document control · they have completed the safe blood transfusion e-learning modules 1 & 2...

Authorisation of Blood Components for Transfusion by Registered Practitioners Policy

of 19 NDHT Transfusion Committee / Authorisation of Blood Components for Transfusion by Registered Practitioners Policy v1.1

Document Control

Title


Author

Author’s job title Haematology Clinical Nurse Specialist

Directorate Clinical Support Services

Department Clinical Haematology

Version Date

Issued Status Comment / Changes / Approval

0.1 30.11.15

Draft Draft for consultation

1.0 Dec 2015

Final Approved by Transfusion Committee 15th Dec 2015

1.1 Oct 2018

Revision Reviewed by M. Bowyer. No changes required.

Main Contact Office 1 Seamoor Corridor North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB

Tel: Direct Dial - Tel: Internal – Email:

Lead Director Director of Nursing

Superseded Documents None

Issue Date Nov 2018

Review Date Nov 2021

Review Cycle Three years

Consulted with the following stakeholders: (list all)

Head of Workforce Development

Haematology Consultants

Hospital Transfusion Committee

Approval and Review Process

Hospital Transfusion Committee

Local Archive Reference G: Pathology Local Path Transfusion Team\Policies & Guidelines folder Filename Authorisation of Blood Components for Transfusion by Registered Practitioners Policy v1.1 Oct2018.doc (right click above text, to update to new filename)

Policy categories for Trust’s internal website (Bob) Haematology

Tags for Trust’s internal website (Bob) Blood Transfusion, Components, Authorisation, Registered Practitioners, Non-Medical



CONTENTS

Document Control ................................................................................................................................. 1

1. Purpose .......................................................................................................................................... 3

2. Definitions ...................................................................................................................................... 3

3. Responsibilities ............................................................................................................................. 3

4. Selection Criteria ........................................................................................................................... 5

5. Training .......................................................................................................................................... 5

6. Monitoring Compliance with and the Effectiveness of the Policy ........................................... 6

7. Equality Impact Assessment ....................................................................................................... 6

8. References ..................................................................................................................................... 7

9. Appendix 1 ..................................................................................................................................... 8

10. Appendix 2 ................................................................................................................................... 17

11. Appendix 3 ................................................................................................................................... 18

12. Appendix 4 ................................................................................................................................... 19



1. Purpose

1.1. The purpose of this document is to detail the process for a senior Registered Practitioner, working in a relevant specialist role, who wishes to undertake the authorisation of blood component transfusions.

1.2. The policy applies to all non-medical staff.

1.3. Implementation of this policy will ensure that:

Any Registered Practitioner wishing to develop their role to include authorisation of blood component transfusion will have completed the relevant training and competency assessment.

The Registered Practitioner who takes on the role of blood component authorisation will need continued support and mentorship with a period of supervision prior to completion of competency assessment to allow independent practice.

1.4. The authorisation of a blood transfusion must only occur when NDDH

policies and guidelines are followed and when there are no alternatives to transfusion.

1.5. That non-medical authorisation is not suitable for all registered

practitioners and should only be taken on within agreed governance structures of the Trust after consideration of service and clinical need and at the recommendation of the designated consultant supervisor and assessor.

2. Definitions

Blood components consist of red cells, platelets, fresh frozen plasma and cryoprecipitate.

3. Responsibilities

3.1. There must be an identified service need within the specific department to implement the non-medical authorisation of blood components

3.2. Role of Registered Practitioner

The registered practitioner is responsible for ensuring that they meet the selection criteria and will be supported by both the lead haematology consultant for transfusion and the designated consultant supervisor and assessor.

The Registered Practitioner is responsible for:



Maintaining accurate documented evidence of training and practice.

Ensuring that they are familiar with current national and local guidelines and policies by accessing the relevant courses and maintaining training and competency.

Must comply with the NMC Code of Practice or equivalent Health Care Practitioner Code of Practice.

The Practitioner will be responsible for obtaining adequate knowledge and experience in authorising blood components including a period of supervision prior to assessment of competency

The practitioner is responsible for keeping training and skills up to date throughout their working life and a duty to practice within their own area of competence.

The practitioner may only authorise blood components in their specific clinical area or identified group of patients and are responsible for their own actions. The practitioner will undertake the extended role solely within a clearly defined clinical management plan

3.3. Consultant Supervisor and Mentor

There must be a consultant practising in the specialist area in which the practitioner is employed.

