Handling, Storage and Transfusion of Blood Samples and Components during COVID-19

Publication: 22/09/2020  --
Last review: 01/01/1900  
Next review: 22/09/2023  
Standard Operating Procedure
CURRENT 
ID: 6642 
Supported by: Hospital Transfusion Committee
Approved By: Clinical Advisory Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

This Standard Operating Procedure 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.

Sandard Operating Procedure
Handling, Storage and Transfusion of Blood Samples and Components during COVID-19

Lead Author: Stephanie Ferguson - Transfusion Practitioner - July 2020

To continue to comply with Government guidelines - Infection prevention and control COVID-19 management checklist, version 1.2 (22 May 2020) https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control the Leeds Teaching Hospitals NHS Trust has developed and implemented a guideline “Principles to support staff cohorting within Leeds Teaching Hospitals” July 2020. This guidance includes the following:

Staff cohorting is an augmentation to the appropriate use of PPE, hand hygiene and environmental cleaning and is intended to further reduce the risk of Covid-19 transmission as outlined in the above guidance within Leeds Teaching Hospitals.

Patient swab testing is undertaken on all in patients in LTHT and allows for cohorting or isolation of patients according to their Covid-19 status and/or clinical specialty presentation.
As the current prevalence of Covid 19 positive patients in Leeds Teaching Hospitals is now low one general ward has been designated for patients who are confirmed as Covid positive.

If the prevalence rate increases either in the general or hospital population then cohorting patients by increasing the number of “confirmed” wards will be appropriate.

This SOP will provide transfusion information based upon the cohorting and isolation guidance provided in the aforementioned document.

Please see Appendix 1 for details on how bed holding CSU’s have organised their services.

Please see Appendix 3 for “quick guide” posters. These are intended to provide a quick guidance for each area and should be printed, laminated and placed near ward computers, satellite blood fridges and other appropriate areas around the ward environment.

Contents

Samples and Transfusion Request Forms

  • Samples received in the Blood Bank laboratory from confirmed or query COVID +ve patients must be double bagged with a Danger of Infection sticker and written notification of “COVID +ve” or “? COVID” to alert the laboratory staff to take the required precautions.
  • Patients must have an ID wristband and the policy for positive identification of a patient and labelling of a transfusion sample MUST be adhered to.

Please refer to Leeds TH Trust Safer Transfusion Policy via Leeds Health Pathways.

  • The request form MUST be labelled with the patient’s:
    • Full name
    • Date of birth
    • Unique ID number
    • Location
    • Clinical condition
    • Contact details of requesting practitioner
    • Number of blood units required (Red Blood Cells)
    • Danger of infection notification and written notification of “COVID +ve” or “? COVID”
  • Date and time sample was taken
  • Signature of person collecting and labelling the sample
  • The sample MUST be labelled with the patient’s core identifiers:
    • Full name
    • Date of birth
    • Unique ID number

As well as:

  • Date and time sample was taken
  • Location
  • Signature of person collecting and labelling the sample

The sample should be delivered to the Blood Bank by hand or sent to the laboratory via the air tube. Air Tube numbers are:

  •  
    • LGI -194
    • LGI point-to-point -4
    • SJUH-1003

Issuing of Blood (RBCs) and other blood components

  • The Blood Bank staff will process the sample and cross match the blood as per BBIFU030 version 1.2 - Instructions for Use - Handling and testing infection risk samples in Blood Bank.
  • The blood (RBCs) will be stored in the Blood Bank fridge until requested by the clinical area.
  • Blood (RBCs) issued for query or confirmed COVID +ve patients will be individually sealed in a clear bag by blood bank staff.
  • Acute theatres and A+E satellite blood fridges will continue to hold stock of Emergency O Rhesus Negative RBCs as per current practice.
  • All blood (RBCs) for issue to acute theatres and A+E regardless of their categorisation will be individually sealed in a clear bag by blood bank staff.
  • Satellite blood fridges MUST also have a categorisation poster affixed to them to ensure it is clear to all staff who may be accessing them which guidance to follow. It is the responsibility of the senior staff in charge of the area with the satellite blood fridge to ensure this is done and checked each day. The fridge categorisation MUST match that of the clinical area and any changes are to be immediately communicated to the blood bank lab staff.
  • The relevant “quick guide” information MUST also be available in close proximity to the satellite blood fridge.
  • RBCs must only be removed from the sealed clear bag at the point of transfusion following the completion of all pre administration checks.
  • All components should be “end transfusion” fated on the ward where possible as per categorisation guidelines.
  • All blood for Chapel Allerton Hospital and Wharfedale General Hospital will be issued in clear sealed bags and guidance should be followed as per instructions below.
  • Emergency O Rhesus Negative blood will be sealed and stored in blood bank prior to request so as not to cause delay when needed in an emergency.

