess the patient’s clinical condition and repeat the coagulation tests after fresh
frozen plasma transfusion to ensure that they are getting an adequate dose, and give
further doses if needed.
 Refer to Appendix 5 for indication of use for FFP.

12.2 Information for Laboratory staff

 Stored in the Blood Transfusion Department in specialist freezers below -250C.
 On thawing, storage temperature is 2-60C in a specialist blood bank.
 Shelf life as a frozen product is 36 months after donation.
 Shelf life on thawing is 4 hours if maintained at room temperature and 24 hours if stored
in a specialist blood bank. .
 Non-UK sourced Methylene blue treated fresh frozen plasma is recommended for
patients born after 1/1/1996.
 Non-UK sourced Methylene blue treated fresh frozen plasma should be considered for
large volume plasma use for example plasma exchange in the absence of other products
such as Octaplas.
 Should be ABO compatible to avoid risk of haemolysis caused by donor anti-A or anti-B.
 D type of the plasma unit is not clinically significant.
 Patients with anti-IgA antibodies may benefit from the use of products from IgA deficient
donors.
 There is no requirement for CMV negative or irradiated FFP.

13 Cryoprecipitate (Cryo)

13.1 Information for Clinical Staff

 Volume in each pooled donation is approximately 120 -150ml.
 Usual requirement is one - two doses for treatment at times of bleeding.
 Cryo must be transfused through an administration filter supplied by the Blood
Transfusion Department. Normal blood giving sets may be used but result in a loss of the
product due to dead volume in the set.
 Consider cryoprecipitate transfusions for patients without major haemorrhage who have:
o clinically significant bleeding and
o a fibrinogen level below 1.5 g/litre
 Do not offer cryoprecipitate transfusions to correct the fibrinogen levels in patients who:
1.0 are not bleeding and
2.0 are not having invasive procedures or surgery with a risk of clinically significant
bleeding.
 Consider prophylactic cryoprecipitate transfusions for patient with a fibrinogen level below
1.0g/litre who are having invasive procedures or surgery with a risk of clinically significant
bleeding.
 Use an adult dose of 2 pools when giving cryoprecipitate transfusions (for children use 16
 5-10ml/kg up to a maximum of 2 pools).
 Reassess the patients clinical condition, repeat the fibrinogen level measurement and
give further doses if needed.
Refer to Appendix 5 for indication of use for cryoprecipitate.

13.2 Information for Laboratory staff

 Stored in the Blood Transfusion Department in specialist freezers below -250C.
 On thawing, storage temperature is at room temperature.
 The shelf life of the frozen product is 36 months.
 Shelf life on thawing is 4 hours maintained at ambient temperature.
 Non-UK sourced Methylene blue treated cryo is recommended for patients born after
1/1/1996.
 Should be ABO compatible to avoid risk of haemolysis caused by donor anti-A or anti-B.
 D type of the plasma unit is not clinically significant.
 Patients with anti-IgA antibodies may benefit from the use of products from IgA deficient
donors.

14 Human albumin solutions

 Available as 500ml and 250ml at 4.5% or 100ml at 20% solutions.

 Stored in the dark at room temperature at 2-250C.
 Instructions for use are supplied by the manufacturer on the product insert.

15 Plasma derivatives (including PCC/Beriplex )

 These are licensed pharmaceutical products.

 Recombinant Factor VIII and Factor IX: Most patients with severe haemophilia now
receive recombinant coagulation factor replacement to avoid risks of transmission of virus
infections
 Factor II, VII, IX and X concentrate (Prothrombin Complex Concentrate, PCC). The main
indication is warfarin overdose where there is life-threatening bleeding. PCC is
recommended product that should be used for warfarin reversal, not FFP. May be used in
patients with haemorrhage, particularly where there is a contraindication to the use of
FFP, and head injury with suspected intracerebral haemorrhage.
 Consider immediate prothombin complex concentrate transfusions to reverse warfarin
anticoagulation in patients having emergency surgery, depending on the level of
anticoagulation and the bleeding risk.
 PCC can be issued without discussion with the Consultant Haematologist if the request
meets the following criteria:

1. The patient is on Warfarin

2. INR is above 2 (The INR MUST have been tested no longer than 24 hours before
requesting PCC)
3. The patient’s weight is known or can be calculated

 The INR must be checked again 1 hour after the administration of PCC. Vitamin K should
be given at the same time as PCC. Requests for PCC for reasons outside these criteria
must be authorised by a Consultant Haematologist prior to issue, unless section 15.1
applies.
 Recombinant factor V11a (NovoSeven). Used in patients with haemophilia and inhibitors.
 Requests should be made directly to the Blood Transfusion Department and may require
referral to a Haematology Consultant.
(For guidance on reversing anticoagulation treatment in people who have stroke and
primary intracerebral hemorrhage refer to NICE guideline 1.4.2.8)
17
 15.1 PCC/Beriplex issue in the emergency situation:

The laboratory will issue 1000 IU PCC without prior referral to a Haematology Consultant in the
following circumstances
 If the patient has been receiving oral anticoagulation (warfarin or other Direct Acting
Oral Anticoagulants - DOAC’s) and is either actively bleeding or is thought to be
bleeding (for example into a joint or a cerebral bleed).
 The request has been made directly by a Consultant or under the direction of a
Consultant
 The patient details have been provided over the phone and match the patient record
already on the Blood Transfusion IT system or, where there is no record on Blood
Transfusion IT system, by a Group and Save request form being brought directly to
the Blood Transfusion Department (usually by a Porter, who can be directed to wait
outside the Laboratory while the product is issued, or through the POD system. Forms
should not be sent through the POD system in an emergency).

16 Granulocyte transfusions

 Discuss with the Haematology Consultant

17 Maximum blood ordering schedule

17.1 These guidelines for the blood ordering schedule have been prepared to reduce unnecessary
cross-matching of blood, to increase the availability of blood for those patients who need it
and to reduce wastage. This blood ordering schedule is flexible in special circumstances.

17.2 If requirement is in excess of the tariff, the case should be discussed with the Blood
Transfusion Department.

17.3 The appropriate EDTA bottle should be filled to the line and at least 6ml of blood sample
should be collected in full accordance with the Trust guidelines for the collection of a blood
sample for transfusion. A smaller sample may not leave sufficient plasma for a cross-match
should it be required or for referral to NHSBT for further investigation in the event that
auto/allo antibodies are detected.

17.4 All forms must be completed in full including a diagnosis, obstetric history, previous
transfusions, special requirements and known blood group. Please refer to the special
requirements policy 16015.

17.5 Orthopaedics

 Total hip replacement Group and Save

 Total knee replacement Group and Save
 Revision of hip prosthesis 4
 Spinal fusion or spinal decompression 2
 Nailing of fractured femur Group and Save
 Internal fixation of femur 2
 Laminectomy Group and Save

17.6 Surgery
18
  Aortic aneurysm 4
 Femoral Popliteal Graft 2
 Nephrectomy 2
 A.P. Resection Group and Save
 TURP Group and Save
 TURBT Group and Save
 Mastectomy Group and Save
 Oesophageal Gastrectomy 6
 Cystectomy 4
 Splenectomy Group and Save
 Laparotomy Group and Save
 Cholecystectomy Group and Save

17.7 Obstetrics

 LSCS Group and Save

 Hysterectomy : abdominal 2
simple Group and Save
 Miscarriage Group and Save
 ERPC Group and Save
 Wertheirn’s 4
 Placenta Praevia : continuous
2 Dependent on staging (repeat samples
required at intervals of 72 hours)
 APH and PPH : variable 2

18 Collection of blood components from blood banks

18.1 Procedure for collection (competency 3, appendix 10)

18.2 It is important to have a full cold chain pathway and audit trail for red blood cells and plasma,
these components are therefore tracked into and out of the blood banks via the blood track
system.

18.3 Instructions for the removal of blood from the blood bank can be found on all blood banks.

18.4 Blood units will be collected from the holding Blood Bank by staff authorised by senior ward
or department staff and trained in the use of BloodTrack and issued with a dedicated
barcode. Access to blood banks fitted with BloodTrack is limited to trained staff by locks on
the blood bank doors. Other staff therefore should not be sent to collect blood or return blood
products.

18.5 It is the responsibility of the senior member of staff in the appropriate department to ensure
that the person to whom they delegate this task is competent and trained to undertake the
task.

18.6 The person collecting the blood from the blood bank must have clear details of the patient
(first name, surname, date of birth and/or hospital number) for whom the blood is being
collected for. The following procedure should be followed:

 Find the Blood Bank Record form in the folder by the blood bank.
 Check that the details are correct against the patient’s Blood Transfusion Patient’s
Record and documentation provided by ward.
19
  Access BloodTrack with personal barcode and select option to remove blood on screen.
 Open the blood bank and select the unit(s) of blood required – select in chronological
order.
 Ensure the blood bank door is then closed.
 Scan the unit barcode and cross check/confirm the blood label with the patient’s full
name, date of birth and hospital registration number displayed on the screen.
 Note the time and date, and sign the Blood Bank Record form found in folder.
 Leave the Blood Bank Record form in the folder by the blood bank.
 If the first unit is collected take the appropriate Patient Record Form from the folder with
the unit (s) to the department.
 Please note only red cells and FFP are collected from the blood bank, other products
should be collected directly from the Blood Transfusion Department.
 Follow the advice given and contact Blood Transfusion Department Staff if any alert
message is displayed in red on the BloodTrack kiosk screen.

19. Procedure for return of blood to the blood bank

19.1 A unit of red cells must not be out of the blood bank for more than 30 minutes before
infusion. If the unit is out for more than 30 minutes and not required for that patient
then the unit should be returned to the blood transfusion laboratory. If however the patient
still requires the unit, it may still be administered as long as the transfusion process is
completed within four hours from when the unit was first removed from the blood bank.

19.2 To return units to the main blood bank or to another blood bank:

 Access BloodTrack using personal barcode and selecting the option of ‘putting in’ blood
into blood bank.
 Scan the barcode on the unit.
 Open the blood bank door and place the unit on the appropriate shelf in the blood bank.
 BloodTrack will display a red screen advising of the need to contact the Blood
Transfusion Department if any unit is be returned after 30 minutes. The transfusion
laboratory needs to be informed immediately if this occurs.
 Never return opened blood packs to the holding blood bank but inform the laboratory to
arrange the return of the unit.

20 Labelling of non-blood bank refrigerators in clinical areas

 Storage of blood - All non-blood bank refrigerators should display prohibition labels advising
against the storage of blood and blood products. These are available from the Blood
Transfusion Department.
 It is the responsibility of the unit manager to ensure that all non-blood bank refrigerators and
deep freezers in their area are correctly labelled.
 Only the storage of blood and blood products suitable for transfusion is permitted in a blood
bank.

21 Process of administering blood and blood products Pre transfusion information

21.1 As soon as the cross-matching/issue of the blood has been completed the laboratory will
release the Blood Transfusion - Patient Record sheet bearing the patient’s surname,
forenames, date of birth, NHS number, hospital registration number, ward and blood group,
together with the serial numbers of the units which have been found to be compatible.

21.2 This record will remain in the patient’s notes.

20
21.3 The medical officer should prescribe the number of units and product required on the
patient’s Parenteral Fluid Therapy card or Blood Product Transfusion Chart. This must
include duration of infusion i.e. rate of flow and volume. The risk with prescribing
(authorising) the blood component on both forms is that the patient may receive double the
amount.

21.4 A medical student must not, in any circumstances, request or prescribe blood for transfusion
or collect a blood sample for transfusion purposes.

21.5 The person putting up the unit must record the name of the medical officer prescribing the
product on the Blood Transfusion - Patient Record sheet issued by the Blood Bank in the
“Prescribed by M.O.’ column.

21.6 A ‘prescription’ is only valid as long as there has been no change in the patient’s medical
condition. In these cases the clinician is required to reassess the patient and the prescription
must be renewed.

21.7 The responsibility to ensure safe collection from, or return to, the holding blood bank of
specific units lies with the person in charge of the ward or department.

21.8 The ‘Blood Transfusion - Patient Record’ must be signed and attached to either the
prescription chart or the blood product transfusion chart. Once the transfusion is completed
this should be filed in the patient’s notes.

22 The procedure of transfusing of blood or blood components

22.1 Only set up a transfusion for one patient at a time.

22.2 When transfusing blood/blood products, an appropriate blood giving set with an integral filter
must be used.

22.3 Blood giving sets must be changed according to manufacturers’ instructions. If filters become
blocked, more frequent changes are necessary.

22.4 Observations must be taken before, during and at the end of the transfusion of each unit. If
the patient is clinically unwell or in a side room, more frequent observations may be
necessary.

22.5 The transfusion of blood and blood products should normally take place during core working
hours (08:00-20:00) when there is sufficient staff to react quickly in the event of a reaction.

22.6 Where transfusion takes place outside core hours due to a clinical need this should be fully
documented in the patients notes.

22.7 Before starting the transfusion, record the patients baseline blood pressure, pulse,
respiration rate, temperature and National Early Warning Score (NEWS) score (must be
within one hour prior to the transfusion commencing).

22.8 Collect the blood or blood component from the blood bank immediately before use. The
relevant blood bank record sheet must be signed.

22.9 Two members of staff complete independent checks of the unit, and the patient:
Carefully check the name, blood group, hospital number and date of birth on the traceability
tag attached to the unit. If in doubt contact the Blood Transfusion Department for advice and
do not start the transfusion. Check the donation number on the tag against the donation
number on the unit, if these do not match, do NOT transfuse the unit.
21
22.10 Check the expiry date of the unit and for any signs of contamination, discolouration or
damage. If in doubt contact the Blood Transfusion Department for advice and do not start the
transfusion.

22.11 Check the details on the compatibility tag attached to the unit with the patient and with the
details on the wristband (not just with the compatibility form issued with the units).
Remember: No wristband, no transfusion.

22.12 The Doctor or Authorised Nurse/Midwife must sign, date and record the time of the
transfusion on the label of the unit being transfused and the Patient Record form with another
competent staff member who may be a Doctor, Registered Nurse/Midwife. An Operating
Department Practitioner (ODP) may check blood with a registered Doctor.

22.13 The front section of the traceability tag has a peel off sticker, once signed and dated this
should be removed and placed on the patients drug card or blood transfusion chart. When
the unit has completed the reverse of the tag is to be completed with the time the transfusion
finished.

22.14 Ask the patient (if appropriate) to inform staff if they feel they become more unwell (change
in current symptoms) during the transfusion.

22.15 Fifteen minutes after the start of the transfusion, recheck the blood pressure, pulse and
temperature, respiration rate and NEWS score and record these on the observation chart.
This check is crucial in early detection of ABO incompatible transfusions and serious
reactions and must be recorded by a qualified member of staff. In extreme situations only,
if a qualified member of staff is not available at this time e.g. called to cardiac arrest, they
must still be recorded and then countersigned by a qualified member of staff when available.

22.16 Observations must be carried out on the patient for each unit that is transfused.

22.17 These are the minimum observations that must be completed for each unit transfused.
Where the patient has underlying conditions or has had previous complications following
transfusion it may be appropriate to complete observations more frequently as indicated by
the clinician responsible for the patient. See also appendix 6 and 10 (Competency
assessment 4 ‘Assessment for preparing and administering a transfusion of blood / blood
products’).

22.18 Repeat the blood pressure, pulse, temperature, respiration rate and NEWS when the
transfusion is completed. This must be recorded within one hour of completion.

27.19 If the patient is conscious, and able to communicate, further recordings are only needed if the
patient becomes unwell or has symptoms or signs of a reaction.

22.20 An unconscious patient or the very young or elderly patient or patients with communication
difficulties should have all observations and NEWS checked at regular intervals during the
transfusion.

22.21 Retain all used units for a period of at least 24 hours in case required as part of a
transfusion reaction investigation, after which they may be disposed via clinical waste.

22.22 It is a legal requirement that evidence of tracebility is kept for thirty years. The traceability
tag must be completed and returned to the Blood Transfusion Department to ensure records
are updated and the traceability tag stored. These can be returned by pod, internal post or
hand collected.

22
22.23 DO NOT return opened units to a blood bank.

22.24 If the red cell unit is opened but not used, the Blood Transfusion Department should be
contacted and the return of the unit arranged.

