ࡱ> 58234 )?bjbj .Fxxs% 8It$ap"accccccxc]###c()))#a)#a)) t|Zz&~wPM<$w 6( | | v) ,!6cc )$####  :  HYPERLINK "http://intranet"  INCLUDEPICTURE "http://intranet/images/logo180.gif" \* MERGEFORMATINET  Tulare Local HealthCare District dba Tulare Regional Medical Center For RNs and LVNs Blood Transfusion Module  HYPERLINK "http://intranet"  INCLUDEPICTURE "http://intranet/images/logo180.gif" \* MERGEFORMATINET  Blood Transfusion Module Introduction: Welcome to the learning module on Blood Transfusion. This module provides a reminder of safety and risk management factors during blood transfusion therapy. Knowledge of signs and symptoms of suspected transfusion reaction is key to providing the safest transfusion possible. Description: This module is designed to refresh the nurses knowledge of transfusion facts. The module includes procedure review and a post-test. Objectives: By completion of this module, the employee will: Describe various transfusion reactions. Identify signs and symptoms of a suspected transfusion reaction. Discuss proper documentation using the Blood or Blood Component Transfusion Form. Target Group: RNs and LVNs performing blood or blood component transfusions. Continuing Education Credit/In-service Credit: In-service only Prepared by: Carol Bradford, BSN, RN, Staff Educator and Desiree Ariaz, BSN, RN, M/S Educator Fee: No fee Course Dates: Start date: September 10, 2012 Completion Date: October 17, 2012 Course Sequence: Read the Procedure Take the Post-test. Must pass with at least 85% or better. Submit the completed test via the computer Learning Management System by October 17, 2012.  HYPERLINK "http://intranet"  INCLUDEPICTURE "http://intranet/images/logo180.gif" \* MERGEFORMATINET  DIVISION OF CLINICAL SERVICES STANDARD OF CARE GUIDELINES FOR REQUEST, ACQUISITION and TRANSFUSION OF BLOOD or BLOOD COMPONENTS TRANSFUSION REACTION RESPONSE. QUALIFIED TO PERFORM: IV Certified RN, LVN STANDARD OF CARE: Patients at Tulare Regional Medical Center requiring the transfusion of blood or blood components can expect to be cared for by staff knowledgeable in the steps of transfusing blood or blood components and the potential complications. STANDARD OF PRACTICE: Licensed nursing staff will demonstrate and maintain competency necessary to promote a safe outcome for the patient requiring the transfusion of blood or blood components using the Perry and Potter text as reference. POLICY: Transfusions will be administered with a physicians order only. Patient must sign an Informed Consent for all transfusions of blood or blood components. A proper request and acquisition of the blood or blood components will be done according to procedure. Temperature monitoring will be maintained by the HemoTemp II indicator. The HemoTemp II System will ensure any units returned to the Blood Bank have been maintained at the proper storage temperature at all times and are acceptable for reissue. BLOOD MUST NOT BE STORED IN REFRIGERATOR ON UNIT. The blood component cannot be left unattended during anytime prior to the transfusion process. The nurse will observe the patient closely for the first 15 minutes of transfusion to monitor for reactions. EQUIPMENT: A. Blood or Blood Component  D. Appropriate Transfusion Tubing and Filter B. IV Tray E. Fluid (Blood) Warmer, IV Pump, or Infuser Cuff (not to exceed 300 mmHg) as needed (If Blood Warmer is used, see IV Fluid (Blood) Warming Procedure) , or syringe pump with appropriate filter for neonatal use.  C. 250-500 ml Normal Saline for Infusion  PRESCRIBED ACTION: REQUEST AND ACQUISITION 1 Verify that Informed Consent has been obtained prior to initiating infusion and verify that all pre-transfusion education has been completed. For an emergency situation, see REQUEST FOR BLOOD OR BLOOD COMPONENT BEFORE COMPLETION OF COMPATIBILITY TESTING (found in the lab). Physician signature required on form. A copy of the completed form will be supplied to the Emergency Department by the lab for the Emergency Departments patient record. 2 Initiate lab request via computer and blue lab slip according to physician order. 3 Obtain blood or blood component from lab at appropriate time, utilizing Blood Bank checkout slip (attachment #1). Appropriately trained staff. (for example: RNs, LVNs, and trained OR/ER techs) may obtain blood from the blood bank. 4 Lab will select the unit of blood or component which corresponds to the chart copy of the Blue Crossmatch form from the blood bank refrigerator. 