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Blood and Blood Components - OR (2.04)

Blood and Blood Components - OR (2.04) - Policies, Clinical, UWHC Clinical, Department Specific, Surgical Services, Clinical

2.04

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

MAY 1991
ORIGINAL
 REVISION

APRIL 2015
PAGE 1
OF 7
POLICY #

2.04
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Operating Room
TITLE
BLOOD AND BLOOD COMPONENTS - OR


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 the following products: red blood cells, white blood cells, platelet and
plasma blood products.

It does not apply specifically to 25% albumin, 5% plasma protein fraction, factor VIII concentrates and factor IX
concentrates.

II. POLICY

A. Obtain Informed Consent according to Administrative 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 (Consent to Operations, Anesthetics, Diagnostic Radiology,
Transfusion, or Other Procedures), or other approved hospital form.
B. Informed consent should be completed once per course of care or once per year for outpatients.
C. The completed form will be available in the patient’s electronic medical record and a copy will be
provided to the Blood Bank. The Blood Bank will not release blood products unless they have seen an
appropriately executed Informed Consent for Blood Products, except in emergency situations.
D. Caring for patients who refuse blood products may be complicated by variability in the blood products
that the patient may refuse or accept.
1. If the patient refuses any and all blood products, refer to UWHC Policy #4.32: Caring for Patients
Who Refuse Blood Transfusions.
2. In the more typical case of patients who refuse some blood products but accept others and / or who
accept some blood conservation methods but refuse others, a “Jehovah Witness Questionnaire (301301-
DT)” must be filled out completely and signed by the patient (not a representative), and scanned into
HealthLink. This form is used to legally and specifically designate what interventions the individual
patient is accepting or refusing. A Jehovah’s Witness Hospital Representative, minister, or family
member may participate in the discussion with the patient but the final decisions must be the patient’s.
E. The appropriately credentialed healthcare provider completes an electronic order for blood and/or blood
components, which must include and indication code. An appropriate healthcare provider enters the
indication code in Health Link while placing the blood product order. To reference hospital indication
codes for blood products, refer to Adult Indications and Pediatric Indications (click on highlighted links
within the order). When the electronic order generates an order requisition prints in the Blood Bank.
When the computer is not functioning or unavailable a written request (form UWH #1280411) must be
completed and sent to the Blood Bank.
F. Transfusions may be administered only by physicians, physician assistants, registered nurses, non-

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

MAY 1991
ORIGINAL
 REVISION

APRIL 2015
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BLOOD AND BLOOD COMPONENTS - OR


physician anesthetists, perfusionists, and ECMO specialists trained in blood administration by Nursing
Staff Education and Development or the Surgical Services Department and/or the Chief Perfusionist.
G. Blood Verification may be completed by Registered Nurses, Nursing Assistants, Surgical Technologists
and surgical clinical monitoring technologists trained in the blood verification process by the Surgical
Services Department and/or the Perfusion Manager.
H. All patients must be identified per policies 7.31 (Patient Identification) and 2.01 (Admission of Patients
to the Surgical Services and Requirements for Initiation of Surgical Procedure).
I. Blood samples for type and crossmatch may be drawn by an appropriately credentialed healthcare
provider.
J. The blood specimen is labeled (computer generated or computer downtime label) with the
date and time the specimen was drawn. The patient information on the label must checked and
compared with the patients ID band and affixed to the specimen AT RECEIPEINTS SIDE (such as bed
side) IMMEDIATELY AFTER BLOOD HAS BEEN DRAWN. The information on the label must
match that on the patients ID band (i.e., patient’s last name, first name, medical record, date of birth).
In order to identify the blood drawer, the label must include one of the following: employee
identification number (preferred), full name (print), or network login identification (for
physicians without employee identification numbers only e.g. BXL02.) The employee identification
number, full name, or physician network login identification indicates the information on the
specimen/label has been verified in accordance with Policy #2.01 (Admission of Patients to Surgical
Services and Requirements for Initiation of Surgical Procedures) to assure it matches the correct
patient.
K. A complete type and screen and two unit crossmatch for patients in the O.R. requires about one hour
under normal circumstances, but may take several hours depending on the patient’s testing. If blood
is needed before testing is completed, an appropriately credentialed healthcare provider (staff/faculty
MD) must submit the electronic order or request form UWH #1280411 and write in the order
instructions that the blood is to be given uncrossmatched.
L. Plasma will be thawed by the Blood Bank.
M. Patient identification will be verified in accordance with Policy #2.01 (Admission of Patients to
Surgical Services and Requirements for Initiation of Surgical Procedures).
N. 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. FORMS USED

