North West Transfer Policy

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1.0 Introduction 3. 2.0 Procedure for dispatching hospital. A: Blood Component Selection and Preliminary documentation 4. B: Blood/Component Packaging and  ...


NORTH WEST TRANSFER POLICY



PROCEDURE FOR THE TRANSFER OF BLOOD AND BLOOD COMPONENTS BETWEEN HOSPITALS



Version 3.0

WRITTEN BY

E Addison, P Baker, D Cain, B Chesterson, N Fuller, C Gallagher, S Richards

Authorised for use by the North West Transfusion Laboratory Managers Working Group

Approved Version 3 – July 2014 Review Date - Aug 2017



CONTENTS

Page

1.0 Introduction 3

2.0 Procedure for dispatching hospital

A: Blood Component Selection and Preliminary documentation 4

B: Blood/Component Packaging and Final Documentation 5

C: Dispatch of Blood/Components 6

3.0 Procedure for receiving hospital

4.0 Appendices

Appendix 1: Hospital Contact Numbers 7- 11

Appendix 2: Blood Component Transfer Form accompanying Patient 12

Appendix 3: Stock Transfer form 13

Appendix 4: Transit box label accompanying Patient 14

Appendix 5: Stock Transfer Transit Box Label 15

Appendix 6: Transit box advice for clinical staff 16

Appendix 7: Acting on transferred blood on arrival advice 17

Appendix 8: NHSBT Clinimed box validation 18

Appendix 9: Capacity and transport time limits of Clinimed boxes 19

Appendix 10: NHSBT packing configurations 20

Appendix 11: Packaging instructions for Clinimed boxes 21

Appendix 12: Electronic hyperlinks to Transfer documents 22

Appendix13: Author Information 23

1. Introduction

This document seeks to standardise the procedures for the transfer of blood and components between hospitals in the North West region. It is intended as a general guide to encompass practices for all users. Hospitals are encouraged to add local protocols to the policy where appropriate but not to detract from the practices outlined in this document.

Principle

Blood and components are often transferred between hospitals either with a patient, or as an efficient use of blood stocks.

It is a legal compliance to ensure the audit trail is maintained when blood is transferred and to ensure patient transfusion records are updated accordingly.

Blood can only be transferred in validated cold boxes. It is the responsibility of the sending Trust to ensure this is complied with.

Blood and components may be transferred for the following reasons:

1. Blood/Blood Components allocated to a specific patient may be needed urgently for resuscitation en route or on arrival at the receiving hospital.

2. Agreed transfer of stock between hospital transfusion laboratories.















2.0 Procedure for the dispatching hospital

A: Blood/Component Selection & Preliminary Documentation

For Blood/Components Accompanying the Patient

1. Document the telephone call from the ward or unit requesting the transfer of the blood/component.

2. Ensure the patient identification is obtained including the full name, unique identification number and date of birth if available.

3. Document the details of the receiving hospital and ward/unit including the approximate time of departure.

4. Identify the blood/components issued to the patient.

5. Within the Laboratory Information System the units must be marked as transferred and the destination hospital recorded if possible.

For Stock Transfer of Blood/Components Between Hospital Transfusion Laboratories

1. Identify the Blood/Components agreed for stock transfer

2. Within the Laboratory Information System the units must be marked as transferred and the destination hospital recorded if possible.

In all cases, prior to packaging the blood/components, ensure suitable transport arrangements are in place.











B: Blood/Component Packaging and Final Documentation

1 Locate the blood/components to be dispatched.

2 Complete a transfer document including a record of the unit donation numbers (this may be computer generated) and make a copy of this documentation for your records and one to Email/fax to the receiving hospital (Appendix 2) Return the units to suitable storage conditions whilst preparing the transport box, packing materials and labels.

3 Immediately before dispatch, place the blood/components and a copy of transfer documentation in a suitably sized, validated transport box and cover with cold packs where appropriate

Blood components should be packaged inside a plastic liner. Do not allow cold packs to be in direct contact with components.

4 All air space should be filled with cold packs. (Cold packs should be equilibrated to 4o C or 22o C as appropriate, for 24hrs prior to use.)