5 Verify with the blood bank scientist that the blood group, RH type and unit number agree with the information on the Blue Crossmatch form [physicians copy] attached to the unit of blood or component. Any discrepancies MUST BE RESOLVED before the blood or component may be issued. 6  The scientist will examine the unit for abnormal color or appearance [purple color, zone of hemolysis above red cell mass, visible clots, murky plasma, purple, brown, or red plasma]. Direct any questions regarding the units color or appearance to the Blood Bank Scientist. 7 Place unit in biohazard bag for transport  8 Complete and sign the Blood Bank Log. Information on the log includes: unit #, type & RH, component, expiration date, patient name, patient number, patient medical record number, physicians name, department, check-out date and time, and blood appearance.  INITIATION OF TRANSFUSION Donor and Autologous 1 Start IV with normal saline [if not in progress] using a #18 gauge venipuncture device if possible. 2 Prime tubing with normal saline only. 3 Obtain baseline vital signs. 4 At the patients bedside, two licensed staff shall verify doctors order to transfuse and check patients name, birth date, blood type, RH factor, donor number and patient medical record number. Both will sign, along with date and time, on the blue lab requisition slip at the bedside after checking against patients armband and blood bank armband. The yellow blood bank armband must be present and the numbers must match the number on the unit copy of the requisition slip, otherwise the unit cannot be transfused. 5 Premedicate if known allergy per Dr. Order. 6 Connect blood or blood component to IV using appropriate tubing & filter. 7 Start infusion slowly at a rate of 120 ml/hr or less for the first 15 minutes, then increase the rate if no signs and symptoms of transfusion reaction occur. Note: the transfusion should be completed in 4 hours (including time unit removed from blood bank refrigerator). In an emergency situation, the flow rate will be dependant on patient condition, an increase in the standard flow rate above the recommended 120 ml/hr for the first 15 minutes requires a physician order. Patients who receive blood or plasma at rates faster than 100 ml/minute for 30 minutes are at increased risk for cardiac arrest unless the blood is warmed. Blood also must be warmed if more than 6 units are infused. (There must be a physician order to warm blood.) 8 Repeat vital signs approximately every 5 minutes for 1st 15 minutes & observe the patient closely for signs & symptoms of reaction. The vital signs should be repeated approximately every 30 minutes until infusion completed. Post infusion vital signs should be taken approximately one hour past completion of the final unit of the transfusion. 9 Observe patient frequently for signs of reaction [chills, fever (increase of 1 degree Celsius or 1.8 degrees Fahrenheit), flushing, pain, rash, itching, hives, CXP, hypotension, back pain, sudden SOB, Cyanosis, HA, tachycardia, diarrhea, nausea, vomiting] or signs of pulmonary congestion throughout the transfusion. 10 After blood has infused, clear tubing with normal saline. 11 Under normal circumstances, tubing and filter must be used for no more than 4 hours 12 Discard disposable items. 13 Place empty blood container with attached tubing in a RED biohazardous bag for disposal on the nursing unit. Return the WHITE crossmatch slip to Lab.  14 All patients being discharged within 6 hours of the start of blood or blood products transfusion will be given a copy of Discharge Instructions for Transfusion at discharge.TRANSFUSION OF PLASMA  1 Follow above guidelines for Request and Acquisition. 2 Plasma units must be checked for fibrin clots by the lab scientist before infusing. 3 Use standard blood infusion tubing and filter that is used for red cells to infuse plasma. 4 Follow above guidelines for Initiation of Transfusion (steps 1-14. Start infusion slowly at a rate of 120 ml/hr or less for the first 15 minutes, then increase the rate if no signs and symptoms of transfusion reaction occur. Patients who receive blood or plasma at rates faster than 100 ml/minute for 30 minutes are at increased risk for cardiac arrest unless the blood is warmed. Blood also must be warmed if more than 6 units are infused. There must be a physician order to warm blood.). 