Transfusion Vitals

[Andersli]

Hi All,

I am new to this group and have enjoyed reading previous posts on the various topics.  I now have a question for the group to see what others may be doing.   

 

We have been tasked by QA administration to look at the process for nursing related to blood administration and documentation of vitals.  Apparently they are not very happy with all of our reports of incomplete documentation we are discovering when we perform the chart audits....

 

The current process is to document vitals at 15 minutes after start, every hour (1 hour, 2 hours, etc) during the transfusion and then 30-60 minutes post transfusion.  Their feeling is that this is too much.  We have looked at the standards, checklist items, technical manual, circular of information, etc., for guidance and have not found anything as specific as our current process.  We of course have our concerns of changing this process...especially for units that hang for 3-4 hours.

 

 

If you are willing to share your process or have any comments, I would appreciate your feedback.

 

Thanks,

Lisa

[Gkloc]

Pretransfusion vitals should also be recorded.  AABB Standard 5.29.1 says pre- and posttransfusion vitals should be recorded in the patients chart.  At my hospital we record the pre vitals, vitals after 15 minutes, and then hourly like you do.

[Andersli]

Oops...yes we also require the pretransfusion vitals to be recorded.

[goodchild]

This excerpt was taken from the circular of information for the use of human blood and blood components:

 

11. Periodic observation and recording of vital signs should occur before, during, and after the transfusion to identify suspected adverse reactions. If a transfusion reaction occurs, the transfusion must be discontinued immediately and appropriate therapy initiated. The infusion should not be restarted unless approved by transfusion service protocol.

 

Basically it's up to your transfusion service medical director to approve the policy that identifies what 'periodic vital signs during transfusion' represents.

 

We have slightly less rigorous standards than you: pre, 15-min, hourly, and post.

[David Saikin]

Join the crowd on incomplete Nursing documentation.  We browbeat our nurses and now have >90% compliance.  We do vitals:  pre, 15 min, hourly, and post.  The standards only require pre, 15 min and completion; the Technical Manual says pre, 5-15 minutes and then by instituional policy.   You (vis-a-vis your Medical Director) need to determine what intervals are necessary to document a safe transfusion event and then enforce the policy.  I wanted to get the FDA involved but once the product leaves the BB they do not care what happens (as long as the pt does not expire due to the transfusion).

[John C. Staley]

You see the thing is, the act of transfusing, for the most part, is a nurse thing.  There are a few facilities out there where the transfusion team falls under the blood bank/lab but that is the exception not the rule.  What I have found over the years is that it is the state nurse organization/agency that drive nursing protocols.  That's where I suggest the QA administration look to determine what is required in your state.  That usually carries enough weight with nurses to get better compliance.  As noted above, our input is little more than recommendations and frankly, nurses don't usualy much care what we have to say.  As far as enforcing a policy for nurses mandated by laboratory, what can we do, refuse to release blood to a nurse with a history of poor documentation!  Just my rambling based on past experience. 

[SMILLER]

As an aside, I would be interested in what you all comsider the "start" of the transfusion in order to begin that 15 minute countdown?  When the unit is spiked? Hung? When the blood enters the vein?

 

Scott

[MAGNUM]

We do pretransfusion vitals, 10 min after start, 30 min, then hourly. We know when the vitals are done because as they are performed they populate in the blood bank module.

[Malcolm Needs ☆]

Surely, SMILLER, it must be as the blood enters the vein, as before that, there is no transfusion?

From avowed Red Cell Serologist, rather than a Blood Transfusionist!

[SMILLER]

Because I have heard of certain nurses who spike and hang the unit and then start the timer (or glance at the time, however it is they do it), not thinking that it may take a few minutes for it to run down to the patient's arm!  If one is looking for signs of a ABO incompatibility for the first 15 minutes, I suppose you could be leaving the patient unobserved vitals-wise, before their time.

 

Scott

[tbostock]

We do pre, 15 min, every hour during, and 1 hour post.  We are looking at getting rid of the 1 hour post (requested by nursing).

[Eoin]

Pre-Transfusion Vitals, 15 mins, hourly till completion and at completion (inside 4 hrs from start). We have BloodTrack, so they cannot shortcut - all is revealed. Our Haemovigilance Officer monitors compliance, advises, retrains and re-applies competency testing as required.

