Purpose: To transfuse blood and blood components safely to patients in skilled nursing and long-term care facilities.
Policy: Administration of blood and blood components, including the use of infusion devices and ancillary equipment, and the identification, evaluation, and reporting of adverse events related to transfusion are established in the following policy with procedures and practice guidelines.
Types of Transfusions:
- Packed Red Cells treat symptomatic or critical deficit of oxygen-carrying capacity.
- Washed Red Cells treat symptomatic or critical deficit of oxygen-carrying capacity, IgA deficiency with anaphylactic reaction, and recurrent severe allergic reactions to unwashed red cell products.
- Platelets treat thrombocytopenia, dysfunctional platelet disorders, active platelet-related bleeding, or serious risk of bleeding.
- Fresh Frozen Plasma treats preoperative bleeding or bleeding patients who require replacement of plasma coagulation factors, clinically significant coagulation deficiencies, patients taking warfarin who are bleeding and need to undergo an invasive procedure, thrombotic thrombocytopenia purpura, and rare specific plasma protein deficiencies.
- Whole Blood treats deficit of oxygen-carrying capacity, blood volume deficits.
- Cryoprecipitate treats bleeding associated with fibrinogen deficiency, Factor XIII deficiency, von Willebrand disease, and hemophilia A (factor VIII deficiency).
Supplies:
- Personal Protective Equipment (PPE).
- Blood or blood product from transfusion services.
- Solution container of 0.9% normal saline (NS), at least 250 milliliter (mL).
- Blood administration set.
- Blood administration sets shall be changed after two consecutive units of blood have been given, but may not be in use for greater than four hours. If a second unit will cause blood administration set to be in use greater than four hours, change blood administration set before starting second unit.
- Infusion pump with IV pole.
- Armboard, if needed.
- Patent IV catheter, 20 gauge or larger.
- In older adults, 22 and 24 gauge catheters are acceptable for use for transfusion of blood and blood components. With smaller catheter, red blood cells must be infused at a slower rate to prevent hemolysis.
- Leukocyte reducing filter.
*Required when unit to be transfused does not come leukocyte depleted. Transfusion services provides. Refer to instructions in package. Verify filter being used is intended for use with component being transfused (red cells or platelets), and note maximum number of units to be administered through one filter.
Special Considerations in the Older Adult:
- The older adult is also at risk for cardiovascular changes in the structure, function, and disease associated with aging. Because of the increased risk for circulatory overload, close monitoring is essential.
- Rapid administration of blood products can result in fluid overload. Red blood cell and plasma products and 25% albumin are the components most associated with circulatory overload. At greatest risk are adults older than 70 years, as well as those with existing cardiopulmonary disease.
- Choose an appropriate vascular access device (VAD) based on patient condition and transfusion needs, and ensure adequate and patent vascular access prior to obtaining the unit of blood from the blood bank.
- Peripheral intravenous catheters: use 20 to 24 gauge based on vein size and patient preference. Use a large gauge catheter when rapid transfusion is required.
- Transfuse red blood cells at a slower rate when using small gauge catheters; The pressure with rapid transfusion via a small gauge catheter may cause hemolysis.
- Central vascular access devices are acceptable for blood administration.
PROCEDURE
- ASSESSMENT
- Assess benefits versus the risk of transfusion prior to administering human blood and blood components (whole blood, red blood cells, plasma and plasma components, platelets, granulocytes, and cryoprecipitate).
- Obtain baseline physical assessment prior to obtaining blood for transfusion: vital signs, breath sounds, identification of conditions that may increase the risk of transfusion related adverse reactions (e.g., current fever, heart failure, renal disease, or risk of fluid volume excess).
- Assess patency of vascular access device (VAD).
- Assess current laboratory values, especially hemoglobin and hematocrit levels.
- PATIENT EDUCATION
- Discuss with patient the risks, benefits, and treatment alternatives to blood transfusion.
- Allow opportunity to ask questions and the right to accept or refuse the transfusion.
- Allow the opportunity for patients to discuss their religious or cultural beliefs regarding blood transfusion.
- Include the following in the educational process: elements of the transfusion procedure (e.g., compatability testing, vascular access), signs and symptoms associated with complications of transfusion therapy (e.g., vague uneasy feeling, pain, breathing difficulties, chills/flushing/fever, nausea, dizziness, rash/urticaria, dark/red urine), and rationale for frequent monitoring during transfusion.