5 Frequently more than one unit of Plasma is ordered for transfusion at a time. Each unit can be spiked with the same infusion set already in place as long as all units are infused within 4 hours. Change filter if infusion rate slows. TRANSFUSION OF CRYOPRECIPITATE1Follow above guidelines for Request and Acquisition.2Cryoprecipitate units must be checked by the lab scientist for fibrin clots before infusing.3Use standard blood infusion tubing and filter that is used for red cells to infuse Cryoprecipitate.4Follow above guidelines for Initiation of Transfusion (steps 1-14. Start infusion slowly at a rate of 120 ml/hr or less for the first 15 minutes, and then increase the rate if no signs and symptoms of transfusion reaction occur. Patients who receive blood or plasma at rates faster than 100 ml/minute for 30 minutes are at increased risk for cardiac arrest unless the blood is warmed. Blood also must be warmed if more than 6 units are infused. There must be a physician order to warm blood.).5Frequently more than one unit of Cryoprecipitate is ordered for transfusion at a time. Each unit can be spiked with the same infusion set already in place as long as all units are infused within 4 hours. Change filter if infusion rate slows.6The volume of cryoprecipitate in each unit is 15-20ml. Therefore, if four units are ordered, they should be given as quickly as possible in succession, not to exceed 120ml/hr for the first 15 minutes. This will require dedicated nursing attention until all units are infused. TRANSFUSION OF PLATELET, PHERESIS  1 Follow above guidelines for Request and Acquisition and administering blood. 2 Platelet units must be checked for fibrin clots by the lab scientist before infusing. 3Use standard blood infusion tubing and filter that is used for red cells to infuse platelets and infuse at a rate of 120ml/hr or less for the first 15 minutes, then increase rate if no S/S of reaction. Platelets are associated with a higher incidence of bacterial contamination than any other component. Platelets are stored at room temperature, providing a conductive environment for growth of microorganisms.4 Follow above guidelines for Initiation of Transfusion (steps 1-14).5Frequently more than one unit of Platelets is ordered for transfusion at a time. Each unit can be spiked with the same infusion set already in place as long as all units are infused within 4 hours. Change filter if infusion rate slows.  IF SUSPECTED REACTION OCCURS (see attachment #2 for signs & symptoms) 1 Refer to Management of Acute Transfusion Reactions (attachment)  2 R.N. initiates Report of Suspected Transfusion Reaction Form and follows directions on that form. Forward paperwork to lab. 3 A Quality Review Form (QRR) should also be completed. ASSOCIATED NURSING DIAGNOSIS: A. Fluid Volume Deficit B. Fluid Volume Excess C. Anxiety R/T Infusion PATIENT & FAMILY EDUCATION TOPICS: A. Indications for transfusion B. Expected care during transfusion C. S & S Transfusion Reaction D. Discharge Instructions for Transfusion at discharge. OTHER RELEVANT STANDARDS: IV Therapy Intravenous Fluid (Blood) Warming, Rapid and Regular Hospital Policy #20-10,002 Guidelines for Blood Products Utilization, Emergency Release of Blood and transfusion Reactions Hospital Policy #13-9031 Consent for Blood Transfusion For transfusions during hemodialysis refer to DaVita Acute Service Policy, procedure 7-06-05,7-06-05A, 7-06-05B located in the dialysis storage area in the basement. DOCUMENTATION REQUISITION SLIP 1 Two signatures verifying correct patient, name, birth date, medical record #, unit #, donor #, blood type, and RH factor at bedside on blue requisition/crossmatch slip. INFUSION RECORD (Depending on department specific documentation) 2 a. Date & time b. Unit # c. Amount in bag d. Amount infused, date, time e. Time & amount normal saline NARRATIVE NOTES  3 Make a reference to the transfusion record in the narrative notes. BLOOD or BLOOD COMPONENT TRANSFUSION FORM 4 Fill out form completely (attached). All information is important  TRANSFUSION PHYSICIAN ORDERS 5 Use of pre-printed