A. UWH #1280411 - Transfusion Service Request
B. Patient Identification Wristband
C. UWH #1280412 - Record of Blood Transfusion
D. UWHC #301301-DT “Jehovah Witness Questionnaire (301301-DT)”


UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

MAY 1991
ORIGINAL
 REVISION

APRIL 2015
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TITLE
BLOOD AND BLOOD COMPONENTS - OR


IV. PROCEDURE

A. TRANSMISSION OF THE ORDER TO THE BLOOD BANK:
1. An appropriately credentialed health care provider completes a Health Link/paper order specifying
hospital indication code for transfusion, blood and blood component to be transfused, number of
units, or transfusion instructions. The request for blood products must also specify special
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 (UWHC #1280411) must be completed and sent to the Blood
Bank. The paper form will have the patient’s full name, medical record number, date of birth,
diagnosis, and the O.R. phone number. On the paper form the appropriately credentialed health care
provider writes the ordering provider’s name and his/her initials and sends the form to the Blood
Bank.
B. BLOOD SAMPLES FOR TYPE AND CROSSMATCH:
1. A label (computer generated or computer downtime label) must be attached with identifying information: Patient’s
last name, first name, medical record number, date of birth.
2. The identifying information on the label must exactly match the corresponding information on the patient’s
identification band.
3. A 6 mL sample of unclotted blood (pink-top vaccutainer tube) is required. The blood specimen
label (computer generated or hand written computer downtime label) must include the date and time
of the 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), or network login
identification (for physicians) e.g. BXL02. The employee identification number, full name, or
network login identification indicates the information on the specimen/label has been verified in
accordance with O.R. Policy and Procedure #2.01 to assure it matches the correct patient. An
unlabeled tube of blood should never be taken outside the O.R.
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 a beside, 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.
2. When ordering plasma allow approximately 45 minutes for the Blood Bank to thaw the unit(s). A
blood sample is required to determine patient blood type and antibody status, if not on file in the
Blood Bank.
3. When the Blood Bank requests a sample or additional samples, the circulating nurse or designee
will deliver a labeled pink top tube immediately to the Blood Bank.
C. MASSIVE TRANSFUSIONS OF RED CELLS: (Average Adult - 10 units)
1. Blood Bank will notify the O.R. RN when additional blood sample is needed.
D. DISPENSING OF BLOOD OR BLOOD COMPONENTS FROM THE BLOOD BANK TO THE
O.R.:

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

MAY 1991
ORIGINAL
 REVISION

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BLOOD AND BLOOD COMPONENTS - OR


