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UWHC,UWMF,

Policies,Clinical,UW Health Clinical,General Care and Procedures,Blood Products

Blood and Blood Component Transfusion (Requiring Pre-Transfusion Testing) (2.2.6)

Blood and Blood Component Transfusion (Requiring Pre-Transfusion Testing) (2.2.6) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Blood Products

2.2.6


UW HEALTH CLINICAL POLICY 1
Policy Title: Blood and Blood Component Transfusion (Requiring Pre-Transfusion
Testing)
Policy Number: 2.2.6
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: May 16, 2017

I. PURPOSE

To assure the availability of blood and blood components when needed and to improve the safety of such
transfusions. This policy applies to inpatients and outpatients for the following products only: red blood cells,
white blood cells, platelet, and plasma blood components.

II. POLICY ELEMENTS

A. Obtain Informed Consent according to UWHC policy #4.17, Informed Consent for Blood Product
Administration prior to the administration of blood and/or blood components except in emergency situations.
The emergency exception is not to exceed 48 hours at which time a completed consent from the patient or
patient's authorized representative must be provided to the Blood Bank unless waived by the Transfusion
Service Attending Physician. Informed consent for transfusion will be documented on form UWH #1289139,
or other approved hospital form.
B. The completed form should be placed in the patient's medical record and a copy provided to the Blood Bank.
The Blood Bank staff will not release blood products unless they have seen appropriate documentation of
informed consent, except in emergency situations.
C. When caring for patients who refuse a blood transfusion refer to UW Health clinical policy #2.2.1, Caring for
Patients Who Refuse Blood Transfusions.
D. The appropriate credentialed healthcare provider completes the order for blood and/or blood components,
which must include an indication code. To reference hospital indication codes for blood products, refer
to Adult Indications and Pediatric Indications (Refer to Indications For Blood Product Transfusion – Adult –
Inpatient/Ambulatory and Indications for Blood Product Transfusion – Pediatric/Neonatal –
Inpatient/Ambulatory Clinical Practice Guidelines).
E. Anyone who transfuses blood products or verifies patient, blood product, and paperwork match are required
to have initial and annual training.
F. Transfusions may be administered only by physicians, advanced practice providers, registered nurses, non-
physician anesthetists, perfusionists, and ECMO specialists trained in blood administration by Nursing Staff
Education and Development or the Surgical Services Department.
G. All patients must have an identification band in place per UW Health clinical policy #3.2.1, Patient
Identification. Additionally, within Surgical Services follow Surgical Services policy #2.01, Admission of
Patients to Surgical Services and Requirements for Initiation of Surgical Procedures.
H. The patient must have one or more I.V. lines in place prior to picking up blood products.
I. Only appropriately trained healthcare providers are to draw blood specimens.
J. The specimen label (computer generated or computer downtime label) is checked/compared with patient's
ID band, and affixed to specimen AT RECIPIENTS SIDE (such as bed side) IMMEDIATELY AFTER BLOOD
HAS BEEN DRAWN. The information on the label must match that on the patient's ID Band i.e., patient's
last name, first name and medical record number. In addition, the conscious patient should be asked to state
their last name, first name, and spell their last name.
K. Stat -- Crossmatch complete in about one hour (if uncomplicated by antibodies).
Routine -- Crossmatch complete within 8 hours (if uncomplicated by antibodies).
L. If blood is needed before testing is completed, an appropriate credentialed healthcare provider must include
in the order that the blood is to be given without a crossmatch.
M. When blood products provided by referring hospitals are transported with incoming patients, any blood
products not being actively administered to the patient must be immediately brought to the Blood Bank.

