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Transfusion reaction protocol


Susan Betler

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An RN reports symptoms to an MD during a transfusion and the MD states that this is not a "reaction " and wants the transfusion to continue. Other than urticaria, medical staff is pondering letting blood be collected, basic workup completed for evaluation and if "negative " continue the transfusion. There would be no physical clerical check. I am against this potential protocol. RNs feel that the MD has the final say and blood bank does not need notified at all. Guidance please and thanks. 

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When I addressed this with our facitlity, I pointed out the reaction happened because of the transfusion that was ordered. Our policy is the doctor and the blood bank are to be notified. (Yes, sometimes they forget step 2.) A specimen is collected. We review the records & perform the workup. It is up to the doctor if transfusion is continued after the workup is finished, but they cannot 'cancel' the workup. 

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On ‎9‎/‎26‎/‎2017 at 6:21 PM, Susan Betler said:

An RN reports symptoms to an MD during a transfusion and the MD states that this is not a "reaction " and wants the transfusion to continue. Other than urticaria, medical staff is pondering letting blood be collected, basic workup completed for evaluation and if "negative " continue the transfusion. There would be no physical clerical check. I am against this potential protocol. RNs feel that the MD has the final say and blood bank does not need notified at all. Guidance please and thanks. 

Our Policy states that it is the responsibility of the Physician to "call" a Transfusion Reaction.  Sometimes, they will call us and try to get us to tell them if it is a Transfusion Reaction (i.e. should they initiate a Transfusion Reaction) and I have advised my staff that this is NOT our call.....we do not know the patient, we do not know what their condition was prior to the transfusion, and we are not Physicians.  When a Nurse suspects a Transfusion Reaction (and I have assisted Nursing education with the PowerPoint presentation on that for which Nurses must complete the assignment annually), they are advised to notify the Physician and let them make the call (they can also notify us, but we will not tell them whether or not to call a reaction; and they are required to notify us if they have decided to call a Transfusion Reaction).

Yes, there are times they call us and based on what they tell us, we may think they should be calling a reaction (but we will not make that decision), and then they end up not calling a reaction (i.e. the Physician decides not to initiate a transfusion reaction).  Those times can be disconcerting, but all I can do is continue to educate staff (and even though the symptoms may sound to us like they should initiate a reaction, that is exactly why we do not advise.....it is possible that the patient has been having those symptoms and the Physician knows that....so they are the ones who have the "big picture" of what is going on with the patient, not us).

There is a Hospital Procedure which I wrote, which clearly describes various symptoms of transfusion reactions; what to watch for.  But they made that call.

Brenda Hutson, MT(ASCP)SBB

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I would ask what "basic work-up" would let them know if they were transfusing a potentially bacterially contaminated unit (in the event of a febrile reaction).  We require BB and MD notification of all suspected reactions.  The Clinical Pathologist determines if a unit is continued (if hives/urticarial only), and must approve additional transfusions for other reactions. 

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1 hour ago, John C. Staley said:

My favorite transfusion reaction work up resulted in closing the blinds on the window to keep the sun from beating down on the patient resulting in a rise in temp.  True story.  :wow:

And remember when the "blood warmer" was a few minutes on the radiator/heating vent ? Good times.

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We require BB notification, and after prelim investigation, the Lab Medical Director makes the call whether it's ok  to continue for hives/itching, and whether additional units may be given. Hives category gets a clerical check and all other "Transfusion Reaction Symptoms" (as defined by AABB) require disconnection of unit and are worked up as reactions. The patient's MD does not make the call. We have a separate transfusion reaction categories for: 1) hives, itching 2) potential bacterial contamination and 3) everything else.

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Same here - transfusionists have list of symptoms; if any are noted, they stop the transfusion and notify the BB. Workup is performed and reported to the Medical Director (or on call pathologist) who makes the decision to continue transfusion or not. The patients' physicians cannot override that protocol.  Unless patient's condition is such that immediate intervention is required, the BB is the first call, the physician is the second.

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Also - examine your Joint Commission Standards if your Lab happens to be under Joint Commission accreditation. 

QSA .05.18.01 - section 2 and 3 state in part:

 2.  The requirement that suspected transfusion reaction-related adverse events are reported immediately to the laboratory, whether or not the physician responsible for the patient deems it necessary to report the event.

3.  Policies and procedures for nursing services related to blood and blood component administration do not conflict with the laboratory's policies and procedures.

That is fairly definitive about what they want to see and it differs from CAP.  We had to change from " what does the physician want to do" to "we need the Transfusion Reaction Workup" if we hear about it at all.

Curious as to what Hospital Joint standards say about the whole thing - I have never seen that set of standards.  And most hospitals are accredited by Joint Commission, even if their Labs are not.

 

 

Edited by carolyn swickard
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1 hour ago, LAS said:

Same here - transfusionists have list of symptoms; if any are noted, they stop the transfusion and notify the BB. Workup is performed and reported to the Medical Director (or on call pathologist) who makes the decision to continue transfusion or not. The patients' physicians cannot override that protocol.  Unless patient's condition is such that immediate intervention is required, the BB is the first call, the physician is the second.

Surely, and with the utmost respect to you LAS, if the patient's physician, who is actually on site and looking after the patient, has the right to over ride the Pathology Medical Director or on-call Pathologist (who either may not be, or, much more likely, especially at night or at weekends, will not be on site, let alone be next to the patient), on the grounds that, apart from exceptional circumstances (for example A into O ABO incompatibility, bacterial infection, and other such acute reactions, which I HOPE the patient's physician [and nursing staff] should be able to recognise, and stop the transfusion themselves - IMMEDIATELY), a transfusion reaction, even ongoing, is easier to deal with than a patient who has died because of exsanguination?

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I have had physicians tell me that patients can't have transfusion reactions to autologous blood and that hypotension is not a sign of a transfusion reaction (even though there is a type named that).  I've seen them order irradiated blood because they think it is less likely to transmit infections.  If the patient has been spiking a temp for another reason and they write off this temp which is actually due to TRALI or a hemolytic reaction and keep giving more of the unit, they have done the patient harm.  If you can tell whether there is a reaction going on by playing the odds based on the patient's history and condition then why do we ever do the testing?  I've never had to let a heavily bleeding patient wait for a transfusion reaction workup.  If their life was in danger from bleeding the medical director would override the usual policy if needed.  I'm afraid, in my experience, the pathologists are more knowledgeable than the bedside physicians in may cases.

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