22.25 Record any adverse effects in the patient’s record. In the event of a reaction to the unit being
transfused, immediately stop the transfusion and summon help. Suspected transfusion
reactions should be reported immediately to the clinician responsible for the patient and the
Blood Transfusion Department. A DATIXWEB report and Transfusion Reaction form should
also be completed, see appendices 7, 8 and 9

22.26 Desferrioxamine Mesylate is the only medication that may be given alongside a blood
transfusion. No other infusion solutions or drugs should be added to any blood component. If
other medications are urgently required to be administered alongside blood components, the
transfusion should be stopped, a 10 ml flush of saline before and after each medication,
before re-starting the transfusion
22.27 Refer to Appendix 7 for guidelines for transfusion reactions

22.28 Refer to the Trust policies for Infection Prevention and Control to ensure that the infection
control measures are followed throughout the procedure.

23 Blood warmers

23.1 If blood is required to be warmed to body temperature, an approved blood warmer must be
used.

23.2 Blood warmers are used for specific cases e.g. for exchange transfusion, rapid large volume
transfusion or patients with cold antibodies.

23.3 Their use should be the only method used for warming blood and blood products for
transfusion. It is the responsibility of the clinician responsible for the patient to ensure nursing
staff are aware of the need for a blood warmer.

23.4 Blood warmers suitable for the transfusion of blood products are available from the Medical
Equipment Library, ext 4782, or bleep 2158.

24 Informing the patient (consent) appendix 16

24.1 There is no current legal requirement in the UK to gain written formal consent from the
patient for the transfusion of blood products. However national guidelines recommend the
patient should be given information on the benefits, risks and alternatives to transfusion, if
appropriate, and that verbal consent to transfusion is obrtained in advance of requirement
whenever possible.

24.2 For medical patients consent should be documented either in the patient’s notes or the blood
product transfusion chart (see appendix 16). For surgical patients it may suffice to document
on the consent for surgery form, although to ensure best practice verbal consent should be
documented separately in the patients’ notes or on the blood product transfusion chart.

24.3 For patient’s who are unable to provide verbal (or written) consent, this must be clearly
documented in the clinical record (e.g. where an MCA 2 is in place), and, if applicable, the
patient given information retrospectively.

24.4 Patient information leaflets produced by the NHSBT are available from the blood transfusion
department. Leaflets are available for Blood Transfusion, Platelet, FFP and Cryoprecipitate
transfusions.
23
24.5 NHSBT patient information leaflets are also available to be given to patients who have a new
requirement for irradiated blood products. These leaflets contain a warning card and needs to
be given to patients with clear advice to show health care professionals this if there may be a
potential they need a blood component.

24.6 Provide verbal and and written information to patients who have had a transfusion and their
family members or carers (as appropriate) explaining:
 The reason for the transfusion
 The risks and benefits
 The transfusion process
 Any transfusion needs specific to them
 Any alternatives that are available and how they might reduce their need for a transfusion
 That they are no longer eligible to donate blood
 That they are encouraged to ask questions.

24.7 This discussion should be documented in the patient’s notes

25 Refusal of a blood transfusion refer to the Consent to Examination or Treatment

Policy 04080 section16.9 and appendix F

25.1 Every patient has the right to be treated with respect and staff must be sensitive to their
needs, values, beliefs and cultural background.

25.2 Staff must be aware of patients’ beliefs in relation to receiving blood or blood products, and of
the alternatives that are available to a blood transfusion.

25.3 Patients who do not wish to receive blood products (for example Jehovah’s Witness) are
encouraged to carry a document which details their wishes for medical care. Clinical staff
must ensure that these patients sign the appropriate form indicating their refusal to receive
blood or blood components.

25.4 Individual patients who do not wish to receive a blood transfusion may still accept treatments
such as dialysis, cardiopulmonary bypass, organ transplants or plasma derivatives.

25.5 In the case of Maternity, refer to Clinical guideline 07040 Management of pregnant women
and postnatal patients refusing blood products.

25.6 Refer to the Mental Capacity Act for patients who may not have the mental ability to
understand the implications of a blood transfusion.

25.7 Refer to policy 04080 Consent to examination or treatment policy’ appendix F for a ‘Consent
to Medical Treatment by Patient who refuses to have a Blood Transfusion’ form.

25.8 Erythropoietin should only be offered to reduce the need for blood transfusion if the patient
declines it because of religious beliefs or other reasons

26 Children

26.1 Pre-transfusion testing for neonates and infants within the first four months

26.2 The request must be discussed with the Blood Transfusion Department (extension 4140).

26.3 Send samples from mother and baby for testing to the Blood Transfusion Department

24
26.4 Label the samples and fill in the cross-match request form completely, in accordance with the
MEHT Blood Transfusion Policy.

26.5 The blood transfusion department will carry out the following tests on all initial requests for
cross-matching:

 ABO and D type mother and baby

 Screen the maternal sample for atypical red cell antibodies
 Perform direct antiglobulin tests (DAT) on the infant’s red cells

26.6 Provided that there are no atypical antibodies demonstrable in the maternal and/or infant
plasma and the DAT on the infant’s red cells is negative, the conventional cross-match is not
necessary. The ABO group of the red cells selected for transfusion should be compatible with
the mother’s and infant’s ABO group.

26.7 The presence of atypical red cell antibodies in the maternal/infant plasma, or a positive DAT
on the neonatal red cells will require serological investigation and full compatibility testing.

26.8 All infants that have received an exchange or intrauterine transfusions require irradiated
blood components.

26.9 Units for neonatal exchange transfusion are irradiated (essential if previous intrauterine
exchange transfusion).

27 Small volume transfusions for infants less than four months

27.1 For small volume or routine transfusions, blood can be used at any time throughout its shelf
life. This will enable multiple aliquots (available from the NHSBT) for transfusion to be used
from a single donation and thereby reduce donor exposure.

27.2 If a neonate, particularly a premature baby, needs multiple red cell transfusions inform the
blood bank so that multiple aliquots of red cells from the same donor can be set aside for the
patient.

27.3 For small volume transfusions, either plasma reduced or red cells suspended in optimal
additive solution (SAG-M) may be used, haematocrit 0.5 – 0.7. Red cells for neonatal use are
group O high titre anti-A, anti-B negative (or ABO compatible with baby and mother) and D
negative (or D compatible with the the neonate), leucodepleted and negative for red cell
antibodies, HbS, CMV (cytomegalovirus) and Kell.

28 Large volume or exchange transfusions (which exceeds baby’s blood volume)

28.1 Red cells less than five days old (negative for red cell antibodies, high titre anti-A, anti-B
negative, CMV, Hb S and Kell negative) are to be used for exchange or large volume
transfusions. These red cells are leucodepleted and plasma reduced with a haematocrit of
0.5 - 0.55.

28.2 The red cells must be irradiated if the baby has had an intrauterine transfusion. Irradiation is
recommended for all exchange transfusions, provided it does not unduly delay transfusion.

29 Use of irradiated products for routine transfusions in infants and neonates

29.1 It is not necessary to irradiate blood for routine ‘top-up’ transfusion of premature or term
infants, unless either there has been a previous intrauterine transfusion or the blood has
come from a first or second degree relative, in which case the blood should be irradiated until
six months after the expected date of delivery (40 weeks gestation).
25
29.2 Products collected from first or second degree relatives are only indicated when it is not
possible to use bank blood due to the presence of atypical red cell antibodies that make it
impossible to find potentially compatible donors. The donation must be collected and tested
as per any other unit of donated blood by the NHSBT (see section 41).

29.3 Platelets should be irradiated, CMV negative and apheresis when given to neonates who
have received either red cells or platelets in utero. However there is no need to irradiate
other platelet transfusions for pre-term or term infants.

29.4 All HLA matched platelets should be irradiated.

30 Granulocyte transfusions for infants and neonates

30.1 All granulocyte transfusions should be irradiated and transfused as soon as possible after
irradiation.

30.2 All requests must be discussed with the Blood Transfusion Department.

31 Blood and blood components for congenital immuno-deficiencies in infants and

children

31.1 It is recommended that all severe T lymphocyte immunodeficiency syndromes should be

considered as indications for irradiation of cellular blood components. Once a diagnosis of
immunodeficiency has been suspected, irradiated components should be given while further
diagnostic tests are being undertaken. A clinical immunologist should be consulted for advice
in cases where there is uncertainty.

32 Acute leukaemia in infants and children

32.1 Advice from the shared care unit should be sought with regard to special requirements.
However this is normally irradiated and often CMV negative cellular blood products.

32.2 Bone marrow transplantation, lymphoma, solid tumours and organ transplantation, please
refer to the British Committee for Standards in Haematology (BCSH) Guidelines on Gamma
Irradiation of Blood Components.

32.3 Patients who have received treatment with purine analogues e.g. fludarabine, should have
irradiated blood products.

32.4 Patients with Hodgkins lymphoma should receive irradiated cellular blood products.

33 Administration of Desferrioxamine Mesylate

33.1 Desferrioxamine Mesylate is available in 500mg and 2 gram vials and is the only medication
that may be given alongside a blood transfusion.

33.2 Desferrioxamine may cause hypersensitivity reactions. This should be remembered during
routine blood transfusion patient monitoring.

33.3 Desferal is a chelating agent for trivalent iron; the resulting chelates are stable and non-toxic.

33.4 Preparing vials:

 Clean top of vial using aseptic technique

 Dissolve 500mgs of Desferal in 5mls of sterile water BP for intravenous use
26
  Draw volume containing prescribed dose into a syringe and add to 250mls or 500mls of
normal saline infusion bag and mix bag contents well

33.5 Complete the drug additive label and stick onto infusion bag, being careful not to obstruct the
identification details of the bag.

33.6 Preparation of desferal and unit of blood:

 Connect the normal saline containing the Desferal to a giving set with a 3 way trap
attached
 Connect blood to 2nd port on 3 way tap
 The blood and Desferal are now ready to be attached to the patient for transfusion.
 The Desferal should run for the complete length of the blood transfusion

34 Clinical Indications for the use of Fresh Frozen Plasma (FFP)

34.1 Definite indications

 Replacement of single clotting factor deficiency

 FFP is only required when specific or combined factor concentrates are unavailable
 Vitamin K deficiency
 Acute Disseminated Intravascular Coagulation (DIC)
 Thrombotic Thrombocytopenic Purpura (TTP)

34.2 Conditional uses

 FFP is only indicated in the presence of bleeding and disturbed coagulation

 Massive Transfusion
 There is no evidence that prophylactic replacement regime with FFP or platelet
concentrates, either prevents bleeding or reduces transfusion requirements. Early
laboratory assessment is needed
 Liver Disease
 Cardio-Pulmonary Bypass surgery.

34.3 No justification for the use of FFP

 Hypovolaemia
 Formula Replacement e.g. 1 unit of FFP for every six units of red cells
 Nutritional support
 Treatment of Immuno-deficiency states
 Reversal of warfarin

34.4 Risk of HIV, Hepatitis B or Hepatitis C is similar to that of a transfusion of red cells.

35 Administration of Prophylactic Anti-D Immunoglobulin

35.1 Indications for the use of Anti-D immunoglobulin

35.2 It is recommended that routine antenatal prophylactic anti-D is offered to all non-sensitised
pregnant women who are D negative to prevention sensitisation to the D antigen during
pregnancy.

35.3 If you have any queries on the indications or dosage for the use of anti-D immunoglobulin,
please contact the Blood Transfusion Department (ext. 4140) or page the BMS on call if
outside core hours #6555 2231. 27
35.4 Also refer to the Maternity Services 06065 Clinical Guideline anti- D immunoglobulin

35.5 Anti-D immunoglobulin is normally given intramuscularly. The intramuscular injections are
best given into the deltoid muscle, as injections into the buttock often only reach the
subcutaneous tissue and absorption may be delayed. On rare occasions, for example,
where the patient has an underlying condition such as Von Willebrand disease or severe
thrombocytopenia, it should be given by sub-cutaneous injection or intravenously after
discussion with the laboratory and Haematologist on call. In these cases it may be
necessary to issue a different batch of anti-D as not all preparations are suitable for
administration by this route.

35.6 For successful prophylaxis, anti-D immunoglobulin should be given as soon as possible after
the sensitising event, but always within 72 hours.

35.7 If anti-D immunoglobulin has not been given within 72 hours of a sensitising episode, a
dose given up to ten days may provide protection in some cases.

35.8 Where administration is delayed beyond 72 hours this is reportable via DATIXWEB and will
be reported by the Blood Transfusion Department to SHOT.

35.9 Dosage overview

35.10 Up to 20 weeks gestation give 500iu.

35.11 After 20 weeks gestation give 500iu.
35.12 Routine prophylaxis of 1500iu is given at 28 weeks in addition to any other doses given for
sensitising events.
35.13 Protocol in cases up to 12 weeks gestation
35.14 In pregnancies <12 weeks gestation, anti-D prophylaxis is only indicated following ectopic
pregnancy, molar pregnancy, therapeutic termination of pregnancy and in cases of uterine
bleeding where this is repeated, heavy or associated with abdominal pain. The dose should
be a minimum of 250iu (500iu will be issued). A test for fetomaternal haemorrhage (FMH) is
not required.

35.15 It is not indicated for spontaneous abortions before 12 weeks gestation unless there is
excessive bleeding or pain.

35.16 Protocol in cases with continual bleeding after 12 weeks gestation

35.17 Threatened abortions after 12 weeks gestation, if bleeding continues intermittently, give anti-
D injections at 6 weekly intervals until delivery.

35.18 Anti-D immunoglobulin is indicated for threatened abortions before 12 weeks where the
pregnancy remains viable, and if there is heavy bleeding or bleeding is repeated or
associated with abdominal pain.

35.19 Protocol for dealing with potentially sensitising events during pregnancy

35.20 All D negative women without pre-existing immune anti-D should receive anti-D
immunoglobulin for the following episodes or procedures:

 Chorionic villus sampling

 Amniocentesis
28
  External cephalic version
 Antepartum haemorrhage – continue the injections at six weekly intervals until delivery
 Abdominal trauma

35.21 The dosage of anti-D immunoglobulin given will be dependent on the number of weeks of the
pregnancy

35.22 Up to 20 weeks gestation give 500iu. Kleihauer test is not required.

After 20 weeks gestation give 500iu and perform Kleihauer test to confirm sufficient anti-D
has been given. The Kleihauer test IS NOT designed to determine whether anti-D is required
or not.

35.23 If a foetal bleed of greater than 4 mls is detected further doses of anti-D will be issued by the
laboratory.

35.24 Any request for anti-D received after 20 weeks (other than routine 28 week dose) must also
have a Kleihauer performed.

35.25 Dosage in routine antenatal prophylaxis at 28 weeks

35.26 Prior to the administration of anti-D at 28 weeks a group and save sample should be taken
within 7 days prior to administration. The result needs to be reviewed prior to the
administration of anti-D to ensure the sample is valid and has been analysed. This is to
check to see if the patient has sensitised to D during pregnancy. Once anti-D is administered
it is not possible to determine if anti-D detected is immune or prophylactic.

35.27 The regime in MEHT is that 1500iu prophylactic anti-D should be given at 28 weeks
gestation, followed by the standard postnatal 500iu dose at delivery if the infant is D positive.

35.28 It is also possible to give 500iu anti-D at 28 and 34 weeks gestation, followed by the standard
postnatal 500iu dose if required. This may be required if patients transfer from another Trust
using a different regime.

35.29 If the patient presents later than 28 weeks for the initial 1500iu dose of anti-D
immunoglobulin, 1500iu dose can still be given but it must be recorded in the patients notes
the dose was given late and therefore a sensitising risk for the patient.

35.30 If the patient presents at over 34 weeks gestation a 500iu dose only is required.

35.31 Protocol for postnatal prophylaxis

35.32 All D negative women who do not have immune anti-D where the group of the baby is
unknown or who have delivered an D positive infant should be considered candidates for
prophylactic anti-D. See also policy, 06065 Administration of anti-D for D Negative patients in
Maternity

35.33 The following blood tests should be carried out before giving anti-D immunoglobulin:

 Red cell antibody screen on maternal plasma

 D typing of infant
 Kleihauer screening (4ml EDTA sample from maternal and cord) to estimate the
fetomaternal bleed

35.34 A standard dose of 500iu is adequate to cover a foetal red cell bleed of 4mls packed cells
29
 (8mls whole blood). Ninety-nine per cent of bleeds are less than 4mls. If a larger dose is
indicated, the laboratory will inform the ward or the doctor.

