Transfusion Protocol for Nursing

[Brenda K Hutson]

It was just brought to my attention that Nursing in my current Hospital, only monitors trasfusions at the initial 15 mins. (and after the transfusion). I know for a fact that at other places I have worked, they "closely" watched the patient for the 1st 15 mins.; then took vitals every hour thereafter.

In looking in the Technical Manual, AABB Standards, CAP Checklist, and Circular of Information, I only see a reference as described above. There are "vague" statements about monitoring throughout the tranfusion (such as the recommendation for periodic observations); but I do not find any place where monitoring after the 15 mins. is "mandated;" nor are there any specific time-frames mentioned.

It clearly states that the Medical Director needs to be involved in those decisions so I am assuming this practice is acceptable to him. It is really not acceptable to me, but before I talk with him, I just want to see:

1. What are other places doing

2. Is there some regulatory requirement somewhere that I am just missing,

regarding a required frequency?

As always, THANKS in advance for your input!

Brenda Hutson, CLS(ASCP)SBB

[John C. Staley]

Brenda, I think that you will find most of the protocols for monitoring transfusions come from the nursing side of things. Quite often they can be found in nursing practice guidelines or in state and local regulations. The reason you are not finding anything specific from AABB or CAP etc... it that the actual transfusion is generally not considered part our our world. Why would they write specific guidelines for something we really have little or no control over? The best they can do is make suggestions like, "the Medical Director should be involved in...."

[Brenda K Hutson]

Well, not sure I totally agree with your premise that "the actual transfusion is generally not considered part of our world." But that may just be my bias. I say that because:

1. I cannot tell you how many times in my career a Nurse has called and told of vital signs a

patient is having, wanting to know if that is a Transfusion Reaction (and asked if they should

they call it).

2. One place I worked had the spaces for vital signs (at 15, 30, 1hr, etc) on the Transfusion

Form. One copy of the Form always came back to the BB after transfusion. We would audit

them to make sure vitals were taken at each interval; to make sure the transfusion took place

within 4 hours of Issue; to make sure they noticed vital signs that could be a reaction; et al.

We definitely came across problems in each of these areas.

Nurses may be the ones who know how to give a patient products through the IV, but when it comes to some of the issues of blood compatibility/incompatibility and reactions for blood, they are not always that knowledgeable.

I have given inservices and training to Nurses enough to know that some things they do with blood products are scary! That is also why we audit transfusions. There are any number of things that occur with blood products once they leave our possession, and I for one would like to know what they are.

Brenda

Brenda, I think that you will find most of the protocols for monitoring transfusions come from the nursing side of things. Quite often they can be found in nursing practice guidelines or in state and local regulations. The reason you are not finding anything specific from AABB or CAP etc... it that the actual transfusion is generally not considered part our our world. Why would they write specific guidelines for something we really have little or no control over? The best they can do is make suggestions like, "the Medical Director should be involved in...."

[KKidd]

Well, not sure I totally agree with your premise that "the actual transfusion is generally not considered part of our world." But that may just be my bias. I say that because:

1. I cannot tell you how many times in my career a Nurse has called and told of vital signs a

patient is having, wanting to know if that is a Transfusion Reaction (and asked if they should

they call it).

2. One place I worked had the spaces for vital signs (at 15, 30, 1hr, etc) on the Transfusion

Form. One copy of the Form always came back to the BB after transfusion. We would audit

them to make sure vitals were taken at each interval; to make sure the transfusion took place

within 4 hours of Issue; to make sure they noticed vital signs that could be a reaction; et al.

We definitely came across problems in each of these areas.

Nurses may be the ones who know how to give a patient products through the IV, but when it comes to some of the issues of blood compatibility/incompatibility and reactions for blood, they are not always that knowledgeable.

I have given inservices and training to Nurses enough to know that some things they do with blood products are scary! That is also why we audit transfusions. There are any number of things that occur with blood products once they leave our possession, and I for one would like to know what they are.

Brenda

Well said, Brenda. I am constantly referring nurses to their own P&P for specifics(rate among other items). We get a copy of the transfusion form back with the vitals and other information. I review each form for completeness and interval that the vitals were taken. Finally, nursing is working on in-servicing their own personnel. They have asked me to work with them. All of this being said, I understand that it is up to the facility to specifiy the intervals at which the vitals will be taken.