The mentor should regularly authorise blood transfusions and make decisions to transfuse and with whom the practitioner can work alongside for learning and assessment purposes.

The mentor is responsible for and supporting the practitioner through the work-based learning and assessment.

The mentor has a critical and highly responsible role in educating and assessing the practitioner in undertaking authorisation of blood products

They are responsible for assuring competence of the practitioner by providing them with supervision, support and opportunities to develop competence in authorisation of blood components during the work based learning.

They are up to date with all mandatory training as per NDDH Trust mandatory training requirements

They have completed the safe blood transfusion e-learning modules 1 & 2 plus consent part 9 and reactions part 11 module of the ‘Learn Blood Transfusion’ e-learning programme

The mentor is responsible for the final agreement to practice. They are required to provide and signed statement of competence at the end of the period of study. They should do this after reading the professional code of conduct.



3.4. Role of the Hospital Transfusion Committee

The Hospital Transfusion Committee is responsible for:

Reviewing and approving the policy in line with the National Guidance.

4. Selection Criteria

Any registered practitioner applying to undertake authorisation of blood components must:

4.1. Be currently registered as a practitioner with at least 3 years post-registration experience and have at least one year working in the Trust within the relevant specialty

4.2. Have a case-load of patients or work as part of a clinical team managing patients’ needs

4.3. Be trained to a level to include skills of history taking, physical examination, advanced communication and clinical reasoning and decision making.

4.4. Identify need for the competency that will benefit their patient caseload.

4.5. Be up to date with all mandatory training as per trust mandatory training requirements, have completed the e-learning modules ‘Safe Transfusion practice’ Part 1 & 2 plus consent part 9 and reaction part 11 on ‘Learn Blood Transfusion’ e-learning programmes.

4.6. Have completed all competency assessments for pre-transfusion blood sample taking, and administration of blood and blood components if required for their role.

4.7. Successfully complete the approved training programme such as the NHS Blood & Transplant Non-Medical Authorisation of Blood components course.

4.8. The candidate must have documented approval from their service manager and mentor.

5. Training

5.1. The candidate must submit a portfolio of evidence to demonstrate knowledge and competence to the mentor



5.2. The period of supervision will be at the discretion of the mentor depending on the needs of the individual. The period of supervision must include the authorisation of blood components which must be recorded.

5.3. On completion of training and competency assessments, a competency declaration form with all the support must be completed and sent to the service manager, lead clinician for transfusion, the blood transfusion specialist nurse and Workforce Development for logging on ESR.

6. Monitoring Compliance with and the Effectiveness of the Policy

Process for Implementation and Monitoring Compliance and

Effectiveness

6.1. The Hospital Transfusion Team and Hospital Transfusion Committee will ensure that patient safety and clinical effectiveness is not adversely affected by introduction of extended practice by monitoring patient safety incidents and clinical audit by the practitioner.

6.2. All incidents will be fully investigated and re-training initiated where appropriate as detailed in the policy. Non-medical authorisers may need to be re-competency assessed following an incident and cease to authorise until this has been completed. The Hospital Transfusion Team will inform them and their mentor of the need for this following an incident.

6.3. The practitioner must ensure they keep themselves up to date with the policies and procedures associated with transfusion and maintain their competencies to authorise transfusion.

6.4. The practitioner must complete trust mandatory training on transfusion in line with Trust requirements and complete ‘learn blood transfusion’ modules every 2 years.

6.5. The practitioner is required to audit their transfusion practice.

6.6. As a ‘user’ of blood components the practitioner should attend the Hospital Transfusion Committee meeting a minimum of once a year following completion to present their audit.

