Policies Relating to Transfusion of Blood Components and Products

1. A physician's order is required for the transfusion of blood components or plasma protein products and must include either the number of units, volume, or dosage of the product.

2. Transfusion of blood products may be performed by physicians, residents, medical students under supervision, and nursing staff as defined in the CHR Nursing Policy and Procedure manual.

3. Before transfusion of blood components, the following must be confirmed:

the physician's transfusion order
the identity of the recipient
the integrity, identity and type of product
the RTSIS number for red cell products

This step is to be performed by two people, one of which is the transfusionist. The other person may be nursing staff as described in the CHR Nursing Policy and Procedure manual, a physician, resident, medical student, perfusionist, or respiratory technologist.

4. The product container should be observed for damage prior to beginning the infusion. If damage is observed, the product must be returned to TM or disposed on the nursing unit after notifying TM.

5. If any discrepancy is discovered, the discrepancy must be resolved before proceeding with the transfusion.

6. All labels and tags must remain attached to the unit until discard of the container.

7. The patient's vital signs should be recorded immediately prior to transfusion, 15 minutes after beginning the transfusion, hourly and at the end of the transfusion.

8. The person administering the product must remain with adult patients during the first 5 minutes of the transfusion and be readily available for the next 10 minutes. For pediatric or neonatal patients, the person administering the product must remain with the patient during the first 15 minutes of the transfusion.

9. The physician should indicate the rate of infusion in the infusion order. Unless otherwise indicated by the patient's clinical condition, the rate of infusion should be no more than 5 mL per minute for the first 15 minutes of the infusion.

10. Infusion should be completed before expiration of the product or within four hours, whichever is sooner. If a product is required to run over more than four hours, the PCU may request to have the product split.

11. All products are to be administered with a sterile, pyrogen-free administration set with a filter designed to retain particles potentially harmful to the recipient. The administration set may be used for up to two units of red cells, or 4 hours, whichever comes first. The administration set must be replaced if it becomes occluded.

12. The largest needle bore size possible must be used to infuse the product. An 18 gauge is preferred.

13. Plastic blood containers must not be vented.

14. Components should be thoroughly mixed before transfusion.

15. No medications or solutions may be added to or infused through the same tubing as blood components, except 0.9% Sodium Chloride, Injection (USP), ABO compatible plasma or 5% albumin.

16. If clinically indicated, blood components may be warmed immediately prior to infusion. Clinical indications include exchange or massive transfusion and patients with cold reactive antibodies.

Only approved blood warmers or rapid infusion devices that are calibrated and maintained not to deliver blood beyond 37°C may be used.
Use of a blood warmer or rapid infusion device requires a physician's order except in clinical areas where there are established policies and procedures.
Clinical areas using blood warmers and rapid infusion devices are responsible for ensuring the devices meet current CSTM standards for safety, use, and maintenance.
Microwave heat devices must NOT be used to warm blood products.

17. Plasma protein (fractionation) products must be administered according to the manufacturer's instructions.

Transfusion Medicine will respond to requests for information regarding product dosage and administration by providing the manufacturer's product insert to the requestor.
Products issued to physicians' offices or for home administration may be stored in non-controlled refrigerators. It is the responsibility of the physician or user to ensure the product is stored according to the manufacturer's recommendation. In order to acquire more product, the physician office must provide Transfusion Medicine with the product recipient documentation.

18. Blood products may NOT be stored in nursing unit refrigerators, except those specifically designed and controlled for blood storage.

19. Adverse reactions to transfusion must be reported to TM as soon as they are recognized.

20. If a febrile non-hemolytic or urticarial reaction is suspected, medications for symptom management may be ordered and administered and the transfusion continued on the order of the physician.

21. The transfusion of all blood products shall be documented on the patient's Health Record or Physician's office chart. The record will include the product type, the date and time of infusion and the unique number or lot number and for red cell products, the RTSIS number. For hospital in-patients, this may be accomplished by mounting the 'patient chart copy' portion of the transfusion tag to the CHR Transfusion Tag Mounting Record (form #100741).