III. PROCEDURE

A. TRANSMISSION OF THE ORDER TO THE BLOOD BANK.
i. The appropriate credentialed healthcare worker completes a Health Link/paper (computer
downtime use form UWH # 1280411) order specifying hospital indication code for transfusion,
blood or blood component to be transfused, number of units or transfusion instructions such as
volume in milliliters to be transfused, the time transfusion is to be initiated, flow rate(s), pre-



UW HEALTH CLINICAL POLICY 2
Policy Title: Blood and Blood Component Transfusion (Requiring Pre-Transfusion Testing)
Policy Number: 2.2.6

medications, blood warmers, etc. The request for blood products must also specify special product
requirements such as Cytomegalovirus (CMV) negative, irradiated, etc. The electronic order
generates a requisition that prints in the Blood Bank. When the computer is unavailable or not
functioning a paper request form (UWH #1280411) must be completed and sent to the Blood Bank.
ii. Red Blood Cell orders will be set up when a clinician releases the product order. Additional units
can be set-up upon order up to 23:59PM (midnight) to three days following specimen collection
[i.e., if collected anytime on Friday (=day 0) specimen will expire at 23:59PM (midnight) on Monday
(=day 3)].
iii. A technologist is on duty in the Blood Bank at all times to process emergency requests.
iv. Notification of Available Blood Products:
a. Cryoprecipitate: Several units are normally given at a time, and are "pooled" by the Blood
Bank into one bag. Pooling must be done shortly before administration. Blood Bank must
be notified by telephone (263-8367) approximately 30-60 minutes before the transfusion is
to begin; they will call the nursing unit when the product is ready for issue.
b. Plasma such as Fresh Frozen Plasma, 24 hour plasma, plasma cryoprecipitate reduced,
etc. notify the Blood Bank 30-60 minutes before administration.
c. Pediatric and neonatal divided or split units will take approximately 30 minutes to prepare.
B. BLOOD SAMPLES FOR TYPE & SCREEN AND CROSSMATCH.
i. A label (computer generated or computer downtime label) must be attached with identifying
information: patient's last name, first name, and medical record number.
ii. The identifying information on the label must exactly match the corresponding information on the
patient's identification band. If the patient has no ID band one should be applied at the time of
sample collection; the information on the specimen label must match the information on the
patient's ID band. In addition, the patient should be asked to state his last name, first name, and
spell his last name.
iii. The blood specimen label must include the date and time of collection. In addition, in order to
identify the blood drawer, the label must include one of the following: employee identification
number (preferred); full name (print) and title; or network login identification (for physicians) e.g.,
BXL02. The employee identification number, full name, or network login identification of the blood
drawer indicates information on the specimen/label has been checked against patient's ID band
and matches exactly.
a. NOTE: The Joint Commission requires that "the blood sample drawn from the recipient for
typing and crossmatching must be LABELED IMMEDIATELY AND ADEQUATELY AT
THE RECIPIENT'S SIDE, such as bedside, in order to maintain certainty of identification
throughout all subsequent testing." IN NO CASE SHOULD AN UNLABELED TUBE OF
BLOOD BE TAKEN FROM THE AREA TO ANOTHER AREA FOR LABELING.
iv. Laboratory personnel (blood drawing team) obtain blood specimens for crossmatching and typing
during regular hours (5:00AM to 11:00PM) for nonemergency inpatient transfusions. Outpatient
drawing hours: See Phlebotomy Services on U-Connect.
v. If testing is needed sooner than a blood specimen can be collected by the blood drawing team; an
appropriately trained healthcare provider may draw blood specimens.
vi. If a patient receives transfusions of red blood cells, s/he may be immunized to one or more red
blood cell antigens and new antibodies may appear in his/her blood within a few days. Therefore,
the AABB and the FDA require use of recipient samples less than 3 days old for all pre-transfusion
testing if the recipient has been pregnant or transfused within the previous 3 months. Blood
products will be set-up just in time as orders are received in Blood Bank.
C. DISPENSING OF BLOOD OR COMPONENTS FROM THE BLOOD BANK.
i. Start IV, if needed, according to Nursing Patient Care policy #1.23, Continuous Peripheral
Intravenous Therapy.
ii. The person requesting blood products to be dispensed releases blood product order that will print
in Blood Bank, include tube station ID so that Blood Bank knows where to send blood product.
During computer downtime complete a paper, "Request to Dispense Blood Product" form that
contains the following information: patient identification (including patient name, and medical record
number), name of product, number of units that will be dispensed/picked up in a given trip,
employee ID, physician requesting product, unit where product will be dispensed, and pneumatic
tube station number.
iii. The "Request to Dispense Blood Product" is tubed or taken to Blood Bank (during computer
downtime) and Blood Bank uses this information to dispense the product(s). Any



