Red Cells at Home, Under the Direction of the Paediatric MacMillan Team ( PMT ) - Guideline for the Administration of

Publication: 30/01/2017  --
Last review: 01/01/1900  
Next review: 01/01/2020  
Clinical Guideline
CURRENT 
ID: 4892 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for the Administration of Red Cells at Home, Under the Direction of the Paediatric MacMillan Team (PMT)

Summary of Guideline
1. Introduction
2. Scope of guideline
3. Authorising red cells for home transfusion
4. Ordering red cells from Blood Bank
5. Collection & Transportation of red cells
6. Equipment required
7. Written Consent & Patient / family information
8. Pre administration bedside checks
9. Administration of red cells
10. Monitoring the patient
11. Actions required in the event of an acute transfusion reaction.
12. Disposal of clinical waste
13. Documentation

Appendix 1
Appendix 2
Appendix 3
Appendix 4
Appendix 5

Summary of Guideline

Home transfusion is an important part of symptom management in paediatric palliative care. This guideline provides guidance on when it’s appropriate to offer home red cell transfusion and who is responsible for making this decision. The guideline provides clear guidance on how to prescribe, request, collect and administer red cells at home. It also covers aspects of patient information and transfusion reaction management and how to comply with traceability regulations BSQR SI 50/2005.

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Treatment / Management

1. Introduction

1.1 Within Leeds Teaching Hospitals NHS Trust (LTHT) transfusions of blood and blood components are mostly administered within the hospital either as an inpatient or as an outpatient. Within the Paediatric Macmillan Team (PMT) the need to give red cells at home in some situations has been highlighted.

1.2 The Hospital Transfusion Team (HTT) and PMT have formulated this Standard Operating Procedure (SOP) for the use of the PMT and the administration of home red cell transfusions

2. Scope of the guideline

2.1 This guideline is for the use of staff in the LTHT PMT only. Staff within the LTHT PMT must be trained once every 3 years by the HTT in home red cell transfusion procedures and be competency assessed once every 3 years.

2.1.1 Personnel responsibilities

  • Prescription - Paediatric Haematology or Oncology Consultant or transfusion authorisation trained Advanced Practitioner, Specialist Registrar or Clinical Fellow / Palliative Care Consultant / Consultant of Shared Care hospital
  • Collection and Administration - PMT Nurses or anyone trained in this procedure

2.1.2 Patients MUST meet all five criteria below to be eligible for home red cell transfusions:

  • The patient has had a previous red cell transfusion with no adverse effects
  • The patient is a child or young adult receiving palliative care from the LTHT PMT
  • The patient is unable to attend the hospital setting because of their medical condition
  • The patient is anaemic
  • The aim of the treatment is to improve or maintain quality of life, and to minimise or prevent distressing symptoms

2.2 For geographical areas and a list of approved staff covered by this SOP, see EQMS BBFORM 014114.0

3. Prescribing/Authorising red cells for home transfusion

3.1 Red cells for home transfusion will be prescribed on an LTHT transfusion authorisation chart. Data MUST include all 7 details outlined below:

  1. Patient Identification – Full name, date of birth and NHS number or hospital number
  2. Date
  3. Time over which red cells will be transfused
  4. Type of component
  5. Volume of component
  6. Special requirements e.g. irradiated, HEV negative (solid organ transplant and pre/post allogeneic stem cell transplant patients only) (NB: CMV negative blood components are now only issued to those patients who are 6 months old or less14.9)
  7. Authorising signature

A routine pre-medication of IV Hydrocortisone and IV Chlorpheniramine is not indicated with red cell transfusion. If the patient has had previous transfusion reactions, it will be more appropriate for red cells to be administered in a hospital. It will be necessary to discuss any exceptional cases with the consultant in charge of the patient, their parents and / or carers.