- Physician/nurse practitioner should present informed consent/refusal for blood or blood component transfusion form for patient to sign.
- ORDERS FOR BLOOD AND BLOOD COMPONENTS
- Before entering orders for blood or blood components: patients receiving blood should be questioned about antibody formation in reactions from prior transfusions. Transfusion service shall be notified of any antibody or reaction history.
- Blood and blood products are ordered by a physician/nurse practitioner via blood product order set in computerized physician order entry (CPOE).
- Physical copy of the order is carried with type and cross sample to Blood Bank.
- Orders for blood or blood products will include component, number of units, and an order to transfuse (if unit is to be transfused). Orders will also include as needed special processing, premedications, parameters for transfusion, and special instructions.
- The transfusion nurse acknowledges orders for blood and/or blood components.
- The transfusion nurse processes blood and or blood component orders, including the number of units ordered in the electronic medical record.
- When blood or blood component is ready for pick up from the blood bank, the blood bank will notify the transfusion nurse.
- PATIENT LABS/IV PRIOR TO BLOOD PICK UP
- When physician/nurse practitioner determine the need for transfusion, the ordering physician/advanced practice provider contacts the transfusion nurse directly with patient information related to transfusion.
- Transfusion nurse then obtains appropriate lab work requisition to perform type and screen or type and crossmatch per policy guidelines.
- Transfusion nurse provides education about the necessary lab work, peripheral IV access, and transfusion process to patient.
- The transfusion nurse then obtains the blood sample for type and screen or type and crossmatch.
- For orders placed prior to 3:00 p.m. Sunday-Thursday, the transfusion nurse should perform the appropriate lab work the same day.
- For orders placed after 3:00 p.m. Sunday-Thursday, the transfusion nurse will obtain the appropriate lab work the following morning.
- For orders placed on the weekends that are non emergent, the transfusion nurse will obtain lab work on the following Monday morning.
- For patients needing blood transfusions on the weekends, or who need emergent transfusions of blood or blood components, patients may be referred to an outpatient transfusion service.
- At the visit when the transfusion nurse obtains the lab work, a peripheral IV catheter (PIVC) should be placed, if one is not already in place, following policy guidelines for placement of PIVCs.
- BEFORE BLOOD/BLOOD COMPONENT PICK UP
- Provide patient education.
- Assemble equipment for transfusion at bedside and explain the procedure to patient.
- Verify patient is wearing a facility identification bracelet and a transfusion services bracelet (Blood Bank ID bracelet).
- Ensure patient assessment is within acceptable standards. Assessment to be completed by registered nurse should include cardiac and respiratory assessments at a minimum.
- Obtain pretransfusion vital signs including: temperature, pulse, respiration, and blood pressure. Document in patient’s chart. Ensure pretransfusion vital signs are within acceptable standards.
- The transfusion nurse will have facility staff perform this set of vital signs prior to blood or blood component pick up and report the results to the transfusion nurse.
- Ensure adult patient has a patent IV site with a 20 gauge catheter or larger, if possible.
- Administer premedications as ordered.
- Oral premedications should be administered at least 30 minutes before starting a transfusion and IV premedications should be administered at least 10 minutes before starting transfusion.
- Facility registered nurses will administer any premedications after reporting pretransfusion vital signs to the transfusion nurse.
- Verify consent form is signed.
- Consent form should be present to the patient by the physician/nurse practitioner.
- Prior to picking up the blood, if patient indicates he or she has additional questions or has not had a conversation with his or her physician/nurse practitioner, the nurse must contact patient’s provider.
- After provider has spoken with patient regarding treatment, nurse may witness patient signature on consent form (if not previously completed).
- Consent form should be present to the patient by the physician/nurse practitioner.
- Oral premedications should be administered at least 30 minutes before starting a transfusion and IV premedications should be administered at least 10 minutes before starting transfusion.
- If patient signs with an X, a second licensed nurse is required.
- If patient is unable to consent and person authorized to give consent is not present to sign the form, consent may be obtained by telephone. Two licensed nurses are required to sign form. Include name of person giving consent and indicate consent was given via telephone.
- This requirement may be waived in an emergency or life threatening situation after reasonable efforts have been made to secure informed consent. Definition of an emergency is defined as physician ordering blood as an emergency release or if physician has documented in a progress note that blood administration was emergent and informed consent was unable to be obtained.