UW HEALTH CLINICAL POLICY 3
Policy Title: Blood and Blood Component Transfusion (Requiring Pre-Transfusion Testing)
Policy Number: 2.2.6

employee/volunteer may pick up the blood component. If blood products are to be dispensed
through the hospital pneumatic tube system you must include the pneumatic tube station number
on the "Request to Dispense Blood Product" form.
iv. Number of units released at one time is restricted, as follows, to minimize the chance of transfusing
a unit of blood to the wrong patient.
a. For routine patient use, no more than one unit of red cells will be issued at one time on
any patient by the Transfusion Service.
b. At the discretion of the Transfusion Service two units of red blood cells may be issued
without ice. Once the red blood cells are issued from the Transfusion Service both units
must be transfused within 4 hours. If a decision is made NOT to transfuse the unit(s) the
blood must be returned to the blood bank within thirty minutes of issue. Blood returned
after thirty minutes is quarantined until it can be discarded.
CAUTION: When two units are issued it is recommended that even the unopened unit be
hung on the I.V. pole to prevent the component from being separated from the
patient. Failure to follow this instruction may result in the unit being misplaced (causing
the red cell unit to expire prior to infusion) or inadvertently hung on another patient.
c. Exceptions will be made on request of an appropriately credentialed healthcare worker in
consultation with Transfusion Service.
D. STORAGE OF BLOOD AND COMPONENTS OUTSIDE OF THE BLOOD BANK.
i. Red blood cell and plasma products may be stored only in designated monitored refrigerators with
very rigid temperature regulations and alarms to indicate abnormal temperatures or in validated
coolers distributed by the Blood Bank. Surgical Services blood refrigerators shall be monitored
according to the AABB standards.
ii. Refrigerators anywhere else in the Hospital are not suitable for storage of blood. If the blood
transfusion is not started within 30 minutes, the blood should be returned to the Blood Bank. DO
NOT STORE BLOOD OR COMPONENTS IN PATIENT CARE UNIT REFRIGERATORS!
iii. DO NOT STORE PLATELET COMPONENTS IN ANY REFRIGERATORS! If the transfusion is not
started within 30 minutes, the platelets should be returned to the Blood Bank.
iv. When blood products provided by referring hospitals are transported with incoming patients, any
blood products not being actively administered to the patient must be immediately brought to the
Blood Bank.
a. NOTE: For Level 1 Traumas see UW Health clinical policy #5.1.10, Adult Trauma: Trauma
Team Response at University Hospital and UW Health clinical policy #5.1.11, Pediatric
Trauma.
E. BLOOD PRODUCTS ADMINISTRATION VERIFICATION.
i. Check the transfusion order to determine blood products to be transfused, number of units or
volume in milliliters, time the transfusion is to be initiated, flow rate, pre-medications if ordered, and
ancillary equipment such as a blood warmer. Also, check special blood product requirements such
as irradiation, CMV negative, etc.
a. NOTE: Do not irradiate or expose Stem Cells to radiation.
ii. Verify informed consent and reevaluate the medical condition of the patient.
iii. Assemble equipment.
a. All blood products must be transfused through a standard blood administration set, and /or
filter.
1. NOTE: Only transfuse Leukocyte concentrates through a standard administration
set. Do not transfuse through a depth-type microaggregate filter or leukocyte
reduction filter.
2. For neonates, the blood bank can provide aliquots in pre-filtered syringe sets that
do not require the use of the filtered blood administration set.
b. Normal saline is the only I.V. solution to prime and flush administration set.
c. Do not add medications to the blood bag or tubing including those intended for
intravenous use. Do not piggyback medications of any kind.
d. Blood warmer if ordered.
iv. Upon receipt of a blood product verify that you received the appropriate blood product with the
attached Unit Tag sticker and accompanying form UWH# 1280412 (e.g. computer downtime,
selected surgical services, level 1 traumas, etc). Inpatient and ambulatory units will not receive
form UWH# 1280412 when Health Link and Blood bank computer system are up because
verification steps will be done in Health Link.