Refer to NHSBT Management Process Description Transport of Blood and Blood Components using the Clinimed Packaging System (Appendix 8) Datasheet detailing Capacity and Storage Time Limits (Appendix 9) NHSBT Packing configurations (Appendix 10 & 11)

5 Place all the appropriate documentation in the transport box, retaining a copy of the transfer document.

6 Replace the box lid and seal with by a method (e.g. cable tie) that alerts the User/ laboratory, If removed or broken, that the cold chain has been broken, and attach a copy of ‘Transit box advice for Clinical Staff’ (Appendix 6) and A copy of ‘Acting on transferred blood on arrival advice’ (Appendix 7)

7 Attach a completed dispatch label to the box transfer box (Appendix 4 or 5)

C: Dispatch of Blood/Components

1 On dispatch of the blood/components, immediately telephone the transfusion laboratory of the receiving hospital, and inform them of the dispatch. (Contact details are listed in Appendix 1 and in embedded spread sheet link).

2 Inform the receiving transfusion laboratory as to the time of dispatch, mode of transport, estimated time of arrival, and the number and type of units. If the blood is accompanying or allocated to a patient, the patient identification details are also required and the ward or department expected to receive the patient. Inform the receiving laboratory of any antibodies or special requirements.

3 Email should be the primary form of contact, The transfer documentation may be faxed to the receiving transfusion laboratory if email is unavailable. (APPENDIX 1)

3.0 Procedure for the receiving hospital

1 The transfusion laboratory will be informed by the dispatching laboratory of the expected delivery.

2 The laboratory staff of the receiving transfusion laboratory should document the expected delivery and where applicable inform the ward or department receiving the patient that blood will be accompanying the patient.

3 Local policies should be in place to ensure received blood and components are transferred to suitable storage facilities as soon as possible.

4 On arrival, transfusion laboratory staff should check the integrity of the box and complete the transfer document to verify the units are still under correct storage conditions.

5 Any blood or components received in the transfusion laboratory, including any which will be disposed of due to poor storage conditions, must be entered into stock and have their fate recorded.

6 The receiving laboratory must ensure that all transferred units are accounted for and their final fate recorded in the Laboratory Information System.

7 For blood/components transferred with a patient, the receiving laboratory must inform the dispatching laboratory (by email or fax) of the fate of the units to enable update of patient records as follows; a) Transfused to patient b) Disposed and for what reason c) Not transfused but entered into stock of receiving hospital



Appendix 1 Contact List

Lancaster Area

|Hospital |Address |Transfusion Lab | |Transfusion | | |Name | |Number |Preferred |Lab Fax |Email | | | | |form of |Number | | | | | |contact Fax | | | | | | |or Email | | | |Victoria Hospital |Whinney Heys |01253 303 746 | |01253 306 290| | | |Road Blackpool| |Fax | | | | |Lancashire | | | | | | |FY3 8NR | | | | | |Royal Preston |Sharoe Green |01772 522 605 | |01772 713 879| | |Hospital |Lane North | | | | | | |Fulwood, | | | | | | |Preston | | | | | | |Lancashire | | | | | | |PR2 9HT | | | | | |Furness General |Dalton Lane |01229 491 276 | |01229 491 256| | |Hospital |Barrow-in-Furn| | | | | | |ess | | | | | | |Cumbria | | | | | | |LA14 4LF | | | | | |Burnley General |Casterton |01282 804318 | |01282 803070 | | |Hospital |Avenue | | | | | | |Burnley | | | | | | |Lancashire | | | | | | |BB10 2PQ | | | | | |Westmorland |Burton Road |01539 795 284 | |01539 795 286| | |General Hospital |Kendal | | | | | | |Cumbria | | | | | | |LA9 7RG | | | | |

















