Transcript Where Quality Runs Through the Veins of Patient Care

Back to Basics Where Quality Runs through
the Veins of Patient Care
Edna Matheson, BN RN
Blood Matters
Nov. 18th, 2016
• There is no involvement with industry to
disclose for this presentation.
Note!
• This presentation highlights key aspects of
safe transfusion practices for transfusionists.
– RN; LPN; NP; anaesthetist; anesthesia
tech/assistant; midwife; RRT (ECLS specialist)
Selected CSA Standards
• Canadian Standards Association develops
standards for transfusion medicine
services in Canada
• Standard CAN/Z902-15, A National
Standard of Canada, Blood and Blood
Components
– Applies to all aspects of transfusion medicine
including collection, processing, storage and
use of blood components and blood products
Nursing Scopes of Practice
• Entry level competency for RNs
– experience in this procedure may or may not
have occurred during their clinical practicum
• Non-mandatory entry level competency for
LPNs is organization specific
– To patients with established plans of care with
predictable outcomes
– Outcomes of component or product must be
predictable
Within LPN Scope of Practice
Examples of patients that would fall within
the LPN SOP for blood component/product
administration include:
• a hemodynamically stable patient with
anemia that requires RBC’s
• administration of WinRho
• subsequent doses of albumin to a patient
whose outcome from the first dose is
progressing as anticipated
Competency Requirements
• Transfusionists must meet the knowledge
and competency requirements of their
organization
• Competency assessment includes but is
not limited to
– assessment of knowledge
– operating procedures and theory
– direct observation of performance
– monitoring of recording and reporting.
Knowledge Requirements
• Blood Transfusion Modules on the
provincial eLearning.nshealth.ca website:
– Transfusion 1 Blood Basics
– Transfusion 2 Administration
– Transfusion 3 Adverse Reactions
– Transfusion 4 Therapy Exam
• Read policy; transfusion safety checklists;
patient guide brochure
Blood and Blood Components
• Blood: referred to as whole blood and is
made up of the following components:
– Red cells, platelets and plasma
– On average, an adult has about
5 liters of blood circulating
throughout their system
Blood and Blood Components
• Blood components: the separated parts
of whole blood
– Red cells transport oxygen and carry
nutrients to the cells and carry away carbon
dioxide
– Platelets participate in clot formation
– Plasma helps with clotting, is used to make
other products
Manufactured Products (Plasma
Derivatives)
• Products that are derived from plasma
manufacturing processes include:
– IVIG (Gamunex, IVIGnex)
– Albumin
– Rh Immunoglobulin (Win Rho)
– Hepatitis B & CMV Immune Globulin
– Octaplex®/Beriplex®
Orders for Blood
Components/Products
• Written order to include:
– Type of component or product
– Specific product requirements (e.g. irradiated)
– Number of units and/or volume
– If warmer or pressure device is to be used
(massive bleeds)
Processing Blood Bank Orders
• Determine if a blood sample is required
• Pre-transfusion blood sample collected to:
– determine patient’s ABO and Rh type
– identify antibodies the patient may have
– crossmatch compatible units when
components are ordered
• Blood sample expires 96 hours after collection,
unless pre-admission clinic patient
Entering Orders in computer
• What does the lingo mean?
– Group and Rh
– Type and Screen
– BBH
– Add on test for product
Collecting blood sample
• Witnessing and verifying blood bank
specimen collection at the bedside
– Misidentification can lead to acute hemolytic
transfusion reactions
– Error in sample labeling is the number one
preventable error in transfusion errors
• It is imperative the bedside identification
and labeling of the sample is performed
precisely
Patient Identification
• Ensure patient wearing correct armband (current
account number)
• Take blood sample labels to the patients bedside.
• Check the patients armband EVEN when the
patient is familiar to you
• Verify the labels match the patient’s ID and
checked by witness
• Label tubes after collection but BEFORE leaving
the bedside
• Document that you drew the blood sample
Pre-transfusion testing
• Compatibility testing on a blood
component is to ensure it will not produce
a harmful reaction with the recipients
blood
Compatibility Table
Donor ABO Group
Recipient ABO
Group
RBCs
Plasma
Platelets
UNKNOWN
O
AB
AB
O
O
O, A, B, AB
O, A, B, AB
A
A, O
A, AB
A, AB
B
B, O
B, AB
B, AB
AB
AB, A, B, O
AB
AB
Blood/Fluid Warmer
• Blood warmers/pressure devices are
recommended during massive bleeds
– Not to exceed 42°C
– Pressure devices (rapid infusers should not
exceed 300mmHg).
• Knowledge gap related to use of blood
warmers – guidelines and quick reference
instructions available on pump
Unmatched blood
• Unmatched blood (e.g. Trauma cases
where patient may be unidentified)
– O Negative Red Cell(s) and AB plasma will be
ordered and issued.
– A pre-transfusion specimen should be drawn
prior to transfusion, if possible.