UW HEALTH CLINICAL POLICY 4
Policy Title: Blood and Blood Component Transfusion (Requiring Pre-Transfusion Testing)
Policy Number: 2.2.6

v. Inspect blood for abnormal color and presence of clots. Turn bag upside down several times to
gently mix all contents. Return to Blood Bank immediately if abnormal in appearance.
a. NOTE: DO NOT STORE BLOOD OR COMPONENTS IN PATIENT CARE UNIT
REFRIGERATORS because regulated temperatures are essential.
vi. The transfusion must be started within 30 minutes after blood product leaves Blood Bank or be
returned to the Blood Bank.
vii. Take blood or blood component to bedside or patient area (in clinic). If appropriate, ask the patient
to state his/her full name, and if possible spell their last name.
viii. Prior to the start of transfusion: Two licensed individuals (for example RN-RN, RN-MD), must each
independently and separately verify by visual inspection that all information identifying the blood
product with the intended recipient has been matched, item-by-item, in the presence of the
recipient. (For exceptions to having two licensed personnel verify the blood refer to Surgical
Services policy #2.04, Blood and Blood Components - OR.) By dually verifying in Health Link or
signing the Record of Blood Transfusion, each individual attests that they have independently
looked at and verified each identifying piece of information listed under the verification steps below.
Date and time your signature. In addition, record one of the following: your employee identification
number (ID Number), printed full name, or network login ID (for physicians). If you find any
discrepancies in the identifying information, DO NOT START THE TRANSFUSION, and
immediately contact the Blood Bank at 263-8367.
ix. Verification Steps in Health Link only.
a. Each individual independently verifies the Patient's Name and Medical Record Number
ARE the SAME on:
1. Identification band
2. Unit Tag sticker
3. The patient’s medical record
b. Each individual verifies the donor blood type and unit number ARE the SAME on:
1. Blood or blood component bag,
2. Unit Tag sticker, and
3. The patient’s medical record
c. Verify from the Unit Tag sticker
1. The patient’s blood type *
2. The crossmatch (XM) test results (Red Cells and Granulocytes Only)
d. Verify the Expiration Date/Time on the Unit
* Note: The blood type between patient and donor may not always match, if unclear
please call Blood Bank at 263-8367or The American Center Laboratory at 234-6600 for
clarification.
x. Verification Steps in for use in IntraOp, Anesthesia, massive transfusion protocol (MTP), Level 1
Trauma, Code setting or during Health Link and/or Blood Bank computer system downtime.
a. Each individual independently verifies the Patient's Name and Medical Record Number
ARE the SAME on:
1. Identification band (except in O.R. follow policy 2.04)
2. Unit Tag sticker
3. Record of Blood Transfusion (form UWH# 1280412)
b. Each individual verifies the donor blood type and unit number ARE the SAME on:
1. Blood or blood component bag,
2. Unit Tag sticker, and
3. Record of Blood Transfusion (form UWH# 1280412)
c. Verify from the Record of Blood Transfusion (form UWH# 1280412)
1. The patient’s blood type *
2. The crossmatch (XM) test results (Red Cells and Granulocytes Only)
d. Verify special transfusion requirements (i.e. irradiated, CMV negative, etc.) and the
Expiration Date/Time on the Unit
* Note: The blood type between patient and donor may not always match, if unclear
please call Blood Bank at 263-8367 for clarification.
e. Each verifier records their signature plus employee ID number, printed full name or
network login ID (for physicians) in the space provided on form UWH# 1280412. Note:
Once dual sign-off is available in Health link these electronic signatures will indicate that
health care providers completed these verification steps..



