Blood Transfusion

The Blood Transfusion Laboratory at UHMN operates a zero tolerance policy on sample labelling.

Sample must be handwritten with the minimum details stated below:

• Surname (spelt correctly)
• Forename (spelt correctly)
• Date of Birth
• Unique identifier- this could be the hospital number or NHS number
• Signature of the person taking the sample

Ideally the sample should also include the patient’s sex and date and time of collection

Any samples not meeting the minimum requirements will be rejected and this will be recorded on the laboratory system

Poorly venepunctured blood samples can dramatically affect the results of a test. Some of the more common issues are listed below:

• Insufficient sample – appropriate volume blood tubes are supplied. Insufficient samples will mean an inability to test and delay in results and provision of blood products.
• Haemolysed sample - if the blood sample has been venepunctured using needle and syringe and a small gauge needle is used to pierce the lid of the Vacutainer tube, haemolysis may occur, especially if the blood is forced into the tube by pushing the plunger. Vacutainer tubes contain a vacuum that will naturally draw sufficient blood into the tube. Changing to a wider gauge needle before piercing the Vacutainer lid may prevent haemolysis. Haemolysed samples cannot be tested as signs of incompatibility between patient and donor may be masked.
• Samples delayed in transit – testing and therefore provision of blood products will be delayed. Significant delays may mean the sample is no longer suitable for testing.
• Clotted samples – samples not taken directly into the Vacutainer and mixed sufficiently may clot. Once clotted the red cells cannot be tested for the blood group and the sample will be unsuitable for testing.

Group and Save (G&S)

In all cases where it is possible that transfusion may be required, a G&S request should be sent to the Transfusion Laboratory (Please see section below on the Two Sample Rule to ascertain whether a further G&S sample is required).

This enables the blood group and antibody status of the patient to be determined so that red cells can be readily available if clinical circumstances change and crossmatching is required.

After testing, the serum is saved for a maximum of 6 days, although a new sample may be requested by the laboratory if the patient has been recently transfused. This is in accordance with BCSH guidelines.

Two Sample Rule

The two sample rule was introduced to comply with the Guidelines for Pre‐Transfusion Compatibility Procedures in Blood Transfusion Laboratories published by the British Committee for Standards in Haematology in 2012. 

What is the two sample rule?

Two blood group samples, taken from separate venepunctures must have been processed by the laboratory before blood components (red cells, plasma, cryoprecipitate, platelets or granulocytes) can be issued.

If there is a historical blood group already on file then only one sample is required for blood components can be issued.

Why was this rule introduced?

Wrong blood in tube (WBIT) is a 'never event' i.e. it should not happen; however on rare occasions it does. The consequences of transfusing somebody with blood of an incorrect blood group is very serious and can lead to serious morbidity and even mortality.

WBIT is a Serious Hazards of Transfusion (SHOT) reportable incident. 

How does the two sample rule work?

If the patient is not known to the blood transfusion laboratory then the two sample rule is invoked:

The two samples must come from separate venepuncture events and ideally should be carried out by two different people who have each carried out their own patient identification checks.

Separate request forms must be completed for each sample.

It is NOT acceptable to take two samples at one venepuncture event and send them to the blood transfusion laboratory on separate request forms. This will not negate the possibility of WBIT.

There is no limit on the time between samples as long as the Blood Transfusion laboratory have a historic blood group on record.

How will I know if a second sample is required?

If the blood transfusion laboratory requires a second sample then a lab comment will be added to the group & save request, this can be checked on ICM or ICE . If you are still unsure then please telephone The Blood Transfusion laboratory on 74946 (RSUH) or 4758(CH).

What happens in an emergency situation?

If blood is required in an emergency e.g. if the massive haemorrhage protocol has been invoked, the two sample rule will still apply and a second sample should be sent as soon as possible. The blood transfusion laboratory will complete all testing on the primary sample without delaying component issue. The second sample will be used for retrospective confirmation of the results.

For more information and reports relating to transfusion safety please visit www.shotuk.org 

Routine Crossmatch requests for Red Cells

If the patient is eligible for an electronic crossmatch, and a valid sample is available in the laboratory on the appropriate site (RSUH or CH), then red cells can be provided within approximately 15 minutes.

Full compatibility testing takes at least 45 minutes from receipt of request within the laboratory.

Routine requests, including those for elective surgical procedures, must reach the laboratory before 4pm on weekdays and 11am on Saturdays since considerable time is required to provide antigen negative crossmatched blood for those patients that require it. 

Inform the laboratory well in advance if the patient is known to have anomalous red cell antibodies, or if you are aware that blood has previously had to be obtained specifically from the National Blood Service.

Urgent Crossmatch requests for Red Cells

• when blood components are required urgently, the MO or delegated nurse responsible for the patient must contact laboratory staff.
• If a G&S request has already been despatched, telephone the appropriate laboratory (during routine hours) or bleep the duty Biomedical Scientist (out of hours). 
• If an urgent crossmatch is being sent during routine hours, telephone the laboratory (RSUH - 74950, CH - 4758) and send the sample via the air tube or porters.
• If an urgent crossmatch request is being sent outside of routine hours, bleep the out of hours BMS (RSUH - 390, CH - 4751) and send the sample via the air tube system or porters. NB The laboratory at County closes at 12 midnight. All urgent requests after this time should be directed to RSUH.
• To instigate use of the Major Haemorrhage bleep the laboratory (RSUH - 715, CH - 4751).

