Blood components are supplied by the Scottish National Blood Transfusion Service. SNBTS is responsible for the recruitment of blood donors, the collection and processing of whole blood and the testing, labelling and distribution of blood components to hospital transfusion laboratories.

The hospital transfusion laboratory is responsible for the storage and inventory management of blood components, pre-transfusion testing of patient samples and issue of compatible blood components to named patients.

• Pre-transfusion testing, compatibility testing, antenatal and postnatal testing are carried out in the NHS Borders Transfusion Laboratory.
• The storage and inventory management of blood and blood components for patients in NHS Borders is the responsibility of Boards Hospital Transfusion Laboratory 01896 826248

The NHS Borders Hospital Transfusion Committee has the oversight for safe clinical transfusion practice in NHS Borders.

The blood transfusion service for the whole of NHS Borders is provided by the Hospital Transfusion Laboratory (HTL) located in the Laboratory Department in Borders General Hospital.

Please remember that early and courteous communication with the transfusion laboratory staff will result in prompt and high quality care for the patient.

Biomedical Scientists are highly trained and skilled practitioners who have considerable expertise.

Clinical and Laboratory transfusion practice is overseen by  the  Hospital  Transfusion  Committee. This is a multi-disciplinary group, with representatives of blood user specialties, whose existence is mandated by the Scottish Executive. It reports to the Chief Executive via the local group for Clinical Governance, and has an important role in transfusion governance, and in improving transfusion practice.

 The Hospital Transfusion Team (HTT) comprises subject matter experts from clinical and laboratory transfusion background. Transfusion advice relating to technical matters is available from Biomedical Science (BMS) staff in the hospital transfusion laboratory while clinical advice can be obtained from a Haematologist (who can be contacted via switchboard) or the Hospital Transfusion Practitioner (helen.adams2@nhs.scot)

 The policy is distributed to all internal stakeholders within NHS Borders. NHS Borders Transfusion Committee members will initiate the  cascade and the distribution  of the  protocol to clinical areas. It  is the responsibility of  the individual Heads  of  Clinical Services and Senior Sisters/Charge Nurses    to oversee the distribution of the policy  within their  own  departments/services and to keep  a record of the document holders for updates and distribution.

There are three key principles of safe blood administration and they will be referred to throughout this policy

1. Correct patient identification (ID)
2. Clear, accurate and timely documentation
3. Good communication

The blood transfusion process is complex with the following ten distinct stages identified.

1. Consent for transfusion
2. Request of the test or blood component for transfusion noting any specific requirements
3. Collecting the blood sample for pre-transfusion testing including positive patient ID and correct sample labelling
4. Sample receipt by the testing laboratory including checking the suitability of the sample for testing and booking into the laboratory information management system
5. Testing the sample in the laboratory and issuing a result for the patient clinical record
6. Component selection based on clinical request and results of testing
7. Labelling of component as compatible with/suitable for transfusion to a named patient
8. Collection of the blood component for a named patient using documentation with full patient ID
9. Authorisation of the blood component by a doctor or trained and competent non-medical authoriser of blood components to include any specific requirements
10. Administration of the blood component after rigorous bedside checks + monitoring of the patient before, during and after the transfusion

It is the responsibility of the registered practitioner, in line with their professional body,  to ensure   that they are trained and competent to participate in any part of the transfusion process relevant to  their role.

Before taking on any transfusion task clinical staff MUST complete mandatory Learn Blood Transfusion: Safe Transfusion Practice accessible via Learnpro and/or TURAS Learn available at https://learn.nes.nhs.scot/ there is additional role based training, which can be found in appendix 1 training matrix for additional mandatory / suggested appropriate to role.

Staff involved in transfusion need to be vigilant at each step in the transfusion process, particularly where patient identification is involved.

The patient must be wearing a patient ID band when they are being transfused regardless of location.

The five core patient identifiers that must be included on their ID band are:

1. First name
2. Last name
3. Date of birth
4. Community Health Index (CHI)number
5. Sex

The patient's ID band must match the information on all transfusion documentation exactly

Positive Patient Identification

Patients with capacity must be asked to identify themselves.  Positive Patient Identification requires  the patient to give their full name and date of birth.  In circumstances where patients do not have capacity, use the ID band, and, if present a relative may be asked.