UW HEALTH CLINICAL POLICY 5
Policy Title: Blood and Blood Component Transfusion (Requiring Pre-Transfusion Testing)
Policy Number: 2.2.6

F. DURING ADMINISTRATION OF BLOOD PRODUCTS.
i. The transfusionist records transfusion start date and time in Health Link (on the Record of Blood
Transfusion during computer downtime).
ii. The Unit Tag sticker must never be removed from blood bag prior to completion of the transfusion.
iii. Do not add medications to blood products or piggyback lines to the blood product infusion or
tubing.
iv. The transfusion must be started by a licensed person who has completed initial and annual training
for administering blood.
v. The licensed person who starts the transfusion must remain with patient for at least five (5) minutes
after transfusion has been started (as blood enters the body). Close observation (every 2-3
minutes) shall occur for an additional ten (10) minutes; observe for signs of immediate adverse
reaction to transfusion.
vi. The flow rate is adjusted according to the appropriate credentialed healthcare providers written
instructions.
vii. If a very rapid flow rate is required, trained personnel may initiate pressure infusion, either by use of
a rapid infusion device or a cuff.
a. NOTE: For instructions on the use of an Infusion Pump refer to Nursing Patient Care
policy #1.24, Alaris System.
viii. All vital signs must be recorded in Health Link (on the Record of Blood Transfusion during
computer downtime) except during use of rapid infuser, apheresis procedures, Surgical Services or
PACU in the operating room. Vital signs should be recorded pre transfusion, at 15 minutes ± 5
minutes after the start of the transfusion, and post transfusion (within one hour of completing
transfusion). Pre transfusion is defined as within 15 minutes before the start of transfusion. Spaces
are available to record additional vital signs and symptoms.
ix. The infusion site should be checked periodically for evidence of obstruction of the needle or
subcutaneous infiltration and flow rate should be maintained as specified by the appropriate
credentialed healthcare provider.
x. In general, transfusion of any blood product must be completed within 4 hours of being dispensed
and prior to the component expiration located on the product. Depending on the blood product, the
patient's size, cardiac status, blood volume status (bleeding versus congestive failure, etc.) the
infusion time may be short or long, but no longer than 4 hours. Therefore, the patient's appropriate
credentialed healthcare provider must individualize the order for each patient.
a. NOTE: If a unit of whole blood or red cells cannot be infused within 4 hours, e.g.,
Pediatrics, ask the Blood Bank to "split" blood product. The remaining portion of blood
product will be stored appropriately in the blood bank until needed. In most cases the
remaining portion will expire within 24 hours if not used.
xi. The administration set should be changed every 4 hours and not to exceed a maximum of 8 hours.
When hanging a subsequent product for infusion on the same tubing, one should consider: if the
administration will exceed the 4 hour limit and utilize a new administration set. More frequent
changes may be necessary as debris collects on standard in-line filters and impedes flow.
xii. The entire volume of platelet suspension including residual in tubing should be administered. If red
cells, whole blood, plasma or normal saline will follow platelet infusion, the lines must be flushed
with an adequate volume of normal saline to remove residual blood product.
xiii. The entire volume of cryoprecipitate solution should be infused. The bag may be rinsed and tubing
flushed with normal saline.
G. POST ADMINISTRATION OF BLOOD PRODUCTS.
i. The patient should be monitored for an hour following transfusion for signs of a delayed reaction. It
is strongly recommended that outpatients remain in the hospital area for this hour after transfusion.
If the patient refuses to stay after instruction of the importance, this should be documented in the
clinical record.
ii. Record information including date and time transfusion ended, volume transfused, and any reaction
in Health Link (or on Record of Blood Transfusion, form UWH# 1280412 during computer
downtime). If you answered yes to a transfusion reaction proceed to section J.
H. DISPOSAL OF EMPTY BLOOD PRODUCT BAG.
Place blood bags and blood administration sets in a plastic bag, then dispose of them as you would any
other biohazard waste.
I. RETURNING BLOOD PRODUCTS TO THE BLOOD BANK.
i. Blood bags are to be returned to the Blood Bank only under two conditions:



