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Blood and Bone Marrow Transplant (BMT) Service Transfusion - Adult/Pediatric - Inpatient [50]

Blood and Bone Marrow Transplant (BMT) Service Transfusion - Adult/Pediatric - Inpatient [50] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols


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Delegation Protocol Number: 50

Delegation Protocol Title:
Blood and Bone Marrow Transplant (BMT) Service Transfusion - Adult/Pediatric - Inpatient

Delegation Protocol Applies To:
UWHC Inpatients: Patients admitted to the BMT service during their initial transplant and
recovery phase and located on inpatient units B6/6 or P4. This protocol does not apply to
patients being followed by the BMT service who are located on any other unit. Additionally, this
protocol does not apply to patients requiring temporary increases in thresholds for procedures,
or patients requiring HLA matched platelets.

Target Patient Population:
Patients on the BMT service who have hemoglobin values less than or equal to 8 grams/deciliter
and/or platelet counts less than or equal to 10,000/microliter for adult patients and
20,000/microliter for pediatric patients.

Delegation Protocol Champions:
Walter Longo, MD – Department of Medicine – Hematology/Oncology
Mark Juckett, MD – Department of Medicine – Hematology/Oncology
Ken DeSantes, MD – Department of Pediatrics – Hematology/Oncology

Delegation Protocol Workgroup:
Kari Stampfli, MS, RN, CPNP, APNP – Oncology – American Family Children’s Hospital
Vicki Hubbard, RN, Manager – Hematology/Oncology

Responsible Department:
Department of Nursing
Bone Marrow Transplant Service
Transfusion Services

Purpose Statement:
The ordering of red blood cells (RBCs) and platelets based on laboratory thresholds is delegated
from ordering providers to RNs. BMT patients have a predictable nadir during which they are at
risk for potentially fatal bleeding and serious anemia. In these patients who are already
clinically complicated, it is important to maintain platelet and RBC counts to help mitigate other
multi-system organ complications.

Who May Carry Out This Delegation Protocol:
Registered Nurses on B6/6 and P4 who are trained in the use of this delegation protocol.

Guidelines for Implementation:
1) Order (“Initiate BMT Service Transfusion Protocol”) within the BMT Admission order sets to
initiate this protocol PRN will be signed. Required questions will be answered to
communicate to the nurse:
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Page 2 of 2
a. Type of platelets
b. Platelet threshold
c. Premedications to be ordered for both platelets and RBCs
d. Post labs to be ordered
e. RBCs total volume in units and milliliters (Pediatrics only)
f. Platelets total units (Pediatrics only)
2) The nurse will monitor platelet count and hemoglobin and initiate the protocol when any of
the following conditions are met:
a. For Adults:
i. Hemoglobin less than or equal to 8 grams/deciliter
ii. Platelets less than or equal to 10,000/microliter
iii. Increased hemoglobin or platelet threshold as ordered per provider.
b. For Pediatrics:
i. Hemoglobin less than or equal to 8 grams/deciliter
ii. Platelets less than or equal to 20,000/microliter
iii. Increased hemoglobin or platelet threshold as ordered per provider.
3) The nurse will open the “IP - BMT - Blood Transfusion - Supplemental“ order set and select
the appropriate premedications and post labs as communicated to them via the “Initiate
BMT Service Transfusion Protocol” order, and the appropriate blood product and transfuse
order based on the lab values monitored.
4) If a type and screen has not been drawn within the past 72 hours, a BPA will fire to place the
order.
5) The nurse will sign the orders with an order mode of “Cosign required Protocol/Policy.”

References:
BMT Standard Operating Policy and Procedures: Located in UConnect Workspaces
• E1.100 Red Blood Cell Infusion Guidelines
• E1.200 Platelet Support Guidelines

Collateral Documents/Tools: NA

Approved By:
UWHC Nursing Practice Council: May 2011, July 2014 (expedited process)
UW Health Clinical Knowledge Management Council: May 2011, May 2014 (expedited process)
UW Medical Board: June 2011, August 2014 (expedited process)

Effective Date: August 2014

Scheduled for Review: August 2016
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org