3.2 IV 0.9% Sodium Chloride should be prescribed on an LTHT Drug chart. For concentration and volume refer to LTHT “Guideline for Insertion, Management, Replacement and Removal of Central Venous Catheters in Adults and Children”14.1

Drugs for use in the event of a reaction to be prescribed on a case by case basis see Appendix 2 or refer to Appendix 1 (Anaphylaxis Algorithm) in your Paediatric Oncology Guideline for the Management of Anaphylaxis in Children)

4. Ordering red cells from Blood Bank

4.0 A valid sample will be required in order to crossmatch the blood. (As per LTHT “Policy to Safer Transfusion Policy14.2)

4.1 Written requests will be on a transfusion request form and will state clearly that red cells are for home transfusion. (All other fields will be completed as per LTHT “Policy to Safer Transfusion Policy14.2)

4.2 Telephone requests will be accepted from Paediatric Oncology/Haematology medical/advanced practitioner staff listed in 2.1.1 as prescribers and from PMT Nurses. The information required is:

  • Full details of patient, including full name, date of birth and NHS number or hospital number
  • Date and time required
  • Type and volume of product
  • Special requirements e.g. irradiated, HEV negative
  • Name and designation of person requesting and contact details
  • Indication that the red cells are for home transfusion

5. Collection and transportation of red cells for home transfusion

5.0 Any trained authorised person may collect the unit(s) of red cells once notified that they are available by Blood Bank (BB)

5.1 The person collecting the red cells will check that details on the authorisation chart, the unit(s) and the compatibility label are in agreement, including:

  • Patient identification – full name, date of birth and hospital number or NHS number
  • Volume and type of product
  • Patient and Donor ABO and RhD blood groups are compatible
  • Any special requirements have been adhered to
  • The donation number(s) is the same
  • The unit(s) is within date
  • The unit(s) appearance is free from abnormalities such as; unusual colour, cloudiness, presence of particles

5.2 BB staff will have packed the red cell unit(s) (with cool packs) in a transportation box ready for collection as per normal issue procedures. See 14.3 for a list of relevant SOP’s

5.3 Time of dispatch should be documented in the patient’s medical notes by the PMT nurse collecting the blood

5.4 The red cell transportation box will be secured and transported in the boot of the vehicle to minimise movement, and transported without delay

6. Equipment required

  • Blood/Red cell giving set
  • Dressing pack
  • Alcowipes
  • 4x 10ml syringe for pre-medication and flushes
  • 1x 5ml water for injection
  • 2x 10ml 0.9% sodium chloride for injection
  • 2x Yellow clinical waste plastic bag
  • Sharps container
  • Biohazard spillage kit

7. Written Consent (LTHT policy)14.4 & Patient / Family information

7.0 Discussion regarding the risks, benefits and alternatives available should be made between the prescriber, patient and family and written consent gained (if not already obtained when the patient was an in-patient). This discussion should include a documented statement which has been agreed between the patient (if appropriate), their family and the doctor in charge to clarify what action to take in event of a severe transfusion reaction. Additional information devised by the PMT is available to give to patients and their parents, see appendix 4

7.1 If not already received, give National Blood Service information leaflet “Will I need a blood transfusion” or “Will your child need a transfusion”14.5

7.2 Inform patient / parent / carer to report by phone any adverse events in the following 24-48hrs to the PMT Nurse

8. Pre-administration bedside check

8.0 The member of staff administering the red cells must perform the pre-administration bedside check

8.1 Inspect the unit(s) for leakage, unusual colour, unusual cloudiness or particulate matter. If any of these are present, the unit(s) must not be used and must be returned to Blood Bank

8.2 Read and take note of any special labels or instructions attached to the unit(s) or printed on the compatibility label

8.3 Positively identify the patient before transfusion. Patients should wear a patient identification wristband (or risk assessed equivalent) at home whilst blood is infusing14.10. The patient’s identification will be checked verbally with the patient against the unit(s) of red cells, the compatibility label and the wristband (or risk assessed equivalent) including their full name and date of birth. The NHS number or hospital number will be checked between the unit(s) of red cells and the compatibility label. If the patient is unable to identify themselves the verbal patient identification check will made with a parent / carer. If there are any discrepancies the unit(s) must not be transfused and must be returned to Blood Bank.