UW HEALTH CLINICAL POLICY 6
Policy Title: Blood and Blood Component Transfusion (Requiring Pre-Transfusion Testing)
Policy Number: 2.2.6

a. The entire blood product was not transfused, or
b. The patient has had a transfusion reaction.
ii. In the event the blood bag is to be returned to the Blood Bank, call Blood Bank and request a zip-
lock bag. Tie a knot in the administration tubing to prevent leakage, place bag and tubing in zip-lock
bag.
iii. If patient is in contact or droplet isolation, the outside of the labeled blood container(s) should be
wiped off with hospital disinfectant then placed in a zip-lock bag for return to Blood Bank. Place a
label with patient's identification on the outer bag.
J. TRANSFUSION REACTION FOLLOW-UP.
i. In the event of a transfusion reaction, vital signs and symptoms must be recorded in Health Link or
on the Record of Blood Transfusion (i.e. operating room, MTP, computer downtime, etc.).
ii. If the patient develops symptoms or signs suggestive of a transfusion reaction, if any other
unexpected change in condition is noted, or any transfusion error occurs the transfusion should be
stopped and the appropriate credentialed healthcare provider and the Transfusion Service (263-
8367)/The American Center Laboratory (234-6600) must be notified immediately. Print Transfusion
Reaction Worksheet (worksheet # 1566.4.13 F4) from link in Health Link or U-Connect.
iii. Follow instructions on Transfusion Reaction Worksheet and/or instructions below:
a. Transfusion should be stopped and physician notified immediately.
b. Administration tubing should be disconnected and sterility maintained, and new
administration set connected; keep the intravenous line open with slow drip of 0.9%
normal saline.
c. Recheck patient and donor unit identification, form UWH# 1280412, or patient’s chart to
determine that the correct patient is receiving the correct blood product. Initial, date and
time this entry on the Transfusion Reaction Worksheet.
d. The physician reporting a reaction must sign, date and time Transfusion Reaction
Worksheet.
e. Save all tubing and blood and return to Blood Bank for analysis.
f. Provider places order for transfusion reaction work-up labs (panel code O189984) which
includes Direct Antiglobulin Test; Hemoglobin Screen, Urine; and ABO & Rh typing. Note:
The keyword “reaction” can be used for an easier orders search.
g. If reaction occurs; call Blood Bank (263-8367), complete reaction section on form UWH#
1280412, Return completed Transfusion Reaction Worksheet to Blood Bank. If UWH #
1280412 was used, return a copy to Blood Bank.
h. Laboratory investigation will be performed by the Blood Bank if a transfusion reaction is
suspected.
i. Refer to appendices 1, 2, and 3 for possible signs and symptoms of a transfusion reaction,
risks of blood transfusion, and management of transfusion reactions.
K. TROUBLESHOOTING HEALTH LINK BLOOD ADMINISTRATION MODULE
i. Unable to scan blood product - Confirm that name on blood product matches name on your
computer. If not, call Blood Bank to resolve.
ii. Name on Blood product matches name on computer. Either Blood Bank forgot to complete product
issue step in HCLL or the interface is down between HCLL and Health Link or HCLL computer is
down. First, call Blood Bank to check the issue status of your blood product. If this doesn’t resolve
the situation Blood Bank should activate banner and call the Help Desk.
L. COMPUTER DOWNTIME
i. Health Link downtime – Blood Bank will need to send paper Record of Blood Transfusion with each
blood product. Dual verification of patient identification and blood product is done on paper.
ii. Interface between HCLL computer system and Health Link is down – Call Help Desk, activate
banner, and Blood Bank sends paper Record of Blood Transfusion with each blood product. Dual
verification of patient identification and blood product may need to be done on paper.
iii. HCLL computer system is down - Call Help Desk, activate banner, and Blood Bank hand writes
labels for blood product and Record of Blood Transfusion and sends paper Record of Blood
Transfusion with each blood product. Dual verification of patient identification and blood product will
need to be done on paper.
M. COMPUTER SYSTEM RECOVERY - send Record of Blood Transfusion to be scanned into patient record.
N. MONITORING OF BLOOD UTILIZATION.
The Tissue and Blood Products Committee, Transfusion Services, and Clinical Labs will monitor and
address transfusion practices in the following categories through evaluations and Patient Safety Net (PSN)