The Unidentified (Unknown) Patient

If a patient is admitted unconscious and their identity is unknown, the following procedure must be followed if blood transfusion is necessary:

• The patient must be allocated a unique identification number ( Using a temporary Borders number TB).
• The minimum identifying dataset must include this number plus Unknown
• Unknown as patient name and include sex (M/F) 
• A patient identification band including this minimum data must be attached to the patient.
• This dataset must be used on sample tubes and request forms for transfusion until additional identification details become available.
• When additional identification details become available, the hospital transfusion laboratory must be informed.

All transfusions MUST be authorised in the transfusion record, which must be completed in full, and kept at the bedside during the transfusion then filed in the patient's notesof the health records after transfusion completed.

The outcome of the transfusion including any adverse events/reactions must be recorded in the patient health records.

The British Society for Haematology and Quality Improvement Scotland Clinical Standards Blood Transfusion 2006 now known as NHS Healthcare Improvement Scotland (NHSHIS) stated that all staff involved in any part of the transfusion process must receive regular and adequate training.

Any member of staff that takes part in any aspect of transfusion MUST have valid transfusion training

Transfusion training incorporates the following:

• Haemovigilance
• Authorising blood components
• ABO serology
• Consent
• Blood sampling
• Blood component collection
• Blood component administration
• Caring for the patient receiving a transfusion

ALL staff involved in the transfusion process must complete, as a minimum, the Learn blood transfusion (LBT): safe transfusion practice module or the equivalent module appropriate to role (i.e. LBT: safe transfusion practice for paediatrics or LBT: safe transfusion laboratory practice).

Designated LBT: phlebotomy and LBT: blood collection pathways are available for staff that are only involved in the sampling and blood collection procedures respectively.

Additionally, the SNBTS Transfusion Team training matrix (appendix 1) aligned to roles provides further guidance on appropriate theory based modules for staff to enhance their knowledge and understanding of transfusion practice as appropriate to role. All modules can be accessed via NHS Learnpro available at https://nhs.learnprouk.com/or TURAS Learn available athttps://learn.nes.nhs.scot/

If you do not have valid transfusion education for your job role, then you must not participate in transfusion practice.There is an additional legal requirement under the Blood Safety Quality Regulations (2005) for all staff involved in the blood collection procedure to undertake a formal practical competency assessment by a trained assessor who has been trained in the Trainers & Assessor Accreditation Programme (TAAP) or Blood Component Collection Assessors Programme (BCCAP). If an assessor has not undertaken any assessments in a period of one year; or is involved in a near miss or adverse event BCCAP training will require to be repeated.   Contact your local Transfusion Practitioner for further advice if appropriate and relevant to role.

Undergraduate students (nursing, midwifery, medical, operating department practitioners and physician associates) can participate, if appropriate, in procedures aligned to their roles which will provide a learning opportunity to develop the knowledge and skills required upon graduation and preparation for practice as a newly qualified practitioner.

Role specific involvement is detailed in appendix 2. Undergraduate students must provide evidence of learning in both theory and clinical skills simulation for roles aligned to the transfusion process and be supervised as per local regional agreements with Higher Education Institutes and NHSS Boards. For local information access practice supervisors and practice assessors page of relevant Higher Education Institute which will detail the clinical skills guidelines or contact local Practice Education Facilitator. Overall accountability and responsibility for undergraduate involvement in the transfusion process on practice placements is the responsibility of the registrant involved in practice supervision and assessment.

All students must provide evidence of safely demonstrating  proficiency at the point  of registration  for the delivery of person-centered, safe and effective care.

If you do not have transfusion competency, then you must not practice transfusion.

Transfusion Disclaimer

If you have no role in transfusion in your place of work, you may sign a disclaimer form. This form  is available from the transfusion practitioner

Face to face practical competency assessment is required for all those who are going to be involved in collecting blood components; theoretical assessment satisfies the requirement for ongoing competency demonstration thereafter.

Therefore, practical assessment should only be undertaken once for staff and revalidated when a staff member has not collected blood for a period of a year or more, or if the individual has been involved in a near miss or adverse event. This is in line with the BSQR 2005 and follows the MHRA Blood Consultative Committee guidance 2008 which states that practice must be "commensurate with the level of risk associated with it".