36 Alternatives to Transfusion

36.1 Alternatives to red cell transfusion should be considered in most cases, even if a patient has
not refused transfusion e.g. healthy diet, oral iron, IV iron, erythropoietin

36.2 In patients who are bleeding or at risk of major blood loss (greater than 500ml), tranexamic
acid should be considered.

36.3 Consider tranexamic acid in children undergoing surgery who are expected to have at least
moderate blood loss (greater than 10% blood volume).

36.4 Surgical patients should be offered intra-operative cell salvage where appropriate.

36.5 Do not routinely use cell salvage without tranexamic acid

36.6 Consider intra-operative cell salvage with tranexamic acid for patients who are expected to
lose a very high volume of blood (for example in cardiac and complex vascular surgery
major obstetric procedures, and pelvic reconstruction and scoliosis surgery).

36.7 Where a patient refuses a red cell transfusion

 Some patients with religious or ethical beliefs will accept certain blood products but not
others.
 If the patient would refuse any of the products ensure the form ‘Consent to medical treatment
by a patient refusing a blood transfusion’ is completed. For example some patients who would
refuse a red cell transfusion may accept other blood products such as cryoprecipitate. Policy
no 04080 Appendix F
 Offer IV iron for pre-operative iron deficient patients.

36.8 Do not offer erythropoietin to reduce the risk of blood transfusion in patients having surgery,
unless;
 The patient has anaemia and meets the criteria for blood transfusion, but declines it because
of religious or other reasons
 The appropriate blood type is not available because of the patient’s red cell antibodies

36.9 Offer oral iron before and after surgery to patients with iron-deficient anaemia

37 Transfusion Reactions

37.1 Monitor the patient’s condition and vital signs before, during and after blood transfusions, to
detect acute transfusion reactions that may need immediate investigation and treatment

37.2 The minimum observations recommended are designed to detect an incompatible blood
transfusion at the earliest opportunity.

37.3 Observe patients who are having or have had a blood transfusion in a suitable environment
with staff who are able to monitor and manage acute reactions.

37.4 If a reaction is suspected, medical/nursing staff should immediately stop the transfusion and
report the suspected reaction immediately to the clinician responsible for the patient, who
must then inform the Blood Transfusion Department (extension 4140).

37.5 A Transfusion Reaction can be defined as the occurrence of one or more of the following
signs or symptoms:
30
  The patient complains of feeling ‘flushed’
 Lumbar pain
 Faintness, throbbing headache
 Rigor
 Temperature rises more than 1.5’C above baseline.
 Changes in blood pressure or pulse rate
 Rash
 Tachycardia

37.6 IF A REACTION OCCURS, THE TRANSFUSION MUST BE STOPPED AT ONCE AND

THE CLINICIAN INFORMED.
37.7 The clinician reporting a transfusion reaction should discuss the nature of the problem with
the laboratory staff and or a Haematology Consultant and agree an approach to its
investigation. Reactions can occur as a result of allergy, overload or red cell / white cell
antibodies. See also appendices 7, 8 and 9.

37.8 A full history is essential in order to maximise the use of the pre-transfusion sample.

37.9 Stop the transfusion, take the unit down, but keep the cannula in situ.

37.10 Seal the end of the tube, place the entire administration set in a protective cover and return
to the blood transfusion laboratory with the blood unit.

37.11 The clinician must complete, in full, a Transfusion Reaction Form and send the form together
with a group and save sample, full blood count sample, and a urine sample to the Blood
Transfusion Department.

37.12 Blood Transfusion Reaction Reporting Forms are available from the Blood Transfusion
Department. A sample of a request form for the investigation of an apparent Transfusion
Reaction refer to Appendix 7.

37.13 A DATIXWEB report must be completed where a patient has been or could have been
harmed as a result of transfusion - to ensure the incident is recorded and investigated.

37.14 The blood transfusion department will assess the event and report to SABRE and SHOT if
required.

37.15 If it is suspected that the reaction is due to an infected unit inform the Blood Transfusuon
Laboratory immediately and discuss with the Haematology Consultant on call. Culture the
patient but DO NOT culture the unit. Return the remainder of the unit to the Blood
Transfusion Laboratory, with the giving set in situ. If required the Blood Transfusion
Laboratory will arrange for the return of the unit to NHSBT for culture. NHSBT will arrange for
a re-call of any other products prepared from the unit.

38. Breach event reporting and adverse reactions and events of transfusion

38.1 Adverse effects of blood transfusions

38.2 Transfusion reactions are relatively common, but severe reactions are rare (1 death/ 34,000
transfusions). Generally, the more acute the reaction, the more rapid is the onset of
symptoms.

38.3 Transfusion reactions may be due to red cell, white cell or platelet incompatibility. There are
31
 in addition, reactions to allergens, endotoxins and cytokines in the transfused blood as well
as very rare immunoglobulin incompatibilities.

38.4 The most severe reaction is due to red cell mismatch, and of these, group A into group O is
the most severe and most rapid.

38.5 Laboratory errors are rare in cross-matching, but unfortunately giving blood to the wrong
patient is not. Estimates of incidents range from 1:1,000 to 1:20,000. Mortality, however, is
probably less than 10%. The need for meticulous checking cannot be stressed enough.

38.6 The results of red cell mismatch are a rapid onset of symptoms, often after the first few
millilitres of the transfusion, and are due to intravascular haemolysis as a result of
complement activation and the release of C3a, C4a and C5a with subsequent Disseminated
Intravenous Coagulation (DIC).

38.7 In the conscious patient there is restlessness, a feeling of oppression and sub-sternal pain.
The main clinical findings are hypotension and oliguria.

38.8 Treatment consists of immediate cessation of the transfusion and its replacement with
crystalloid or colloid to counteract the hypotension.

38.9 Frusemide may be given intravenously to maintain filtration in the presence of free
haemoglobin. Circulatory support with inotropes and vasopressors may be required but only
after volume loading.

38.10 The laboratory should be informed immediately and the blood returned to them with the
corresponding labels.

38.11 The only other acute reaction that produces anaphylactic shock is of slightly later onset in the
transfusion and is due to IgA incompatibility. It is, however, very rare. The commonest
reaction seen is urticaria due to foreign protein in the donor blood activating IgE in the
recipient’s plasma.

38.12 Febrile reactions are relatively common and are generally due to reactions to incompatible
white cells. The recipient’s plasma contains leucocyte antibodies that react with leucocytes in
the donor blood.

38.13 Febrile reactions are more common in those who have been pregnant or who have had
previous transfusions.

38.14 Most reactions are mild and are seen 15 to 30 minutes after the onset of the transfusion.

38.15 More severe reactions may occur if the donor plasma contains potent white/platelet -
antibodies.

38.16 Transfusion Related Acute Lung Injury (TRALI) is characterised by chills, fever, a
non-productive cough and dyspnoea. A chest x-ray would show numerous nodules,
predominantly peri-hilar with infiltration of the lower lung fields.

38.17 Transfusion associated circulatory overload (TACO) is when too much fluid is transfused or
the transfusion is too rapid and results in acute left ventricular failure (LVF) with dyspnoea,
tachypnoea, non-productive cough, hypotension, tachycardia and frothy pink sputum. In
order to reduce the risk of TACO it is recommended that the patient’s condition be reviewed
after each unit transfused. The exception to this rule is where the patient is being transfused
due to acute major haemorrhage. Consider the patient’s weight, age and co-morbidities.

32
38.18 The Consultant Haematologist must be contacted in cases of severe transfusion reactions.

39. Reporting to MHRA via Serious Adverse Blood reactions and Events (SABRE) and
Serious Hazards of Transfusion (SHOT)

39.1 This is a formal system for reporting serious complications of transfusion.

39.2 All serious events surrounding transfusion should first be reported to the hospital Consultant
Haematologist On Call. Any complications can be discussed with the Blood Transfusion
Department and if necessary directly with consultants at the NHSBTcentre at Colindale.

39.3 All cases of suspected transfusion related infections must be reported to the Blood
Transfusion Department who will discuss with the Consultant Haematologist On Call and the
NHSBT in order that that they can withdraw other components and investigate the
donor/cause if deemed appropriate.

39.4 Infectious Complications are reported by the NHSBT to a surveillance scheme organised by
the transfusion centres and the Communicable Disease Surveillance Centre (they also
gather information about viral markers in the blood).

39.5 Non Infectious Complications are reported to a confidential database to the MHRA via
SABRE and to SHOT. A follow-up questionnaire is then issued for more detailed information.

39.6 Reporting Scheme for Serious Hazards of Transfusion:

 Hospital detect incident in a blood transfusion event

 Incident reported to SHOT via the SABRE web site by the Blood Transfusion Department
 The EU Directive defines a serious adverse reaction as ‘an unintended response in donor
or patient associated with the collection or transfusion of blood or blood components that
is fatal, life-threatening, debilitating, incapacitating or which results in or prolongs
hospitalisation or morbidity’
 Blood Transfusion Department investigates the transfusion event
 Confirmation report sent to SABRE
 Incidents reported and reviewed at HTT, HTG and departmental Clinical Governance
meetings

39.7 Hospital detected incident in which there is a suspected transmitted infection:

 Initial suspected report sent to MHRA by the hospital blood bank

 Initial report sent to NHS Blood and Blood Transplant Centre to investigate
 Surveillance data sent to the NBS/HPA Infection Surveillance
 Case details submitted to SHOT
 Conclusion reported to the NHSBT and Hospital Blood Transfusion Department
 Incidents reported and reviewed at HTT, HTG and departmental Clinical Governance
meetings

39.8 Incidents reportable to SABRE – Reactions (SAR’s):

 Immunological haemolysis due to ABO incompatibility

 Immunological haemolysis due to other allo-antibody
 Non-immunological haemolysis
 Transfusion-transmitted bacterial infection
 Anaphylaxis / hypersensitivity
 Transfusion related acute lung injury (TRALI)
 Transfusion-transmitted viral infection (HBV)
33
  Transfusion-transmitted viral infection (HCV)
 Transfusion-transmitted viral infection (HIV-1/2)
 Transfusion-transmitted viral infection, other (specify)
 Transfusion-transmitted parasitical infection (Malaria)
 Transfusion-transmitted parasitical infection, other (specify)
 Post-transfusion purpura
 Graft-versus host disease
 Other serious reaction(s) – specify (e.g. transfusion associated circulatory overload
(TACO), transfusion associated dyspnoea (TAD), febrile non-haemolytic reactions (FNHTR)
and uncategorised unintended responses)

39.9 Incidents reportable to SABRE – Events (SAE’s)

SAEs that occur within the hospital blood bank scope of responsibility as monitored by the
quality system (i.e. training of staff, security of equipment and premises, adherence to
policies and procedures) should be reported when one or more of the following criteria apply:

 inappropriate blood/blood components have been issued/distributed for clinical use,

even if not used
 the adverse event resulted in the loss of any irreplaceable autologous blood/blood
component (e.g. rare blood group) or any highly matched (i.e. recipient specific)
allogeneic blood/blood component
 the adverse event resulted in the loss of a significant quantity of unmatched blood or
blood components
 the adverse event could have implications for other patients or donors because of
 shared practices, services, supplies or donors (i.e. repeated event inside or outside
the BE/HBB)
 the adverse event could have a significant impact on the blood transfusion system
e.g. by jeopardising the confidence of blood donors or recipients in the system.

39.10 Incidents reportable to SHOT

39.11 IBCT - Wrong Blood Transfused (Incorrect Blood Component Transfused, where a patient
was transfused with a blood component:
 of an incorrect blood group
 which was intended for another patient and was incompatible with the recipient
 which was intended for another patient but was fortuitously compatible with the recipient
 which was other than that prescribed, e.g. platelets instead of red cells

39.12 IBCT- SRNM (Specific Requirements Not Met) Where a patient was transfused with a blood
component that did not meet their specific transfusion requirements. Examples currently
include failure to provide:
 Pathogen inactivated plasma components to patients born after 1st January 1996
 CMV negative components where indicated
 Irradiated components where indicated
 HLA matched platelets where indicated
 Antigen negative red cells for a patient with known antibodies
 Red cells of extended phenotpye required for a patient with a
 specific clinical condition e.g. haemoglobinopathy
 Components with a neonatal specification
Also:
 Failure to use a blood warmer when required.
 Inappropriate use of Electronic Issue

39.13 Avoidable, Delayed or Under Transfusion (ADU) formerly inappropriate, unnecessary 34

 and under/delayed transfusion (I and U):

 Where the intended transfusion is carried out, and the blood/blood component itself is
suitable for transfusion and compatible with the patient, but where the decision leading to
the transfusion is flawed
 Where a transfusion of blood/blood component was clinically indicated but was not
undertaken or was significantly delayed
 Avoidable use of emergency O negative blood where group-specific or crossmatched
blood was readily available for the patient

39.14 Handling and Storage Errors (HSE) Transfusion of the correct blood component to the
intended patient, where handling or storage errors may have rendered the component less
safe for transfusion, for example:

 Cold chain errors such as transfusion of a unit that has been out of temperature control
for too long or stored inappropriately, including equipment failure
 Transfusion of an expired unit
 Excessive time to transfuse ( > 5h)
 Technical errors i.e. using an inappropriate giving set or setting an infusion pump
incorrectly
 Transfusion of a unit of red cells where the interval between sampling and transfusion
exceeds recommendations in BCSH guidelines (72hrs) or a risk-assessed local policy
 Transfusion of a component that has had a drug added, or coadministration of a blood
component and drug through the same venous access
 Component transfused despite the component being visibly damaged, or having been
tampered with.

39.15 Right Blood Right Patient (RBRP) Incidents where a patient was transfused
correctly despite one or more serious identification or prescription errors which in other
circumstances might have led to an IBCT. This category currently includes errors
associated with labelling and patient ID such as:

 administration with incorrect or incomplete/missing details on the label

 transposition of labels between units that are all intended for the same patient
 Absence of a patient identification band
 Transfusion of a blood component that was intended for the patient, but was not formally
prescribed/authorised

39.16 Near Miss A near miss is an error or deviation from standard procedures or policies that is
discovered before the start of the transfusion and that could have led to a wrongful
transfusion or a reaction in a recipient if transfusion was to have taken place. For all
incidents where transfusion did NOT take place, and the error was detected prior to
commencing the transfusion. This will include wrong blood in tube incidents (WBIT)

39.17 Acute Transfusion Reaction (ATR)

 Febrile type reaction (simple febrile reactions associated with chills and/or rigors or
involving a 20C temp rise over baseline, or an absolute temp of 390C).
 Allergic type reaction.
 Reactions with both febrile and allergic features
 Hypotensive reactions.

39.18 Acute Haemolytic Transfusion Reaction (AHTR)

Acute HTRs are defined as fever and other symptoms/signs of haemolysis within 24 hours
of transfusion; confirmed by one or more of the following:
 a fall of Hb
35
  rise in LDH
 positive DAT
 positive crossmatch

39.19 Delayed Haemolytic Transfusion Reaction (DHTR)

Delayed HTRs are defined as fever and other symptoms/signs of haemolysis more than
24 hours after transfusion; confirmed by one or more of the following:

 a fall in Hb or failure of increment

 rise in bilirubin
 incompatible crossmatch not detectable pre-transfusion

39.20 Post Transfusion Purpura (PTP)

 Thrombocytopenia arising 5 - 12 days following transfusion of cellular blood components
(red cells or platelets), associated with the presence in the patient of alloantibodies
directed against the HPA (Human Platelet Antigen) systems.

39.21 Previously Uncategorised Complication of Transfusion (PUCT)

 Pathological reaction or adverse effect in temporal association with transfusion which
cannot be attributed to already defined side effects and with no risk factor other than
transfusion.

39.22 Transfusion Associated Graftversus-Host Disease (TA-GvHD)

 Characterised by fever, rash, liver dysfunction, diarrhoea, pancytopenia and bone marrow
hypoplasia occurring less than 30 days after transfusion. The condition is due to
engraftment and clonal expansion of viable donor lymphocytes in a susceptible host.

39.23 Transfusion Associated Circulatory Overload (TACO)

Cases of TACO are confirmed by any four of the following which occur within six hours of
transfusion:
 Acute respiratory distress.
 Tachycardia.
 Increased blood pressure.
 Acute or worsening pulmonary oedema.
 Evidence of positive fluid balance.

39.24 Transfusion Associated Dyspnoea (TAD)

TAD is characterised by respiratory distress within 24 hours of transfusion that does not
meet the criteria of TRALI, TACO, or allergic reaction. Respiratory distress should not be
explained by the patients underlying condition.