Good luck!

:crazy::crazy:

[LOVEOURTEKS]

Hi all, we had worked with our nursing folks long and hard to improve on our transfusion forms. The guidance regarding montioring of the patient during transfusion was actually found in nursing references (what and at how many intervals). They also really appreciate the fact that they can call us at anytime. We put a reference regarding types of transfusion reactions on the back of our transfusion form, which seems to help them. We have also attended education fairs to help train the nursing staff on our transfusion forms and to get the word out about different types of reactions and what to look for. Its a win-win for everyone - esp our patients!

[John C. Staley]

I never said that we should not be a resource to help them with information and training. Unless your facility has transfusion teams based in the laboratory/bloodbank the monitoring of transfusions is something you have no direct control over and no regulatory support from the laboratory inspecting agencies. If you want to swap horror stories about nurses and transfusion I can hold my own but the bottom line is, the only real support you will find comes from the nursing side and often that is thin and varies from location to location depending on the local regulations. Your best option is to work with your hospital risk management department to find out just what the local rules and regulations are. Then make sure the nurses are aware of them and THEY are monitoring through nursing QA. If you decide they to your liking then you have a very difficult road ahead of you. Pick your battles wisely.

:coffeecup

[Brenda K Hutson]

Our Nursing Dept. does have all of that information also. In fact, to meet a CAP requirement of annual review, I had the Nursing Educator here create a powerpoint presentation that is actually used as part of their annual review of Health and Safety processes (which here, is done by a computer program called Healthstream; they read the information, then have to take and pass a quiz). I think it was a really good powerpoint presentation; thorough. Also, I recently revised our Transfusion Reaction Form (big-time) with input from Nursing (and of course, our Hospital Forms Committee; which has Nurses on it). They were given additional information regarding Transfusion Reactions at that time.

So I would not say that the "biggest" problem is not knowing what to look for. I would say that my concern at this point is the frequency at which they look for the symptoms. But yes, there is still the occassional Nurse (everywhere I have worked) that will call and ask us if they should initiate a transfusion reaction (even though the symptoms are clearly indicated in the protocol). We always tell them it is up to the Physician to make that call; but that they should use the protocol as a guide to making those decisions. But I can also say, there have been instances everywhere I have worked where a patient has clearly had the symptoms of a reaction, yet they did not call it (or they called us and told us about it a couple of days later; or the patient has a 2nd reaction at 1 point and they tell us that the patient had reacted the other time also, but they did not submit a reaction form; things like that).

Thanks,

Brenda

Hi all, we had worked with our nursing folks long and hard to improve on our transfusion forms. The guidance regarding montioring of the patient during transfusion was actually found in nursing references (what and at how many intervals). They also really appreciate the fact that they can call us at anytime. We put a reference regarding types of transfusion reactions on the back of our transfusion form, which seems to help them. We have also attended education fairs to help train the nursing staff on our transfusion forms and to get the word out about different types of reactions and what to look for. Its a win-win for everyone - esp our patients!

[LOVEOURTEKS]

Hi John, thanks for your advice! You are correct and I'm sure we are 100% in agreement... we must choose our battles wisely. One bummer is; in NYS we have bi-annual inspections for CLIA compliance and if they find something in transfusion administration that is not meeting a regulatory standard.... the Lab is documented with a deficiency not nursing. So we must be on top of our game and work as a team with nursing to ensure everything is A+. It has been working well so far, JCA and NYS have liked what we have done to improve quality in this area.

[Brenda K Hutson]

I do appreciate where you are coming from John; I do not mean to dispute your experience and/or opinions. I just think our experiences have been different.

When we audited those Forms in 1 place I worked, and found problems, the Nurses were absolutely held accountable! In part because our Medical Director had participated in coming up with the Nursing SOPs for monitoring Transfusions and looking for reactions; and in part because the FDA and AABB would actually look at our audits and at the very least, make suggestions regarding non-compliance from Nursing; and at the most, cite us for incomplete documentation by Nursing and/or not following their own protocol. And even though those were Inspections of the Transfusion Service, you better believe the head of Nursing was told to be present at the closing meetings and later held accountable (by the Lab and the Hospital) for following protocol.

But that may largely go back to another issue that comes up occassionally in various threads; how involved and supportive is one's Medical Director with Hosptial Policy that involves Lab processes.