Liverpool Area

|Hospital |Address |Transfusion |Preferred |Transfusion | | |Name | |Lab Number |form of |Lab Fax |Email | | | | |contact Fax |Number | | | | | |or Email | | | |Arrowe Park |Arrowe Park Road |0151 604 7525 | |0151 604 | | |Hospital |Upton Wirral | |Fax |0034 |[email protected]| | |CH49 5PE | | | |t | |Broadgreen |Thomas Drive |0151 600 1293 | |0151 600 | | |Hospital |Liverpool | | |1286 | | | |L14 3LB | | | | | |Countess of |Liverpool Road |01244 365 385 | |01244 365 | | |Chester Hospital |Chester | | |322 | | | |CH2 1UL | | | | | |Glan Clwyd |Bodelwyddan |01745 534 200 | |01745 534 | | |Hospital |Rhyl | | |016 | | | |LL18 5UJ | | | | | |Gwynedd Hospital |Penrhosgarnedd |01248 384 368 | |01248 385 | | | |Bangor | |Fax |399 | | | |LL57 2PW | | | | | |Liverpool Women's|Crown Street |0151 702 4127 | |0151 702 | | |Hospital |Liverpool | | |4166 | | | |L8 7SS | | | | | |Noble's Isle of |The Strang |01624 650 630 | |01624 651 | | |Man Hospital |Douglas | | |315 | | | |Isle Of Man | | | | | | |IM4 4RJ | | | | | |Nuffield Health |Wrexham Road |01244 674 629 | |01244 671 | | |The Grosvenor |Chester | | |564 | | |Hospital |CH4 7QP | | | | | |Ormskirk and |Wigan road |01695 656 645 | |01695 571 | | |District General |Ormskirk | | |305 | | |Hospital |Lancashire | | | | | | |L39 2AZ | | | | | |Royal Liverpool |Prescot Street |0151 706 4331 | |0151 706 | | |University |Liverpool | |Email |5810 |[email protected]| |Hospital |L7 8XP | | | |hs.uk | |Southport |Town Lane |01704 704 176 | |01704 704 | | |Hospital |Kew Southport | | |469 | | | |PR8 6PN | | | | | |University |Longmoor Lane |0151 529 3415 | |0151 529 | | |Hospital Aintree |Liverpool | | |2840 | | | |L9 7AL | | | | | |Warrington |Lovely Lane |01925 662 547 | |01925 662 | | |Hospital |Warrington | |Email |007 |[email protected] | | |WA5 1QG | | | | | |Whiston Hospital |Warrington Road |0151 430 1584 | |0151 430 | | | |Prescot | | |1823 | | | |Merseyside | | | | | | |L35 5DR | | | | | |Wrexham Maelor |Croesnewydd Road|01978 725 371 | |01978 725 | | |Hospital |Wrexham | | |371 | | | |Clwyd | | | | | | |LL13 7TD | | | | |

Manchester Area

|Hospital |Address |Transfusion Lab |Preferred |Transfusion | | |Name | |Number |form of |Lab Fax |Email | | | | |contact Fax |Number | | | | | |or Email | | | |North Manchester |Delaunays |0161 720 2100 | |0161 720 2629| | |General Hospital |Crumpsall Road | |Fax | | | | |Manchester | | | | | | |M8 5RB | | | | | |Royal Albert Edward |Wigan Lane Wigan |01942 822 145 | |01942 822 145| | |Infirmary |Lancashire | |Fax | | | | |WN1 2NN | | | | | |The Christie |550 Wilmslow Road |0161 446 3287 | |0161 446 3315| | |Hospital |Withington | | | | | | |Manchester | | | | | | |M20 4BX | | | | | |The Royal Oldham |Rochdale Road |0161 627 8372 | |0161 652 0204| | |Hospital |Oldham | |Fax | | | | |Lancashire | | | | | | |OL1 2JH | | | | | | |Southmoor Road | |University Hospital of South Manchester |Wythenshawe | | |Manchester | |Wythenshawe |M23 9LT | |Delivered to: |Date and time removed from transport box:| |Signature |Give EXACT time HH:MM | | | | | | | |Print Name and Designation | | | | | | | | |Date: Time | | | |Unit 1: | | |Unit 2: | | |Unit 3: | | |Unit 4: | | |Unit 5: | | |Unit 6: | | |Unit 7: | | |Unit 8: |

|This transport box has been validated for the storage of blood components. | |The contents of this box will be suitable for transfusion until | |HH:MM hours | | | |Transport box opened / seal broken at: ……………………………………………………………………… |



Appendix 5 Transit Box Label for Stock Transfer



Insert Dispatching Hospital Logo here if required

To: Insert Receiving Hospital Here BLOOD [pic]

The Blood / Components contained in this box were issued from the Transfusion Laboratory at Insert Hospital here If found please telephone Insert Number Here immediately |Packed By: |Taken By: | |Signature of BMS |Signature of Person taking box | |Print Name |Print Name | | | | |Date: Time:|Date: Time|

| This transport box has been validated for the storage of blood components. | |The contents of this box will be suitable for transfusion until | |HH:MM hours |

[pic]

Appendix 6 Blood Transfer Advice for Clinical Staff

Insert Hospital Logo Here if Required

BLOOD TRANSFER ADVICE FOR CLINICAL STAFF

The blood and blood components have been packed in this transport box following Blood Transfusion Laboratory guidelines

In order to ensure integrity of contents please follow instructions below

During Transfer:

➢ If blood is required during the patient’s journey please ensure it is checked and transfused in accordance with local policy.