39.25 Transfusion Related Acute Lung Injury (TRALI)

Acute dyspnoea with hypoxia and bilateral pulmonary infiltrates during or within six hours
of transfusion, not due to circulatory overload or other likely cause.

39.26 Transfusion Transmitted Infections (TTI)

Include as a TTI if, following investigation, the recipient had evidence of infection post-
transfusion, and there was no evidence of infection prior to transfusion and no evidence of
an alternative source of infection, plus:
 Either at least one component received by the infected recipient was donated
by a donor who had evidence of the same transmissible infection.
 Or at least one component received by the infected recipient was shown to
contain the agent of infection.

39.27 Anti-D prophylaxsis

Events relating to the requesting and administration of anti-D immunoglobulin to women 36
 of childbearing potential. This category now includes events relating to the administration
of anti-D Immunoglobulin following transfusion of D-mismatched platelets.

39.28 Cell Salvage

Events and reactions in relation to the use of intraoperative and postoperative cell
Salvage.

39.29 Alloimmunisation
Alloimmunisation occurs when, after a transfusion, there is demonstration of clinically
significant antibodies against red blood cells which were previously absent (as far as is
known) and when there are no clinical or laboratory signs of haemolysis. This term is
categorised as a Delayed Serological Transfusion Reaction by the ISBT.

39.30 Haemosiderosis
Iron overload as indicated by laboratory investigation or biopsy due to chronic transfusion
and which can result in organ injury (heart, liver and or endocrine glands).

39.31 All the above incidents reported to SABRE and/or SHOT will be reported via the Trust
Datixweb system. Other incidents that will be reported via the Trust Datixweb but not
necessarily to SHOT or SABRE are:

39.32 Incidents occurring inside the Laboratory

 Incorrect data entered on LIMS but sample and form have correct data. Picked up at
verification
 Incorrect results or report issued
 Reagent fault
 Equipment fault e.g. analyser/ blood bank
 Wastage of blood products
 Samples part processed (test not booked in but requested on form or booked in and not
tested)
 Delay in phoning results
 Incorrect results released or phoned
 Product re-call
 NEQAS failure
 IPEX failure

39.33 Incidents occurring outside the Laboratory

 Sample labelling errors – unlabelled samples, samples with a sticky label or pre-
printed data label on and samples where the form and sample does not match.
 Delay in giving blood product not due to laboratory error
 Blood product not issued within guideline (for example anti-D / Beriplex)
 Expired product used
 Handling and storage error
 Transfusion reaction No incompatibility Detected
 Adverse cell salvage event
 Product re-call

39.34 Where there is no evidence of harm to the patient but an error has occurred the
incident is reported internally by the laboratory via the Q-Pulse system and reviewed
by the HTT and HTG.

39.35 Following review of all incidents appropriate corrective and preventative action will be
implemented (action taken/lessons learnt).

40 Autologous Transfusion
37
40.1 Requests for autologous donations are not able to be processed by the Blood Transfusion
Department at Broomfield Hospital because of the requirement to comply with the EU
Blood Directive – Blood Safety and Quality Regulations 2005.

40.2 The Blood Transfusion Department adheres strictly to guidelines jointly published by The
British Committee for Standards in Haematology and The British Blood Transfusion
Society.

40.3 Autologous blood transfusion is the process by which a patient donates their own blood for
possible transfusion during/following a surgical procedure. Autologous donation is
recommended in few situations, for example, where the presence of atypical red cell
antibodies makes it extremely difficult/impossible to find donor blood.

40.4 Where appropriate, requests for autologous donation should be referred to a Haematology
Consultant and would be processed by the National Health Service Blood and Transplant
(NHSBT).

40.5 In this Trust, following some knee joint operations, peri operative cell salvage is used in
place of autologous blood transfusions

40.6 Intra-operative cell salvage is also available in General Theatres and Maternity. In patients
that it is thought it might be used, it should be discussed with the patient if possible, e.g.
pre-operative assessment. For the use of cell salvage in pregnancy please refer to policy
administration of anti-D for D negative patients in maternity, ref 06065.

41 Directed Donations

41.1 Directed donations are donations for red cell transfusions between close family members
and are discouraged for good medical and scientific reasons. Their use is restricted to
very rare occasions when it is not possible to obtain blood from the NHSBT due to the
presence of atypical red cell antibodies which make it impossible to find blood from the
normal donor population.

41.2 There are limited appropriate indications for directed donations from related donors
including:
 Provision of matched platelets if an unrelated donor cannot be found for a patient refractory
to random donor platelets.
 Provision of red cells of very rare phenotype for a patient with multiple antibodies or
antibodies to high-incidence antigens.
 Transfusion of lymphocytes from a bone marrow or PBSC donor to the recipient of their stem
cells post-transplant.
 Provision of granulocytes if a suitable unrelated donor is not available for a patient with
severe neutropenia who fulfils the criteria for granulocyte transfusions.
 Provision of maternal platelets in the very unlikely situation that platelets from a suitable
unrelated donor cannot be provided for an infant with Neonatal Alloimmune
Thrombocytopenia

41.3 There are several risk factors involved:

 The directed donor may be inhibited from giving frank answers to questions about risk factors
 Directed donors often have higher incidence of markers for infection than the normal donor
population.
 These directed donors are often a first-time donor with no history of previous testing
 The blood group may not be compatible with the patient.
 There is a greater risk of graft-versus-host disease.
38
  If the directed donor is a mother, there is a risk that the maternal plasma will have antibodies
to the child’s red cells, platelets and white cells.
 Transfusion of the father’s blood to the child carries risks similar to those of using the
mothers’ blood.
 Transfusion of partner’s blood to a patient who is or has been pregnant can cause acute
reactions
 A directed donor must fulfil all of the criteria used for a normal volunteer donor and must be
donated via the NHSBT.

42 Transportation of blood and blood products

42.1 Where blood and blood products are transported throughout MEHT, plastic blood transport
bags should be used.

42.2 Where blood is transported to hospitals outside Broomfield Hospital this should be packed by
the Blood Transfusion Department who will ensure the products are packaged correctly with
the appropriate documentation and that the blood transport box is sealed. Once the seal is
cut the contents of the box must be transported to an identified blood storage device suitable
for the product or used within the time frame specified for that product.

42.3 Where blood is not transported correctly in the correct containers the products will be
deemed un-fit for use and discarded by the receiving hospital.

42.4 Blood received from a different Trust as part of a patient transfer, that has not been used,
should be taken directly to the Blood Transfusion Department who will check the packaging
and transportation documentation to ensure this has been completed correctly. It should not
be automatically assumed that the blood can be stored in a blood bank and suitable for use.

43 Audit and Monitoring

43.1 The Trust will work towards effective Governance and monitoring of the policy by regular
audits against the policy.

43.2 The Blood Transfusion Department will take part in all appropriate NHSBT audits to
monitor and assess the trusts performance nationally against the procedures in the
transfusion policy. Findings from all National Audits organised by the NHSBT will be
reported to the Hospital Transfusion Team (HTT) and Hospital Transfusion Group (HTG)
meetings.

43.3 Annual audits of compliance with the following will be undertaken by the Transfusion
Practitioner:
 The process for requesting blood samples for compatibility testing;
 The process for the administration of all transfusions, including patient identification;
 The care of patients receiving a transfusion.
 The audit tool is included in Appendix 12.

43.4 The findings will be reported to the HTG and this group will monitor implementation of any
organisational actions developed to address any deficiencies. The Chair of the HTG will be
responsible for ensuring actions are progressed.

43.5 Audit findings will also be reported to appropriate divisional / directorate governance
meetings and clinical leads will be responsible for developing local actions to address any
non-compliance.

43.6 In addition monthly snap shot audits will be undertaken by the Transfusion Practitioner such
that all high / high risk areas are assessed on a rolling programme. The findings of these
39
 audits are fed back to local line managers for action as required. The findings will also be
reported to Divisional Governance Meetings and the HTG.

43.7 The Blood Transfusion Department will produce an annual audit schedule in order to monitor
and improve its procedures and processes.

44 References

44.1 References and further reading list:

Blood Transfusion Services of the United Kingdom 2014 Handbook of Transfusion Medicine
(Fifth Edition) London HMSO.

British Committee for the Standards in Haematology (BCSH 2001) The clinical use of red cell
transfusion. www.transfusionguidelines.org.uk.

British Committee for the Standards in Haematology (BCSH 2003) Guidelines for the use of
platelets. www.transfusionguidelines.org.uk.

British Committee for the Standards in Haematology (BCSH 2004) Guidelines for Neonates
and older children. www.transfusionguidelines.org.uk

British Committee for the Standards in Haematology (BCSH 2006) Guidelines

for the use of fresh-frozen plasma, cryoprecipitate and cryosupernatant.
www.transfusionguidelines.org.uk.

2007 amendment to the guidelines for the use of fresh-frozen plasma, cryoprecipitate and
cryosupernatant (clarification on storage after thawing). www.transfusionguidelines.org.uk.

British Committee for the Standards in Haematology (BCSH 2009) The administration of
blood components. www.transfusionguidelines.org.uk

British Committee for the Standards in Haematology (BCSH 2009) Guidelines on the use of
irradiated blood components

British Committee for the Standards in Haematology (BCSH 2009) Guidelines on the use of
irradiated blood components. Addendum to guidelines on the use of irradiated blood
components (2012)

British Committee for the Standards in Haematology (BCSH 2011) UK Guidelines on the
management of iron deficiency in pregnancy

British Committee for the Standards in Haematology (BCSH 2012) Guideline on the
investigation and management of Acute Transfusion Reactions

British Committee for the Standards in Haematology (BCSH 2012) Guidelines on the
management of anaemia and red cell transfusion in adult critically ill patients

British Committee for the Standards in Haematology (BCSH 2012) Guidelines for pre-
transfusion compatibility procedures in blood transfusion laboratories
www.transfusionguidelines.org.uk

British Committee for the Standards in Haematology (BCSH 2012) Red cells in critical care.
www.transfusionguidelines.org.uk

British Committee for the Standards in Haematology (BCSH 2012) Addendum to The
administration of blood components. www.transfusionguidelines.org.uk
40
 British Committee for the Standards in Haematology (BCSH 2014) Guideline for the use of
anti-D immunoglobulin for the prevention of haemolytic disease of the fetus and newborn

British Committee for the Standards in Haematology (BCSH 2014) Guideline for the use of
anti-D immunoglobulin for the prevention of haemolytic disease of the fetus and newborn.
Prophylactic Anti-D immunoglobulin AMENDMENT

British Committee for the Standards in Haematology (BCSH 2015) A Practical Guideline for
the Management of those with, or at risk of Major Haemorrhage

NHS Blood and Transplant. Directed Donations (2015). INF176/1.3

NICE August 2008. Guidance on the use of routine antenatal anti-D prophylaxis for Rh D
negative women. www.nice.org.uk

NICE November 2015. NICE guideline 24. Blood Transfusion. nice.org.uk/guidance/ng24

HSC 1998/224 Better Blood Transfusion, NHSE

HSC 2002/009 Better Blood Transfusion – Appropriate use of blood NHSE
HSC 2007/001 Better Blood Transfusion - Safe and Appropriate Use of Blood NHSE

Mid Essex Hospitals 2006 Emergency Red Cell Shortage Plan. Prepared on behalf of the
Mid Essex Hospitals by the Transfusion Committee from the Integrated Blood Shortage plan
for the National Blood Service and hospitals.

Mid Essex Hospitals 2006 Emergency Platelet Shortage Plan. Prepared on behalf of the Mid
Essex Hospitals by the Transfusion Committee from the Integrated Blood Shortage plan for
the National Blood Transfusion Authority

SaBTO Guideance for clinical staff to support patient consent for blood transfusion
(Dec 2011)

SaBTO guidance for

clinical.pdf

45. Statutory requirements

Directive 2002/98/EC of the European Parliament and of the Council – The Blood Safety and
Quality Regulations 2005
National Patient Safety Agency. Safer Practice Notice. November 2006, Right patient, Right
blood. Further information of assessments and competencies can be found at:
www.npsa.nhs.uk

NMC May 2008 Standards of performance and ethics for nurses and midwives

NMC July 2009 Record keeping: Guidance for nurses and midwives

NMC March 2015 The Code: Professional standards of practice and behaviour for nurses
and midwives.
https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf

41
Appendix 1

The Hospital Transfusion Group

1 Core Membership

Consultant Anaesthetist (Chair)

Consultant Haematologist (Deputy Chair)
Blood Transfusion Lead
Blood Transfusion Practitioner
Medical Consultant or representative
Surgical Consultant or representative
Paediatric representative
Obstetrics / Gynaecology representative
Theatres representative
Ward Sister
Head of Governance
Pathology Directorate Manager
Patient Representative

In addition to the membership detailed above, any other individual may be invited to
attend at the Chair’s discretion.

2 Purpose

2.1 The role of the Hospital Transfusion Group is to co-ordinate the varying interests of all
parties involved in the process of blood and blood product transfusion in order to ensure
the safe and appropriate use of products. This is mainly achieved by the provision of a
transfusion policy.

2.2 The composition of the group is designed to reflect a broad representation of service
users or interested parties.

3 Quorum

3.1 No business shall be transacted at a meeting unless at least six members, which must
include the Chair or Deputy Chair and representatives from three different directorates.

3.2 Members may nominate appropriate representatives to attend on their behalf where they
are unable to attend.

4 Accountability

4.1 The group is accountable to the Patient Safety Group.

4.2 The group will; report any serious non-compliance risks to the relevant directorate team
after every meeting.

5 Duties

 Promote safe and appropriate blood transfusion practice by preparing policies and
procedures for blood and its derivatives based on national guidelines
 Modify policies and procedures in line with new guidance and evidence
42
  To initiate and be involved in audit
 Review of transfusion incidents including SHOT and SABRE data reports
 Review wastage of blood and blood products
 Propose developments to maintain good practice
 To promote education and information on blood transfusion
 To participate in and report to the Regional Transfusion Committee

6 Reporting arrangements

6.1 To report quarterly to the Patient Safety Group.

6.2 A report of each meeting will be circulated to:

 Group Members
 Chief Executive of Trust
 Medical Director of Trust
 Chief Nurse
 Clinical Directors
 Associate Chief Nurses

7 Frequency

7.1 Meetings will be held quarterly.

7.2 Core members or their representatives should attend a minimum of at least three
meeting per year.

8 Review

8.1 To review performance against the above terms of reference annually in April or the
nearest meeting to 1st April and the outcome of this review to be reported to the Clinical
Governance Group meeting including any corrective action taken to meet any non-
conformances raised.

43
Appendix 2 The Hospital Transfusion Team

1 Membership

Consultant Haematologist
Haematology and Blood Transfusion Lead
Blood Bank Manager
Blood Transfusion Practitioner
Biomedical Scientist

2 Purpose

The Hospital Transfusion Team (HTT) reviews national, regional and local policies,
procedures, research and guidelines to provide the HTG with information to update local
policies and change/update education and audit programmes. The HTT also reviews local
incidents to determine trends and implement any actions to prevent recurrence and improve
patient safety.

3 Quorum

No business shall be transacted at a meeting unless at least two members, which must
include the Chair or Deputy Chair, are present.

4 Accountability

To report quarterly to the Hospital Transfusion Group (HTG).

5 Duties

 To raise the profile of blood transfusion and the use of blood components within the Trust
 To develop procedures and protocols that are based on current national guidelines,
research and best practice.
 To supports the HTG by undertaking national and local audits and making
recommendations from audits to the HTG to improve practice and impact on patient
safety.
 To update training sessions from national guidelines and recommendations made in the
Serious Hazards of Transfusion (SHOT) annual report.
 To provide an educational role

6 Frequency

Meetings will be held quarterly.

Core members should attend a minimum of at least three meeting per year.

7 Reporting arrangements

Meeting meeting will be circulated to: HTG Lead

Consultant Haematologists
Haematology and Blood Transfusion Lead
Blood Bank Manager
Pathology Manager
Blood Transfusion Practitioner

To report quarterly to the HTG meeting

44
8 Review

To review against the above terms of reference annually in April or the nearest meeting to 1st
April and the outcome of this review to be reported to the next HTG meeting including any
corrective action taken to meet any non conformaces raised.

