Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [198], C).
2. 2.Show
   Check that the component has a correct written instruction, including any special requirements such as irradiated or cytomegalovirus (CMV)‐negative blood, and if the patient requires any other medications, for example diuretic or premedication.
   To prevent incorrect blood component transfused (IBCT) error and transfusion‐associated circulatory overload (TACO): ABO incompatibility or non‐irradiated CMV‐positive products may cause a fatal reaction if transfused (Bolton‐Maggs [27], C; Robinson et al. [236], C).
3. 3.Show
   Check that the patient's baseline vital signs, temperature, pulse, blood pressure and respirations have been recorded within 60 minutes prior to the start of the transfusion.
   To ensure that any transfusion reaction can be immediately identified due to changes from the baseline. E

   To ensure any such reaction can be managed appropriately (Robinson et al. [236], C).
4. 4.Show
   Conduct a visual inspection of the component to be used for signs of clumping, discolouration, damage or leaks.
   Expired or damaged products can cause patient harm and must not be used (Robinson et al. [236], E).
5. 5.Show
   If there are any discrepancies at this point, do not proceed until they have been resolved.
   To ensure an IBCT event does not occur (Bolton‐Maggs [27], C).
6. 6.Show
   Positively identify the patient by asking them to state the following information:

   • first name
   • surname
   • date of birth.

   If the patient is unable to positively identify themselves, verification can be given by a carer or relative. This information must match the identity band exactly.
   This is the final check of identity, which must be performed next to the patient prior to transfusion and is absolutely vital in minimizing the risk of IBCT errors (Robinson et al. [236], C; SNBTS [261], C).
7. 7.Show
   Check the details given against the patient's identity band and the patient details on the blood component (see Figure 12.79).
   To minimize the risk of giving the wrong blood to the patient (SNBTS [261], C).
8. 8.Show
   Check that the information on the compatibility label matches the details on the blood component, checking expiry date, unique component donation number and blood group on the component label against the laboratory‐produced label. Check any special requirements have been met. If there are any interruptions during the checking procedure, the entire process should be restarted from the beginning.
   To minimize the risk of error (Robinson et al. [236], C).
9. 9.Show
   If there are any discrepancies at any point during the bedside check, do not proceed until they have been resolved.
   To ensure an IBCT event does not occur (Bolton‐Maggs [27], C).

Procedure

1. 10.Show
   Prime the set with the blood or blood components, unless there are concerns about the patency of the device, in which case prime with 0.9% sodium chloride.
   Other agents may damage the product components and precipitate transfusion complications (SNBTS [261], C). For example, dextrose should never be used to prime a set or flush the blood administration set following a transfusion as this can cause haemolysis (SNBTS [261], C).
2. 11.Show
   Set up the infusion either via gravity or via an infusion pump if appropriate. Check the infusion pump is appropriate for the administration of blood and blood components.
   Some older infusion pumps can damage the red cells; check the manufacturer's instructions. Blood administration sets for specific infusion pumps must always be used. If none are available, the standard blood administration set should be used via gravity and the rate monitored as necessary. E
3. 12.Show
   Set the desired infusion rate as indicated by the blood component being used and the patient's condition. Monitor to ensure the expected volume is given at the correct rate.
   The rate of administration is indicated by the patient's clinical condition (Norfolk [202], E; Robinson et al. [236], C).
   Either:
    
   Red cell administration can range from 5 to 10 minutes in acute blood loss and must be completed within a maximum of 4 hours of removal from storage. Typical transfusion time is 90–120 minutes in patients who are not at risk of TACO (Norfolk [202], Robinson et al. [236]).
   To minimize the risk of bacterial growth and transfusion‐transmitted infection (Norfolk [202], E; Robinson et al. [236], C).
   Or:
    
   Platelets, fresh frozen plasma and cryoprecipitate should be transfused over 30–60 minutes, with the process completed within 4 hours of removal from temperature‐controlled storage.
   To ensure the patient receives the optimum benefit from the component. E
4. 13.Show
   Sign the written order (‘prescription’) as the person administering the component. The unique component donation number, date and start time should be recorded in the patient's clinical notes.
   To ensure that documentation and traceability requirements are met (BSQR [34], C; Norfolk [202], E; Robinson et al. [236], C).
5. 14.Show
   Fifteen minutes after the commencement of each component, take and record patient observations – blood pressure, temperature, pulse and respiratory rate. Follow local hospital policy regarding how observations are documented, but they should be easily identifiable as being related to the transfusion.
   Adverse reactions will often occur during the first 15 minutes of transfusion (Tinegate et al. [270], C). Complaints of serious anxiety, transfusion site pain, loin pain, backache, fever, skin flushing or urticaria could be indicative of a serious transfusion reaction (NICE [190], C; Norfolk [202], E; Robinson et al. [236], C; Tinegate et al. [270], C).
6. 15.Show
   Observe and monitor the patient throughout the transfusion episode. If there are any concerns, undertake additional observations as appropriate. If there are any signs or symptoms of a transfusion reaction, the transfusion should be stopped immediately and urgent medical advice sought (see Box 12.11).
   To monitor for any adverse reactions (Norfolk [202], E; Robinson et al. [236], C; Tinegate et al. [270], E).
7. 16.Show
   Record the finish time of each unit. All units must be completed within 4 hours of removal from storage.
   To minimize the risk of a bacterial transmission (Norfolk [202], E).
8. 17.Show
   Take and record the patient's observations on completion of each unit, ensuring that post‐transfusion observations are performed within 60 minutes of completion of the unit.
   To ensure the patient's progress is recorded, to detect delayed reactions and act as a baseline for subsequent units (Robinson et al. [236], C).

Post‐procedure

1. 18.Show
   Record the time the transfusion finished and the volume of the component transfused on the patient's fluid balance chart.
   To ensure an accurate record of fluid is maintained as fluid balance monitoring can identify fluid overload in at‐risk patients (Bolton‐Maggs [27], E).
2. 19.Show
   Carefully file all transfusion documentation in the patient's clinical record. In line with local policy, return information on the final fate of each blood component to the hospital transfusion laboratory.
   To ensure the transfusion episode has been recorded, maintaining the clinical record for patient safety. To comply with the Blood Safety and Quality Regulations ([34], C), which specify that the final fate of all blood components must be held for 30 years.
3. 20.Show
   Return any unused blood components to the laboratory promptly, preferably within 30 minutes.
   To allow unused components to be reallocated if returned in time. Refer to local guidelines. E
4. 21.Show
   If there is any suspicion of a transfusion reaction, return the pack to the transfusion laboratory with full clinical details. If the transfusion is completed uneventfully, dispose of the empty pack and administration set according to local policy.
   To ensure transfused bags are available for laboratory tests and investigation (Tinegate et al. [270], C).
5. 22.Show
   For patients receiving ongoing transfusion support, the blood administration set should be changed at least every 12 hours or in accordance with the manufacturer's instructions. Dispose of the used set in the clinical waste: refer to local guidelines and protocols.
   To minimize the risk of bacterial contamination (Robinson et al. [236], C).