7. Equality Impact Assessment

Table 1: Equality impact Assessment

Group Positive Negative No Comment



Impact Impact Impact

Age X

Disability X

Gender X

Gender Reassignment X

Human Rights (rights to privacy, dignity, liberty and non-degrading treatment)

X

Marriage and civil partnership

X

Pregnancy X

Maternity and Breastfeeding

X

Race (ethnic origin) X

Religion (or belief) X

Sexual Orientation X

8. References

J Green RN and L. Pirie RN. A Framework to Support Nurses and Midwives Making the Clinical Decision and Providing the Written Instruction for Blood Component Transfusion. 2009 Denise Watson Regional Lead: Patient Blood Management Team NHSBT Newcastle Upon Tyne. Implementing Nurse Authorisation of Blood Components Blood and Transplant Matters information for hospitals served by NHS. Blood and Transplant Mat 2013 issue 39 p 5. Kirsty Dalrymple Jill Martin, Kerri Davidson and Elisabeth Pirie. Extending the role of a senior haematology or oncology nurse. October 2011; Cancer Nursing Practice: volume 10 number 8. All Wales policy for Non-Medical Authorisation of Blood Component Transfusion. September 2013. Policy Template for the Authorisation of Blood Component Transfusion by Advanced / Specialist Nurses Caring for Adult and/or Paediatric Patients Requiring Transfusion London and South East Regional Transfusion Committees Non-Medical Authorisation of Blood Components Working Group September 2014 http://www.transfusionguidelines.org.uk/uk-transfusion-committees/regional-

transfusion-committees/london/policiesRelatedDocuments

http://www.transfusionguidelines.org.uk/uk-transfusion-committees/regional-transfusion-committees/london/policiesRelatedDocuments

http://www.transfusionguidelines.org.uk/uk-transfusion-committees/regional-transfusion-committees/london/policiesRelatedDocuments



9. Appendix 1

Portfolio of evidence to support Registered Practitioners in

making the clinical decision and providing the written

instruction for blood component transfusion

NAME (CANDIDATE NAME (CONSULTANT MENTOR)

Job Title: Job Title:

Hospital: Hospital:

Ward/Dept: Ward/Dept:

Study Completion

Details

Date Copy of certificate Attached to Portfolio

Safe transfusion Practice 1

Safe transfusion Practice 2

Consent Module 9

Reaction Module 11

Non-medical authorisation

course

Trust Mandatory Individual

Training Matrix



Understanding

of

Knowledge &

Competencies Evidence Submitted

Signed

Practitioner Mentor Date

Patient

Assessment

and clinical

decision

making

How to take

a patient

history

Accounting

for co-

morbidity

Consent

issues

Prescribing

of

concomitant

drugs

Understand the

requirement to

accurately document all

actions and

conversations with the

patient

Ability to make

appropriate referral if

the patient refuses

blood transfusion or has

an advanced directive

Ability to take a medical

history

Ability to link the clinical

picture with the

interpretation of blood

results

Understands how to

explain the risks and

benefits of transfusion

and available

alternatives

Know to provide patient

information leaflets

Can assess the patient

is fit for transfusion i.e

take account of co-

morbidities, day case or

in-patient

Know which

concomitant drugs may

be required



Understanding

of

Knowledge &

Competencies Evidence Submitted Signed

Interpreting

blood results

Can demonstrate

knowledge and

understanding:

Of normal, variations of

normal and abnormal

haemoglobin and

platelets counts &

clotting results

Ability to interpret

results and initiate

treatment

Know if more tests

and/or further evaluation

is required

Writing the

Instruction to

transfuse the

blood

component

Demonstrates knowledge

that the written instruction

includes

Patient’s full name

Date of birth

Hospital number

Product description

The route of

administration

The length of time the

transfusion is to take

place

The number of

units/volume

Any special

requirements

Concomitant drugs that

need to be administered



Understanding

of

Knowledge &


Signed


Constituents of

blood

components

Gain insight into the

production from whole

blood of:

Red cells

White cells

Platelets

Plasma

Has knowledge of:

Storage

Safe handling

Temperature

control/cold chain

requirements

Understanding

of

Knowledge &


Signed


Understanding

of anaemia

Can define the types of

anaemia

Understands

physiological process

for iron deficiency

anaemia

Knows when to refer

patients for further

investigation and

treatment

Knows how to order

appropriate

investigations

Understands the

different types of iron

therapies

Understands the use of

EPO



Understanding

of

Knowledge &


Signed


Pre-transfusion

testing process

Can demonstrate an

understanding

of the:

Pre-transfusion

sampling process

Sample labelling

requirements

BSCH guidelines for pre

transfusion testing

Time limits surrounding

the validity of samples in

storage

The laboratory

processes for pre-

transfusion testing

including how long

testing takes

Indications for

the use of

Platelets

Demonstrates a clear

understanding for the

use of platelets

(including platelet count)