Please be aware:-

  • ONLY RBCs will be sealed in clear bags. FFP, Platelets and Cryoprecipitate will continue to be issued without a clear bag. Collection, storage and handling guidelines for ALL components, as detailed below in the “Collection, Storage, Handling and Transfusion of Blood (RBCs) and other components” section MUST be adhered to.

Collection, Storage, Handling and Transfusion of Blood (RBCs) and other components

  • Blood (RBCs) and other components for a Confirmed area:
    • The laboratory staff will send ONE unit to the area when request by that clinical area (LGI) or
    • Request placed on carps requesting that only ONE unit be delivered to that area for the named patient or
    • A trained member of the clinical team will remove ONE unit of blood (RBCs) from the blood bank or local satellite fridge / collect ONE blood component from blood bank lab and deliver to the clinical area immediately.
    • Blood (RBCs) and blood components should be transported in a green carrier bag - which can be disposed of following arrival on the ward.
    • Blood should not be sent to a Confirmed area in a blood transport box.
    • Blood components must be scanned as per policy by trained staff using the BloodTrack system.
    • End Fating of a Unit should be completed before entering the room to administer using the blood tack autofate system. Ensure to document on PPM+ if anything changes or anything of note happens e.g. whole unit not transfused; query transfusion reaction.
    • If unable to scan the unit as per above or if requested by the Blood Bank lab please return the brown tag ONLY; double bagged and sealed with a danger of infection sticker attached as per sample guidance.
    • Please contact the blood bank lab or HTT with any other ‘fating’ queries.
    • In case of an emergency in a Confirmed area where the Major Haemorrhage Protocol is activated all required components will be issued together.
    • Blood (RBCs) and blood components must only be requested on CARPS or collected when the patient is fully ready to receive the transfusion.
    • RBCs must only be removed from the sealed clear bag at the point of transfusion following the completion of all pre administration checks.
  • Blood (RBCs) and other components for an Assessment area:
    • The laboratory staff will send ONE unit to the area when request by that clinical area (LGI) or
    • Request placed on carps requesting that only ONE unit be delivered to that area for the named patient or
    • A trained member of the clinical team will remove ONE unit of blood (RBCs) from the blood bank or local satellite fridge / collect ONE blood component from blood bank lab and deliver to the clinical area immediately.
    • Blood (RBCs) and blood components should be transported in a green carrier bag - which can be disposed of following arrival on the ward.
    • Blood should not be sent to an Assessment area in a blood transport box.
    • Blood components must be scanned as per policy by trained staff using the BloodTrack system.
    • End Fating of a Unit should be completed before entering the room to administer using the blood tack autofate system. Ensure to document on PPM+ if anything changes or anything of note happens e.g. whole unit not transfused; query transfusion reaction.
    • If unable to scan the unit as per above or if requested by the Blood Bank lab please return the brown tag ONLY; double bagged and sealed with a danger of infection sticker attached as per sample guidance.
    • Please contact the blood bank lab or HTT with any other ‘fating’ queries.
    • In case of an emergency in an Assessment area where the Major Haemorrhage Protocol is activated all required components will be issued together.
    • Blood (RBCs) and blood components must only be requested on CARPS or collected when the patient is fully ready to receive the transfusion.
    • RBCs must only be removed from the sealed clear bag at the point of transfusion following the completion of all pre administration checks.
  • Blood (RBCs) and other components for a Non Elective / Urgent Elective area:
    • RBCs will NOT be issued in sealed clear bags.
    • The laboratory staff will send ONE unit to the area when request by that clinical area (LGI) or
    • Request placed on carps requesting that only ONE unit be delivered to that area for the named patient or
    • A trained member of the clinical team will remove ONE unit of blood (RBCs) from the blood bank or local satellite fridge / collect ONE blood component from blood bank lab and deliver to the clinical area immediately.
    • Blood (RBCs) and blood components should be transported in a green carrier bag - which can be disposed of following arrival on the ward.
    • The blood bank must be contacted if more than one blood (RBCs) is required in a Non Elective / Urgent Elective area and needs transport via a blood transport box.
    • Blood components must be scanned at each stage as per policy by trained staff using the BloodTrack system.
    • In case of an emergency in a Non Elective / Urgent Elective area where the Major Haemorrhage Protocol is activated all required components will be issued together.
    • Blood (RBCs) and blood components must only be requested on CARPS or collected when the patient is fully ready to receive the transfusion.
    • Non Elective / Urgent Elective areas with a satellite blood fridge can store and access RBCs as per policy.
  • Blood (RBCs) and other components for a Planned Elective area:
    • RBCs will NOT be issued in sealed clear bags.
    • Blood (RBCs) and blood components should be transported in a green carrier bag - which can be disposed of following arrival on the ward.
    • The blood bank must be contacted if more than one blood (RBCs) is required in a Planned Elective area and needs transport via a blood transport box.
    • Blood components must be scanned at each stage as per policy by trained staff using the BloodTrack system.
    • In case of an emergency in a Planned Elective area where the Major Haemorrhage Protocol is activated all required components will be issued together.
    • Blood (RBCs) and blood components must only be requested on CARPS or collected when the patient is fully ready to receive the transfusion.
    • Planned Elective areas with a satellite blood fridge can store and access RBCs as per policy.

