Pediatric/Adult Transfusion Therapy 2009 Annual Review for RNs and other Transfusionists Annual Review for RNs and other Transfusionists* *“Transfusionist” includes Physicians, Licensed Independent Practitioners, Registered Professional Nurses, Clinical Laboratory Technologists, and Cardiovascular Perfusionists. Graduate Nurses (GNs) may transfuse (check and administer) blood only with a Registered Professional Nurse (RN)

Purpose: review of Kaleida Health policy CL.53: Adult/Pediatric Transfusion Therapy for Registered Nurses and other Transfusionists*. The purpose of this activity is to provide a review of Kaleida Health policy CL.53: Adult/Pediatric Transfusion Therapy for Registered Nurses and other Transfusionists*.

Objectives: At the end of this activity the Registered Nurse and other Transfusionists will be able to: 1. List the steps involved in obtaining blood products. 2. Cite the steps involved in checking and administering blood products. 3. Recognize signs and symptoms of common transfusion reactions

The Process Begins The unit is busy, and you are precepting a newly hired nurse. Michael Jones, one of your patients, has an order for the administration of 1 unit of packed red cells. It is your intent to teach the new nurse the correct process.

The Process In order to make sure that no steps are missed, you give a checklist to your new nurse that includes: 1. Check MD order for transfusion and assess patient 2. Obtain informed transfusion consent 3. Draw sample for blood bank testing 4. Obtain blood product 5. Check blood product 6. Administer blood product 7. Document administration of blood product

1. Check MD order and assess patient You instruct the nurse to:  Review the MD order in the patient chart  Assess the patient for: History of previous transfusion reaction Pre-transfusion symptoms that could be confused with a transfusion reaction (ex. fever, chills)

2. Obtain Informed Consent Obtain informed transfusion consent from Mr. Jones prior to issuance of the blood product if the patient is an adult. If Michael is a minor, obtain consent from parent or legal guardian. Informed transfusion consent M. Jones Acceptable consent forms are: Consent for Transfusion of Blood Products (KH ) Authorization for Medical and/or Surgical Consent (KH 00049) You note that there is no transfusion consent form in Mr. Jones’ chart. You guide your nurse to:

3. Draw blood sample for blood bank Blood is needed for a type and cross match, so you instruct your nurse to use standard venipuncture procedure to obtain the sample. Once finished you make sure that the: contains Label on tube for blood bank testing contains the following:  Initials  Initials of person drawing sample  Time  Time sample is drawn  Date  Date sample is drawn, at the bedside. and that the label was placed on tube at the bedside. Initials Time Date

4. Obtaining blood product The Blood Bank notifies you that the unit of packed red blood cells is ready. The new nurse asks who to send to pick it up. You tell the nurse: Who can pick up blood products:  Registered Nurse (RN)  Graduate Nurse (GN)  UAP, PCA You make sure to note that only hospital employees, with the exception of LPNs, are authorized to pick up blood products. You emphasize that the following MAY NOT pick up blood products: Volunteers, Student Nurses, LPNs

4. Obtaining the blood product: At the blood bank Healthcare worker will read and Blood Bank staff will verify the following regarding the patient:  Patient name  Patient identification number  Patient date of birth  Patient blood type Healthcare worker will read and Blood Bank staff will verify the following regarding the blood product:  Unit number  Donor blood type  Unit expiration date Note: only one unit is issued at a time, unless special authorization from the Director of Transfusion Services has been obtained. The nurse decides to pick up the blood himself. You make sure that the nurse knows how to check the unit in the Blood Bank. Your instructions include:

5. Checking the blood product: At the bedside of the patient a. Physician’s order b. Consent c. Blood product with attached Transfusion Record d. Patient with attached ID band e. Vital signs (TPR and BP) Once the nurse returns with the blood, you make sure that just prior to administration, following are checked at the patient’s bedside:

5. Checking blood, at the bedside Blood Unit Tag

5. Checking blood products*: You are careful that the following are checked by two (2) authorized healthcare professionals (LPNs and UAPs may not check blood at the bedside) Patient name, Patient identification number, Patient date of birth, Patient blood type, Donor blood type, Unit expiration, Unit number (* blood products include: Whole blood, packed red cells, plasma, platelets, white blood cells, cryoprecipitate)

5. Checking blood products at the bedside  You and the new nurse compare the information on the blood unit tag against the patient ID band. Pt. name Date of Birth Medical record number