Brenda

I never said that we should not be a resource to help them with information and training. Unless your facility has transfusion teams based in the laboratory/bloodbank the monitoring of transfusions is something you have no direct control over and no regulatory support from the laboratory inspecting agencies. If you want to swap horror stories about nurses and transfusion I can hold my own but the bottom line is, the only real support you will find comes from the nursing side and often that is thin and varies from location to location depending on the local regulations. Your best option is to work with your hospital risk management department to find out just what the local rules and regulations are. Then make sure the nurses are aware of them and THEY are monitoring through nursing QA. If you decide they to your liking then you have a very difficult road ahead of you. Pick your battles wisely.

:coffeecup

[Brenda K Hutson]

And that is part of where I am coming from; experience of the Lab being cited due to Nursing non-compliance for protocols that work very closely with the Lab (i.e. transfusions and transfusion reactions). And in every place I have worked, we performed periodic audits of the transfusion process on a patient to ensure all steps were following protocol (we actually follow a unit to the floor and document results on a checklist we carry with us).

And I absolutely understand "picking one's battles." believe me, having worked at a number of Facilities where I have come in and had responsibility for the Transfusion Service, I have always had to pick my battles.

And perhaps I should explain where this question even came from as you might be surprised. We are a beta site for a barcode system whereby we will be printing out barcode labels on the paperwork of blood products; then when we Issue them, we will scan that barcode; then on the Nursing unit, the Nurse will scan the barcode on the paperwork of units, against the armband. The Rep. for the company (whose past career is actually in High Tech.), was surprised to see (when up on a Nursing unit going through the process with them), that they only documented the vital signs at 15 mins (because they are documenting them in this hand-held monitor) and "his experience" was that the transfusions are monitored more frequently (i.e. hourly). And that is coming from a non-Blood Banker; or non-Technologist for that matter! To me, that says something.

Brenda

Hi John, thanks for your advice! You are correct and I'm sure we are 100% in agreement... we must choose our battles wisely. One bummer is; in NYS we have bi-annual inspections for CLIA compliance and if they find something in transfusion administration that is not meeting a regulatory standard.... the Lab is documented with a deficiency not nursing. So we must be on top of our game and work as a team with nursing to ensure everything is A+. It has been working well so far, JCA and NYS have liked what we have done to improve quality in this area.

[LOVEOURTEKS]

Hi Brenda,

Great info thanks so much! Would you be willing to share your "checklist"? We too do imprompto tracers to the floors and were awaiting JCA Lab inspection anytime now.... Thanks, Kim

[jalomahe]

Our nursing service currently use a paper Transfusion Record (their form although the Transfusion Service/Med Director give input whenever it is up for review). On the record it gives the intervals for recording vitals.

Pre-infusion; 5 min, 15 min, 1 hour, 2 hour, 3 hour, and then Post-infusion. There are also questions they need to answer post-infusion "Infusion completed? Yes No" and "Did patient display symptoms of possible reaction? Yes No. If yes, Transfusion Reaction form initiated Yes No. Name of MD notified: _____________"

This is a 2 part form so one copy goes for the chart the other goes to the unit's QA nurse for review.

Periodically our hospital's Blood Management Co-ordinator (also and RN) will do an audit of the forms also.

We are currently in the process of moving to a new/improved HIS that will allow this information to be documented electronically. The plan is for the information currently on the form will be duplicated in the electronic version.

[blut]

Brenta,

To my knowledge, various international standards and guidelines all require monitoring before, during, and after transfusion, but none specify specific time frames for during the transfusion, other than for the first 15 minutes (where monitoring should be close), although by 'during' they mean throughout, including after the first 15 minutes.

My guess is that they do not want to handcuff staff by mandating too many specifics for the throughout part and thus leave it to institutions to develop suitable guidelines for when to monitor the 'during' part, after the first 15 minutes.

For reference, TraQ has many excellent nursing resources that you may want to bring to the attention of Nursing at your hospital. They clearly indicate that best practice for throughout does not mean only for the first 15 mins.