8.4 The ABO, RhD blood groups and the National Blood Service donation number on the unit must be checked and found identical to that on the compatibility label. The blood group on the unit must be compatible with the blood group of the patient indicated on the compatibility label, if in doubt contact Blood Bank

8.5 The unit(s) must be checked for compliance with any special requirements on the prescription e.g. irradiated, HEV negative

8.6 The unit(s) must be checked cool box transport slip to ensure it has not passed its expiry date and must not have exceeded the 3-4 hours expiry from dispatch

8.7 If any discrepancies are found during the bedside check process the unit must not be transfused and Blood Bank must be contacted

9. Administration of red cells

9.0 IV access to administer red cells will be via the patients central venous access device i.e. Hickman line or Portacath as per LTHT “Guideline for Insertion, Management, Replacement and Removal of Central Venous Catheters in Adults and Children”14.1

9.1 The lid of the cool/transportation box must only be opened to remove one unit of red cells at a time and then be firmly closed between each access

9.2 Each unit of red cells must be administered via a blood administration set over a 4 hour maximum period

9.3 ALL units of red cells MUST be completely transfused within 8 hours of the dispatch of the units from Blood Bank14.3

9.4 A medical device for administration may be used if approved for blood product use by the manufacturer and a compatible blood administration set is used

10. Monitoring the patient

10.0 The person administering the red cells will remain with the patient throughout the transfusion and for a period of 30 minutes after completion of transfusion

10.1 Observations should be performed and recorded as per “LTHT Safer Transfusion Policy”14.2

Pre-transfusion

Temperature, Pulse, Blood Pressure, Respiration rate

15 minutes

Temperature, Pulse, Blood Pressure

Completion

Temperature, Pulse, Blood Pressure

Or in the event of a mild reaction, any additional observations will be at the discretion of the MacMillan Nurse.

11. Actions required in the event of a transfusion reaction

11.0 The decision regarding the extent of treatment to given to an individual patient will be made by the consultant according to the PMT protocols and should be clearly documented

11.1 Minor reactions can be defined as small temperature rises (< 2oC from baseline) and / or urticarial rashes

11.2 Actions to be taken in the event of a minor transfusion reaction:

  • Stop the transfusion
  • Treat mild temperatures with paracetamol
  • Treat urticarial rashes with an appropriate anti histamine such as chlorphenamine
  • Re-commence the transfusion at a slower rate (taking into account the 4 hour limit)

11.3 A major reaction is usually recognised by unexplained sharp pain in the drip vein or loins, by a rise in temperature (greater than 2°C), by shock (low blood pressure (see Appendix 2) and fast thready pulse) or breathing problems

11.4 Actions to be taken in the event of a major transfusion reaction:

  • Stop transfusion immediately
  • Maintain the patency of the line with sodium chloride 0.9% (normal saline)
  • Immediate medical assistance must be sought. Transfer to hospital may need to be arranged as per PMT protocols (discuss with doctor in charge)
  • Check the patients identification details with those on the donor unit and compatibility label
  • Closely monitor and record the patient’s temperature, pulse, blood pressure, respirations and urine output (urine may become red or dark brown from free haemoglobin, or production may stop if there is renal failure)
  • Inform Blood Bank, return the donor unit(s) and obtain any samples requested as soon as possible
  • Further action will be dependent on type of reaction, management advice see ‘Reaction Flowchart’ - see section 15.3 & for suggested drug doses see appendix 2 or refer to Appendix 1 (Anaphylaxis Algorithm) in the LTHT Guideline for the Management of Anaphylaxis in Children)
  • Complete Datix web incident report and mark it for the attention of a member of the Hospital Transfusion Team (Fran Hartley, Sue Rabett or Jennifer Rock)

12. Disposal of clinical waste

12.0 Empty or wasted donor bags must have the used portal sealed with the blue bung and then be placed in a clinical waste plastic bag. This should then be returned to ward L31 or Children’s Day Hospital LGI and immediately disposed as clinical waste as per LTHT “Standard Infection Prevention and Control Precautions”14.6