45
Appendix 3
Indications for the use of red cells

1 Overview of the Process

1.1 Clinician prescribing red cell transfusion should be aware of indications, the risks and
benefits of transfusion.

1.2 Patients should be given information about the risks and benefits of red cell transfusion in
advance of transfusion whenever possible, together with possible alternatives – this should
be documented in the patients notes. NHSBT information leaflets are available on wards
prescribing blood. Consent for treatment/transfusion should be documented. Patients have
the right to refuse a red cell transfusion and this must be documented in their medical notes.

1.3 The cause of anaemia should be established where possible and alternatives to transfusion
considered.

1.4 There is no universal “trigger” for red cell transfusion (a haemoglobin concentration at
which transfusion of red cells is appropriate for all patients). Clinical judgement plays a
vital role in the decision whether or not to transfuse red cells.

1.5 The reason for administration of red cell transfusion and the record of each unit of blood
must be documented in the patient’s medical records.

1.6 The duration of transfusion of the unit will is usually 2-3hours per unit 150mls/hr, dependant
on the patients condition/co-morbidities.

1.7 Normally patients should not be transfused if haemoglobin concentration is above 100g/l

1.8 A strong indication for transfusion is haemoglobin concentration below 70g/l

1.9 Transfusion will become essential when haemoglobin concentration decreases to 50g/l

1.10 Symptomatic patients should be transfused.

1.11 Red cell transfusions must be given through a blood giving set.

1.12 Patients should be informed informed they have had a blood component/product
transfusion

2. Indications for the use of red cell transfusion

2.1 These are based on current guidelines and may change depending on new evidence
(NBTC Indication Codes for Transfusion, September 2016).

2.2 For a single transfusion episode in adult patients with a potentially reversible cause of
anaemia e.g. after surgery, consider transfusing one unit only with a further Hb estimation
before further units are given. Neonates and small children require doses calculated in
mls/kg of blood and require separate consideration.

2.3 Red cell transfusion in the surgical patient:

2.4 Surgical patients receive more than one million units of red cells in the UK annually, half of
all the allogeneic blood transfused.

2.5 Several factors need to be taken in account before considering a red cell transfusion:
46
  Ensure all surgical patients have a pre-operative assessment, where possible
 The decision to transfuse should always be made on an individual patient basis
 Patients should not be transfused to achieve a normal haemoglobin concentration
 The reason for pre and post-operative transfusions must be recorded in the clinic notes
 Record of the administration of each unit of blood must be kept permanently in the clinical
notes
 Surgical blood ordering schedule should be followed and reviewed if practices change or
indicated by audit.
 Up to 30% of blood loss can be treated with crystalloid or colloid solutions. There is no
increase in mortality providing the haemoglobin concentration was kept above 80g/l even
in an elderly population
 Post-operative patients who are limited in their activity are unlikely to have oxygen
demands that exceed supply
 Wound healing is not affected, only when haematocrit is less than 18%
 Iron deficiency anaemia should be investigated and corrected during pre-operative period

2.6 Use a restrictive red blood cell transfusion thresholds for patients who need red blood cell
transfusions and who do not:
1. Have acute major haemorrhage
2. Have acute coronary syndrome or
3. Need regular blood transfusions for chronic anaemia.

2.7 When using a restrictive red blood cell transfusion threshold consider a threshold of 70g/litre
and a haemoglobin concentration target of 70-90 g/lire after transfusion.
 Consider a red blood cell transfusion threshold of 80g/litre and a haemoglobin
concentration target of 80-100g/litre after transfusion for patients with acute coronary
syndrome.
 Consider setting individual thresholds and haemoglobin concentration targets for each
patient who needs regular blood transfusions for chonic anaemia.
 Consider single-unit red blood cell transfusions for adults (or equivalent volumes
calculated based on body weight for children or adults with low body weight) who do not
have active bleeding.
 After each single-unit red blood cell transfusion (or equivalent volumes, calculated based
on body weight for children or adults with low body weight), clinically reassess and check
haemoglobin levels and give further transfusions if needed.

2.8 Indication codes - Red cell concentrates

R1. Acute bleeding:-

Acute blood loss with haemdynamic instability, after normovolaemia has been achieved
maintained, frequent measurement of Hb should be used to guide the use of red cell
transfusion see suggested threshholds below.

Empirical decisions about the immediate use of red cell transfusion are required by
clinicians experienced in resuscitation, for example:-

 <30% loss of blood volume (<1500ml in an adult): transfuse crystalloid. Red cell
transfusion is unlikely to be necessary.

 30-40% loss of blood volume (1500-2000ml in an adult): rapid volume replacement is

required with crystalloid. Red cell transfusion will probably be required to maintain
recommended Hb levels.

47
  >40% loss of blood volume (>2000ml in an adult): rapid volume replacement including
red cell transfusion is required.

R2. Hb ≤70 Stable patient

Acute anamia. Use Hb threshold of 70g/L and a target Hb of 70-90g/L to guide red cell
transfusion. Follow local/specific indications such as post cardiac surgery, traumatic brain
injury, acute cerebral ischaemia.
Consider the patient’s age: ≤65 70g/l, ≥ 65 70g/l

R3. Hb ≤ 80g/L if cardiovascular disease

Use an Hb of 80g/L and a target Hb of 80-100g/L.
Chest pain; hypotension or tachycardia unresponsive to fluid resuscitation; or cardiac
failure. Severe sepsis ≥ 90x 109/L

R4. Chronic transfusion dependent anaemia

Transfuse to maintain an Hb which prevents symptoms. Suggest an Hb threshold of 80g/L
initially and adjust as required. Haemoglobinopathy patients require individualised Hb
thresholds depending on age and diagnosis. Consider the patient’s age e.g. < 65, ≥ 65 and
weight.

R5. Radiotherapy maintain Hb ≥ 100g/L

There is limited evidence for maintaining Hb >110g/L in patients receiving radiotherapy for
cervical and possibly other tumours.

R6. Exchange transfusion

5.0 ABO compatibility

5.1 First choice is identical ABO group to the patient if possible.

5.2 Using ABO non–identical but compatible red cells is acceptable transfusion practice, in
particular when red cells are in short supply and the requirement is urgent or where the
presence of an atypical red cell antibody makes it difficult to find ABO compatible red cells.
When supplying non identical red cells the Blood Transfusion Department will telephone the
ward prior to issuing the units.

5.3 The transfusion of ABO incompatible red cells may lead to life threatening haemolysis. If in
doubt as to the suitability of the unit(s) supplied DO NOT use until confirmed by the Blood
Transfusion Department.

6 D compatibility (previously Rh D)

6.1 D Negative red cells should be given to D Negative women of child-bearing age unless there
is life threatening haemorrhage, due the potential to become sensitised to the D antigen.

6.2 If D Positive red cells are transfused to D negative patients there is the possibility of
sensitisation to the D antigen.

6.3 Where D Positive red cells are transfused in error to a woman of child bearing age, the
advice of the Haematology Consultant should be requested and the Blood Transfusion
Department informed. Depending on the volume transfused the patient may require
exchange transfusion and prophylactic anti-D immunoglobulin.

Appendix 4
48
 Indications for the use of platelets

1 Overview of the process

1.1 Platelet transfusions are indicated for the prevention and treatment of haemorrhage in
patients with thrombocytopenia or platelet function defects.

1.2 Platelet transfusions are not indicated in all causes of thrombocytopenia and maybe contra-
indicated in certain conditions. Hence, the cause of thrombocytopenia should be established
before making a decision about platelet transfusion.

1.3 The risks versus benefits should be assessed before any platelet transfusion.

2 Risks

2.1 The risks of a platelet transfusion are similar to those of a red cell transfusion:

 Alloimmunisation

 Transmission of infection

 Allergic reactions

 Transfusion-related acute lung injury

3 Platelet concentrate specifications

3.1 Dose: 1 adult therapeutic dose (ATD) for an adult

3.2 Volume: 150 – 300 ml for platelet concentrate prepared by apheresis.

150 – 450 ml for platelet concentrate prepared from whole blood

3.3 Storage and Shelf Life

3.3.1 In a closed system, current packs allow storage at 22ºC ± 2ºC with continual gentle
agitation for up to 7 days

3.3.2 In an open system (after suspension in PSM or washing, the shelf life is reduced to 24
hours)

3.4 Giving sets – filters

3.4.1 Platelet concentrates should be transfused through a standard blood or platelet

administration set provided by the Blood Transfusion Department

3.4.2 Platelet concentrates should not be transfused through giving sets that have been used for
blood

4 Administration of platelets
49
4.1 Platelet concentrate should be inspected by Blood Transfusion Department staff prior to
issue, with particular attention to the integrity of the bag and any evidence of unusual colour
or turbidity which might suggest bacterial contamination

4.2 It is good practice for the staff administering the unit to check it in a similar way before
administration and to return it to the Blood Transfusion Department if any abnormalities are
found.

4.3 It is recommended that a single bag of platelet concentrate is transfused over a 30 minute
period in adults.

4.4 The patient should be informed about the possible complications of transfusion prior to
commencing the transfusion.

4.5 Visual observations of the patient must be made during transfusion.

4.6 Baseline observations should be carried out prior to commencing the transfusion (within one
hour prior to the start time), after 15 minutes and at the end of the transfusion (within one
hour of the completion time).

4.7 Monitoring the platelet response should be assessed first clinically. To measure the
incremental rise of the platelet count a blood sample should be taken after 10 - 60 minutes
and 24 hours of completing the transfusion and sent to the haematology department for
testing.

5 Indications for the use of a platelet transfusion

5.1 With the exception of where the Major Haemorrhage protocol has been activated, requests
for more than one dose of platelets should be discussed with the Haematology Consultant
On Call, prior to phoning the Blood Transfusion Department.

5.2 If the reason for thrombocytopenia is unclear, further investigation is required to determine
appropriate management.

5.3 Offer platelet transfusions to patients with thrombocytopenia who have clinically significant
bleeding (WHO grade 2 and a platelet count below 30x109 per litre.

5.4 Use higher platelet thresholds (up to a maximum of 100x 109 (per litre) for patients with
thrombocytopenia and either of the following:
1. Severe bleeding (WHO grades 3 and 4)
2. Bleeding in critical sites, such as the central nervous system (including eyes)

5.5 Offer prophylactic platelet transfusions to patients with platelet count below 10x109 per litre
who are not bleeding or having invasive procedures or surgery, and who do not have any
following conditions:
1. Chronic bone marrow failure
2. Autoimmune thropmbocytopenia
3. Heparin induced thrombocytopenia
4. Thrombotic thrombocytopenic purpura

5.6 Consider prophylactic platelet transfusions to raise the platelet count above 50x10 9 per litre
in patients who are having invasive procedures or surgery.

5.7 Consider a higher threshold (for example 50-75x109 per litre) for patients with a high risk of
bleeding who are having invasive procedures or surgery after taking into account:
50
 1. the specific procedure the patient is having
2. the cause of the thrombocytopenia
3. whether the patient’s platelet count is falling
4. any co-exisiting causes of abnormal haemostasis

5.8 Consider prophylactic platelet transfusions to raise the platelet count above 10x10 9 per litre
in patients having surgery in critical sites, such as the central nervous system (including the
posterior segment of the eyes).

5.9 P1 Prophylactic use if reversible BMF

Recommendations for prophylactic transfusion of platelets to patients with thrombocytopenia

because of reversible bone marrow failure where recovery is anticipated:

a) Give prophylactic platelet transfusions (platelet transfusions to patients who do not have
clinically significant bleeding [WHO grade 0 or 1] and do not require a procedure) to
patients with reversible bone marrow failure receiving intensive chemotherapy or
undergoing allogeneic (HSCT) to maintain a platelet count at or above 10 x 109/L.
b) Use only one adult dose (one unit) routinely for prophylactic platelet transfusions.
c) Consider not giving prophylactic platelet transfusions to well patients with no evidence of
bleeding who have had an autologous stem cell transplant.
d) Consider increasing the threshold for prophylactic platelet transfusion to between 10 and
20 x109/L in patients judged to have additional risk factors for bleeding, e.g. sepsis,
antibiotic treatement, abnormalities of haemostasis. Individual review
is required.

5.10 P2 Prophylactic use if BMF with additional risk factors (sepsis, antibiotic treatment,
abnormalities of haemostasis
Recommendations for prophylactic transfusion of platelets to patients with thrombocytopenia
because of chronic bone marrow failure, where recovery is not anticipated:

a) Use a ‘no prophylactic platelet transfusion’ strategy for asymptomatic patients with
chronic bone marrow failure (including those taking low dose oral chemotherapy or
azacitidine)
b) Give prophylactic platelet transfusions to patients with chronic bone marrow failure
receiving intensive treatment.
c) Manage patients with chronic bleeding of WHO grade 2 or above individually, according
to the severity of their symptoms and signs. Consider a strategy of prophylaxis (e.g. twice
a week) 20 x 109/L.

5.11 P3 Invasive procedures. Recommendations for prophylactic platelet transfusion prior to

procedures or surgery:

Whenever possible use a procedure/equipment associated with the lowest bleeding risk
apply local measures, such as compression, to reduce the risk of bleeding post-procedure.

P3a Platelet count <20 x 109/L central venous line

P3b Platelet count <40 x 109/L pre lumbar punture/spinal anaesthesia

P3c Platelet count <50 x 109/L pre liver biopsy/major surgery

P3d Platelet count <80 x 109/L epidural/spinal anaesthesia

P3e Platelet count <100 x 109/L pre critical site surgery e.g. CNS

51
 Do not give platelet transfusions routinely prior to:
 bone marrow aspirate or trephine biopsy
 peripherally inserted central catheters (PICCs)
 traction removal of tunnelled CVCs
 cataract surgery

c) Consider performing the following procedures above the platelet count threshold indicated:

 Venous central lines (both tunnelled and un-tunnelled), inserted by experienced staff
using ultrasound guidance techniques, when the platelet count is > 20x10 9/L.
 Epidudural/spinal anaesthesia ≥ 80x109/L.
 Lumbar puncture when the platelet count is ≥ 40x10 9/L.
 Insertion/removal of epidural catheter when the platelet count is ≥80x10 9/L.
 major surgery - when the platelet count is > 50x109/L
 neurosurgery or ophthalmic surgery involving the posterior segment of the eye when
the platelet count is > 100x109/L
 percutaneous liver biopsy when the platelet count is > 50 x 10 9/L
 Consider trans-jugular biopsy if the platelet count is below this level
 CNS surgery (including posterior segment of eye ≥ 100 x 109/L

d) Prior to renal biopsy ensure potential risk factors for bleeding are corrected: anaemia
(iron and erythropoietin), uraemia (dialysis).

e) If renal biopsy is urgent consider desmopressin (DDAVP) pre-procedure or oestrogen if

time allows.

f) Avoid platelet transfusion in renal failure since infused platelets will acquire a dysfunction
similar to the patients’ own platelets and platelet transfusion may result in
alloimmunisation

5.12 P4 Recommendations for therapeutic platelet transfusions

P4a In major haemorrhage, < 50 x 109/l.

P4b Critical site bleeding e.g. CNS platelet count <100 x 109/L

P4c Clinically significant bleeding platelet count <30 x 109/L

 In patients with multiple trauma, traumatic brain injury or spontaneous intracerebral

haemorrhage maintain the platelet count above 100 x 10 9/l.
 In patients with bleeding that is not considered severe or life-threatening, consider
platelet transfusion if the platelet count is below 30 x 109/l.

5.13 P5a Acquired platelets dysfunction (e.g. patient on aspirin, clopidogrel, NSAIDs)

 Do not use platelet transfusion pre-procedure when antiplatelet agents have not been
discontinued
 Use general haemostatic measures to treat bleeding in patients during treatment with
aspirin, P2Y12 antagonists or GPIIa/IIIb inhibitors. If necessary, consider drug
cessation and reversal of the effect of co-prescribed anticoagulants
 Use TXA to counteract the effect of anti-platelet agents when a risk/benefit
assessment would support this
 Consider the use of platelet transfusion as an additional measure to those suggested
above for critical bleeding
52
  Consider platelet transfusion to prevent bleeding in severe thrombocytopenia (platelet
count < 10 x 109/l) caused by abciximab

P5 b Immune thrombocytopenia
As emergency pre surgery or with haemorrhage. Aim for platelet count >80 x 10 9/l pre
surgery and >70 x 109/l for obstetric regional axial anaesthesia.

 Platelet transfusion should be reserved only for life-threatening bleeding.

 A large number of platelet doses may be required to achieve haemostasis as a
result of reduced survival of the transfused platelets.
 Intravenous immunoglobulin or Methyl Prednisolone should be given at the
same time to maximise the chances of stopping the haemorrhage and raising
the platelet count.