  • Blood (RBCs) and other components for a Speciality area:
    • RBCs will NOT be issued in sealed clear bags with the exception of RBCs requested for query or confirmed COVID-19 patients.
    • Blood (RBCs) and blood components should be transported in a green carrier bag - which can be disposed of following arrival on the ward.
    • The blood bank must be contacted if more than one blood (RBCs) is required in a Speciality area and needs transport via a blood transport box.
    • Blood components must be scanned at each stage as per policy by trained staff using the BloodTrack system.
    • In case of an emergency in a Speciality area where the Major Haemorrhage Protocol is activated all required components will be issued together.
    • Blood (RBCs) and blood components must only be requested on CARPS or collected when the patient is fully ready to receive the transfusion.
    • Speciality areas with a satellite blood fridge can store and access RBCs as per policy.
    • End Fating of a blood component for query or confirmed COVID-19 patients should be completed before entering the room to administer using the blood tack autofate system. Ensure to document on PPM+ if anything changes or anything of note happens e.g. whole unit not transfused; query transfusion reaction.
    • If unable to scan the unit as per above or if requested by the Blood Bank lab please return the brown tag ONLY; double bagged and sealed with a danger of infection sticker attached as per sample guidance.
    • Please contact the blood bank lab or HTT with any other ‘fating’ queries.
    • For query or confirmed COVID-19 patients RBCs must only be removed from the sealed clear bag at the point of transfusion following the completion of all pre administration checks.

Fating

The fating of ALL blood components is a legal requirement. Following the transfusion of the blood component the unit MUST be fated as “END TRANSFUSION” as per the specific category guidance detailed in the “Collection, Storage, Handling and Transfusion of Blood (RBCs) and other components” section.

Units that have not been transfused

  • Units of RBCs in a Confirmed area:
    • If the seal of the clear bag remains intact and there is no visible damage the bag may be cleaned with Trust approved disinfectant wipes and returned to a Confirmed satellite blood fridge or returned to blood bank in a green transport bag. The lab should be notified that the Unit is being returned and the transport must be completed within the approved timeframe as per Trust guidelines.
    • If the seal has been broken or the clear bag damaged the blood bank lab must be informed. Advice will be given and the area will be informed if the Unit must be wasted in the clinical area or if another clear bag will be sent to allow the unit to return to the lab for quarantine. This will depend upon the extent of the damage to the original sealed clear bag.
  • Units of RBCs in an Assessment area:
    • If the seal of the clear bag remains intact and there is no visible damage the bag may be cleaned with Trust approved disinfectant wipes and returned to an Assessment satellite blood fridge or returned to blood bank in a green transport bag. The lab should be notified that the Unit is being returned and the transport must be completed within the approved timeframe as per Trust guidelines.
    • If the seal has been broken or the clear bag damaged the blood bank lab must be informed. Advice will be given and the area will be informed if the Unit must be wasted in the clinical area or if another clear bag will be sent to allow the unit to return to the lab for quarantine. This will depend upon the extent of the damage to the original sealed clear bag.