transfusion orders for blood or blood component transfusion is recommended. There must be a physician order to transfuse blood or blood components documented in the chart either hand written by the physician, pre-printed and signed, or telephone/verbal order with documented read back (RB).RESOURCES: AABB Technical Manual, pg. 485-495; American Association of Blood Banks 14th Edition, 2002; AABB Standards for Blood Banks and Transfusion services 22nd Edition, 2003, pg. 44-54; Perry and Potter-Clinical Nursing Skills and Techniques 7th Edition, pg. 785-801. REPLACES: 1/97, 8/98, 5/02, 5/04, 7/05, 11/05, 5/06, 2/09 REVIEWED AND APPROVED BY STANDARDS OF PRACTICE COMMITTEE: 4/25/12 CB REVIEWED/APPROVED BY CHIEF CLINICAL OFFICER: Pat Mathewson, RN REVIEWED/APPROVED BY MEDICAL DIRECTOR OF LABORATORY: Gary A. Walter, MD Tulare Regional Medical Center Department Of Nursing Standard of Care Management of Acute Transfusion Reactions Immediate Steps for All Reactions: Stop transfusion; Document time on Transfusion Form Keep IV open with 0.9% NaCl Verify correct unit was given to the correct patient. Notify attending physician and the Blood Bank (ext. 3653) that the transfusion was terminated due to signs and symptoms of a transfusion reaction NOTE: Transfusions can only be resumed with Mild Allergic reactions that show improvement with antihistamines (as described below). After transfusion is terminated (except Mild Allergic, see below): Send urine sample with blood unit and administration set to the Laboratory Blood Bank. Laboratory will draw post-transfusion blood specimens upon notification of possible Transfusion Reaction. Reaction TypeSigns and SymptomsClinical ActionsAllergic (mild)Pruritus, urticaria (hives)Steps 1-3 above; administer antihistamines (PO, IM, or IV); resume transfusion if improved; if no improvement in 30 minutes, treat as below.Allergic (moderate to severe)Hives and dyspnea, abdominal pain, hypotension, nausea, anaphylaxisSteps 1-6 above; mild-administer antihistamines, epinephrine, vasopressors, and corticosteroids as needed; avoid future reactions by premedication and use of washed red cells Febrile (mild to moderate)Fever, chills, rigors, anxiety, mild dyspneaSteps 1-6 above; mild administer antipyretics as needed; avoid future reactions by premedication.Acute Lung InjuryFever, chills, dyspnea, respiratory failureSupportive therapy for respiratory failure, oxygen, mechanical ventilation.Acute HemolyticAnxiety, chest pain, flank pain, dyspnea, chills, fever, shock, unexplained bleeding, hemoglobinemia/hemoglobinuria, cardiac arrestSteps 1-6 above, treat shock with vasopressors, IV fluids, corticosteroids as needed; maintain airway; increase renal blood flow (IV fluids; furosemide); maintain a brisk diuresis; monitor renal status for acute renal failure. Monitor coagulation status for DIC; administer blood components as needed after etiology is clear.Septic/ToxicChills, fever, hypotensionSteps 1-6 above; treat shock with vasopressors, IV fluids. Culture patient and blood bag. Reference: Darrell J. Triulzi, MD (ed), American Association of Blood Banks, 9/99. TULARE LOCAL HEALTH CARE DISTRICT dba TULARE REGIONAL MEDICAL CENTER POLICY / GUIDELINE TO: All Departments FROM: Administration SUBJECT: Guidelines for Blood Products Utilization, Emergency Release of Blood and Transfusion Reactions I. POLICY The transfusion of blood and components has risks and benefits that must be considered. This policy follows the guidelines of the American Association of Blood Banks (aabb), Americas Blood Centers, the Red Cross and Joint Commission. Because of the risks and the limited blood supply, patient should be transfused the minimal units to relieve symptoms. Risks include Hemolytic transfusion reaction, alloimmunization, circulatory overload, Iron overload, Non-immunologic hemolysis, Febrile nonhemolytic reactions, allergic reactions, anaphylactoid reactions, Transfusion-related acute lung injury (TRALI), Transfusion of infectious diseases, bacterial contamination, hypothermia, metabolic complications, immune suppression. The following guidelines are in place to minimize the effects of blood transfusion and over-utilization of blood products. II. APPROPRIATE USE OF RED BLOOD CELLS Hematocrit d" 21% or hemoglobin d" 7.0 grams/dl in a patient