1. Blood or blood components must be picked up by the circulating nurse or designee.
2. A computer generated label or hand written computer downtime label will be used in the case of
downtime by the Blood Bank to verify the patient’s name, medical number, and date of birth. When
prompted, inform the Blood Bank personnel of your employee ID number, the O.R. Room number
where the patient is located and the ordering physician.
3. One person may not pick up blood for two (or more) patients at the same time.
E. USE OF SURGICAL SERVICES PNEUMATIC TUBING SYSTEM FOR DELIVERY OF BLOOD
PRODUCTS:
1. The pneumatic tube system can be used to receive blood products according to the following
guidelines:
a. Send to the Blood Bank:
i. Index card or piece of paper with a computer generated label or hand written computer
downtime label in the case of downtime with the patient’s full name, medical number, and
date of birth.
ii. Tube station number : i.e., #831 - Inpatient OR Hallway 17-22
iii. Blood products needed: i.e. 2 RBCs; or 2 FFP or 1 RBC and 1 FFP.
iv. Employee ID number of the person responsible for removing the products from the station. .
v. O.R. room number and phone number.
vi. The ordering physician
b. To Receive a Tube:
i. It may take the Blood Bank up to 5 minutes to process the request. Tube travel time is
approximately 30-45 seconds.
ii. The tube station will beep until the secured tube is released into the bin.
iii. The person receiving the blood product will need to punch in the last 4 digits of the
patient’s medical record number and the tube will drop.
Note: Disadvantages:
i. The Blood Bank can tube no more than two products at a time.
ii. Large products, such as Transcyte, do not fit in the tube.
iii. Refrigerated and non-refrigerated products cannot be tubed together.
F. ADMINISTRATION AND VERIFICATION OF BLOOD OR BLOOD COMPONENTS:
1. As blood or blood components are brought into the Operating Room, identification of patient and
donor blood/blood components will be made independently by two persons, one of which has to be
a member of that operative team.
a. The first verification of blood/blood components and patient information will be done upon the
product(s) arrival in the Operating Room where the patient is present.
b. The first person checks the information on the patient's identification band or verified patient
label (computer generated label or hand written computer downtime label in the case of
downtime) information against the corresponding information on the Record of Blood
Transfusion, form UWH #1280412, which accompanied the donor unit. The medical record

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

MAY 1991
ORIGINAL
 REVISION

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number, patient full name and birth date must match exactly.
c. The expiration date, donor unit number, and donor blood group given on the Record of Blood
Transfusion (UWH #1280412) must match the donor label on the container and the unit tag. In
addition, for autologous blood, the name on the Record of Blood Transfusion (UWH
#1280412) must match the donor label on the container.
d. The person starting the transfusion must repeat the entire verification procedure (items b and c
above).
e. In most cases the blood group of the patient and the donor unit should be the same. (Exceptions
may occur if the product is frozen/deglycerolized red cells, FFP, platelets).
f. If there are discrepancies between the information on The Record of Blood Transfusion (UWH
#1280412) and patient's identification band, or verified patient label, the donor unit label, or
unit tag, the blood should not be given. Any units found to have discrepancies are to be
immediately returned to the Blood Bank.
g. Both persons must sign the Record of Blood Transfusion (UWH #1280412) in the appropriate
spaces. The UWH #1280412 is to be placed in the patient chart.
h. All autologous and/or directed donor blood products will be given prior to allogenic
transfusions.
i. All blood/blood components must be transfused through a standard blood administration set.
j. Leukocyte concentrates will not be transfused through a depth-type microaggregate filter or
leukocyte reduction filter.
k. Drugs and medications, including those intended for intravenous use, must not be added to
blood/blood components.
l. Stem cells will not be exposed to gamma irradiation or x-ray irradiation because sufficient cell
death could occur to harm engraftment.
G. STORAGE OF BLOOD AND COMPONENTS
1. Packed red blood cells and Cryoprecipitate preparations may be stored only in special refrigerators
with very rigid temperature regulations and alarms to indicate abnormal temperatures. Refrigerators
are monitored according to AABB requirements by the Surgical Services. Refer to Policy #6.07
Inpatient and AFCH Operating Room Refrigerator Monitoring
2. Blood refrigerators in the Operating Room are suitable for long-term storage of blood/blood
components. However, for patient safety unused blood must be returned to the Blood Bank as soon
as possible or at the end of the case. Blood should not be left out of the refrigerator for more than
thirty minutes.
3. DO NOT STORE PLATELET COMPONENTS IN ANY REFRIGERATORS OR ON ICE.
4. 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.
H. GENERAL INFORMATION ABOUT THE BLOOD BANK
1. Several units of platelets are normally given at a time. They are "pooled" by the Blood Bank into