12.1 Other clinical waste / sharps must be disposed as per LTHT “Standard Infection Prevention and Control Precautions”14.6

12.2 In the event of a blood component spillage the person administering the red cells must clean the spillage using a biohazard spillage kit as per LTHT “Standard Infection Prevention and Control Precautions”14.6

13. Documentation

13.0 The staff authorising the red cells must document in the medical notes the type and volume of the product to be transfused, the date and approximate time to be transfused, the indication for administration (transfusion stamp may be used). They should also complete the transfusion authorisation chart as per item 3.1

13.1 On completion of the bedside check the administering nurse will sign, and complete date and time details against the administered unit on the transfusion authorisation chart, which must be kept readily available during the transfusion.

The donation number, date, start and stop time of administration, volume transfused and signature must be completed on the transfusion authorisation chart, (the sticker on the compatibility label may be used to record the donation number on the authorisation chart). The authorisation chart must then be filed in the medical notes

N.B. On completion of the transfusion the statement on the back of the manila compatibility label MUST be signed and returned to the issuing Blood Bank to comply with the Blood Safety & Quality Regulations 2005 (UK traceability law)14.7 and the transfusion authorisation chart signed to confirm the completed compatibility label has been returned to the issuing Blood Bank.

13.2 The nurse administering the red cells must record in the patient’s progress notes the entire transfusion episode; including details of type and volume of product transfused, observations performed and any adverse reactions and subsequent treatment given

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Provenance

Record: 4892
Objective:

Aims
To improve the management of home transfusion of red cells for paediatric palliative care patients under the Paediatric MacMillan Team

Objectives
To provide evidence-based recommendations for appropriate diagnosis, investigation and management of home transfusion red cells in paediatric palliative care patients under the Paediatric Macmillan Team

Clinical condition:

All paediatric palliative care conditions

Target patient group: Paediatric MacMillan Team Palliative Care Patients
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

14.0 EQMS BBFORM 0141; available via LTHT Blood Bank

14.1 Leeds Teaching Hospitals Guideline for Insertion, Management, Replacement and Removal of Central Venous Catheters in Adults and Children

14.2 Leeds Teaching Hospitals Policy to Safer Transfusion Policy.

14.3 BBSOP Issuing blood and blood components at LGI [BBSOP0076]
BBSOP Routine Crossmatching of blood [BBSOP0132]
BBSOP Out of Hospital Blood Transfusions (Transfusion at Home)
[BBSOP0102]; available via LTHT Blood Bank

14.4 Leeds Teaching Hospitals NHS Trust policy: Written Informed Consent for Transfusion of Blood & Blood Components

14.5 NHS Leaflet “Will I need a blood transfusion” / “Will your child need a blood transfusion” – supplied in clinical areas or available from HTT

14.6 Leeds Teaching Hospitals Standard Infection Prevention and Control Precautions

14.7 Blood Safety & Quality Regulations SI 50/2005. See http://www.legislation.gov.uk/uksi/2005/1098/made

14.8 “Handbook of Transfusion Medicine” – Fifth Edition, 2013. See http://www.transfusionguidelines.org.uk/transfusion-handbook

14.9 Leeds Teaching Hospitals “Guideline for the Use of Irradiated and HEV negative and CMV negative Blood Components, 2016.

14.10 British Committee for Standards in Haematology: Administration of Blood Components, Harris A. et al 2009.
See section 17: http://www.b-s-h.org.uk/media/5152/admin_blood_components-bcsh-05012010.pdf

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Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Appendix 1

Pre-medication doses (if required after discussion with authorising consultant) see below suggested IV or if preferred oral doses.