5.14 P6a Acute disseminated intravascular coagulation (DIC) and bleeding

DIC in the presence of bleeding and severe thrombocytopenia, in addition to management
of the underlying disorder and coagulation factor replacement.
 Frequent platelets and coagulation screen testing should be carried out.
 Aim to maintain platelet count of more than 50 x 10^9/l.
 In chronic DIC, or in the absence of bleeding, platelet transfusion should not be
given to correct a low platelet count.

5.15 P6b Inherited platelet dysfunction

For example Glanzmans thrombocythaemia, storage pool disease.
 With bleeding or pre surgery.

6 Contraindications to platelet transfusions

6.1 When prophylactic platelet transfusions are not indicated:

 Chronic bone marrow failure
 Autoimmune thrombocytopenia
 Heparin-induced thrombocytopenic pupura
 Do not offer prophylactic platelet transfusions to patients having procedures with low risk
of bleeding, such as adults having central venous cannulation or any patients having
bone marrow aspiration and trephine biopsy.
 Only consider giving more than a single dose of platelets in a transfusion for patients with
severe thrombocytopenia and bleeding in a critical site, such as the central nervous
system (including eyes).

6.2 Do not routinely transfuse more than a single dose of platelets.

6.3 Reassess the patient’s clinical condition and check their platelet count after each platelet
transfusion, and only give further doses if needed, discuss with the Consultant
Haematologist for advice.

7 ABO compatibility

7.1 First choice is identical ABO group to the patient if possible.

7.2 Using ABO non–identical platelets is acceptable transfusion practice, in particular when
platelets concentration are in short supply, or when HLA match platelets are required and the
best match is not ABO compatible.

7.3 ABO non–identical platelet transfusion may have lower platelet count increments, but this is
not usually clinically significant
53
7.4 Group O platelets should be used only for Group O patients unless there is a clinical need or
the platelets are HLA-matched.

7.5 The transfusion of ABO non–identical platelets concentrate may be a cause for unexplained
platelet refractoriness

8 D compatibility

8.1 D Negative platelets concentrate should be given where possible, to D Negative patients,
particularly to women of child-bearing age

8.2 If D Positive platelets are transfused to D negative women of child-bearing potential, it is

recommended that anti-D immunoglobulin should be given.

8.3 It is not necessary to administer anti-D to D Negative men or women without child-bearing
potential who have haematological disorders and receive platelet concentrate from donors
who are D Positive

9 Gamma irradiation

9.1 Transfusion associated graft versus host disease (TA-GVHD) is the most frequent cause of
transfusion-associated death (SHOT 2002). Patients at risk of TA-GVHD should be given
gamma irradiated platelets according to our current guidelines

9.2 If irradiated products are required contact the Blood Transfusion Department as soon as
possible.

9.3 If this is the first occurrence, or there has been a change in the patients special requirements
complete a Special Blood Transfusion Requirements Form (Appendix 13).

9.4 It is especially important to do this where patients have shared care. Where there is shared
care ensure all parties are aware of the requirements.

9.5 Failure to do this may results in life threatening TA-GVHD.

9.6 Platelet concentrates can be irradiated at any stage during their 7-day shelf life

9.7 Gamma irradiation – sensitive labels will appear on the packs.

9.8 Permanent record of all gamma – irradiated units must be kept.

10 Platelet Refractoriness

10.1 Platelet refractoriness is a repeated failure to obtain satisfactory response to platelet

transfusion. Some patients may have a poor response to one platelet transfusion and good
responses to subsequent ones. Refractoriness is diagnosed after a poor response to two or
more platelet transfusions.

10.2 Causes of platelet refractoriness

10.3 Immune

54
  Alloimmune thrombocytopenia is mainly caused by HLA antibody formation. These
antibodies mainly occur in women with a history of pregnancy, and there occurrence in
other patients has been reduced since the introduction of leukocyte depletion of blood
components. HPA antibody production is an alternative but rarer cause.

 ABO incompatibility

 Platelet autoantibodies

 Drug-related platelet antibodies

10.4 Non-immune cause

 Shortened platelet survival due to infection (including treatment with antibiotics and
anti-fungal drugs)

 DIC

 Splenomegaly

10.5 Investigation of refractoriness

10.6 Clinical assessment to exclude non-immune platelet consumption

10.7 If immune mechanism suspected, test for HLA antibodies

11 Management of platelet refractoriness

11.1 If HLA antibodies are positive, HLA-match platelet transfusion should be used

11.2 HLA-match platelet transfusion can also be justified, if there is no time to carry out serological
tests, in particular when a patient has bleeding and the HLA type is known

11.3 Responses to HLA-match platelet transfusion should be carefully monitored using post-
transfusion platelet count both at 10-60 minutes and 24-hours post transfusion.

11.4 If no response to HLA-matched platelets, other causes should be checked

 Check for non-immune causes

 Test for Human Platelet Antibodies (HPA)

 Check ABO incompatibility.

 Re-test for HLA antibodies.

11.5 HPA matched platelets should be used if HPA are antibodies identified.

11.6 Platelet cross-matching may be helpful in some patients with non- specific HPA antibody.

Appendix 5
Indications for the use of Fresh frozen Plasma and Cryoprecipitate

1 Overview of process 55
1.1 These guidelines are to aid the clinician to decide when it is appropriate to transfuse fresh
frozen plasma (FFP) and cryoprecipitate, and to minimise the risk of exposure.

1.2 These guidelines do not replace clinical assessment of the patient.

1.3 The blood transfusion laboratory must be contacted to order FFP or cryoprecipitate

1.4 Baseline clotting screen (PT APTT) and repeat after FFP transfusion.

1.5 Fibrinogen level is required prior to administration of cryoprecipitate unless in the case of
major haemorrhage.

1.6 The risks of transmitting infection are similar to those of transfusing any other blood
Components.

1.7 The risk of transfusing FFP also include allergic reactions and anaphylactic shock,
transfusion related acute lung injury, and haemolysis.

1.8 Patients receiving large volumes of FFP should be considered for Hepatitis A and Hepatitis
B vaccinations.

1.9 FFP should never be used to reverse the effect of warfarin in the absence of bleeding.
However it may be needed in patients needing urgent surgery or when the INR is very high,
particularly in the elderly patients.

1.10 There is no requirement to transfuse further plasma components if the source of bleeding in
a major haemorrhage has been controlled and there is no evidence of microvascular
bleeding.

1.11 Definite indications

- Replacement of single clotting factor deficiency
- FFP is only required when specific or combined factor concentrates are unavailable
- Vitamin K deficiency
- Acute disseminated intravascular coagulation (DIC)
- Thrombotic thrombocytopenic purpura (TTP)

1.12 Conditional uses

- FFP is only indicated in the presence of bleeding and disturbed coagulation
- Major Haemorrhage
- There is no evidence that prophylactic replacement regime with FFP or platelet
concentrates, either prevents bleeding or reduces transfusion requirements. Early
laboratory assessment is needed
- Liver Disease
- Cardio-Pulmonary Bypass surgery.

1.13 No justification for the use of FFP

- Hypovolaemia
- Formula Replacement e.g. 1 unit of FFP for every six units of red cells
- Nutritional support
- Treatment of Immuno-deficiency states
- Reversal of warfarin
-
2 Preparation of products

2.1 FFP can be thawed within 20 minutes of the request in the dry heat plasma thawer
56
2.2 Once thawed, FFP is best used immediately, but can be stored in the blood bank at 4'C for
up to 24 hours

2.3 If the FFP is removed from the blood bank and not to be used within 30 minutes it must be
returned to the blood bank

2.4 Cryoprecipitate will be thawed within 20 minutes in the dry heat plasma thawer

2.5 Thawed cryoprecipitate is stored at room temperature and must be used within 4hours of
thawing

3 Indications for the use of fresh frozen plasma (FFP)

3.1 Dose: 15ml/kg body weight (BW). Equivalent to 4 units for an adult.

3.2 One unit of FFP has approximately 250-300ml in volume per pack.

3.3 One unit of solvent detergent virally inactivated FFP has approximately 200ml in volume per
pack.

3.4 One unit of methylene blue virally inactivated neonatal FFP has approximately 50-70ml in
volume per pack.

3.5 The D status is not important in transfusing FFP and D positive FFP can be transfused to D
negative patients.

3.6 Indication codes

F1. Major Haemorrhage. Early infusion of FFP is recommended in a ratio of 1 unit FFP:1 unit
red cells for trauma and at least 1 unit FFP:2 units red cells in other major haemorrhage
settings. Once bleeding is under control, FFP use should be guided by timely tests for
coagulation as indicated below.Replacement of single coagulation factor deficiencies, where
a specific or combined factor concentrate is unavailable e.g. factor V.

F2. PT Ratio/INR >1.5 with bleeding. Clinically significant bleeding without major
haemorrhage. FFP required if coagulopathy. Aim for a PT and APTT ratio of ≤1.5.

. F3. PT Ratio/INR >1.5 and pre-procedure. Prophylactic use when coagulation results are
abnormal e.g. disseminated intravascular coagulation and invasive procedure is planned with
risk of clinically significant bleeding.

F4. Liver disease with PT Ratio/INR >2 and pre-procedure. FFP should not be routinely
administered to non-bleeding patients or before invasive procedures when the PT ratio/INR is
≤2.

F5. Thrombotic thrombocytopenic purpura (TTP), usually with plasma exchange.

F6. Replacement of single coagulation factor. Liver disease; there is no evidence of benefit
for FFP in non-bleeding patients regardless of the PT ratio.

4 Indications for use of cryoprecipitate

57
4.1 Dose: For an adult use 2 pools when giving cryoprecipitate transfusions, for children, use 5–
10 ml/kg up to a maximum of 2 pools.One dose is equivalent to five single donor units.
containing 3g of fibrinogen

4.2 Cryoprecipitate should be used in combination with FFP unless there is an isolated deficiency
of fibrinogen.

4.3 Indication codes:

C1. Clinically significant bleeding andfibrinogen <1.5g/L (<2g/L in obstetric bleeding)

C2. Fibrinogen <1g/L and pre procedure

C3. Bleeding associated with thrombolytic therapy causing hypofibrinogenaemia.

C4. Inherited hypofibrinogenaemia, fibrinogen concentrate not available

Hypofibrinogenaemia secondary to massive transfusion. Emerging evidence suggests a

fibrinogen level of 1.5g/l is required.

5 ABO compatibility

5.1 First choice is identical ABO group to the patient if possible.

5.2 Using ABO non–identical FFP and cryo is acceptable transfusion practice providing the
antibodies present in the plasma are ABO compatible with the patients ABO group.

5.3 Group O FFP and cryo should be used only for Group O patients unless there is a clinical
need.

6 D compatibility

There is no requirement for FFP or cryo to be selected according to D type as there are no
red cells present to induce sensitisation.

Appendix 6 Procedure for administering blood and blood components

58
ACTION : RATIONALE :

Check the reason for the transfusion has been
documented in the patient’s notes. Ensure the time
of the transfusion is taken into consideration. E.g.
is the transfusion required to be given out of core
hours (20:00-08:00) due to the clinical condition of
the patient
Explain procedure to patient
Record patient’s blood pressure, pulse, respiration
rate, temperature and NEWS/MEWS within one
hour prior to the commencement of transfusion.
To ensure there is clear evidence that
the transfusion is required and
expected result. Ensuring the safety
of the patient is maintained.
To obtain co-operation, consent and
allay anxiety
To obtain a baseline observation.

Wash and dry hands. Apply alcohol hand scrub.
Put on gloves.
Each unit of blood / blood products must be
checked by 2 Registered Nurses/Midwives (or one
Nurse/Midwife & one Doctor/ODP) in accordance
with the Use of Medicines Policy by the patient’s
bedside.
To remove transient organisms and
to prevent cross infection.
To ensure that the patient is
administered correct blood / blood
products.

Check the blood pressure, pulse, respiration rate,

temperature and NEWS/MEWS of patient has
been recorded within one hour of commencement
of transfusion.

Check compatibility label on each unit with the To ensure only compatible units of
patient’s identity wrist label for: blood are administered to the patient
 Patient’s name
 Date of birth
 Hospital number
 NHS no if available
 Patient’s blood group
 Unique donation number
 Date and time for which blood is requested
 Expiry date on unit of blood
 Check blood bag for any sign of damage
and signs of leakage.
To ensure the correct donation is
transfused
Check the donation number on the traceability tag
Return units if the donation number
against the donation number on the unit
on the tag does not match the unit
Check patency of the cannula. Observe insertion The cannula is a focus for infection.
site for signs of inflammation, swelling or leakage. These signs or symptoms may be
The patient should be questioned regarding pain or indicative of infection or displacement
soreness around the cannula insertion site. of the cannula.

If any of these signs or symptoms are present,

remove the cannula and re-site.
Flush cannula with 2mls of 0.9% sodium chloride. To maintain patency.

Attach unit of blood / blood products to To prevent extrinsic contamination.

administration set taking care that the sterile tip of
the administration set does not touch the
transfusion unit when being inserted fully into it.
59
If contamination occurs, the administration set
must be discarded.
Care must be taken not to puncture the infusion
bag/unit. If this occurs then the bag must be
returned to the laboratory to be discarded.
Adjust flow rate and administer transfusion at
prescribed rate.
If the transfusion is administered via a pump,
ensure that the administration set is a blood
administration set suitable for this device. Also
ensure the rate is set to the correct rate, as per the
prescription
Ensure tubing is anchored securely with a sterile
dry dressing.
After 15 minutes, recheck blood pressure, pulse,
respiration rate, temperature and NEWS (must be
recorded by a qualified member of staff)
To achieve infusion over the
prescribed time period, from starting
the infusion to completion of the pack
should take a maximum of 4 hours
from time removed from the blood
bank to prevent deterioration of
blood.
To prevent dislodging of the cannula
leading to extravasation.
Anaphylactic shock, though rare, is a
life threatening reaction requiring
immediate detection and treatment.

Observe for signs of adverse reactions / collapse

and anaphylaxis.

STOP TRANSFUSION IF THE PATIENT

EXHIBITS ANY SIGNS ADVERSE SIGNS/
SYMPTOMS AND SUMMON THE CRASH TEAM

Administer medications per the patient’s

symptoms,e.g. chlorphenamine,
hydrocortisone, adrenaline
If a reaction has occurred, refer to the Blood To provide appropriate
Transfusion Department for advice regarding treatment/support for the patient.
investigation and the safe transport of the whole
system i.e. blood products, administration set, etc.
Advise the Clinician responsible for the patient who
should seek advice from a Haematology
Consultant.
Observe cannula site for duration of transfusion. If To prevent contamination of cannula.
inflammation or extravasation of transfusion
occurs, stop transfusion. Take a swab for
microbiology. Re-site cannula.

If a change of dressing is necessary, it must be

performed aseptically each time keeping insertion
site clean and dry.
If no further intravenous infusion is required on To ensure safe transportation of
completion of transfusion, disconnect returned blood products. To comply
administration set from cannula using a new with Health and Safety Regulations.
venflon plug / obturator.

At the end of the transfusion, repeat blood

pressure, pulse, respiration rate, temperature and
NEWS. If a further unit is required within one hour,
repeat the steps above. Change the giving set after
all blood products have been administered or after
12 hours, whichever is sooner.
60
Flush cannula with 2mls of 0.9% sodium chloride.
Dispose of administration set directly into sharps
box.
Empty blood bags must be retained in a sealed
plastic bag on the ward for at least 24 hours before
disposing in the clinical waste bin.
The Traceability Tag attached to the unit
transfused must be returned to the Blood
Transfusion Department.
Wash and dry hands.
Record procedure in nursing notes.
To comply with Health and Safety
Regulations for disposal of clinical
waste.
May be required for investigation if
patient suffers a delayed transfusion
reaction.
This is to comply with the EU Blood
Directive – Blood Safety and Quality
Regulations 2005
To comply with Health and Safety
Regulations.
To maintain continuity of care and
accurate record keeping.
61
Appendix 7 (copied from Pathology Q-Pulse system BS-BT-FR-9, version 2.71, 30/08/2018)

62
63
Appendix 8 East of England guideline on investigation of transfusion reactions
65
Appendix 9 Summary of acute and delayed complications of transfusion

For further reading refer to the Handbook of Transfusion Medicine (Fifth Edition) and BCSH
Guideline on the investigation and management of Acute Transfusion Reactions

Problems Cause When? How Dangerous? Treatment

How often? Avoidance
Acute intravascular ABO incompatible Often during first few mls Mortality. Follow protocol for safe
of infusion.
haemolysis of red Transfusion. Group documentation and checking
cells A donor into group Incidence: Rare system for blood administration
O recipient is the
worst.