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

MAY 1991
ORIGINAL
 REVISION

APRIL 2015
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ADMINISTRATIVE MANUAL
NURSING MANUAL
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BLOOD AND BLOOD COMPONENTS - OR


one bag. Pooling must be done shortly before administration. The Blood Bank must be notified by
telephone approximately 30 minutes before the transfusion is to begin: the Blood Bank will call the
Operating Room when the product is ready for issue.
2. For emergency cases, as soon as the Blood Bank receives an appropriately credentialed healthcare
provider order for blood/blood component administration it will be released.
Note: If possible, it is important that a sample for crossmatch be drawn before blood issued for
emergency release is transfused
3. If excessive bleeding is anticipated, the circulating nurse shall notify the Blood Bank to facilitate
communication about the need for blood product dispensing.
4. In event of uncontrolled hemorrhage, type specific uncrossmatched blood may be ordered either
electronically by a staff/faculty MD or on paper. The legal release on the Transfusion Services
Request (UWH Form #1280411) must be filled out and signed by an appropriately credentialed
healthcare provider
.
5. Dispose of empty bags as you would any other biohazardous waste.
I. RETURNING UNUSED BLOOD/COMPONENTS:
1. All unused blood and blood products and their respective The Record of Blood Transfusion (UWH
#1280412) form must be returned to the Blood Bank by the nursing staff or designee
2. All blood products being returned to the Blood Bank will be handed directly to any Blood Bank
personnel at the window.
3. Cell saver blood will be handled according to policy #2.14 (Intraoperative Blood Salvage).
J. TRANSFUSION REACTION OR ERROR:
1. If the patient develops any signs or symptoms of a reaction or any transfusion error occurs, the
transfusion should be stopped. Follow the instructions on The Record of Blood Transfusion form
(UWH #1280412) and complete the reaction section. Notify the patient’s physician and the Blood
Bank.
2. For transfusion reactions, signs and symptoms, and management of acute or delayed reactions refer
to related documents associated with policy 8.12 (Blood and Blood Component Transfusion
Requiring Pre-transfusion Testing).
K. GUIDELINES FOR USE OF TRANSFUSION DEVICES:
1. Specific guidelines from manufacturers and clinical departments will be followed when using
medical devices for transfusion of blood/blood components, e.g. blood warmers, rapid infusion
systems, refrigerators.

V. REFERENCES

A. UW Administrative Policy #8.12 - “Blood and Blood Component Transfusion”
B. AABB Standards, Current Edition
C. UW O.R. Policy #2.14 - “Intraoperative Blood Salvage”

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

MAY 1991
ORIGINAL
 REVISION

APRIL 2015
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ADMINISTRATIVE MANUAL
NURSING MANUAL
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TITLE
BLOOD AND BLOOD COMPONENTS - OR


D. UW O.R. Policy #2.01 - “Admission of Patients to Surgical Services and Requirements for Initiation of
Surgical Procedures.”
E. UW Administrative Policy # 7.31 - “Patient Identification”
F. Transfusion Services Policy #6.05 - “Pediatric Red Cell Transfusions”
G. UW Administrative Policy # 4.17 - “Informed Consent”
H. UW Hospital Policy #8.11 - "Trauma Policy"

VI. COORDINATION

Thomas Steffens, Perfusion Manager - 12/2014Mary Evans, Nursing Education Coordinator - 1/2015
Keith Hoerth, Clinical Labs Manager-Transfusion Service 11/2014
Christopher Turner, M.D., Director of Perioperative Services 12/2014


SIGNED BY

Jeffrey Fenne, MHA, RN, CNORDirector, Surgical Services Department