➢ Please ensure transport box remains sealed unless blood is required for transfusion. Once opened, the cold chain has been broken and all the units must be transfused within 4 hours

➢ If blood is removed for transfusion, please replace the lid

➢ If blood is transfused complete details of date & time against appropriate unit on box lid

➢ Blood is suitable for transfusion within the timeframe stated on the associated paperwork with the transport box, provided the seal is UNBROKEN

On Arrival:

➢ When the patient arrives in the receiving clinical area, please ensure the transport box is handed over to the receiving staff member.

➢ Please state how much blood was transfused during the journey and any adverse events (if occurred)

The responsibility for the blood now lies with the receiving hospital in line with their local policy Appendix 7 Acting on transferred blood Components upon arrival

ACTING ON TRANSFERRED BLOOD COMPONENTS UPON ARRIVAL

Appendix 8 Clinimed transport box temperature validation



| | UBP 110 | UBP 130 | | |Ambient Temperature |Ambient Temperature | |Red Cell | | | |Components |2 to 60C |Up to 270C | |Including all | | | |component(s) | | | |stored at 40C +- | | | |20C | | | |Platelet | | | |Components |-2 to 60C |Up to 270C | | | | | |Including all | | | |component(s) | | | |stored at 220C +-| | | |20C | | | |Frozen Components|2-60C |Up to 270C | | | | | |Including all | | | |component(s) | | | |stored below - | | | |300C | | |

Reproduced from Guidance for the Emergency Transfer of Blood and Components with Patients between Hospitals 24/03/11

Appendix 9 Capacity and Transportation Time Limits for Transport Boxes |MED|Box Type |Amb |Red Cell Components |Platelet Components |Frozen Components | |ICO|and |˚C | | | | |OL |Capacity | | | | | | | | |Including all products stored |Including all products stored|Including all | | | | |at 4˚ C +/- 2˚C |at 22˚C +/- 2˚C |products stored | | | | | | |below -30˚C | | | | |2˚C to 6˚C |7˚C to 27˚C | | |Va-Q-Tec | | | | | |Max 15 Adult Platelets | | | | | |Max 10 Clinical Buffy | | | | | |Coats | | | | | |Max 2 Granulocytes | | | | | |(Green PCM) | | | | |Extreme Weather Conditions and use of Transport Boxes for Red Cells and Platelets - 5˚C and lower and 35˚C and | |above | |Component Type |Red Cells |Platelets | |Outside Temperature |/= 35˚C |/= 35˚C | |Journey | |Box Type |Description |Red Cells Components‡ |Platelets Components | | |and | | | | |Dimensions | | | | | | Medicool | | | |Pack Layers | | | |Bottom Top | | | |Bottom Top | | |UBP110 | | | | | | |Int: 175x180 |0 |1 or more |2 |1 or more | | |Ext:320x320x320 | | | | | |CLINIMED | | | | | | | |UBP130 | | | | | | |Int:210x210 |0 |1 or more |2 |1 or more | | |Ext:360x360x360 | | | | | | |UBP150 | | | | | | |Int:270x325x190 |0 |1 or more |1 |1 or more | | |Ext:410x465x330 | | | | | | | | | |All empty airspace must be filled with equilibrated Medicool packs (to reduce weight, paper | | |towel/roll/sheets/bubble wrap may be used to fill void provided at least 1 layer of Medicools has | | |been placed on top) | | | Frozen Components | | |UBP140 | | | |Int:238x238x222 |2 X 500g bags of dry ice Top | | |Ext:360x360x360 | | | |UBP150 | | | |Int:270x325x190 |3 X 500g bags of dry ice Top | | |Ext:410x465x330 | |

Note ‡ Red cells must be packed upright to reduce risk of damage if transport box is accidently dropped.