Theoretical education (LBT: Safe Transfusion Practice) is completed every 2 years.

Decision to transfuse must be made by assessing all the risks and benefits of transfusion.

Clinicians should base their decision to transfuse on the patient's complete clinical picture. This includes an appropriate trigger for transfusion combined with an assessment of severity of symptoms related to the anaemia, thrombocytopenia or coagulation defect or expected adverse outcome if the blood component is not given (see appendix 4).

It is essential, in order to maintain patient safety, to transfuse patients when medically necessary and not to delay transfusing when it is clinically indicated. Patients have a right to refuse transfusion, however they must be given a complete clinical picture to enable them to make an informed decision.

Other treatment options should be considered. Alternatives to Blood Transfusion should be implemented on an individual patient basis. (NICE Guidelines for Transfusion 2015)

Every patient has a right to be treated with respect and have their concerns addressed.

Standardised information on risks and benefits of transfusion should be available to any patient considering a transfusion and to patients where a transfusion has been given in an emergency, after the event

The information should be accessible and where necessary translated. It should be used to inform the patient about the following issues and hence guide shared decision making. Patients should be encouraged to ask questions.

• The reason for transfusion of blood components
• The risks and benefits of transfusion
• The transfusion process
• Any transfusion needs specific to the patient. Any alternatives that are available
• That the patient has the option to refuse
• The patient will no longer be eligible to donate blood

To document understanding it is good practice to get the patient to repeat the information that they been given in their own words. Use teach back approach to ensure that the patient has understood the information provided. The teach-back method allows you to better assess your patients understanding of their clinical condition and plan of care.  It allows you to uncover and clarify any misunderstandings patients may have. It also helps the clinician and patient engage in a more collaborative relationship.

Please refer to NHS Borders Policy for the treatment of patients who refuse transfusion of blood and blood products and NHS Borders Policy for the treatment of Obstetric patients who refuse transfusion of blood and blood products for further information.

Informed consent for transfusion is necessary in all elective situations.  Additionally, a record of the conversation with the patient should be documented in the patient's health records.

Ensure the patient has a Patient Information Leaflet given to them.

https://www.nss.nhs.scot/media/2059/receiving-a-blood-transfusion.pdf

Patients on regular transfusion programmes do not require consent to be documented for every transfusion after the initial discussion but consent should be reviewed periodically. This is clarified in the 2020 SaBTO Consent guidance.

The Blood Transfusion Prescribing Guidelines is a resource for guidance for clinical staff on the decision to transfuse (see appendix 4)

For neonates transfusion trigger please refer to appendix 5.

Blood components must be authorised in the Transfusion Record by a member of medical staff or designated Non-Medical Authoriser of blood components

Text must be clearly written and unambiguous.

The authoriser must complete in full the following sections:

• Patient details (surname, forename, date of birth, CHI number and gender)
• Consent
• Risk assessment for transfusion associated circulatory overload (TACO)
• Which blood components are required and when
• Any specific requirements
• Transfusion of components (rate of transfusion should not exceed 4 hours from removal from controlled storage.)

When authorising red cells (and platelets) authorisers should consider transfusion of a single unit for non-bleeding patients and reassess after each unit.

All transfusion requests must be appropriate, accurate and specific.

• A request for a group and screen means that pre-transfusion testing will be performed but no blood will be issued
• A request for blood or blood components means that the sample will be tested and blood issued for the patient, based on the urgency denoted on the request form
• To convert a Group and Screen to a request for blood or blood components contact the transfusion laboratory to see if they have a valid sample.
• If there is no historic blood group on record, it will be necessary to send an additional sample to confirm the patient's blood group prior to issuing blood or components. Please contact the transfusion laboratory to check whether an additional sample is required.

Routine Request: Date, time, number of units and location of transfusion will always be required; this will usually take between 1-2  hours to provide a compatible component.

Urgent Request: Blood or blood component required as a priority, contact laboratory to advise.

Emergency Request: Requests for emergency transfusion support should include a phone call to the hospital transfusion laboratory advising them of the situation. (For Major Haemorrhage Activation phone 2222) Follow NHS Borders Major Haemorrhage policy.