Maximum Surgical Blood Ordering Schedule (MSBOS)

The MSBOS lists the number of red cells routinely crossmatched for elective surgical procedures.

Its main advantages are a reduction in crossmatching workload for the Transfusion Laboratory, which reduce the response time for emergency requests, and more efficient use of blood stocks and a reduction in wastage.

A G&S or crossmatched red cells will be provided according to the UHNM surgical blood ordering tariff detailed in Trust Policy C03 'Blood Transfusion Policy Including Alternatives to Transfusion and Guidelines' and the Trust Surgical Guidelines

(For staff:

To access Trust Policies via the internal intranet under "Policies". 

To access the Trust Surgical Guidelines via the internal intranet follow A-Z> Clinicians> Clinical Guidance> Clinical guidelines and pathways> Surgical & Specialised> Surgical guidelines)

If the clinical circumstances indicate that extra blood may be required for a particular patient, extra units will be crossmatched provided the reason is clearly identified on the request form.

Requests for Blood Components (other than red cells) and Special Requirement Products

When blood components e.g. fresh frozen plasma (FFP) and platelets, or special requirement products e.g. irradiated red cells are required, this must be identified to the laboratory as early as possible since certain products have to be ordered from the National Blood Service, Birmingham. The request may be referred to a Consultant Haematologist.

In the event of an acute transfusion reaction, stop the transfusion immediately and report the incidence to the MO who will contact Haematology Medical Staff. 

Refer to the Guidelines on the Administration of Blood and Blood Components within the Medical and Surgical handbooks regarding the management of adverse reactions. 

The blood component which appears to have caused the reaction plus all other used or partially used products from the transfusion episode must be returned to the Transfusion Laboratory along with a post-transfusion group & save request detailing the transfusion reaction.

This will facilitate an investigation into the possible causes of the reaction.

All potential transfusion reactions must be reported to Transfusion nurse/practitioner to ensure appropriate actions are taken.

Any cases of suspected bacterial contamination must be immediately reported to NHSBT.

Royal Stoke University Hospital:

Medical advice on Blood transfusion or related issues can be obtained at all times;

• By contacting the duty clinician on bleep 15723 between 09:00 and 17:30 on weekdays.
• Outside these hours, by contacting switchboard (Internal 0, External 01782 715444), and asking for the Medical Haematologist on call.

County Hospital:

Medical advice on Blood transfusion or related issues can be obtained at all times;

• By contacting the duty clinician on bleep 15723 between 09:00 and 17:30
• Outside these hours, by contacting switchboard (Internal 0, External 01785 257731), and ask for the Medical Haematologist on call

It is essential that blood and blood products are stored correctly to minimise any adverse incidents from occurring:

• Blood must only be stored in authorised blood refrigerators
• Blood transfusions should be commenced no longer than 30 minutes from the time the unit was taken from the Blood fridge. 
• Fresh Frozen Plasma (FFP) must be used within 4 hours of thawing if stored at room temperature or within 24 hours if stored in an authorised blood fridge.
• Platelets should be kept agitated in The Blood Transfusion laboratory. They should not be collected until the department is ready to administer them to the patient.

Avoidable wastage of blood and blood products will generate a 'Wastage Report' and the units will be charged for. This is monitored by the Hospital Transfusion Committee.

The Blood Transfusion department will refer samples to the NHS Blood and Transplant Reference (NHSBT) Laboratories for the following tests:

• Complex antibody identification and complex crossmatches

Red Cell Immunohaematology (RCI)
NHSBT Birmingham
Vincent Drive
Birmingham
West Midlands
B15 2SG

• Platelet Immunology
• Heparin Induced Thrombocytopenia screen quantitation (H.I.T)

Histocompatibility & Immunogenetics (H&I)
NHSBT, Filton,
North Bristol Park
Northway
Filton
Bristol
BS34 7QH

The Transfusion Team assist in the development and implementation of the Trust Policy and Procedures for the Administration of Blood and Blood Components C03 designed to improve the safety and effectiveness of blood transfusion medicine within the Trust:

• Promote and provide advice and support to clinical teams on the appropriate use of blood to ensure that agreed protocols for the indications for transfusion of blood, plasma and platelets are adhered to.

• Implement the Hospital Transfusion Committee action plans including competency based training and assessment for all staff involved in blood transfusions.

• Invoke the investigation of blood transfusion-related incidents, monitors trends and introduces appropriate corrective actions through changes in Trust policies and procedures.

• Provide advice and support to patients (and their carers) requiring blood components.

Contact details

Mon – Fri  (8am – 5pm) 

Pager – either through switchboard, or Ange Salmon on 07623616520, Pam Irving on 07623929358 and Dionne Bentley on 07623950511

Email – All queries relating to traceability, training etc. – transfusion.team@uhnm.nhs.uk

Telephone – Transfusion Team office - 01782 (6)71909 or 01782 (6)71534. Voicemails may be left outside normal working hours.