VOL: 103, ISSUE: 39, PAGE NO: 28-29
Helen Watkins, BSc, RGN
Specialist transfusion practitioner, Poole Hospital NHS Trust
This article covers the crucial area of correct and appropriate observations of patients during blood transfusion. An integrated care pathway can help staff by reminding them of these checks and observations. It can also provide a systematic way of ensuring documentation is accurate and care is evidence-based.
Watkins, H. (2007) Improving safety for patients receiving a blood transfusion.
Transfusion errors are often due to failure of the proper pretransfusion checks. Correct and appropriate observations of the patient during transfusion are critical. An integrated care pathway can help staff by reminding them of these checks and observations. It can also provide a systematic way of ensuring documentation is accurate and care is evidence-based.
The greatest risk from blood transfusion is not, as many might imagine, being exposed to a blood-borne infection, but rather receiving the wrong blood. The reasons for this are almost exclusively human error, and, in particular, failure to complete the proper checks before commencing the transfusion. In 2003, our hospital took part in the national comparative audit of transfusion practice, organised by NHS Blood and Transplant. This entailed recording 40 transfusion episodes, looking specifically at the practice of nurses at the bedside. In 2005, we repeated the audit with a further 40 transfusion episodes. Overall, there was little difference between the results of the two audits, which both showed that there was wide variation in what was actually happening at ward level, and that unsafe practices were still occurring.
Reports from Serious Hazards of Transfusion (SHOT) (Stainsby et al, 2005; 2003) consistently show that transfusion errors often happen due to a failure to carry out proper bedside pretransfusion checks. The two national comparative audits also highlighted that, in our trust, there was inconsistency in recording the correct observations, and, in some cases, poor management of suspected transfusion reactions. Failure to correctly observe the patient during transfusion can mean that early signs of an acute transfusion reaction go unnoticed. By the time that more obvious signs such as dyspnoea or profound tachycardia become apparent, it may be too late to prevent major morbidity (McClelland, 2007). The Health Service Circular Better Blood Transfusion (Department of Health, 2002) set out minimum standards for documentation in order to improve the safety of blood transfusion.
Planning an improvement
We looked at ways to improve transfusion practice across our trust and specifically at ways to:
- Improve and maintain patient safety;
- Ensure that the correct checks and observations are made in order to prevent errors and spot transfusion-related reactions at an early stage;
- Improve the documentation of blood transfusion episodes.
After the 2003 audit, one of the recommendations was to introduce an integrated care pathway (ICP) in order to address some of these issues. An ICP can be defined as follows: ‘An integrated care pathway determines locally-agreed, multidisciplinary practice based on guidelines and evidence, where available, for a specific client group. It forms all or part of the clinical record, documents care given and facilitates the evaluation of outcomes for continuous quality improvement.’ (National Pathways Association, quoted in Middleton, 2002). An ICP must have space to record variances, where the patient’s actual given care diverges from the planned care.
Following a systematic review of several ICPs from other trusts, a team designed and wrote an ICP which would encompass all locally agreed policies and procedures. Unfortunately the project could not progress at the time due to lack of a transfusion practitioner to implement it. After the 2005 audit showed lack of improvement in practice, the new transfusion team wanted to trial the ICP. Despite reservations about the length and complexity of the document, the team decided to trial the ICP on the cancer day unit as a baseline assessment before attempting to make any further revisions.
The documentation was approved for use by the trust nursing policies and procedures committee. Approval for an audit of the ICP was sought from the clinical audit department, and criteria were set to determine the effectiveness of the audit (see Table 1). The initial sample size was 40 patients. The staff (nursing and medical) on the cancer centre day ward were shown the new documentation, and were trained in its use. They were encouraged to use it wherever possible for adult patients attending for blood transfusion. The staff were asked to complete feedback forms to assess the ICP for ease of use, and advantages and disadvantages against current documentation.
To assess how well the ICP had been completed, the medical notes of patients known to have received a blood transfusion during the audit period were examined retrospectively. The new ICP was found in 26 case notes, but not in the remaining 14. This in itself showed that the problem of retaining a permanent record of a transfusion was not simple to address. It later transpired that some ICPs had been ‘borrowed’ by other staff to look at or test, and had not been returned. The trust clinical audit department offers help and advice to all staff undertaking any form of clinical audit.