Neonates: Request for infants less than 4 months old should include the full maternal and baby details i.e. surname, forename(s), date of birth gender and CHI. on the request form to enable lab to link records. Neonate must receive red cells that are ABO compatible with both mother and baby. A maternal group and screen sample will also be required to ensure compatability of units to any maternal antibodies.

Specific Requirements: For example, does the patient require irradiated components,  phenotyped blood or CMV negative. In addition to asking the patient, check the case notes for  a transfusion history and transfusion alerts on TRAK. Specifically, for evidence of previous transfusion reactions, presence of alloantibodies, and evidence of any previous specific requirements. This is only for routine  non-urgent  requests  for blood; however, this should be checked in all cases where possible.

In emergency situations, concessionary release of blood components or blood products is sometimes the necessary and appropriate course of action in the best interest of patients.

Examples include:

1. Use of D positive blood for a D negative patient who would normally be excluded from receiving D positive units.
2. Use of antigen positive or un-typed red cells in patients with atypical red cell antibodies.
3. Issue of red cells to patients with AIHA without the necessary exclusion of underlying antibodies. This is the only circumstance where ‘least incompatible’ red cells might be the best option.
4. Issue of components that do not meet known special requirements, e.g. CMV negative or irradiated.

To transfuse a blood component that does not fully meet patient’s specific requirements prior to authorisation, a Haematologist will discuss the clinical consequences with the clinicians in charge of the patient, as soon as possible when practical after the event.

The laboratory will contact the Haematology Consultant and clinical area when a concessionary release may be required.  The concessionary release form will be sent to the clinical area with the non-conforming unit for signature by the medical officer.

A request to the transfusion laboratory for grouping and/or compatibility testing and to request blood components must be made on a blood transfusion request form (appendix 3), which contains the following information for identification. Registered nurses/midwives or medical staff can request pre- transfusion testing.

The request form should include the following information:

• The patient's forename (no abbreviations), surname, date of birth, CHI (Community Health Index) number or TB number
• Location and clinical details.
• Signature and details of the person making the transfusion request and the date and time the sample was taken, plus the signature of person taking the sample if different.
• An indication of urgency and any specific transfusion requirements must be documented. Urgent requests should be discussed with the Transfusion laboratory on X26248 or on call duty BMS bleep 6247 or via switchboard.
• Samples taken in the community should specify where and when the patient will attend for transfusion.
• Current pregnancy or pregnant within the preceding three months
• Administration of anti-D in the previous 12 weeks
• Known haemoglobinoathy
• Drugs which may interfere with compatibility testing such as Daratumumab Any transfusion in the last three months
• Provide a clear and unambiguous reason for transfusion and relevant co-morbidities. Terms such as pre-op are not acceptable.
• Where blood is definitely required, the number of units, date and time required should be clearly stated on the request form. If group and screen sample has previously been sent please contact the transfusion laboratory on X26248 for advice on conversion to a cross match/issue of units.
• For elective surgical patients, please refer to the NHS Borders Maximum Surgical Blood Ordering Schedule (MSBOS) which is evidenced-based on local blood usage and practice

All information should be unambiguous and written clearly or an addressograph label can be attached to the request form. However, the sample tube must be handwritten.

A transfusion sample tube must accompany the signed request form. Please ensure sample tube expiry date is valid before taking sample.

It is the responsibility of the person completing the request form to fully complete all details on the request form including the need for any specific requirements e.g. irradiated cells. ALL details must be correctly completed on the sample tube and request form.

The person who takes the blood sample MUST sign the sample tube.  The person who takes the sample MUST also sign the form even if they are the same person that has completed the request form.

The sample tube and form MUST arrive in the transfusion laboratory together. Incomplete or missing details on the form or the sample tube will result in the sample being rejected. Repeat samples and forms will then have to be requested.

In the event of a national blood shortage please refer to the NHS Borders Emergency Blood Management Plan

Only staff who are trained and competent in the pre-transfusion sampling procedure can participate.  Clinical staff must complete the NHS Borders venepuncture training programme before participating in the sampling procedure. Supervised practice as part of the programme includes transfusion sampling and competency sign off. Clinical staff are required to complete theory based learning (LBT: Safe Transfusion Practice or LBT: Phlebotomy pathway) appropriate to role as a pre-requisite to attending the NHS Borders Venepuncture programme.

Phlebotomy staff must complete the phlebotomy training programme which includes theory and practical based learning prior to competency sign off.