UW HEALTH CLINICAL POLICY 7
Policy Title: Blood and Blood Component Transfusion (Requiring Pre-Transfusion Testing)
Policy Number: 2.2.6

reports:
i. Ordering practices.
ii. Patient identification.
iii. Sampling collection and labeling.
iv. Infectious and noninfectious adverse events.
v. Near-miss events.
vi. Usage and discard.
vii. Appropriateness of use.
viii. Blood administration policies.
ix. The ability of services to meet patient needs.
x. Compliance with peer-review recommendations.
xi. Clinically relevant laboratory results.

IV. FORMS

UWH# 1280411 Transfusion Services Request (Manual/Computer Downtime Form)
UWH# 1280412 Record of Blood Transfusion
Transfusion Reaction Worksheet 1566.4.13 F4
Intake-Output form
ICU Flow Sheet
Hemodialysis Flow Sheet
Blood or blood component, as prescribed
Blood administration set (Y-type Blood Administration Set) or IV pump Blood Administration set 0.9% NS IV
solution
Appropriate Peripheral I.V. catheter Gauge for adults, e.g., 18-22 gauge, for children 20-24 gauge
Central venous catheter 18 gauge/4Fr or larger lumen size preferred for adult
Extension set with SafesiteÔ valve, as indicated
Protective replacement cap (blue dead end cap), as indicated

V. COORDINATION

Author: Director, Lab Services
Senior Management Sponsor: SVP/COO
Reviewers: none
Approval committees: Tissue and Blood Products Committee; Nursing Lab Committee; UW Health Clinical
Policy Committee
UW Health Clinical Policy Committee Approval: April 17, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

Appendix: Possible Signs and Symptoms of a Transfusion Reaction
Appendix: Risks of Blood Transfusion
Appendix: Management of Transfusion Reactions
Circular of Information for the Use of Human Blood, 2013



UW HEALTH CLINICAL POLICY 8
Policy Title: Blood and Blood Component Transfusion (Requiring Pre-Transfusion Testing)
Policy Number: 2.2.6

N Engl J Med Feb. 11, 1999; 438-447
Blood Supply: Risks, Dodd & Leiby; Annual Review of Medicine 2004
AABB Technical Manual 2014
CAP Transfusion Medicine Checklist, TRM.41025, 8/17/16
Surgical Services policy #2.04, Blood and Blood Components – OR
Surgical Services policy #2.01, Admission of Patients to Surgical Services and Requirements for Initiation of
Surgical Procedures
Nursing Patient Care policy #1.23, Continuous Peripheral Intravenous Therapy
Nursing Patient Care policy #1.24, Alaris System
UWHC policy #4.17, Informed Consent
UW Health clinical policy #2.2.1, Caring for Patients Who Refuse Blood Transfusions
UW Health clinical policy #3.2.1, Patient Identification
UW Health clinical policy #5.1.10, Adult Trauma: Trauma Team Response at University Hospital
UW Health clinical policy #5.1.11, Pediatric Trauma
21 CFR 606.151
UW Health Clinical Practice Guideline, Indications for Blood Product Transfusion – Adult –
Inpatient/Ambulatory
UW Health Clinical Practice Guideline, Indications for Blood Product Transfusion – Pediatric/Neonatal –
Inpatient/Ambulatory

VIII. REVIEW DETAILS

Version: Revision
Last Full Review: May 16, 2017
Next Revision Due: May 2020
Formerly Known as: UWHC policy #8.12