Infective shock Bacterial Usually during infusion Very high mortality. Manage septicaemia. Fluids
contamination of first 100mls of and intravenous antibiotics
of red cells or Contaminated pack. 2 per e.g. Gentamicin plus
platelets million blood components ceftazidime.
with e.g. transfused (UK).
Pseudomonas,
Yersinia,
Staphylococci.

Transfusion Related Donor plasma has During or soon after
Acute Lung Injury. antibody to patient transfusion.
Non-Cardiogenic leucocytes.
Pulmonary Oedema Rare: greater risk if large
volumes of donor plasma
given e.g. whole blood or
plasma exchange.
Life-threatening Respiratory support, diuretics
and high dose steroids.
Don’t transfuse, especially
plasma
Donor selection

Non-Haemolytic Antibodies to Within an hour or less. Unpleasant, especially Paracetamol (a simple

Febrile Reactions transfused if the patient requires antipyretic now thought to be
(NHFTR) to white cells. Mostly in patients who regular transfusions. as effective as
transfusion of Usually from have had several previous chlorpheniramine and
platelets and red previous transfusions hydrocortisone). Paracetamol
cells pregnancies or is preferred as patient may be
transfusions. Thrombocytopenic.

Urticaria (allergic Patient has Unpleasant. Temporarily stop transfusion

reaction). antibodies and give chlorpheniramine 10-
that react with 20mg IV before transfusion.
proteins in
transfused blood.
Appendix 9 Delayed Complications of Transfusion
Problems Cause When? How Dangerous? Treatment
How often? Avoidance
Delayed Patient has IgG 5 - 10 days after red Reduced survival of No treatment to prevent
haemolysis of antibodies to red cell transfusion. transfused red cells so antibody formation per se.
transfused red cell antigens, transfusion may be
cells. usually: clinically less effective. Once present, they are a
Rh - c, E, C problem for future red cell
Kidd - Jka Consequences of transfusions.
Duffy - Fya haemolysis can
Kell - K complicate other Write prominently in case
conditions. notes.

Inform the hospital transfusion

department if aware of
presence of antibodies

Good practice in pre-

transfusion testing.

Development of Transfusion of red Days to weeks after Dangerous if the patient No treatment to prevent
antibodies to red cells of a different Transfusion. Anti-D later receives a red cell antibody formation per se.
cells in the patients phenotype from the will develop in many D transfusion.
plasma patient. negative patients Avoid unnecessary
(allo-immunisation) Also caused by transfused with a unit May cause haemolytic transfusions -especially in
fetal/maternal of D positive cells. disease of the newborn. premenopausal females.
bleeding during
pregnancy and Other red cell antigens Inform the hospital transfusion
child birth. stimulate antibodies department if aware of
much less frequently. presence of antibodies

Antibodies are much Good practice in pre-

more common in transfusion testing.
female patients.

Development of Transfusion of Patients receiving Can cause unpleasant No treatment to prevent

antibodies that blood cells of a platelet support transfusion reactions antibody formation per se.
react with antigens different for more than 2 (NHFTR).
on white cells or phenotype from weeks may develop Antibodies to HLA If the antibodies reduce
platelets. patient. leucocyte and/or antigens may contribute clinical response to platelet
platelet antibodies. to poor transfusion, HLA/HPA
clinical response to matched platelets may help.
platelet transfusion.

Post Transfusion
purpura -
thrombocytopenia may
be profound.

Iron overload One unit of red Clinical problems Liver damage and other Use chelating agent to
cells contains after several years of increase iron excretion
250mg of iron. regular transfusion.
It accumulates
over time in Common in long term
transfusion recipients of frequent
dependent red cell
patients. transfusion.

67
Appendix 10 Competency forms
Assessment Criteria for Obtaining a Venous Blood Sample
Competency Statement 1 – Observational Assessment

STOP - High Risk. Do not use this core task unless you are competent to do so.
Competency Statement – Obtaining a venous blood sample for transfusion
This framework is for assessing staffs ability to obtain a venous blood sample for blood transfusion purposes. Staff
should be assessed after they have attended a local training course on this core task.
This framework was developed by the National Patient Safety Agency (NSPA) to assess the core transfusion
competencies
This workforce competence is linked to the Knowledge and Skills Framework dimensions developed by Skills for
Health. The dimensions are Communication, Health and Safety, and Health and Well-being
How to use this competence assessment framework
The framework should be completed whilst observing a member of staff obtaining a venous blood sample. It is
available from the local blood transfusion lead in every trust and is part of the NPSA’s ‘Right patient, right blood’
initiative
Please note that when the competence assessment framework is used to evaluate the competence of porters, they do
not have the responsibility for verbal patient identification.
Date

Member of Staff
Name Contact Details

Job Title Grade

Assessor
Name Contact Details

Job Title Grade

Statement
I certify that I am aware of my professional responsibility for continuing professional development and I realise that I am
accountable for my actions. With this in mind I make the following statement

I require further training before I can use this product in a competent manner
Date Signature

Indicate how you plan to meet your learning needs

I am competent to carry out this core task without further training

Date Signature

File:Obtaining a Venous Blood Sample Version: 1.3

Author: Blood Transfusion Department, MEHT NHS Last Reviewed / Next Review Date: August 2017 / June 2020

68
Observational Assessment
Core Competency Met
Did the member of staff check for each of the following on the request form
Full Name No Yes
Date of Birth No Yes
Hospital Number No Yes
Gender No Yes
Did the member of staff
Sign and write their contact details to show who had taken the sample No Yes
Print their name to show who had taken the blood sample No Yes

Did the member of staff bleed only one patient at a time No Yes

Patient Identification for Conscious Patient

Did the member of staff ask the patient to state their
Full Name No Yes
Date of Birth No Yes
Did the member of staff check
Details on the wristband or other attached identifier No Yes
The information on the wristband against that on the prescription or transfusion request No Yes
form

Patient Identification for Unconscious Patient or Patient Unable to Verbally Respond

Did the member of staff check details on the wristband or other attached identifier No Yes
Did the member of staff also check at least their
Full Name No Yes
Date of Birth No Yes
Hospital Number No Yes
Did the member of staff check the information on the wristband with the prescription or No Yes
transfusion request form
Can the member of staff describe the trusts policy for identifying unconscious patients No Yes
If an emergency situation, does the staff member know that the wristband must contain No Yes
an emergency/trauma number as a core identifier

Personal Checks
Did the member of staff wash their hands No Yes
Did the member of staff use personal protective equipment No Yes

Taking the Venous Blood Sample

Did the member of staff
Prepare the skin properly No Yes
Use the tourniquet appropriately No Yes
Minimise discomfort for the patient No Yes
Take blood appropriately if a transfusion is being carried out alongside other sampling No Yes
procedures
Monitor the patients responses No Yes
Remove needles using an appropriate technique No Yes
Apply a dressing at the end of the procedure. No Yes
If the last two questions are not applicable to the patient from whom the
sample has been taken, can the member of staff say what they would do in No Yes
these circumstances
69
File:Obtaining a Venous Blood Sample Version: 1.3
Author: Blood Transfusion Department, MEHT NHS Last Reviewed / Next Review Date: August 2017 / June 2020

Labelling the Venous Blood Sample

Did the member of staff label the venous blood sample as soon as it was taken No Yes
Is the member of staff aware that pre data labels are not acceptable on samples No Yes
Does the label include the following information
Full Name No Yes
Date of Birth No Yes
Hospital Number No Yes
Gender No Yes
Date No Yes
The member of staffs signature No Yes

Package and Documentation

Did the member of staff take the blood sample to the correct collection point No Yes
Did the member of staff record the following information in the patients notes
Why the sample had been taken No Yes
When the sample was taken No Yes
Who took the sample No Yes

All of the above must be achieved to pass the assessment

Knowledge Assessment
Did the member of staff know and understand the importance of
Using open-ended questions for identifying patients No Yes
Not pre-labelling bottles No Yes
Correct procedure if patient is unconscious or unable to give verbal identification No Yes
The risks created if more than on patient is bled at a time No Yes
Correct action to take if the information identifying a patient is missing No Yes

Keep this in your personal portfolio or training record. Ensure that your manager receives a copy of the
form and enters details of your competencies in their records

File:Obtaining a Venous Blood Sample Version: 1.3

Author: Blood Transfusion Department, MEHT NHS Last Reviewed / Next Review Date: August 2017 / June 2020

70
 Organising the Receipt of Blood / Blood Products for Transfusion
Competency Statement 2 – Observational Assessment

STOP - High Risk. Do not use this core task unless you are competent to do so.
Competency Statement – Organising the receipt of blood / blood products
This framework is for assessing staffs ability to organise the receipt of blood / blood products for transfusion. Staff
should be assessed after they have attended a local training course on this core task.
This framework was developed by the National Patient Safety Agency (NSPA) to assess the core transfusion
competencies
This workforce competence is linked to the Knowledge and Skills Framework dimensions developed by Skills for
Health. The dimensions are Communication, Health and Safety, and Health and Well-being
How to use this competence assessment framework
The framework should be completed whilst observing a member of staff organising the receipt of blood / blood products
for transfusion. It is available from the local blood transfusion lead in every trust and is part of the NPSA’s ‘Right
patient, right blood’ initiative
Please note that when the competence assessment framework is used to evaluate the competence of porters, they do
not have the responsibility for verbal patient identification.
Date

Member of Staff
Name Contact Details

Job Title Grade

Assessor
Name Contact Details

Job Title Grade

Statement
I certify that I am aware of my professional responsibility for continuing professional development and I
realise that I am accountable for my actions. With this in mind I make the following statement

I require further training before I can use this product in a competent manner
Date Signature

Indicate how you plan to meet your learning needs

I am competent to carry out this core task without further training

Date Signature

File:04184 Blood Transfusion Policy Version: 1.3

Author: Blood Transfusion Department, MEHT NHS Last Reviewed / Next Review Date: August 2017 / June 2020

71
Observational Assessment
Core Competency Met
If the transfusion is to be completed out of core hours ensure that the reason for this is No Yes
clearly documented
Confirm that the reson for the transfusion is documented in the notes No Yes
Check that verbal consent has been gained and documented No Yes
Ensure the product is prescribed No Yes
Confirm that the blood /blood product for transfusion is ready for collection No Yes
Check the cannula is patent No Yes
Ensure a set of baseline observations have been recorded and that the transfusion can No Yes
be safely started

Blood Transfusion Collection Slip / Prescription

Did the member of staff understand what information needs to be provided for staff to be able to collect
the correct product by describing that it should contain
Patients Full Name No Yes
Date of Birth No Yes
Hospital Number or other Identification number No Yes
Appropriate Persons to Collect the Blood / Blood Product
Did the member of staff identify an appropriate person to collect the blood / blood products for
transfusion and ensure
There was a clear communication about which blood / blood products to collect No Yes
There was verbal confirmation on where the blood / blood products should be collected No Yes
from
There was verbal instructions on the procedure to be carried out at the collection point No Yes
Receipt of Blood / Blood Products
Did the member of staff respond promptly to the delivery of blood / blood products by
Checking that the details on the delivered blood / blood products match the patient No Yes
documentation (i.e. blood transfusion collection slip or prescription)
Ensure that when the blood was received it was taken to the correct place (e.g. either No Yes
patient for transfusion or departmental blood bank to be re-stored)
All of the above must be achieved to pass the assessment
Knowledge Assessment
Did the member of staff know and understand the importance of
Why information provided must be accurate No Yes
The potential risks in the blood component collection process No Yes
Why information should not be cross-checked against the blood compatibility form No Yes
attached to the blood component
Blood being restored in another blood bank must be tracked into the Blood Bank within 30 No Yes
minutes of its removal

Keep this in your personal portfolio or training record. Ensure that your manager receives a copy of
the form and enters details of your competencies in their records

file:04184 Blood Transfusion Policy Version: 1.3

Author: Blood Transfusion Department, MEHT NHS Last Reviewed / Next Review Date: August 2017 / June 2020

72
 Assessment for collecting Blood / Blood Products for Transfusion
Competency Statement 3 – Observational Assessment

STOP - High Risk. Do not use this core task unless you are competent to do so.
Competency Statement – Collecting blood / blood products for transfusion
This framework is for assessing staffs ability to collect blood / blood products for transfusion. Staff should be assessed
after they have attended a local training course on this core task.
This framework was developed by the National Patient Safety Agency (NSPA) to assess the core transfusion
competencies
This workforce competence is linked to the Knowledge and Skills Framework dimensions developed by Skills for
Health. The dimensions are Communication, Health and Safety, and Health and Well-being
How to use this competence assessment framework
The framework should be completed whilst observing a member of staff who is collecting blood / blood products for
transfusion. It is available from the local blood transfusion lead in every trust and is part of the NPSA’s ‘Right patient,
right blood’ initiative
Please note that when the competence assessment framework is used to evaluate the competence of porters, they do
not have the responsibility for verbal patient identification.
Date

Member of Staff
Name Contact Details

Job Title Grade

Assessor
Name Contact Details

Job Title Grade

Statement
I certify that I am aware of my professional responsibility for continuing professional development and I
realise that I am accountable for my actions. With this in mind I make the following statement

I require further training before I can use this product in a competent manner
Date Signature

Indicate how you plan to meet your learning needs

I am competent to carry out this core task without further training

Date Signature

File:Collecting Blood Products for Transfusion Version: 1.3

Author: Blood Transfusion Department, MEHT NHS Last Reviewed / Next Review Date: August 2017 / June 2020

73
Observational Assessment
Core Competency Met
Did the member of staff demonstrate effective use of health and safety measures
by
Washing their hands No Yes
Using personal protective equipment No Yes
Adhering to other infection control procedures No Yes

Matching the Information on the Blood Product to the Minimum dataset information on the
blood collection slip (i.e. Patient Documentation)
Did the member of staff correctly check
Patients Full Name No Yes
Date of Birth No Yes
Hospital Number or other Identification number No Yes
Patients Full Name No Yes

Documentation
Did the member of staff correctly document the removal of or placement of blood
in the fridge by
Recording the date and time blood is removed from or placed in the fridge No Yes
(Where electronic tracking system is in place) Demonstrating that they know how to No Yes
maintain a secure ID throughout and showing this by scanning in and out correctly
Logging themselves in to the Blood Track system with their bar code No Yes
Successfully logging out of the Blood Track system, No Yes
If removing from Pathology Blood Bank, did the member of staff check they
completed
Writing their signature and contact information on the blood sign out sheet No Yes
Removing the compatibility form from the folder (purple headed form) No Yes
Correctly press 'taking out' No Yes
Removing the correct blood unit/s from the Blood Bank No Yes
Scanning each unit individually using Blood Track No Yes
Confirming demographic information on Blood Track with the details on the blood No Yes
traceability tag
Were aware that Blood units need to be restored within 30 minutes of removal from a No Yes
blood bank into the next blood bank
If placing Blood Units into the Blood Bank on the Ward/Department, did the
member of staff check they completed
Selecting "putting in" option No Yes
Scanning each unit individually into Blood Track No Yes
Placing blood units into the Blood Bank No Yes
If /When removing blood from the Blood Bank on the ward, did the member of
staff check they completed
Selecting "taking out" option No Yes
Selecting correct blood unit for the patient from the blood bank No Yes
Scanning the blood unit using Blood Track No Yes
Confirming the patient details on the screen with those on the traceability tag No Yes

File:04184 Blood Transfusion Policy Version: 1.3

Author: Blood Transfusion Department, MEHT NHS Last Reviewed / Next Review Date: August 2017 / June 2020

74
Transportation and handover of blood / blood products
Did the member of staff
Transport the blood product immediately to the clinical area No Yes
Not leave the blood unattended at any point No Yes
Hand the blood product over to an appropriate member of staff immediately No Yes
Ensure that receipt of the blood was recorded No Yes

All of the above must be achieved to pass the assessment

Knowledge Assessment
Did the member of staff know and understand the importance of
Why information provided to collect blood products must be accurate No Yes
The potential risks in the blood component collection process No Yes
Why information should not be cross-checked against the blood compatibility form No Yes
attached to the blood component
Not carrying clear blood products in a cool box No Yes
Aware that if blood is being transferred to other hospitals it must be arranged with the No Yes
blood transfusion laboratory to be packed in a blood transport box with the appropriate
paperwork