The following procedure MUST be followed every time a blood sample is taken for pre-transfusion compatibility testing:

• The request form should be completed BEFORE the blood sample is taken.
• The patient must be asked to positively identify themselves by giving their full name (first and last name) and date of birth prior to being bled.
• This must be checked against the details on the request form and, for in-patients, what is on the patient ID band. All in-patients including day case patients must wear a patient ID band or an alternative risk assessed identification device.
• Identity must not be assumed even for 'familiar' patients who are regular attendees or long-standing in-patients.
• See section 4.2 for patients who are unable to identify themselves
• The full name and date of birth stated by the patient must EXACTLY MATCH the patient's Identification wristband or equivalent, and the information on the request form. If there is any doubt, the patient should be asked to spell out their name to the individual taking the blood sample.
• The patient's blood sample should be drawn into a 7.5ml EDTA transfusion sample tube (check tube expiry date prior to taking sample).
• Once blood has been drawn, label the tube by hand with the minimum identifiers whilst still at the patient's bedside taking details from patient's ID wristband:
  • Surname
  • Forename
  • Date of Birth
  • CHI number or other acceptable unique identifier (TB Number for unidentified patient)
• Pre-labelling of tubes is extremely dangerous and must be avoided.
• Addressograph labels on the sample tube will NOT be accepted        the sample must be labelled by hand at the bedside after blood is drawn into the sample tube.
• Always label the sample fully BEFORE moving on to take blood from another patient. Complete sampling procedure and send sample to laboratory before moving to next patient  The person taking the sample must sign the sample tube
• The person taking the sample must be satisfied that the identity of the patient matches the information on the request form, and the sample tube, and (for in-patients) the patient ID band BEFORE signing the request form and sending the sample to the transfusion laboratory.
• Zero tolerance is in place in the Transfusion Laboratory. Pre-transfusion request forms and samples that do not meet the minimum patient identification data set will be rejected. Evidence shows with any discrepantly labelled samples there is an increased risk of transfusion errors including wrong blood in tube.

If in doubt discard the sample and bleed the patient again

Blood Collection is the only part of the transfusion process for which it is mandatory for the member of staff to be competency assessed. This is a legal requirement as part of the Blood  Safety & Quality Regulations 2005, which are monitored by the Medicine Healthcare Regulatory Agency (MHRA).

The requesting practitioner will request a porter using the porter order request system on the intranet. Should the electronic order system be out of use a porter can be contacted on X1405 (Monday to Friday 9-5pm) or out of hours, bleep General Services on 6059. Staff must inform porters they require blood or blood components to be collected. At no time should patient details be given on the electronic request/phone. Blood components must only be collected and received by a trained, competent and authorised member of staff.  The porter will go to the clinical area generating the collection request and be given a collection slip.

Blood can only be collected against a Blood Collection slip containing all the information outlined below:

• Surname
• Forename
• Date of Birth
• CHI number or other acceptable unique identifier (TB or Major Incident number)
• Details of the component type to be collected.
• Requesting clinical area

Red cell concentrate units are collected from the issue blood bank which is accessed from the theatre corridor on the top floor of BGH. Access to this area is controlled by swipe card and only staff who have been trained and are authorised may gain entry. Other blood components are collected directly from the Transfusion Laboratory.

NHS Borders utilises an electronic blood tracking system. Only trained and competency assessed blood collectors have access to the system which controls the locks on the blood bank doors.

The following collection procedure must be followed:

• Using the electronic blood tracking system the patient's CHI barcode on the collection slip is scanned in to the kiosk. The patient identification data will display on the screen which the collector should check against the collection slip before proceeding.
• The blood bank lock will then release and allow the collector to remove the required unit of blood/component.
• The donation number of the unit will then be scanned in to the kiosk, where an electronic check that the correct unit has been removed will take place before allowing the collector to complete the collection.
• Please note: blood must not be removed from the blood issue fridge without scanning the unit via the electronic system.
• The collection slip must contain the patient's core identifiers and these details must be checked against the details on the laboratory-generated compatibility label attached to the blood component pack (appendix 7).
• Check that it is the correct component type and component expiry date.
• For each component, the date, time and identification of staff collecting must be recorded. The component should be delivered directly to the clinical area.
• Blood transport boxes will be used at all times. PLEASE NOTE: transport boxes are for transportation purposes only and are not for storage of blood or blood components
• Upon receipt in the clinical area check that the correct blood component has been delivered, and record the date and time it arrived.
• On delivery of blood to requesting clinical area, a signature, date and time is required from registered nurse receiving unit. The blood collection slip is filed on the mount sheet of the Transfusion Record to provide evidence related to the cold chain audit and will be retained as part of the NHS Borders Completion of Health Records Policy
• For transfusion in community hospitals, blood will be transported and stored in an authorised storage box validated for 8 hours. For collection of blood from the storage boxes in community hospitals, a blood collection slip must also be completed and the steps to ensure positive patient identification must be followed.