- BLOOD PICK UP
- Blood and blood components are picked up from transfusion services or blood bank by the transfusion nurse (RN), licensed practical nurse (LPN), or medical assistant (MA). Blood products may only be picked up by staff who have been trained on the process for picking up blood and blood components.
- The first time a courier picks up blood or blood components from the blood bank, courier must complete education for transporting blood and blood components.
- Blood and blood products may be picked up for more than one patient at a time if blood products are being transported to the same facility for multiple patients.
- Each patient’s blood is packed in a separate cooler for transport to the skilled nursing facility.
- Transfusion services or blood bank staff verify patient’s name, date of birth, and medical record number before handing blood over to the courier (RN, LPN, MA, MD).
- Transfusion services technician asks courier to read aloud to verify each of the following on the component and component label:
- Patient’s name, medical record number, transfusion services arm band number, and ABO/Rh.
- Donor ABO/Rh.
- Blood and blood components are picked up from transfusion services or blood bank by the transfusion nurse (RN), licensed practical nurse (LPN), or medical assistant (MA). Blood products may only be picked up by staff who have been trained on the process for picking up blood and blood components.
- Donor unit number- expiration date, an compatibility (only on component label).
- Attributes if applicable, e.g., CMV negative and/or irradiated (irradiated will be labeled only on component).
- Special antigen typing if applicable (only on component).
- Courier checks appearance of blood component for:
- Discoloration.
- Foaming.
- Bubbles.
- Abnormal cloudiness.
- Clots or clumps.
- Loss of integrity of bag.
- Transfusion services staff also checks and documents appearance of blood and blood components.
- TRANSPORTATION OF BLOOD FROM BLOOD BANK TO FACILITY
- Blood or blood components are transported via blood bank/transfusion services approved cooler immediately to the facility where the transfusion will occur.
- Courier must drive directly to the facility where the transfusion will occur without stopping at a secondary location/running other errands.
- While blood remains in the transport cooler, temperature checks must be completed and documented every 30 minutes.
- Red blood cell temperature inside the cooler must be maintained between 1-6°C.
- Red blood cells are viable for 4 hours inside the cooler as long as the correct temperature is maintained; they are viable for up to 30 minutes once removed from the cooler and must be transfused within 4 hours after removal from cooler.
- Blood or blood components are transported via blood bank/transfusion services approved cooler immediately to the facility where the transfusion will occur.
- PRETRANSFUSION
- Obtain and review provider’s order for transfusion.
- A transfusion order form must be used (paper form or EMR order set).
- Perform baseline physical assessment, including vital signs.
- Obtain appropriate vascular access or check patency of existing VAD.
- Review informed consent or patient assent per organizational policy.
- Gather supplies.
- Obtain and review provider’s order for transfusion.
- PROCEDURE
- Obtain blood product from the transfusion service.
- Perform hand hygiene before direct contact with patient and subsequently as required throughout the procedure.
- Perform patient and blood identification process at time of obtaining blood.
- Verify recipient’s two independent identifiers according to organizational policy (e.g., name and date of birth), ABO group, and Rh type, if required; donation identification number; crossmatch test interpretation, if performed; special transfusion requirements; expiration date and time; and date and time of issue.
- Inspect each blood component prior to transfusion; do not use if container is not intact or if the appearance is not normal (e.g., excessive hemolysis, significant color change in blood bag compared to tubing, presence of floccular material, cloudy appearance), and return it to the transfusion service.
- Perform patient and blood identification process using an independent double check by two licensed health care providers (e.g., 2 RNs, 1 RN and 1 LPN, 1 RN and 1 MD) in the presence of the patient. Information must be read aloud in the presence of the patient.
- Verify patient identity using two independent patient identifiers according to organizational policy and ask the patient to state his or her name and date of birth, if possible.
- Medical record number
- Blood bank bracelet number
- Verify the blood component.
- Review the provider’s order for transfusion.
- Patient blood type compatibility with the unit to be transfused.
- Crossmatch test interpretation, if performed.
- Donor identification number.
- Unit expiration date and time.
- Any product modification, such as irradiation or cytomegalovirus seronegative.
- Prepare to transfuse.
- Perform hand hygiene.
- Put on gloves.
- Open blood administration set and close all clamps.
- Spike bag of 0.9% sodium chloride with one of the Y-administration set spikes.
- Hang on IV pole and prime administration set according to the manufacturers’ directions for use.
- Attach primed administration set to VAD either directly to catheter hub or to needleless connector after disinfection.
- Initiate slow infusion of 0.9% sodium chloride solution.