Chlorphenamine (slow IV)  
Children aged less than 6 months 250 micrograms/kg (max 2.5mg)
Children aged 6 months – 6 years 2.5mg
Children aged 6 – 12 years 5mg
Children aged over 12 years 10mg
   
Chlorphenamine (Oral)  
Children 1 month - 6 years 1mg
Children aged 6 – 12 years 2mg
Children aged over 12 years 4mg
   
Hydrocortisone (slow IV)  
Children aged less than 6 months 25mg
Children aged 6 months - 6 years 50mg
Children aged 6-12 years 100mg
Children aged over 12 years 200mg

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Appendix 2

Severe allergic reaction doses (seek senior help, transfer patient to the nearest hospital). See also: Appendix 1 (Anaphylaxis Algorithm) in the LTHT Guideline for the Management of Anaphylaxis in Children)

Doses of Adrenaline:
(1:1000 solution IM) Doses may be repeated several times if necessary at 5 minute intervals according to blood pressure, pulse and respiratory function, suitable syringe to be used for measuring small volume; injected preferably into the anterolateral aspect of the middle third of the thigh

Children aged less than 6 years 150 micrograms IM (0.15ml)
Children aged 6 – 12 years 300 micrograms IM (0.3ml)
Children aged over 12 years 500 micrograms IM (0.5ml)

Doses of Chlorphenamine:
(slow IV over 1 minute)

Children aged less than 6 months 250 micrograms/kg (max per dose 2.5mg)
repeated if necessary; maximum 4 times per day
Children aged 6 months – 6 years 2.5mg
repeated if necessary; maximum 4 times per day
Children aged 6 – 12 years 5mg
repeated if necessary; maximum 4 times per day
Children aged over 12 years 10mg
repeated if necessary; maximum 4 times per day

 

Doses of Hydrocortisone:
(slow IV over 1 minute)

Children aged less than 6 months Initially 25 mg IV: 3 times a day, adjusted according to response
Children aged 6 months – 6 years Initially 50mg IV: 3 times a day, adjusted according to response
Children aged 6 – 12 years Initially 100mg IV: 3 times a day, adjusted according to response
Children aged over 12 years Initially 200mg IV: 3 times a day, adjusted according to response


Normal blood pressures (systolic) NB: hypotension is often a very late sign of shock

Age < 1 years 70 – 90 mmHg
1 - 5 years 80 – 100 mmHg
5 – 12 years 90 – 110 mmHg
> 12 years 100 – 120 mmHg

*The above drug doses for treating severe allergic reaction have been approved by the LTHT Paediatric Pharmacy Department & by the LTHT Paediatric Drugs & Therapeutics Committee.

Blood Bank Contact Number:
Leeds General Infirmary, telephone: 0113 392 3398

NB: traceability records must be returned to LGI Blood Bank. All empty blood bags must be returned to the appropriate LGI ward and immediately disposed.

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Management of a severe acute transfusion reaction (paediatric) –from “Handbook of Transfusion Medicine” Fifth Edition, 2013. 14.8   See also: Appendix 1 (Anaphylaxis Algorithm) in the LTHT Guideline for the Management of Anaphylaxis in Children)

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Appendix 4: Information for Parents / Patients having Home Blood Transfusion

The role of blood component support at home will be discussed by your consultant and your Macmillan Liaison Clinical nurse Specialist. It will only be undertaken if attending the outpatient department / ward is not feasible i.e. pain is not well controlled, transport issues etc.

It is also important to note that although blood is given to improve symptoms and improve quality of life, there may come a time in the patient’s palliative care when receiving a transfusion is not appropriate or in their best interest; this will again be discussed with you by your consultant and Macmillan Nurse.

Having blood does carry a number of possible risks, i.e. allergic reactions, temperatures and if the person requiring a transfusion has had a history of transfusion reactions then it would not be appropriate to carry out a transfusion at home.

Nursing staff in the community do not have access to all the emergency equipment and drugs that outpatient / ward areas have, it is therefore vital to establish a full history of previous transfusions with no adverse effects.

However, some patients may have a pre-medication prior to the transfusion to reduce the risk of allergic reaction and have access to further medication if required and agreed to prior to receiving the transfusion.

We need to ensure that all patients and parents fully understand the benefits and potential risks associated with having blood transfusions at home.

All parents and patients will therefore need to sign a consent form for the use of blood transfusions in the home setting.

If you have any further questions regarding this then please contact your Liaison Nurse or Consultant.

Appendix 5

Process Monitoring Audit Tool

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The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.