Uses local policy and

national indication

codes to demonstrate

appropriate use

Can demonstrate in

which conditions their

use is not appropriate



Understanding

of

Knowledge &


Signed


Indications for

the use of red

cells


understanding for the

use of red cells


national indication


appropriate use

Indications for

the use of

Fresh Frozen

Plasma


understanding of

appropriate use of FFP

in the context of

correction of deranged

INR results in the face

of bleeding or invasive

procedures which may

cause bleeding

Can demonstrate the

indications for which

FFP is not used


national indication


appropriate use

Aware of normal and

abnormal clotting results



Understanding

of

Knowledge &


Signed


Special

Transfusion

Requirements


and understanding of:

Which patient groups

will have special blood

requirements and why

Understands the

process to prevent

these patient’s receiving

the wrong blood

Transfusion

guidelines and

protocols

Can demonstrate

knowledge and

understanding of:

SABRE/SHOT

HSC Better Blood

Transfusion

1998/224, 2002/009,

2007/001

BSCH guidelines

Blood Safety and

Quality Regulations

2005 including

traceability

requirements

Patient information

leaflets



Understanding

of

Knowledge &


Signed


Legal

responsibilities

Record

keeping

Has knowledge and

understanding of NMC

Standards of conduct,

performance and ethics

Can explain why the

reason for transfusion

should be recorded in

the patient’s notes

Can explain why all

actions must be

documented

Ordering blood

components

Has knowledge of local

guidelines for ordering of

blood components and the

need to provide the

following details:

Full name of patient

Date of birth

Hospital number

When the patient is to

be transfused

How many units and

any special

requirements

Where the patient is to

be transfused

Diagnosis

Indication code

Appropriate for

overnight transfusion or

not

Contact name / bleep

number



Understanding

of

Knowledge &

Competencies

Evidence Submitted Signed


Risks and

adverse events

associate with

transfusion and

how to deal

with them


and understands the risks

of transfusion and describe

the management of the

following:

Transfusion and

transmitted bacterial

and viral infections

Transfusion Related

Acute Lung Injury

(TRALI)

Acute haemolytic

transfusion reaction

Wrong blood to wrong

patient

Fluid overload

Anaphylaxis

Iron overload



10. Appendix 2

Log of transfusions

Hospital Number Location Number of units Diagnosis

Rationale for the transfusion Any other medication prescribed

Comments

Signature of RP

Signature of Mentor

Hospital Number Location Number of units Diagnosis

Rationale for the transfusion Any other medication prescribed

Comments

Signature of RP

Signature of Mentor



11. Appendix 3 Record of supervised authorisation of Blood Components

Date Patient Hospital Number

Component Rationale for transfusion Comments on review of transfusion episode

Mentor signature if transfusion was satisfactory



12. Appendix 4

Declaration of Competence Form

Registered Practitioner Authorisation and Written Instruction of

Blood Components

I have met the knowledge and competency criteria and I am proficient to undertake the

authorisation and written instructions for red cells and platelets

Name

……………………………………………………………………………………………………………

……………………………..

Signature………………………………………………………………………………………………

Clinical Area / Specialty:

…………………………………………………………………………………………………………

I have assessed the above practitioner and deem them proficient to undertake the authorisation and

written instructions for red cells and platelets. If practitioner is a nurse I have read the NMC code of

conduct http://www.nmc.org.uk/standards/code/read-the-code-online/

Name: ……………………………………………………………………………………………………………

Signature: …………………………………………………………………………………………………………

Date: ……………………………………………………………………………………………………………

Lead Haematology consultant for transfusion:

I agree the above practitioner proficient to undertake the authorisation and written instructions for red

cells and platelets

Name: ………………………………………………………………………………….......

Signature: …………………………………………………………………………………

Date: ………………………………………………………………………………………

Please send a copy of this form with Appendix 1, 2 and 3 to: -

Your clinical manager

The Transfusion Practitioner

Workforce Development for logging on ESR

Keep the original for your own records.

Copy of form will be returned to all individuals by BTNS

I have met the knowledge and competency criteria and I am proficient to undertake the authorisation and written

instructions for red cells and platelets

Name ……………………………………………………………………………………………………………………………

Signature………………………………………………………………………………………………………………………

Clinical Area / Specialty: …………………………………………………………………………………………………….

Date:……………………………………………………………………………………………………………………………

http://www.nmc.org.uk/standards/code/read-the-code-online/