We also tell them that the first 15 min is vital - not to leave the bedside.

 

Cheers

Eoin

[MRPalisades]

It seems everyone has a problem with incomplete transfusion slips.  We have set our target at <2.0%.  Last year our average was 5% incomplete.  As of now we are 4.6%.  It is a difficult task to manage.  The nurses are required to take vitals 15 minutes prior transfusion, 15 minutes after transfusion started, and every half-hour until transfusion is completed.  They document pre, 15 mins, and post on our Blood Bank transfusion slips. 

[knelson]

We require vitals pretransfusion, every 15 min during the first hour and hourly afterwards during transfusion, then 15 min post transfusion. 

[Mabel Adams]

I have had inspectors insist that the nurses consider the start time as when the blood hits the vein so that is what we teach.

 

New question: how long before start of transfusion do you allow pre-transfusion vitals to be taken?  We did an audit where the nurse started the blood, then copied vitals from 27 min prior onto the transfusion record.  I am inclined to think this is an acceptable baseline but would not want it to extend out much further.  Is it a bigger problem that maybe a CNA took those vitals and the nurse starting the blood was not aware of, say, whether the patient had a fever before starting the blood?  Or maybe the CNA would report that sort of info to the nurse?

[AMcCord]

We allow pre-vitals to be taken up to 30 minutes prior to the start of infusion. The CNA may take the vitals, but the nurse is expected to look at them/know what they are before checking out the blood product.

[aafrin]

Our nurses are required to check the vitals before they send the issue note for release of components. Our requirements are checking vitals pretransfusion, every 15 min during the first half-hour and hourly afterwards during transfusion, then 30 mins. post transfusion.

[Michaele]

Question--what are you all using for your taget completion of transfusion vitals tag (since everyone seems to have this problem)?  MRPalisades uses <2.0 target.  Years ago, our powers that be decided that our target needs to be 100% completion on the transfusion tag.  Nursing staff can rarely meet that target. 

[cthherbal ☆]

Michaele we use >/= 95% compliance rate of completed slips.

[Bill Sinn]

from medium size hospital..

 

Vitals:    pre transfusion, 15 min, 30 min,  post tranfusuion, 

 

Compliance:  somewhat spotty

[EDibble]

Mini rant. We have compliance issues too, but what really sets me off is when the transfusion paperwork comes back (as our policy requires) for a transfusion reaction, and vital information is missing.

 

And, whenever I have observed a transfusion starting, the nurse times it when the blood enters the patient, so at least that is being done correctly.

[Abdulhameed Al-Attas]

 We do vitals:  pre, 15 min, hourly, and post.

[Mabel Adams]

Now I have an audit with pre-transfusion vitals done 1 hr 18 minutes before start of transfusion (time when blood hit vein).  Anyone else want to weigh in with how far in advance pre-transfusion vitals can be done?  If these vitals were done before they sent for the blood and they had some delays so were near the 30 minutes after issue start time, I can see it taking around an hour sometimes.  Thoughts?  Should we have a firm time limit or let nurses use their judgment on how stable the patient is?

[Eoin]

We are lucky with BloodTrack. They must do vitals just before hanging & record them in BloodTrack (via handheld PDAs).

 If you leave it to nurses judgement - that might be fine on a stable patient, but as Mabel says - How long before?? So I'm afraid we insist on the above. That of course does not stop them putting in pre-recorded vitals, but has not been detected in any visual audits by our Haemovigilance team and would generate a non-conformance if we saw it. I have done a few spot checks on patient's chart & values into BloodTrack to see if this happens, but negative - so far anyway!

 

Cheers

Eoin

[David Saikin]

Question--what are you all using for your taget completion of transfusion vitals tag (since everyone seems to have this problem)?  MRPalisades uses <2.0 target.  Years ago, our powers that be decided that our target needs to be 100% completion on the transfusion tag.  Nursing staff can rarely meet that target. 

 

I don't think there is very mucy that is "allowed" to be 100% - it is almost impossible when dealing with humans.  We demanded 100% for ABORh typing for our blood bank staff and HR said we could not have that . . . we asked them what % of pts we could kill by ABO mismatch - we got the 100% for that standard.