• TraQ's nursing resources
  

Cheers, Pat

UA: http://www.ualberta.ca/~pletendr/

TraQ: http://www.traqprogram.ca/

Twitter: http://twitter.com/bogeywheels

It was just brought to my attention that Nursing in my current Hospital, only monitors trasfusions at the initial 15 mins. (and after the transfusion)....In looking in the Technical Manual, AABB Standards, CAP Checklist, and Circular of Information, ....there are "vague" statements about monitoring throughout the tranfusion (such as the recommendation for periodic observations); but I do not find any place where monitoring after the 15 mins. is "mandated;" nor are there any specific time-frames mentioned....

[Eoin]

Hi Brenda,

Don't you just hate it when regulations don't cover enough for good practice. We came up against just this some time ago. Since then we have a very active Hospital Transfusion Committee (HTC) (Lead by Consultant Haematologist with specialty in Transfusion, DON, Best Practice Manager, Nurse Practice co-ordinator, Nursing representative, Haemovigilance Officer, Anaesthetist, Consultant Physician, Surgeon, Lab Manager, Chief in Transfusion, and me - Quality Manager). We set our own guidelines and they are at 15mins (we recommend they do not leave during this time), and each hour after start time of the transfusion. We follow with BloodTrack Manager (they use BloodTrack Tx on the wards) and we send letters to nurses who fall outside these times by any significant margin (non-punitive but as swift follow-on for re-training purposes). Nursing practice does improve with this method. Anything not done though will generate a full non-conformance.

The great key is working hard at getting a good team on the committee. Look for your champions in the hospital

The key is the HTC.

The regs may not be there, but is no excuse for sloppy practice I feel.

Good Luck with it.

Cheers

Eoin

[MAGNUM]

At our facility we use a process called BCTA (barcode enabled transfusion administration), and the process forces the nurse to take vitals prior to the start, at 15 min, at 30 min, and hourly thereafter and then 1 hr post.

[John C. Staley]

At our facility we use a process called BCTA (barcode enabled transfusion administration), and the process forces the nurse to take vitals prior to the start, at 15 min, at 30 min, and hourly thereafter and then 1 hr post.

That sounds like a great system. Too bad it's not universal but...... that still leaves the question of; how were the time frames devised? What were they based on? I'm not arguing the validity or the clinical need for them, just wondering where they came from. That seems to be the bottom line of this entire discussion.

[Mabel Adams]

Our form asks for vitals at 15 min then each hour but I checked the AABB Primer of Blood Administration and it is no more precise than the references quoted above.

As for the MD making the call on reactions, the Joint Commission has specifically stated that they want a workup done if criteria are met, regardless of the opinion of the doctor. I quoted the standard exactly in my reaction procedure (which made my inspector very happy) but we got dinged because while the inspector was there we were notified of a case that they did as the doctor requested instead. Now the nursing procedure matches the requirements in the BB SOP and states that it is a JC requirement. Nurses listen to JC!

[Brenda K Hutson]

I can post it on this website when I get time, but if you want to give me your e-mail, I can at least get it to you sooner!

Thanks,

Brenda

Hi Brenda,

Great info thanks so much! Would you be willing to share your "checklist"? We too do imprompto tracers to the floors and were awaiting JCA Lab inspection anytime now.... Thanks, Kim

[Brenda K Hutson]

If it were not for the fact that you lived in Ohio, I would think perhaps you worked at one of the places I worked previously in that your process sounds just like theirs.

Thanks, that is what I am asking for; what intervals of documenting vitals are in-place at various Institutions.

Brenda

Our nursing service currently use a paper Transfusion Record (their form although the Transfusion Service/Med Director give input whenever it is up for review). On the record it gives the intervals for recording vitals.

Pre-infusion; 5 min, 15 min, 1 hour, 2 hour, 3 hour, and then Post-infusion. There are also questions they need to answer post-infusion "Infusion completed? Yes No" and "Did patient display symptoms of possible reaction? Yes No. If yes, Transfusion Reaction form initiated Yes No. Name of MD notified: _____________"

This is a 2 part form so one copy goes for the chart the other goes to the unit's QA nurse for review.

Periodically our hospital's Blood Management Co-ordinator (also and RN) will do an audit of the forms also.

We are currently in the process of moving to a new/improved HIS that will allow this information to be documented electronically. The plan is for the information currently on the form will be duplicated in the electronic version.

[Brenda K Hutson]

Thank you for taking the time to provide all of that information; I will look at it. And I agree that the Lab cannot totally mandate the transfusion process used by Nursing. But that being said, the current process where I am at (check patient at 15 mins only) just seems way too out-of-line with patient safety for my comfort. And given that it has been my experience that Medical Directors are to be involved in transfusion policies, I do think it valid to be familiar with what your Institution does, and speak up if you have concerns.