For all other components (platelet, fresh frozen palsma, cryoprecipitate), BMS staff will check the collection slip for patient identification and component type and locate the blood component. The electronic blood tracking kiosk in the blood transfusion laboratory will be used by the collector, following the same procedure listed above.

Emergency blood collection

In emergency situations it may be necessary to collect the emergency uncrossmatched O Rh (D) Negative blood that is not specifically prepared for the patient concerned. The issue of emergency stock must be controlled and documented, so that patient safety and audit trails are not compromised. Please inform the transfusion laboratory if emergency O negatives are taken from the blood bank. To assist traceability, ward staff must complete the patient's full name, DOB and CHI number on the blue tag, along with date and time transfused, before returning to transfusion laboratory.

In the event of a major haemorrhage event occurring in a Community Hospital, the patient must be transferred as an emergency to the Emergency Department (ED) department at the Borders General Hospital.

See also NHS Borders Major Haemorrhage Protocol and Major Emergency Procedure Manual

Transfer of blood to another hospital with patient

Any patient being transferred to another hospital with blood cover must have blood and any components transported in a validated transfer box. It is critical a member of the clinical team contacts the Blood Transfusion Laboratory on X26248 or bleep 6247 (out of hours) to discuss the transfer. Additionally, any units which have already been collected and delivered to the clinical area must be returned back to the Transfusion Laboratory to be packed in a validated transport box.

Returning units

Transfusion should commence within 30 minutes of removal from the blood fridge and MUST be completed within 4 hours from the time of removal. If transfusion is delayed for any reason blood must be returned to the blood issue fridge within 30 minutes from the time of removal.

Blood returned to blood fridge after the 30 minute time period must be discarded by the transfusion laboratory. If unit is scanned electronically, screen will display a prompt if the blood has been out of the fridge for greater than 30 minutes. If the unit is returned after 30 minutes please give the unit to transfusion BMS or place unit in box marked "returned units do not use" in the lowest compartment of the issue blood fridge and contact the Blood Transfusion department immediately on x26248 or bleep 6247 out of hours.

If blood has been out of the fridge for greater than 30 minutes and patient still requires the transfusion the unit may still be given but the transfusion must be completed or stopped within 4 hours of removal from Blood Bank.

In community Hospitals, if blood is removed from the validated storage container, the unit must not be replaced back into storage. Please contact blood transfusion laboratory for further advice on 01896 826248.

If returning platelets FFP or Cryo contact the Blood Transfusion laboratory immediately

All patients receiving blood should be in a clinical area where resuscitation facilities are available. After a blood component has been removed from approved blood storage and taken to the patient's bedside, the following procedure should be adhered to:

• Blood components must be administered by registered medical or nursing/midwifery staff who have undergone appropriate training as per local policy
• All patients receiving blood or blood components must wear a patient ID band (or risk assessed alternative identification device), whether an in-patient or a day patient.

Transfusions at night must proceed where there is a clear clinical indication and where there are sufficient staff to permit safe transfusion, including all required patient observations. There is a greater risk of clinical error at night so if there is no clear clinical indication to transfuse overnight, consideration should be given to deferral of transfusion to the following day.

See appendix 8 for information on Administration sets and equipment used

Use the National Transfusion Record Checklist for each component transfused to ensure the following steps are completed in the right order.

If the checking process is interrupted, the entire process should restart from the beginning.

