Pre‐procedure

ActionRationale

1. 1.Show
   Explain and provide written information about the apheresis procedure.
   To ensure the patient or donor is properly informed about the procedure (DH [28], C; NMC [86], C).
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   Check that written informed consent has been taken and re‐confirmed and that the patient has a good understanding of the procedure.
   To enable patients or donors to actively participate in and comply with their treatment (FACT‐JACIE [40], C; Human Tissue Authority [56], C; NMC [86], C).
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   Check that all documentation, which may vary according to local policy and also procedure type, is complete.
   To maintain accurate records and comply with regulatory policy (FACT‐JACIE [40], C; Human Tissue Authority [56], C; NMC [86], C).
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   Ensure the patient or donor is wearing a wristband correctly labelled with their name, hospital number and date of birth.
   To prevent patient safety incidents and near misses relating to missing or incorrect wristbands (FACT‐JACIE [40], C).
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   Check that pertinent serological tests have been carried out within the timeframes stipulated by local and/or regulatory policy.
   To prevent cross‐infection with bloodborne infections (FACT‐JACIE [40], C; Human Tissue Authority [56], C).
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   Consider oral sedation (e.g. lorazepam) for very anxious patients.
   To ensure that the procedure is performed safely and with minimal distress to the patient. E
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   Document which apheresis machine is being used.
   To ensure traceability of procedures and assist in the audit of collection efficiency (FACT‐JACIE [40], C).
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   Obtain and record the patient or donor's biological parameters, for example height, weight and gender, to calculate total blood volume.
   To ensure accurate data input and machine settings. E
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   Obtain and record the patient or donor's baseline observations, for example temperature, pulse rate, blood pressure.
   Subsequent observations can be compared against the baseline to assist in accurately informing the need for intervention if the patient or donor's condition appears to deteriorate during the procedure. E
10. 10.Show
    Check and record pertinent blood results (e.g. haemoglobin, haematocrit, platelet count, white cell differential, blood group, electrolytes, plasma viscosity, haemoglobin S, peripheral CD34‐positive count and clotting). The blood tests required will differ depending on procedure type. Local policy should be followed.
    To ensure accurate data input, machine settings, disease monitoring and patient/donor safety (Human Tissue Authority [56], C; JACIE [61], C).
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    Ensure solutions and drugs needed for the procedure have been prescribed.
    To ensure good medicines management (NMC [85], C).
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    If a central venous catheter has been placed with the tip in the superior vena cava, check the documentation of the catheter tip position prior to use. This should be documented in the medical records after a chest X‐ray.
    High flow rates are required for apheresis so good venous access is essential (FACT‐JACIE [40], C).
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    Check that the apheresis machine has been cleaned and maintained as per local policy. This must be documented.
    Environmental conditions must be controlled for surface contaminants to minimize the risk of contamination or cross‐contamination (FACT‐JACIE [40], C).
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    Prepare the procedure trolley and ensure that all the necessary equipment and specimen containers are readily available.
    To ensure the procedure is performed efficiently and that all the necessary specimens are collected and handled correctly (Smock and Perkins [105], E).
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    Visually examine all reagents used for damage or evidence of contamination prior to use. Note the lot numbers and expiry dates of all reagents. Ensure local incident reporting systems are used if any reagents are not suitable for use.
    To ensure an effective quality management plan is established and maintained and to minimize the risk of contamination or cross‐contamination (FACT‐JACIE [40], C).
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    Select and load the disposable set and reagents. The set will differ depending on what procedure is undertaken and which type of cell separator is used.
    To prepare the apheresis machine prior to connecting the patient and to ensure that it is in good working order (Choi and Foss [22], E; Strauss [106], E; Terumo BCT [109], C)
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    Prime the disposable tubing set with 0.9% sodium chloride and anticoagulant.
    To expel air from the disposable tubing set. E
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    Perform alarm tests and checks.
    To prepare the apheresis machine prior to connecting the patient and to ensure that it is in good working order (Choi and Foss [22], E; Strauss [106], E; Terumo BCT [109], C).
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    If the apheresis machine alarm sounds during the procedure, refer to the troubleshooting section of the operator's manual and follow the relevant instructions.
    To prepare the apheresis machine prior to connecting the patient and to ensure that it is in good working order (Choi and Foss [22], E; Strauss [106], E; Terumo BCT [109], C).
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    Enter the patient or donor's biological parameters and pertinent blood results into the apheresis machine as prompted. Amend settings as required by local policy.
    To customize and optimize the procedure (Choi and Foss [22], E; Strauss [106], E; Terumo BCT [109], C).
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    Document target run results and pertinent information as required by local policy.
    To maintain accurate records (NMC [86], C).
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    Ensure patient privacy by drawing the curtains as per patient preference. A blanket or sheet may be needed if vascular access is via a femoral, percutaneous or tunnelled central venous catheter.
    An environment that facilitates the patient's need for privacy and dignity is essential (NMC [86], C).
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    Assist the patient into the correct position, which is usually the supine position with arms comfortably rested at their sides. The back of the bed or apheresis chair is usually slightly elevated, but this is guided by patient preference.
    To maintain patient comfort and access either peripheral or central venous access devices. E
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    Wash hands and apply gloves. Non‐sterile gloves must be used when handling biological specimens (JACIE [61]).
    To protect the nurse from any contamination (European Commission [39], C).