– Physician must sign Emergency Release of
Unmatched Blood provided by Blood Bank
(required for red cells)
Consent
• Written consent must be obtained by
authorized prescriber and signed by
patient or substitute decision maker
• Single consent sufficient to cover ongoing
transfusion requirements related to that
treatment
• Refusals must be documented in writing
Pre-Administration
• Patient education
– Pamphlet
– Document teaching
• Ensure patient wearing correct armband
• Review order for transfusion and if there is a
pre-med
• Specific product requirements (irradiated)
Pre-Administration
• Pre-medicate only if ordered by physician
• Perform a baseline physical assessment
prior to obtaining component or product:
– Vitals signs within 1 hr of starting transfusion
– Lung assessment
– Identify conditions that may increase risk of
transfusion-related adverse reactions
– Presence of appropriate and patent vascular
access
– Current lab values
Vascular Access
• Ensure IV site is patent
– Short peripheral IV catheter can be 20 – 22
gauge for adults based on vein size and patient
preference. (INS 2016)
– For rapid administration, use 14 – 18 gauge
• Central Venous Access Devices (CVADs)
– Multiple lumens allow for concurrent
administration of medications/solutions
– Infusion may be slower in smaller gauge PICCs
– Risk for hypothermia is increased with CVAD
Prepare Blood Infusion Set
• Prime set with 0.9% Normal
Saline
• Close all clamps
• Do not suspend container
directly over infuser
• Open clamp
• Repeatedly squeeze drip
chamber until fluid level is
slightly above top of filter
• Tap chamber to eliminate air
Pre-Administration Verification
• Verify in presence of patient by transfusionist
and another LPN, RN, PCP, NP, Midwife
– Order for transfusion
– Double identifiers on patient’s ID band against
blood tag or report match
– ABO group, Rh type and serial number on tag
or report matches or is compatible with label
• Product will not expire during transfusion
• For home care setting, RN, Midwife and
responsible adult
This is the donation
number (i.e. unit
number). It is used
for any double checks
and documentation.
ABO and Rh Group
Collection date
and time
Component
description, e.g.
red blood cells.
If the product has
been irradiated, it
will be indicated
here
Product
Volume
Expiration date
and time
Special
testing (i.e.
CMV or
specific
antibodies)
Stop in Your Tracks
• If any of the above criteria are not met, do not
start the transfusion, notify Blood Transfusion
Services (BTS)
• Do not start the transfusion until the
discrepancy is satisfactorily resolved
Pre-Administration
• Visually inspect component for clots,
clumps and discoloration (cloudy, floaties)
• Gently agitate blood component to mix
thoroughly
• Do NOT use if container is not intact or if
the appearance is not normal – return to
BTS
Time of Issue
• Blood tags or Issue/Transfuse Record
have the time of issue a blood component
or product is removed from a monitored
blood refrigerator
– If greater than 30 minute delay from time of
issue to start of transfusion expected, return
product to Blood Bank (monitored fridge).
– If the blood component or products is not
used, time must be stamped again on return
to the blood refrigerator
Pull port protector
apart with both hands
• Insert spike using ¼ turns until septum is pierced.
• Do NOT over-spike
• Remove spike by twisting using ¼ turns as you pull.
• Pulling spike downward will tighten the port on the spike
• Once spike is loosened from port – pull straight down
Four hours?
• Red Blood Cells must be completely
transfused within 4 hours from the time it
is issued from the monitored blood
refrigerator (i.e. from the LAB)
• Blood sets are to be changed every 4
hours
• Any remaining RBCs after 4 hours from
the time of issue from the fridge must be
discontinued and discarded
Caution on Blood Set Package
Administration
• Sign or print Meditech ID and start time on
blood tag
– Keep tag attached during transfusion
Infusion rates
• Monitor infusion rates (slower rates may be
necessary for elderly, cardiovascular
compromise or at risk for fluid overload)
– Red cells are started at 2 mL/minute (120
mL/hr) for first 15 minutes
• Subtract the 30 mLs from total volume and
infuse the remaining volume over 1.5 to 2
hours
Monitoring
• Monitor patient for signs of reaction
throughout transfusion
– Stay with patient first 5 minutes from the
first time the blood enters the vein (Most
transfusionists stay with patients during
the first 15 minutes)
– Check for reaction q5min x 2; q1h; 1 hr
post (exception would be 15 mins after
routine maternal WinRho)
Vital signs and reaction checks
• LPNs may be assigned/participate in care by
performing VS/reaction checks.
• Increase frequency of monitoring for patients
with a greater risk for circulatory overload,
history of previous reactions or who are
unstable.
• Repeat initial monitoring for each new bag / lot
number
• If the transfusion is less than sixty (60) minutes,
do vital signs prior and just after transfusion.
Administration
• Never add medications to blood
components
• Accurate documentation (refer to your
organization’s health record documents /
PCS)
Post-administration without
Reaction
• Disconnect blood set and store for 4 hours
• Continue to monitor for febrile or
pulmonary reactions
• Complete blood tag, remove and send to
BTS within 24 hours
• If no reaction, discard container and
administration set in stiff sided Biohazard
container with lid
• Review post-transfusion bloodwork
Patient Notification
• Notification Letter
– Given to patients once during LOS or course
of treatment (e.g. series of IVIG)
• Do not need product specifics (available in
patient record if ever needed)
• Document notification given and place
copy on health record
– Prompt added to discharge checklist
Transfusion Reactions
• Serious Sign or Symptom
– Disconnect transfusion (i.e. do not just clamp
blood and open saline)
• Maintain IV line with appropriate solution
(usually normal saline)
• Notify physician
• Check VS q15 mins until stable (SpO2)
• Repeat clerical check (pt ID and ABO/Rh)
Minor Reaction
• If minor reaction with onset more than 15
minutes into transfusion, can resume
cautiously ONLY as directed by physician
• Stay with patient for 5 minutes initially,
then assess q5 min x 2, and hourly
thereafter (change to staying for 15 mins)
• Assess vital signs after 15 minutes
• Immediately stop transfusion if serious
signs and symptoms develop
Reaction investigations and
follow up
• Notify Blood Bank of ALL reactions
– Remove transfusion tag and add comment re
reaction
– Place container and administration set in ziploc
bag and return to Blood Bank
• Meditech - Enter TRX for Lab tests
• Lab to determine which tests to perform
per Appendix B – Table on Investigations
• Complete a SIMS report
Questions?