• Before collecting components check baseline observations Ask patient to state full name  and date of birth and check patient's response matches details on patient ID band.
• Check that the compatibility label information matches the information on the blood product.
• Check component label attached against patient ID band
• Proceed if component label and patient ID band details exactly match. Do not proceed if  any discrepancies and contact the laboratory for advice.
• Put pink sticker on authorisation sheet in transfusion record, ensuring date time and name of member of staff are documented on sticker
• Detach blue tag and complete date time and name of member of staff administering component. Then return blue tag to the laboratory as per hospital policy
• Ensure patient has call bell and knows to inform staff if they feel unwell

Key principle: Observations pulse (P), blood pressure (BP), temperature (T) and respiratory rate (RR) should be undertaken and documented for every unit transfused. Minimum monitoring of the patient receiving a blood transfusion should be strictly adhered to.

Record observations on a National Early Warning System (NEWS) chart and highlight as 'transfusion observations'

The minimum* transfusion observations for each unit are temperature, blood pressure, respiratory rate & pulse at:

• Baseline no more than 60 minutes prior to the start of the unit
• 15 minutes after the start
• Hourly thereafter until the unit is completed *
• At the end of each unit, within 60 minutes of completion of transfusion
• Contact Doctor to review if any significant changes in baseline observations

NB All blood component transfusions must be completed within 4 hours of removal from controlled storage.

In patients of all ages who are incapacitated* it is more difficult to detect signs of early transfusion reactions therefore more frequent observations may be required.    *This includes those who are ventilated, confused, sedated or unconscious

• All patients should be in easy reach of the bedside call bell, asked to inform clinical staff if they are feeling unwell, which might indicate a developing transfusion reaction.
• For patients who are not able to call for help if symptoms arise, consideration should be given to nursing them in an appropriate area where they can be readily observed rather than a side room, or performing observations more frequently.
• Once a blood component transfusion has commenced, it is highly recommended that the patient remain in the same clinical area until the component has been fullytransfused. Exceptions would be in a critically ill bleeding patient.
• All in-patients should continue to be observed for signs of a transfusion reaction for the 24 hours following transfusion.

On completion of the transfusion all component bags should be disposed as per hospital policy in the clinical waste. Administration sets must be disposed in appropriate clinical waste bin. All sharps must be disposed of in sharps bin.

Ensure that the pink adhesive traceability label has been completed and secured to the Blood Transfusion Record and that the completed blue traceability tag has been returned to the transfusion laboratory.

Ensure that the time the transfusion was completed is documented in the Blood Transfusion record.

Upon completion of the transfusion, ensure the Blood Transfusion Record is fully completed before filing in the patient's health record.

Record in the patient's health record whether or not the transfusion achieved the desired effect, along with the management and outcome of any transfusion reactions or adverse events.

At discharge, ensure the patient and the patient's GP are informed that the patient has received a transfusion, and therefore no longer eligible to donate blood.

Please refer to flowchart in the Transfusion Record inpatient, day patient and neonatal on the initial management of a suspected acute transfusion reaction as a quick reference guide.

Any adverse reaction experienced by a patient in association with a transfusion should be considered as a possible transfusion reaction. If any concern re-transfusion reaction, transfusion should be stopped and patient immediately assessed. The most commonly observed reactions are volume overload and allergic reactions. Severe transfusion reactions are usually as a consequence of anaphylaxis, haemolysis due to red cell incompatibility or septic shock.

When a transfusion reaction is suspected, stop the transfusion, inform medical staff and assess the patient's Temp, pulse, blood pressure, oxygen saturations. Temp rise <2 degrees and no other features of concern give paracetamol and consider restarting transfusion at slower rate.

Rash/pruritits and no other features of concern then IV chlorpheniramine 10mg should be given.

Common complications and mild transfusion reactions include:

• Fever (up to 2 degrees C above baseline temperature)
• Symptoms/signs of allergy - Urticaria, pruritis, rash
• Fluid overload

PLEASE NOTE: pyrexia may be the only signs of an acute transfusion reaction.

If symptoms progress then management should be as for a suspected severe acute transfusion reaction.