An important part of preparing for audit is setting the standards, or criteria, by which the results will be judged. For example, in blood transfusion the most vital standard is that the patient receives the correct unit of blood. This can be achieved by ensuring that the correct pretransfusion checks are made to confirm that the right unit of blood is about to be given to the right patient.
The criteria for the use of the transfusion ICP were set as follows:
|All patients undergoing blood transfusion to have checks completed including verbal ID||100%||Unconscious patients||Poole Hospital NHS Trust hospital transfusion committee (hospital policy) (2005); British Committee for Standards in Haematology (BCSH) (1999)||Unconscious patients - checks to be completed as alternative to verbal ID. Data collected from completed ICP|
|All patients will be given written or verbal information relating to transfusion||100%||Unconscious patients, patient choice, previously transfused patients||Hospital Policy (2005); BCSH (1999)||Unconscious patients - checks to be completed as alternative to verbal ID. Data collected from completed ICP|
|Documentation provided will prompt staff administering blood to complete the correct checks and document administration||100%||None||Data collected from staff feedback questionnaires|
Documentation to be legible
|100%||None||Hospital Policy (2005); BCSH (1999)||Data collected from completed ICP|
Table 1. Standards required in use of blood transfusion
ICP Staff feedback, both written and verbal, indicated that the ICP was a good idea, but that the documentation was overly long, wordy and too detailed to be helpful. It also became apparent that some boxes (for example, the one for the date) were too small to write in. This was an important lesson, because one of the main complaints about some forms of documentation is that once they are completed, they look too ‘busy’ or are illegible. We were also aware that completion of documentation can be in inverse proportion to its the length - the longer the document, the less will be filled in. Common themes from staff in other areas, when shown the ICP, were:
- We would not have time to complete it;
- It is longer than ICPs for more complex procedures.
Revision of ideas
The team went back to the beginning and thought again about the main purposes of blood transfusion documentation:
- To allow nurses and doctors space to record a prescription, observations and evidence of the transfusion;
- To keep all the data and information relating to the transfusion episode together as a permanent legal record;
- To provide information which guides staff on how to prescribe, check and administer blood components safely;
- To guide staff in recognising and managing acute transfusion reactions.
For the majority of patients a blood transfusion is simply an element of care for a health condition, which may itself be part of another integrated care pathway. For these patients, there may often be several other clinical factors contributing to the need to diverge from the planned care for a transfusion episode. This would make it very difficult to record variances on a transfusion ICP which did not then need to be duplicated elsewhere in the medical notes. However, we also have many patients who attend the cancer day ward on a frequent basis just for a blood transfusion. Taking all of these points into consideration, the team moved from a true ICP towards a record of transfusion, since the main purpose of the documentation was to provide a permanent legal record of the transfusion episode.
The second draft transfusion ‘ICP’ was designed as a single A4 sheet printed on both sides. The first page (Fig 1) is mainly for medical staff to complete - the patient’s details, pretransfusion haemoglobin level, reason for transfusion, special blood requirements, previous reactions and the prescription. British Committee for Standards in Haematology (BCSH) guidelines stipulate that the rationale for transfusion should always be recorded in the medical notes. This serves a multiple purpose: it alerts the doctor to consider the benefits to the patient against the potential risks of transfusion; it helps to ensure the transfusion is appropriate and justified; and it ensures that other members of the team are aware a transfusion is planned or has taken place. We knew from reviewing medical notes that this guideline is rarely followed, more often there is simply a comment ‘for three units blood’ or even just ‘for blood’, with no indication of how much or why. The new transfusion record allows the doctor prescribing the blood to tick relevant boxes and reminds them to check the pretransfusion haemoglobin level.
In one transfusion-related error, a patient received a three-unit transfusion twice, because medical staff failed to record in the notes that it had already taken place. A second medical team then failed to recheck a pretransfusion haemoglobin level before prescribing blood, leading to the patient being overtransfused. The second page of the transfusion record (Fig 2) is mainly for nursing or theatre staff administering the blood components to the patient - pretransfusion checks of the patient and blood, observations prior to and during the transfusion, and recognition and early management of acute transfusion reactions.
As our previous audits had shown, correct and appropriate observations may not always occur during transfusion. For some staff this can be because they have rarely taken part in administration of blood or have out-of-date knowledge of the observations required to identify an acute reaction at an early stage. There is now an extensive programme of transfusion training that emphasises correct patient identification and observations during transfusion.