Keep this in your personal portfolio or training record. Ensure that your manager receives a copy of the
form and enters details of your competencies in their records

File:04184 Blood Transfusion Policy Version: 1.3

Author: Blood Transfusion Department, MEHT NHS Last Reviewed / Next Review Date: August 2017 / June 2020

75
Assessment for Preparing and Administering a Transfusion of Blood
/ Blood Products
Competency Statement 4 – Observational Assessment

STOP - High Risk. Do not use this core task unless you are competent to do so.
Competency Statement – Preparing and administering a transfusion of blood / blood products
This framework is for assessing staffs ability to prepare and administer blood / blood products to a patient. Staff should
be assessed after they have attended a local training course on this core task.
This framework was developed by the National Patient Safety Agency (NSPA) to assess the core transfusion
competencies
This workforce competence is linked to the Knowledge and Skills Framework dimensions developed by Skills for
Health. The dimensions are Communication, Health and Safety, and Health and Well-being
How to use this competence assessment framework
The framework should be completed whilst observing a member of staff who is involved in preparing and administering
blood / blood products. It is available from the local blood transfusion lead in every trust and is part of the NPSA’s
‘Right patient, right blood’ initiative
Please note that when the competence assessment framework is used to evaluate the competence of porters, they do
not have the responsibility for verbal patient identification.
Date

Member of Staff
Name Contact Details

Job Title Grade

Assessor
Name Contact Details

Job Title Grade

Statement
I certify that I am aware of my professional responsibility for continuing professional development and I
realise that I am accountable for my actions. With this in mind I make the following statement

I require further training before I can use this product in a competent manner
Date Signature

Indicate how you plan to meet your learning needs

I am competent to carry out this core task without further training

Date Signature

File:04184 Blood Transfusion Policy Version: 1.3

Author:Blood Transfusion Department, MEHT NHS Last Reviewed / Next Review Date: August 2017 / June 2020

76
Observational Assessment
Core Competency Met
Did the member of staff carry out the four types of pre-transfusion checks correctly
Personal - Clean hands, wear personal protective equipment and adhere to infection No Yes
control guidelines at all times
Equipment - Check that all equipment is clean and available (i.e. prescription chart, No Yes
observation chart, giving set, disposable bags and a trolley)
Patient - Carry out a baseline assessment of the patient; check venous access has been
obtained prior to blood being collected from the fridge; read through the prescription; and No Yes
check that the patient understands they are going to receive a transfusion
Gained verbal consent, if not; the reason is documented in patients notes No Yes
Confirm the reason for the transfusion is documented in the notes No Yes
If the transfusion is to be completed out of core hours (20:00-08:00) ensure the reason is No Yes
clearly documented in the notes
Blood Component - Check the quality of the blood product, expiry dates and any special No Yes
transfusion requirements

Patient Identification for Conscious Patient

Did the member of staff ask the patient to state their
Full Name No Yes
Date of Birth No Yes
Did the member of staff check
Details on the wristband or other attached identifier No Yes
The information on the wristband against that on the prescription or transfusion request No Yes
form

Patient Identification for Unconscious Patient or Patient Unable to Verbally Respond

Did the member of staff check details on the wristband or other attached identifier No Yes
Did the member of staff also check at least their
Full Name No Yes
Date of Birth No Yes
Hospital Number No Yes
Did the member of staff check the information on the wristband with the prescription or No Yes
transfusion request form

Recording Vital Signs

Did the member of staff record the patients vital signs within 1 hour of start
Blood Pressure No Yes
Temperature No Yes
Pulse rate No Yes
Respiratory rate No Yes
NEW/MEWS Score No Yes
Did the member of staff record the patients vital signs after 15 minutes
Blood Pressure No Yes
Temperature No Yes
Pulse rate No Yes
Respiratory rate No Yes
NEW/MEWS Score No Yes
Did the member of staff record the patients vital signs within one hour of completion
Blood Pressure No Yes
Temperature No Yes
Pulse rate No Yes
77
Respiratory rate No Yes
NEW/MEWS Score No Yes
File: 04184 Blood Transfusion Policy Version: 1.3
Author:Blood Transfusion Department, MEHT NHS Last Reviewed / Next Review Date: August 2017 / June 2020

Administering the Blood Transfusion

Did the member of staff ensure that the blood transfusion was completed
RBC within four hours of it leaving the blood bank No Yes
Or - Within 30 minutes for platelets leaving the agitator/transfusion laboratory No Yes
Or - Within 30-60 minutes for Fresh Frozen Plasma No Yes
Or Cryoprecipitate within 4 hours No Yes
Did the member of staff know (see appendix 17 for compatibility of other
blood components
Which RBC group is the universal donor No Yes
Which RBC groups are compatible with group A D+ve patients No Yes
Which RBC groups are compatible with group A D –ve patients No Yes
Which RBC groups are compatible with group B D +ve patients No Yes
Which RBC groups are compatible with group B D –ve patients No Yes
Which RBC groups are compatible with group AB D +ve patients No Yes
Which RBC groups are compatible with group AB D -ve patients No Yes
Which RBC groups are compatible with group O D +ve patients No Yes
Which RBC groups are compatible with group O D –ve patients No Yes
Documentation
Did the member of staff record the following information in the patients
notes
Date No Yes
Start time No Yes
Stop time of the transfusion No Yes
Did the member of staff
Complete the traceability documentation in accordance with national law No Yes
Know to return the traceability label to the Blood Transfusion department within 24 No Yes
hours of the transfusion
Know that Traceability of Blood Products is a legal requirement and this evidence No Yes
of transfusion/administration is kept for 30 years.
All of the above must be achieved to pass the assessment

Knowledge Assessment
Did the member of staff know and understand the importance of
Using open-ended questions for patient identification No Yes
The timescales for administering blood and / or blood products safely after it had No Yes
been collected from the fridge
Correct procedure if unconscious patient or unable to give verbal identification No Yes
The risk associated with checking the blood compatibility form against the blood No Yes
product instead of the information on the wristband
Monitoring the patients vital signs throughout the transfusion process No Yes
Know the process to take if the IV line is blocked No Yes

Keep this in your personal portfolio or training record. Ensure that your manager receives a copy of the form
and enters details of your competencies in their records
File: 04184 Blood Transfusion Policy Version: 1.3
Author: Blood Transfusion Department, MEHT NHS Last Reviewed / Next Review Date:August 2017 / June 2020

78
Appendix 11 (copied from Pathology Q-Pulse system BS-BT-FR-26 version 1.20
10/05/2016)
Appendix 13a (copied from Pathology Q-Pulse system BS-BT-FR-33, version 1.12)

Request for Special Requirements - Blood Products

Date: ..………………………………….. NHS Number: ………….………………………

Patient Surname: …………………….. Hospital Number: …………………………….

First Name: ………………………..….. Date of Birth: ………………………………….

Address: ……………………………….. Male / Female (circle/delete)

……………………………………………. Consultant:……………………………

Blood Group: ………………………… Known antibodies:……………………………

Name of Doctor requesting special requirement:

Print: ………………………………Sign: …………………….……Contact details: (bleep/ext no)………

Relevant drug therapy e.g. Bendamustine, Fludarabine, Cladrabine, Deoxycoformicin, Anti-

thymocyte globulin (ATG) or Alemtuzumab (anti-CD52) (circle/delete)
Other (please document):…………………………………….

Relevant condition e.g. Hodgkin Lymphoma Other: ……………………………………..

Please ensure you :

 Give the patient the NHSBT leaflet on irradiated products 

 Put the sticker from the NHSBT leaflet in the patients notes 

 Place alert sticker on the inside of the front cover of notes 

 Send this form to the transfusion laboratory 

 Place copy of this form in patient medical notes 

Stem Cell Transplant/Bone Marrow Transplant: Yes / No

Original Group: ........................................... Donor Group: ................................................................

Name of Transplanting Centre – please supply the laboratory with a copy of the transfer
documentation

...................................................................................................................................................................
Special requirements:
 Irradiated  PTO for guidance

 HLA matched 

 IgA deficiency 

 CMV negative 

 Other  (Please document) ………………………………….

Rationale...................................

Blood Bank Staff:` Entered onto Computer: Y / N (if N document rationale):

Date: ………… By Print: ……………………… Date………... Checked By Print……………………

Signed: .................................... Signed:.....................................................

* Who needs to receive irradiated blood components?

  Patients receiving transfusions from a first degree relative (parent, child or sibling) or second degree
relative (grandparent, grandchild, uncle, aunt, nephew, niece or half sibling).

 Patients receiving a granulocyte transfusion.

 Patients receiving Human Leucocyte Antigen (HLA) – selected components.

 Patients receiving purine analogues (e.g. fludarabine, cladrabine, deoxycoformicin): probably safer
to use them indefinitely. For newer purine analogues and related drugs, such as bendamustine,
irradiated components should be given until further data are available.

 All intrauterine transfusions (IUT). Other neonates receiving red cell or platelet transfusions – where
there has been a previous IUT (irradiated components should be given until six months after the
expected delivery date) or if the donation is from a first or second degree relative.

 Neonatal exchange transfusions (ET) if there has been a previous IUT or if the donation comes from
a first or second degree relative. For other neonatal ET, irradiation is recommended providing that
irradiation does not unduly delay transfusion.

 Patients with Hodgkin Lymphoma, at any stage of the disease (for life).

 Patients receiving allogeneic haemopoietic stem cell (HSC) grafts, from the start of conditioning
therapy and while the patient remains on Graft-versus-Host Disease (GvHD) prophylaxis (usually six
month post-transplant). If chronic GvHD is present or the patient is taking immunosuppressant’s,
continue irradiated blood components indefinitely.

 Allogeneic HSC donors being transfused seven days prior to or during the harvest of their HSC.

 Patients who have autologous HSC graft:

1. Any transfusion seven days prior to and during the one marrow-stem cell harvest.
2. Any transfusion from the start of conditioning chemo-radiotherapy until three months post-
transplant (six months if total body irradiation was used).

 Patients with aplastic anaemia receiving immuno suppressive therapy with anti-thymocyte globulin
(ATG) and/or alemtuzumab (anti-CD52).

 Patients with known or suspected T-cell immunodeficiency, such as Di-George syndrome, the blood
should be transfused within 24 hours of irradiation.

 Patients receiving alemtuzumab for solid organ transplantation.

Who should you inform if you patient requires irradiated blood components?
 In order to prevent the risk of TA-GvHD, please inform the transfusion laboratory, the shared care
hospital (if appropriate), nursing staff and most importantly of all, the patient of the need for
irradiated blood components. A patient information leaflet ‘Information for patients needing irradiated
blood’ is available from the blood transfusion department.

Why is it important these patients receive irradiated blood components?

 Irradiating blood components prevents the donor white cells replicating and mounting an immune
response against a vulnerable patient causing transfusion-associated graft-versus-host disease (TA-
GvHD).

Which components need to be irradiated?

 Only cellular blood components (red cells, platelets and granulocytes) need to be irradiated.
 Fresh Frozen Plasma (FFP), cryoprecipitate, frozen washed red cells and fractionated plasma
products do not need to be irradiated as the lymphocytes will not, or are extremely unlikely to,
survive the freezing/washing/fractionation process.

*For further information see current version of “Irradiated Blood Components Information for Healthcare
Professionals Factsheet”
Appendix 13b

Request for the Removal of Special Requirements - Blood Products

Date: ..………………………………….. NHS Number:………….………………………

Patient Surname: …………………….. Hospital Number: …………………………….

First Name: ………………………..….. Date of Birth: ………………………………….

Address: ……………………………….. Male / Female (circle/delete)

……………………………………………. Consultant:…………………………………….

Details of Doctor requesting the removal of the special requirement:

Print: ………………………………… Grade/Job Role: …………………………………….

Sign: …………………….…………… Contact details: (bleep/ext no) ………………………………

Confirm which special requirement is to be removed

 Irradiated 

 HLA matched 

 IgA deficiency 

 CMV negative 

 Other  (Please document) ………………………………….

Rationale for the special requirement being removed:……………………………................................

………………………………………………………………………………………………………………..

Blood Bank Staff: Entered removed from the laboratory records: Y / N (if N document
rationale):

Date: ………… By Print: …………………….… Date……….. Checked By Print: …………………

Signed: .................................... Signed: ............................................................

Appendix14

Flow chart for Major Haemorrhage in adults

Appendix 15 Flow chart for Major Haemorrhage in children
Appendix 16 Adult Blood and Blood Components Authorisation Chart
Appendix 17

Blood Transfusion Selection of Blood Products

Ref SPECIFICATION SPN223/6.2

NHSBT Portfolio of Blood Components

Red Cell selection for ABO group

Recipient’s group O A B AB

1st choice O A B AB

2nd choice - O O A or B

3rd choice - - - O

Rhesus D red cell selection

1. Red cells of the correct Rh D type should be used.
2. Recipients with preformed anti-D antibodies should receive RhD negative red cells
3. Females of child bearing potential in an emergency, should receive RhD negative red cell

Platelet selection for ABO group

O A B AB
Recipient’s group
1st choice O A B AB
2nd choice A or B AB AB A or B HT neg
3rd choice AB B or O HT neg A A or O HT neg O HT neg

Rh D negative platelet concentrates should be given to Rh D negative patients where possible, particularly
to Rh D negative women of child bearing potential. When Rh D incompatible platelets are required,
guidance on anti-D administration is in BCSH guidelines

FFP Compatibility
FFP of the same ABO group should be used as far as possible. If ABO identical FFP is not available then
FFP of another group can be given as directed in the table below.
Group AB is haemolysin free and may be used if the patient’s group is unknown, but is in short supply and
should only be used for non AB recipients if absolutely essential.

FFP selection for ABO group

O A B AB
Recipient’s group
1st choice O A B AB

2nd choice A AB AB *A HT neg

3rd choice B *B HT neg *A HT neg *B HT neg

TH
4 choice AB - - -

Group O FFP MUST only be given to O recipients.

* Only suitable for emergency use in adults if unit is tested and found to negative for high titre ABO
antibodies.
Rh D group compatibility: FFP, Cryoprecipitate and Plasma, Cryo Depleted do NOT need to be matched for
RhD group. RhD positive plasma components may be given to any RhD negative individual and no anti-D
prophylaxis need be given in this situation. The EU Blood Directive currently requires that the RhD group is
stated on the label.
Appendix 18

To ensure compliance with Blood Transfusion Competency One

To be completed and returned to Tina Parker the Blood Transfusion Nurse D228 Blood
Transfusion Department

MEHT requires all staff who take blood samples for transfusion purposes to be compliant with
competency one: sample taking for blood transfusion purposes. E.g. cross match, group and save
or antibody status.

The 2012 SHOT report (Serious Hazards of Transfusion) states that wrong blood in tube incidents ould
result in an incompatible transfusion and death, due to incompatibility. A ‘Wrong Blood in Tube
Incident’ (WBIT), is where there is a historical record for the patient (one or many which could be from
anytime such as yesterday or 10 years ago) and the blood group does not match the sample just
received. If the patient only has one historical group on record, and this sample does not match this
group, another sample will be required to confirm the correct group.

Within MEHT, in 2014 there were a number of incidents of wrong blood in tube reported. There
may be other instances that we are unaware of – for example the patient bled has the same blood
group as the patient’s details on record. Or the patient has only been bled once and therefore the
error will not be found until the next blood transfusion sample is taken and processed.

In order to be compliant with competency one you must state that you will:-

Complete to the required standard all blood transfusion request forms to include the patient’s
details including: first name, surname, date of birth, gender and hospital number.

Full name (Print)……………………………………………..

Signed………………………………………

Date………………………………………………………………….

N.B If the patient has special requirements, e.g. CMV negative or irradiated products, the ‘Yes’
must be circled, the requirement documented and the laboratory informed of which requirement is
needed.

If you then go on to take the sample you must check the form against the patients identification
and verbally (if possible) with the patient. The details on the tube must be completed with the
above information, handwritten at the patient’s bedside; this reduces the risk of the incorrect
details being written on the tube.
I certify that I will follow the above procedure:

Full name (print)............................................................

Signed...........................................................

Date…..........................................................................

Note: sign above if you are involved in the sample process and below if not:
I certify that I do not complete forms for blood transfusion purposes and do not take samples of
blood for transfusion purposes:

Full name (print)............................................................... Signed...............................................

Date…...……....................................................................