Brenda

Brenta,

To my knowledge, various international standards and guidelines all require monitoring before, during, and after transfusion, but none specify specific time frames for during the transfusion, other than for the first 15 minutes (where monitoring should be close), although by 'during' they mean throughout, including after the first 15 minutes.

My guess is that they do not want to handcuff staff by mandating too many specifics for the throughout part and thus leave it to institutions to develop suitable guidelines for when to monitor the 'during' part, after the first 15 minutes.

For reference, TraQ has many excellent nursing resources that you may want to bring to the attention of Nursing at your hospital. They clearly indicate that best practice for throughout does not mean only for the first 15 mins.

• TraQ's nursing resources
  

Cheers, Pat

UA: http://www.ualberta.ca/~pletendr/

TraQ: http://www.traqprogram.ca/

Twitter: http://twitter.com/bogeywheels

It was just brought to my attention that Nursing in my current Hospital, only monitors trasfusions at the initial 15 mins. (and after the transfusion)....In looking in the Technical Manual, AABB Standards, CAP Checklist, and Circular of Information, ....there are "vague" statements about monitoring throughout the tranfusion (such as the recommendation for periodic observations); but I do not find any place where monitoring after the 15 mins. is "mandated;" nor are there any specific time-frames mentioned....

[Brenda K Hutson]

Thank you; well said. Unfortunately, my current Hospital does not have a Transfusion Committee! That in itself is problematic to me. But I do have certain Reports I write that are seen by various depts. in the Hospital so that is my way of bringing up issues. But as with so many things, you really need a supportive Medical Director backing you up to accomplish much outside of the Lab. It sounds like you are very fortunate with the Team you have there.

Brenda Hutson

Hi Brenda,

Don't you just hate it when regulations don't cover enough for good practice. We came up against just this some time ago. Since then we have a very active Hospital Transfusion Committee (HTC) (Lead by Consultant Haematologist with specialty in Transfusion, DON, Best Practice Manager, Nurse Practice co-ordinator, Nursing representative, Haemovigilance Officer, Anaesthetist, Consultant Physician, Surgeon, Lab Manager, Chief in Transfusion, and me - Quality Manager). We set our own guidelines and they are at 15mins (we recommend they do not leave during this time), and each hour after start time of the transfusion. We follow with BloodTrack Manager (they use BloodTrack Tx on the wards) and we send letters to nurses who fall outside these times by any significant margin (non-punitive but as swift follow-on for re-training purposes). Nursing practice does improve with this method. Anything not done though will generate a full non-conformance.

The great key is working hard at getting a good team on the committee. Look for your champions in the hospital

The key is the HTC.

The regs may not be there, but is no excuse for sloppy practice I feel.

Good Luck with it.

Cheers

Eoin

[Brenda K Hutson]

You make a good point for Medical Director involvement in Nursing SOPs around transfusion. While I have seen the Nursing SOPs, and while I have written the Lab Transfusion Reaction SOP (with types of reactions; signs indicating them; etc), the truth of the matter is that unless we are told of a reaction, we have no way of knowing something occurred! And I have to say that in every Facility I have worked, there have been occassions where we have found out "after the fact" that a patient had a reaction that the Doctor decided was probably not due to the transfusion; and they therefore directed Nursing to NOT call a reaction.

I appreciate your JCAHO reference. As we know, Nursing do not have to answer to the AABB, CAP, FDA (and that in fact, the Blood Banks often get cited for Nursing issues; but as an Institution, that usually assists the Lab in obtaining compliance from Nursing on the given issue); but they do have to answer to JCAHO.

Brenda Hutson

Our form asks for vitals at 15 min then each hour but I checked the AABB Primer of Blood Administration and it is no more precise than the references quoted above.

As for the MD making the call on reactions, the Joint Commission has specifically stated that they want a workup done if criteria are met, regardless of the opinion of the doctor. I quoted the standard exactly in my reaction procedure (which made my inspector very happy) but we got dinged because while the inspector was there we were notified of a case that they did as the doctor requested instead. Now the nursing procedure matches the requirements in the BB SOP and states that it is a JC requirement. Nurses listen to JC!