5. Checking blood products: ABO compatibility  ABO and Rh group of the donor MUST match or be compatible with the patient’s information.  You must check blood compatibility table on the back of the transfusion record if information does not match patient’s information  If there are any questions, consult the blood bank. You make sure to emphasize that:

5.Checking Blood Products: Blood group compatibility tables DONOR (Person who has donated blood) RECIPIENT-Whole Blood or PRBC GROUPOABAB OYesNo AYes No BYesNoYesNo ABYes GROUP O= Universal Whole Blood or Red Cell Donor GROUP AB= Universal Whole Blood or Red Cell Recipient GROUP OABAB RECIPIENT-Plasma OYes ANoYesNoYes BNo Yes ABNoNONoYes GROUP O= Universal Plasma Recipient GROUP AB=Universal Plasma Donor DONOR (Person who has donated plasma)

6. Administering blood product In order to transfuse the unit of PRBC, you have the new nurse: Insert a large bore IV Cannula (18-20 gauge is preferred in the adult patient, gauge in pediatric patients.) For PICC or midline catheters: 4 Fr or gauge for adults 3 Fr or 20 gauge for pediatric patients Set up tubing for pump administration (pump required). Emphasize that: Only normal saline (0.9% sodium chloride) may be used No drugs or medications may be infused through same line as blood Pediatric patients, due to their smaller size, are at greater risk for fluid overload.

6. Administering blood products  Infuse blood slowly for the first 15 to 30 minutes, while observing the patient for reactions.  After 15 to 30 minutes, reassess the vital signs and adjust the flow rate to the desired speed. You make sure that the new nurse knows to: Refer to Adult/Pediatric Transfusion Therapy Policy CL.53 Attachment A Blood Product Administration Chart (Adult Patient) Attachment B Blood Product Administration Chart (Pediatric Patient) for specific recommendations regarding blood product, use of filters, infusion instructions, etc.

6. 6. Administering blood products You make certain to check that:  Vital signs were taken (TPR and BP) BEFORE beginning transfusion, and values written on blood unit tag.  Time and date have been indicated  TWO required signatures are in place.

6. Administering Blood Products: Vital Signs You give careful instructions on when to take vital signs: 1. Immediately BEFORE 1. Immediately BEFORE beginning transfusion minutes minutes after start of transfusion completion 3. On completion of transfusion

6. Administering blood product  Warming  Warming: specific physician order required as soon as possible  Blood product must be hung as soon as possible after issuing. If there is a delay in starting the transfusion FOR ANY REASON, the unit must be returned to the Blood Bank within 30 minutes after issuance. MUST BE FINISHED within 4 hours  Transfusions MUST BE FINISHED within 4 hours; if not finished in the 4-hour time limit, unit must be taken down. The nurse has some questions about the process of administering blood. Your answers include the following information:

Safety/Infection Control 6.Administering blood products: Safety/Infection Control  Patient identification MUST BE DONEwith each unit!  Patient identification and comparison to blood unit tag MUST BE DONE with each unit! gloved hands  Handle all blood products with gloved hands  Dispose of biohazard bags  Dispose of empty blood packs and administration sets in biohazard bags.  Tubing changes: after each unit  Tubing changes: after each unit which is not to exceed 4-hours You make sure that the following safety and infection control details are clear:

Transfusion Reaction You explain that if the patient has a transfusion reaction that the Adverse Reactions portion of the Transfusion Record Adverse Reactions portion of the Transfusion Record must be completed:

Transfusion Reaction And you point out that the most common reactions are listed on the back of the blood unit tag:

Transfusion Reaction You make sure that your new nurse understands the steps to take if a transfusion reaction is noted: 1. Stop transfusion, leave IV (0.9% sodium chloride) running 2. Recheck patient information and tag information 3. Notify responsible physician 4. Complete premedication, and volume information 5. Draw blood: 1 pink or lavender tube 6. Send blood sample and unfinished unit to Blood Bank asap. signature, date, and time 7. Make sure that signature, date, and time are on form.

The Process Continued Your new nurse has completed all the steps for a safe transfusion. The patient has tolerated the procedure without reaction Your new nurse has completed all the steps for a safe transfusion. The patient has tolerated the procedure without reaction. final check Make one final check: allvital signs 1. Are all vital signs written in the appropriate spaces? two signatures 2. Are there two signatures in the verification area? date and time 3. Is there a date and time indicated for start and end of transfusion? detach the blood transfusion tag If so, you may now detach the blood transfusion tag, and place it in the medical record.