Procedure

1. 25.Show
   Place the sterile field under the patient's venous access and clean the end of the needlefree connector attached to the vascular access device.
   To maintain asepsis throughout the procedure to minimize the risk of infection (Fraise and Bradley [41], E).
2. 26.Show
   Connect the patient or donor to the apheresis machine via the preselected venous access devices. There must be one lumen for access and one for return of blood. Check that all venous access devices are patent by withdrawing blood and flushing with 10 mL 0.9% sodium chloride. No resistance should be felt.
   High flow rates are required for apheresis so good venous access is essential (NHS Blood and Transplant [83], C).
3. 27.Show
   Proceed with the run as per the operator's manual depending on procedure type.
   To achieve therapeutic or donation targets (Kaushansky et al. [63], E).
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   Monitor the condition of the patient or donor and also the progress of the procedure and intervene as required (see Problem‐solving table 21.6 for troubleshooting).
   To ensure the procedure runs smoothly and the patient or donor is safely managed. E
5. 29.Show
   Dependent on the procedure type, perform a rinseback when the procedure targets have been met. A rinseback is when the cell separator is flushed through with sodium chloride 0.9% to ensure that any blood remaining in the machine is returned to the patient (Burgstaler [18]).
   To ensure accurate fluid balance and haemodynamic stability (Howell et al. [52], C). For this reason, it is unusual to perform a rinseback in, for example, paediatric cases (where a blood prime has been used) or after red cell exchanges for patients with sickle cell disease (Burgstaler [18], E).

Post‐procedure

1. 30.Show
   If undertaking a donation procedure, permanently seal the product bags, preferably by using a heat sealer. As a contingency, three sealing clips closed by clamp may be used.
   To ensure safe handling and protect product from exposure to pathogens (DH [29], C; Loveday et al. [73], C).
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   Take any post‐collection blood sampling, for example full blood count, from the access device prior to removal.
   To monitor cellular loss as a result of the apheresis procedure (Crookston and Novak [26], E) and to make corrections or give advice as necessary.
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   Disconnect the donor/patient from the machine before unloading the pumps and removing the disposable set from the apheresis machine.
   To ensure the safety of the patient/donor. E
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   Dispose of sharps and waste products as per local policy.
   To ensure the safe handling and disposal of needles and other sharp instruments and to protect staff, patients and visitors from exposure to bloodborne pathogens (DH [29], C; HSE [53], C; Loveday et al. [73], C; European Commission [39], C).
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   Inspect the cannulation sites for bleeding. A pressure dressing may be applied over sterile gauze.
   To achieve haemostasis and decrease the risk of infection. E
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   For donation products, label collection bags and complete documentation for release of products from the collection facility. JACIE ([61]) compliant labels and paperwork must be used.
   To ensure correct management of the product (JACIE [61], C).
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   Place the collection bags in a secondary container (e.g. a zip‐type resealable bag) prior to transfer to the appropriate processing facility (for donation procedures).
   To prevent the loss of a portion of the collection, to minimize the potential for post‐collection contamination of the component and to prevent potential spillage of biohazard material in areas where it may pose a risk to employees, visitors or patients (JACIE [61], C).
8. 37.Show
   For donation procedures, transport the collection bags to the appropriate processing facility with the necessary forms and in a JACIE [61] compliant container.
   To allow for cell measurement, storage and/or issue of the donated product. E
9. 38.Show
   Record the necessary information in the appropriate documents as per local policy.
   To maintain accurate records (NMC [86], C).
10. 39.Show
    Ensure post‐donation care is appropriately managed (see ‘Post‐procedural considerations’).
    To ensure the safe management of patients and to enable them to actively participate in and comply with their treatment (NMC [86], C).
11. 40.Show
    Remove the disposable tubing set from the apheresis machine as per the operator's manual and dispose of it in a hazardous waste container.
    To ensure the safe handling and disposal of clinical waste to protect staff, patients and visitors from exposure to bloodborne pathogens (DH [29], C; Loveday et al. [73], C).
12. 41.Show
    Clean the apheresis machine with a suitable decontaminating agent as per local policy (Howell et al. [52])
    To protect staff, patients and visitors from exposure to bloodborne pathogens (JACIE [61], C).