Appendix 11 Packaging of Clinimed boxes

|Note | |Medicool Packs should not be in with contact blood components | | | |Pack issued red cells, |Place a plastic liner |To reduce risk of damage | |platelets. |into a box. |to component if box | | |Place issued components |accidently dropped. | | |within liner. Pack | | | |upright if possible. | | |Secure plastic liner. |Expel the air from the | | | |liner and secure by | | | |either; |Gather and twist the ends| | |Making a knot |and tuck down side of | | |Or |box. | | |Making a ‘swan neck’ fold| | | |Or | | | |Cable tie | | |Add Medicool packs to |Select correct size and | | |box. |number of packs for box | | | |size and number of |Medicool packs above | | |components. |components In sealed bag.| | |Check integrity of each | | | |pack discard any not | | | |suitable. | | | |Place one layer or more | | | |on top of liner until no| | | |air space remains in | | | |box. | | | |All empty airspace must | | | |be filled with | | | |equilibrated Medicool | | | |packs | | | |(Paper towel | | | |roll/sheets/bubble | | | |wrap may be used to fill | | | |void provided at least 1 | | | |layer of Medicools has | | | |been placed on top) | | | |If components are not to | | | |be despatched | | | |immediately, return to | | | |designated temperature | | | |controlled storage with | | | |lid closed. | | | | | |

Appendix 12 Embedded Electronic links to transfer documents





[pic] [pic] [pic]

Note: ‘Printable copies.xlsx’ and ‘Electronic scanable blood stock transfer’ files require Office 2010 or above to open

Appendix 13 Author Information

Elaine Addison, Transfusion Laboratory Manager, Blackpool Victoria Hospital

Pete Baker, Transfusion Laboratory Manager, Royal Liverpool University Hospital

Dave Cain, Operations Manager, Warrington & Halton Hospitals NHS Foundation Trust

Barry Chesterson, Senior Specialist Biomedical Scientist, Warrington & Halton Hospitals NHS Foundation Trust

Neil Fuller, Transfusion Laboratory Manager, University Hospital Aintree

Steven Richards, Transfusion Laboratory Manager, Stepping Hill Hospital and University Hospital of South Manchester NHS foundation Hospital

Christine Gallagher, NHSBT Customer Service Manager (North West)

Policy Based on :-

NHSBT Appropriate Use of Blood Group & National Laboratory Managers’ Group of the CMO’s National Blood Transfusion Committee: Guidance for the Emergency Transfer of Blood and Components with Patients between Hospitals

Electronic transfer documents developed at Warrington & Halton Hospitals NHS Foundation Trust

----------------------- URGENT FOR IMMEDIATE DELIVERY

DO NOT open unless immediate transfusion of the patient is indicated

In compliance with BSQR 2005, it is confirmed that the contents of this box have been stored securely in accordance with Guidelines for the Blood Transfusion Services.

URGENT FOR IMMEDIATE DELIVERY

In compliance with BSQR 2005, it is confirmed that the contents of this box have been stored securely in accordance with Guidelines for the Blood Transfusion Services.

Medical Emergency

Send any unused blood and transport box to the transfusion laboratory ASAP

Call the Transfusion Laboratory

Not packed correctly

SEND UNOPENED TRANSPORT BOX AND UNUSED BLOOD TO THE TRANSFUSION LAB ASAP

DO NOT TRANSFUSE

[?]!lpx{|~‰”•?¥´µ¾çÏ·Ÿ·‡·o·‡ZEZE0E0E)h¹h…d…B*[pic]CJOJ[?]QJ[?]^J[?]aJph)h¹hÉ ~¯B*[pic]CJOJ[?]QJ[?]^J[?]aJph)h¹hg[?]×B*[pic]CJOJ[?]QJ[?]^J[?]aJph/h¹hÉ~¯5? B*[pic]CJ$OJ[?]QJ[?]\?^J[?]Ensure that a group & Antibody screen sample has been taken

Blood can be transfused

Packed correctly

➢ Take a blood sample for group and antibody screen

➢ Request more blood if required

Inform transfusion Laboratory

Non Emergency

Packed correctly

➢ Checked documentation and transport box integrity. If unsure call the Transfusion Laboratory

Not Packed correctly

➢ Blood arrives in an inadequate container eg Plastic bag, cardboard box ➢ No time of packing is documented ➢ Transport seal is broken ➢ Out of transport time

NHSBT Clinimed Transport Box Temperature Validation

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