  • Units of RBCs in a Non Elective / Urgent Elective area:
    • RBCs may be returned to storage as per current Trust guidance.
  • Units of RBCs in a Planned Elective area:
    • RBCs may be returned to storage as per current Trust guidance.

  • Units of RBCs in a Speciality area:
    • For query or confirmed COVID-19 patients if the seal of the clear bag remains intact and there is no visible damage the bag may be cleaned with Trust approved disinfectant wipes and may be returned to the Speciality satellite blood fridge or returned to blood bank in a green transport bag. The lab should be notified that the Unit is being returned and the transport must be completed within the approved timeframe as per Trust guidelines.
    • If the seal has been broken or the clear bag damaged the blood bank lab must be informed. Advice will be given and the area will be informed if the Unit must be wasted in the clinical area or if another clear bag will be sent to allow the unit to return to the lab for quarantine. This will depend upon the extent of the damage to the original sealed clear bag.
    • RBCs issued for COVID -ve patients may be returned to storage as per current Trust guidance.

Please be aware:

  • If sealed RBCs are stored in a fridge to cover emergency situations and are labelled with “UNKNOWN PATIENT” they can remain in that blood fridge until the expiry date noted on the individual unit.
  • All blood (RBCs) in the satellite blood fridges within acute theatres and A+E regardless of their categorisation will be individually sealed in a clear bag by blood bank staff. These units CAN be cleaned with Trust approved disinfectant wipes and placed back into satellite fridges as the risk of cross contamination is minimal as all units are held in sealed clear bags.

Appendix 1

A. Confirmed - clinical areas or side rooms caring for patients who are confirmed as Covid positive

B. Assessment - clinical areas where patients are being assessed and who are waiting for Covid swab results

C. Non-elective and urgent elective - clinical areas that are caring for non- elective patients or patients that have come into hospital in a planned but urgent way where they are either confirmed Covid negative and are not displaying any symptoms, or are in isolation in a single room awaiting a test result (this is the same as an indeterminate status) - these patients are within the incubation period and could become positive during their inpatient stay.

D. Planned elective - clinical areas caring for elective patients that have had a confirmed Covid negative swab test 48hrs prior to their admission date and have self-isolated prior to admission

E. Specialty - clinical areas where, due to their specialist nature are likely to have patients from any of the above categories in with Covid +ve patients isolated in side rooms.



Appendix 2

Posters

These are intended to provide quick guidance for each area and should be printed, laminated and placed near ward computers, satellite blood fridges and other appropriate areas around the ward environment.

Satellite blood fridges MUST also have a categorisation poster affixed to them to ensure it is clear to all staff who may be accessing them which guidance to follow. It is the responsibility to the senior staff in charge of the area with the satellite blood fridge to ensure this is done and checked each day. The fridge categorisation MUST match that of the clinical area and any changes are to be immediately communicated to the blood bank lab staff.

Categorisation poster information can be found in Leeds Teaching Hospitals NHS Trust guideline “Principles to support staff cohorting within Leeds Teaching Hospitals” July 2020.
This document also includes order codes for each categorisation poster.

The designation guide poster and separate designation posters are available to order via the Trust Oracle system:

LTH3532 - Clinical Area COVID-19 Designation Signs Poster
LTH3527 - Confirmed Covid-19 Poster
LTH3526 - Assessment Covid-19 Poster
LTH3528 - Non-Elective / Urgent Elective Covid-19 Poster
LTH3529 - Planned Elective Covid-19 Poster
LTH3530 - Specialty Covid-19 Poster

Posters come in packs of 10 and have a 2-3 day turnaround.

Appendix 3

Quick guides are to be positioned around the clinical area and attached to satellite blood fridges

Provenance

Record: 6642
Objective:
Clinical condition:
Target patient group:
Target professional group(s): Allied Health Professionals
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Not supplied

Approved By

Clinical Advisory Group

Document history

LHP version 1.0

Related information

Not supplied

Equity and Diversity

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.