Standard 7: Blood Management

Documenting blood management information

Action 7.5

Clinicians document decisions relating to blood management, transfusion history and transfusion details in the healthcare record

Intent

The history of blood product use, and relevant clinical and product information are documented in the patient’s healthcare record to minimise risks and optimise clinical outcomes.

Reflective questions

How does the health service organisation ensure that a comprehensive history of blood product use, transfusion history, optimising a patient’s own blood and assessing the patient’s bleeding risk are documented in the patient’s healthcare record?

What processes are used to document adverse reactions to blood or blood products in the patient’s healthcare record?

Key tasks

  • Document comprehensive information, including blood use, transfusion history and transfusion details, before, during and after transfusions
  • Develop and implement education activities for the workforce responsible for PBM about documenting transfusion of blood or blood products in the patient’s healthcare record, recognising and responding to adverse transfusion reactions, and documenting adverse reactions in the patient’s healthcare record.

Strategies for improvement

Hospitals

Transfusion-related adverse events can be associated with high rates of morbidity or mortality.1 To reduce this risk, assess the patient for a history of RBC antibodies, transfusion reactions or any other special transfusion requirements.2

Ensure that the integrated patient healthcare record required under Actions 1.16 and 1.17 includes a record of the administration of blood components. Routinely document the following information in the patient’s healthcare record:

  • Patient consent, limited consent or refusal, including documentation of information provided to the patient
  • Relevant medical conditions
  • Indications for transfusion or administration of the blood product
  • Any special product or transfusion requirements (for example, irradiated products)
  • Known patient transfusion history, including RBC antibodies, transfusion reactions, and any adverse reactions to blood or blood products
  • Blood or blood product identification to ensure traceability, such as the blood pack donation numbers (or the product ID and batch number for plasma and recombinant blood products)
  • Blood transfusion compatibility label, or the report form, if applicable (this includes a statement of compatibility)
  • Type and volume of product transfused or administered
  • Date and time of both start and end of transfusion
  • Evidence of observations documented on an appropriate form
  • Pathology results, including haemoglobin levels and ferritin, as appropriate
  • Patient response to administration of blood products, including occurrence and management of any adverse reactions.

Ensure that transfusion details also appear in discharge documentation. If the patient becomes unwell after receiving blood, their transfusion history is important for the treating doctor.2

Consider developing local protocols for recording transfusions in the patient’s healthcare record. Further guidance about the administration of a blood transfusion, as well as documentation of the transfusion, is in the Australian and New Zealand Society of Blood Transfusion (ANZSBT) guidelines for the administration of blood products.1

Provide orientation and training to all clinicians involved in the clinical administration or prescription of blood or blood products. This should include record taking, recognising and responding to suspected transfusion reactions, and reporting to appropriate governance committees.3

Audit the contents of patient healthcare records to assess compliance with the requirements of Action 7.5. Include details of this audit in the organisation’s audit plan. The audit should reveal the level of compliance of documentation against the requirements of Action 7.5 and/or the protocol for documentation relating to transfusion (if developed to support implementation of Action 7.5).

Set up a process for identifying the proportion of patient healthcare records that do not document transfusion (for example, by auditing the fate of the product as recommended under Action 7.10 against completed patient records).

All members of the workforce involved in transfusion of blood or blood products are expected to receive orientation or training to recognise and respond to adverse transfusion reactions, and document the transfusion and any adverse reactions in the patient’s healthcare record.

A checklist for blood product checking is included in the ANZSBT Guidelines for Transfusion and Immunohaematology Laboratory Practice.3 Ensure that organisational blood and blood product management policies, procedures and protocols are consistent with these guidelines.

Day Procedure Services

Applicability of actions

The actions in the Blood Management Standard will not be applicable for day procedure services that do not use blood or blood products. These services should provide evidence that they do not use, receive, store, collect or transport the blood or blood products governed under this standard.

Services using blood or blood products should refer to the information provided for hospitals for blood management.

MPS & Small Hospitals

MPSs and small hospitals will need to set up processes for:

  • Documenting comprehensive information, including blood use, transfusion history and transfusion details, before, during and after transfusions
  • Provide access to education activities for the workforce responsible for PBM about documenting transfusion of blood or blood products in the patient’s healthcare record, recognising and responding to adverse transfusion reactions, and documenting adverse reactions in the patient’s healthcare record.

Transfusion-related adverse events can be associated with high rates of morbidity or mortality.251 To reduce this risk, assess the patient for a history of red blood cell antibodies, transfusion reactions or any other special transfusion requirements.252

Ensure that the integrated patient healthcare record required under Actions 1.16 and 1.17 includes a record of the administration of blood components.

Routinely document the following information in the patient’s healthcare record:

  • Patient consent, limited consent or refusal, including documentation of information provided to the patient
  • Relevant medical conditions
  • Indications for transfusion or administration of the blood product
  • Any special product or transfusion requirements (for example, irradiated products)
  • Known patient transfusion history, including red blood cell antibodies, transfusion reactions, and any adverse reactions to blood or blood products
  • Blood or blood product identification to ensure traceability, such as the blood pack donation numbers (or the product ID and batch number for plasma and recombinant blood products)
  • Blood transfusion compatibility label, or the report form, if applicable (this includes a statement of compatibility)
  • Type and volume of product transfused or administered
  • Date and time of both start and end of transfusion
  • Evidence of observations documented on an appropriate form
  • Pathology results, including haemoglobin levels and ferritin, as appropriate
  • Patient response to administration of blood products, including occurrence and management of any adverse reactions.
Last updated 30th May, 2018 at 01:14am
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References

Australian and New Zealand Society of Blood Transfusion, Royal College of Nursing Australia. Guidelines for the administration of blood products 2nd ed. Sydney: ANZSBT; 2011.

Australian and New Zealand Society of Blood Transfusion. Guidelines for transfusion and immunohaematology laboratory practice. 1st ed. Sydney: ANZSBT; 2016.