Following the redesign, the new transfusion record was taken back to the same ward, so the differences in the two styles of documentation could be compared. Initial feedback was very positive, particularly that it was user-friendly, shorter and much clearer. The staff were asked again to start using the new documentation for all patients undergoing transfusion in the cancer centre day ward. Twenty records were randomly audited retrospectively to see if:
- The document was correctly filed in the correct patient’s medical notes;
- The document was correctly and legibly completed, including the prescription, rationale and signatures, and showed evidence of the transfusion taking place;
- The document showed evidence of the correct pretransfusion checks, observations and care being completed during the transfusion.
Evidence from this second audit showed that the new document was being used far more effectively to record the patient’s experience of transfusion. All 20 documents were found in the correct patient’s medical notes, correctly completed, legible, signed and providing appropriate evidence. A second ward asked to be included in the trial of the new transfusion record and staff were trained in its use. Medical staff were supportive of the aims and began to use the document for prescribing blood on the ward. Staff feedback was again positive, in particular that the documentation was very clear and it was easy to find the information on the form.
Since then, the document has been rolled out to most areas of the hospital, and has recently been introduced in a slightly amended format into paediatrics, taking into account children’s specific needs. Staff have commented that they found it easier to remember the correct checks that need to take place and are reminded by the documentation that transfusion requires specific sets of observations to ensure the patient is appropriately monitored. It is also used by our surrounding community hospitals and our local private hospital, with whom we have an agreement to supply blood.
I would add a word of warning: when embarking on a project such as this, have flexible goals in terms of timing. It takes much longer than you would imagine to get agreement from appropriate groups or committees responsible for vetting trust documentation, and the process for getting documents professionally printed and available for staff to order is lengthy.
The current transfusion record is not appropriate for use in massive haemorrhage, when 10 or 20+ units of blood may be used, and other blood components such as platelets and plasma may also be required. While working in theatre during an obstetric massive haemorrhage, I noted that the anaesthetic chart had inadequate space for recording the huge numbers of blood components being transfused. Additionally, it was difficult to quickly determine how much had already been given, and of which component, for example, red cells, platelets or plasma.
We have been working together with one of the anaesthetists to produce a transfusion record for these circumstances, to aid speedy and accurate documentation in an emergency. It will enable the anaesthetist to see at a glance the quantities of various blood components already transfused. This new record also offers advice on which blood samples are required and at what point, contact numbers for transfusion staff including a haematology consultant, information about using cell salvage to reduce the amount of donor blood required or to ‘buy time’, and what to consider before using specialised blood products such as Factor VIIa and Factor VIII to stem the flow. It is hoped that it will be available to trial within the next few months.
Implications for practice
Consider a process or procedure which is known to be at high risk of errors. Nurses could ask their risk management department to help them identify problem areas.
- Audit what happens now as a baseline, so that any improvement after implementing new procedures or documentation can be measured.
- Use documentation to simplify the steps in a process. Remember that the longer the paperwork, the less will be completed accurately.
- Get everyone involved and ask for constructive feedback at every stage - this is essential to success.
The staff and patients of the Dorset Cancer Centre Sue Redfearn, blood transfusion manager, clinical audit department, Poole Hospital NHS Trust.
British Committee for Standards in Haematology Blood Transfusion Task Force (1999) The administration of blood and blood components and the management of the transfused patients. Transfusion Medicine; 9: 3, 227-38.
Department of Health (2002) Health Service Circular, Better Blood Transfusion - Appropriate Use of Blood. HSC 2002/009 04 July 2002.
McClelland, D.B.L. (2007) Adverse effects of transfusion. In: Handbook of TransfusionMedicine,United KingdomBlood Services. London: The Stationery Office.
Middleton, S., Roberts, A. (2002) Integrated Care Pathways. Oxford: Butterworth-Heinemann.
NHS Blood and Transplant (2003 and 2005) National Comparative Audit of Blood Transfusion. www.blood.co.uk/hospitals/safe_use/clinical_audit/National_Comparative/index.asp
PooleHospital NHS Trusthospital transfusion committee (2005) Blood and Blood Products Policy. Poole: Poole Hospital NHS Trust.
Stainsby, D. et al (2003) Annual Report 2003: Serious Hazards of Transfusion (SHOT). Manchester: SHOT.
Stainsby, D. et al (2005) Annual Report 2005: Serious Hazards of Transfusion (SHOT). Manchester: SHOT.