- Initiate transfusion.
- Gently agitate blood bag to mix cells with plasma.
- Spike blood component with the other Y-administration set; close clamp to sodium chloride container.
- Open clamp and initiate transfusion.
- Start the transfusion slowly at approximately 2 milliliters per minute for the first 15 minutes and remain near the patient; if there are no signs of a reaction, increase the transfusion rate and ensure the completion of the unit within four hours.
- Consideration should be given to patient’s size, blood volume, cardiac status, and hemodynamic condition. Most patients not in congestive heart failure or in danger of fluid overload should tolerate infusion within 1 ½ to two hours.
- A unit of blood or blood product should be infused within four hours. If a unit is not infused within four hours, discontinue at 4 hours, document amount infused, and notify physician/nurse practitioner of amount infused.
- Medications may be administered into distal port of blood tubing only when unavoidable. Tubing must be flushed with 0.9% sodium chloride before medication infuses to clear tubing of blood and must be flushed with 0.9% sodium chloride after medication to clear tubing of medication before blood is resumed. This interruption of blood transfusions should be done only when unavoidable.
- Monitor patient.
- Do not leave patient room for the first 15 minutes of transfusion.
- Obtain vital signs every 5 minutes for the first 15 minutes.
- Additional vital signs are taken at 30 minutes from start of transfusion, one hour from the start of transfusion, hourly, as needed, and at the end of transfusion.
- Document vital signs.
- Compare the baseline vital signs to identify any early signs of a transfusion reaction.
- Hemolytic reactions (e.g., fever, chills, tachycardia, hypotension, dyspnea, red or dark urine)
- Febrile nonhemolytic reactions (e.g., fever rise of 2°F, chills, headache, vomiting).
- Allergic reactions (e.g., itching, urticaria, flushing, runny eyes, angioedema).
- Anaphylactic or anaphylactoid reactions.
- Transfusion related acute lung injury (e.g., fever, chills, dyspnea, cyanosis, hypoxemia, hypotension, bilateral pulmonary edema).
- Transfusion associated circulatory overload.
- Observe VAD site.
- Stop the transfusion immediately if any signs and symptoms of a transfusion reaction are present; disconnect the blood administration set from the catheter hub. Start a 0.9% sodium chloride infusion with new primed administration set and infuse at a rate to maintain catheter patency.
- Notify the provider and transfusion service, administer emergency medications as prescribed, and obtain prescribed blood sample for additional lab tests as prescribed. Return blood container with remaining blood and set attached to the transfusion service.
- Initiate blood transfusion reaction policy.
- Notify facility nursing staff.
- Notify the provider and transfusion service, administer emergency medications as prescribed, and obtain prescribed blood sample for additional lab tests as prescribed. Return blood container with remaining blood and set attached to the transfusion service.
- Complete transfusion of red blood cells within four hours; plasma within 15 to 60 minutes; and platelets within one to two hours.
- Close clamp to blood product on completion.
- Open clamp to 0.9% sodium chloride to clear the administration set and VAD of blood.
- Discard empty blood container and administration set in biohazard container.
- Continue to monitor patient, as reactions may occur after the completion of the transfusion; instruct patient in signs and symptoms to report.
- Blood or blood components should not be stored in a facility refrigerator.
- Do not use a blood warmer unless specifically ordered by a physician. Ideal temperature is 37°C.
- Blood must never be warmed above 42°C or red cell hemolysis occurs. If blood is warmed above 42°C, it must be discarded. Once blood has been warmed, it should not be saved for future transfusions.
- Patient Refusal: If a physician/nurse practitioner orders blood or blood products to be administered, but a patient refuses, a refusal to permit blood transfusion form should be signed by the patient or person authorized to consent for patient. Notify provider of refusal to permit transfusion. Notify transfusion services of refusal if order has been processed.
- Transport of Patients Receiving Blood: Patients will be transported to areas within a facility only if deemed sufficiently stable by ordering physician and should be accompanied by a licensed staff member or transfusion nurse for length of examination.
- DOCUMENTATION
- Document in the patient’s health record:
- Pretransfusion assessment and vital signs.
- VAD placement, if indicated, and VAD assessment.
- Document in the patient’s health record:
- Blood component, blood unit/donor/recipient identification, compatibility, and expiration date.
- Vital signs and assessment during post transfusion.
- Volume of blood component and 0.9% sodium chloride administered.
- Patient’s response to the procedure.
- Patient education.