Severe life-threatening complications of transfusion include:

Acute haemolytic transfusion reaction* (due to ABO incompatibility or atypical RBC antibodies) Infusion of bacterially contaminated unit*

Transfusion associated lung injury* (TRALI) develops within 6 hours of the transfusion Severe allergic reaction or anaphylaxis*

Transfusion Associated Circulatory Overload (TACO)

Signs and symptoms of severe acute reactions include:

• Collapse*
• Feeling of apprehension/agitation
• Flushing
• Pain at cannula site* Loin pain*
• Hypotension/hypertension* Tachycardia
• Breathlessness, wheezing or respiratory distress*  Pyrexia
• Urticaria Pruritus
• Uncontrollable bleeding (oozing from wounds or puncture sites)*
• Haematuria*

*In community Hospitals if a patient experiences an acute life-threatening event, suspected acute severe reaction or associated signs and symptoms (marked with an * above) urgent transfer may be required to Borders General Hospital. Dial 999, covering GP and on call Consultant Haematologist, transferring patient immediately to Accident & Emergency Department, Borders General Hospital.

In the event of a suspected anaphylaxis please refer to the NHS Borders Guidelines for the administration of adrenaline (epinephrine).

Please ensure Epinephrine is administered as a priority and prior to transfer to BGH.

PLEASE NOTE: Only staff who have received appropriate training can activate and implement the NHS Borders Guidelines for the administration of adrenaline (epinephrine).

A GP must assess all patients with a suspected transfusion related adverse event regardless of   how mild. For day patients attending for a transfusion who experience mild complications, a GP must assess the patient prior to discharge. Advice must be provided on the signs and symptoms of a delayed transfusion reaction with contact details for further advice. If any day patient requires admission to hospital following a suspected transfusion reaction, please report event on Datix.

Please follow procedure below on the management of suspected transfusion reactions for all patients.

If a severe transfusion reaction is suspected, the following actions must be taken:

• Stop transfusion immediately
• Repeat final bedside checks (check patient and component compatibility)
• Change blood administration set, keep IV access patent with slow 0.9% saline
• Repeat systemic observations, temperature, pulse, blood pressure, respiratory rate, oxygen saturation level. Follow SIR protocol.
• Contact medical team immediately and have patient assessed
• Instigate specific management depending on nature of reaction eg anaphylaxis Contact on call Haematologist for further advice as required
• Contact blood transfusion laboratory
• Return unit with administration set intact immediately to transfusion  laboratory
• Complete NHS Borders Transfusion Reaction Investigation Form and return to transfusion laboratory with appropriate samples and any remaining units in the clinical area

The following blood samples from the recipient are required:

• FBC and coagulation screen (Red and Green tubes)
• Blood transfusion sample (large red tube)
• Blood cultures - Central and peripheral (Blood culture bottles)
• U&Es and LFTs including LDH (Brown Tube)

The Hospital Transfusion team are legally required to report any serious adverse events or serious adverse reactions associated with transfusion of blood and blood components to the Serious Adverse Blood Reactions and Events (SABRE) scheme governed by the MHRA. Additionally all clinical incidents and near miss events are required to be reported to the Serious Hazards of Transfusion (SHOT) haemovigilance scheme.

If you are involved in any clinical incidents, near miss events or a patient has suffered a suspected transfusion reaction please report via the Datix reporting system under 'transfusion related event'.  All incidents will be reviewed by the transfusion team.

Please refer to the Transfusion Record for further advice and guidance. Additionally, refer to the NHS Borders Incident Management Policy

Appendix 1  SNBTSTT - Training Matrix

Appendix 2  Roles & Responsibilities

Appendix 3  Sampling Policy & local Blood Transfusion Request Form

Appendix 4  Triggers and Transfusion Rates

Appendix 5  Neonatal Transfusion

Appendix 6  Specific Requirements

Appendix 7  Blood Collection Flow Chart

Appendix 8  Blood Bag Label Traceability

Appendix 9  Equipment - Blood Warner, Infusion Devices

Appendix 10 Avoiding Delays in Transfusion Advice

1. Major Haemorrhage Policy
2. Management of Major Obstetric Haemorrhage
3. Refusal of blood/ Obstetric Refusal of Blood
4. Provision of Specific Requirements of Blood and Blood Componenets
5. Emergency Blood Management Arrangement (EBMA)
6. Anti-D immunglobulin administration for the prophylaxis of maternal Anti-D sensitisation
7. Non-Medical authorisation of blood componenets
8. Beriplex/reversal of warfarin
9. Maximum Surgical Blood Ordering Schedule (MSBOS)