symptomatic of tissue hypoxia. (In most patients, one unit of blood should increase the hemoglobin by 1 gram/dl). Hematocrit d" 24% or hemoglobin d" 8.0 grams/dl in a patient with coronary artery disease and unstable angina or myocardial infarction or cardiogenic shock. C. Transfusion may be administered with: active bleeding or surgical procedures that may result in rapid blood loss or on-going blood loss. D. Infants < 4 months of age may be transfused with a hemoglobin d" 10 grams/dl and on < 35% hood oxygen. E. Patients should not be transfused if anemia can be corrected by Iron, B12, Folate or Erythropoietin. F. Patients should not be transfused if low hemoglobin is due to hemodilution. III. EMERGENCY RELEASE OF BLOOD BEFORE COMPATIBILITY TESTING A. When there is a desperate requirement for blood, the patients physician must weigh the hazard of transfusing uncrossmatched or partially crossmatched blood against the risk of waiting until testing is completed. When blood is released before the crossmatch is completed, the records must contain a statement of the requesting physician indicating that the clinical situation was sufficiently urgent to require release of blood. Attachment A Emergency release of blood or blood component before completion of compatibility testing forms must be completed and signed by the physician within twenty-four (24) hours of transfusion. B. When urgent release is requested, uncrossmatched blood is issued to nursing staff and compatibility testing procedures are started by lab staff. The blood type released will be determined by the Blood Bank, but the blood released should be: 1. ABO- and Rh-group compatible, if there has been time to perform ABO and Rh testing on the patients current blood specimen. Previous records must not be used to determine which blood group to issue, nor may the patients blood group be taken from other records such as cards, dog tags or drivers license. 2. Group O Red Blood Cells for group AB recipients if group AB donor blood is unavailable. 3. Group A or B Red Cells for group AB recipients if group AB donor blood is available. C. Emergency units will be tagged or labeled with the patients identification and indicate that compatibility testing had not been completed at the time of issue. D. Compatibility testing is completed. If incompatibility is detected at any stage of testing, the lab will immediately notify the patients physician, patients nurse and the Laboratory Supervisor or Manager. IV. APPROPRIATE USE OF PLASMA FROZEN WITHIN 24 HOURS A. Management of pre-operative or bleeding patients who require replacement of multiple coagulation factors (eg. liver disease) demonstrated by a PT/PTT > 1.5 times the mean of the reference range. B. Immediate reversal of Warfarin effect in patients who are actively bleeding or who are about to undergo emergency surgery (cannot wait 8-12 hours for vitamin K to work). C. Massive blood transfusion to prevent exsanguination [replacement of more than one (1) blood volume (approximately 5 liters in a 70-kg. adult) within several hours with evidence of coagulation deficiency]. D. Documented congenital or acquired coagulation deficiency when used for bleeding or prophylactically for surgery or an invasive procedure (congenital factor deficiencies of Factors II, V, VII, X, XI, or XIII, congenital or acquired deficiency of Factor VIII, acquired deficiency of multiple factors such as seen in severe liver disease, DIC or Vitamin K depletion). E. Deficiency of Anti-Thrombin III, heparin co-factor II, protein C or Protein S. F. Hypoglobulinemic states in rare instances (IV immune globulin is preferable). G. Plasma exchange for TTP or HUS. V. APPROPRIATE USE OF PLATELETS Platelet count of less than 10,000\mm in a non-bleeding patient. Platelet count less than or equal to 50,000\mm in the setting of active bleeding or patient undergoing surgery. Patients undergoing cardiopulmonary bypass, neurological or ophthalmologic surgery may receive platelets if the platelet count is less than 100,000\mm (high risk bleeding site). Patients with massive bleed documented by replacement of one (1) blood volume within several hours. In cases of platelet dysfunction which has not responded to pharmacological methods of enhancing their function (e.g., DDAVP). F. Do not transfuse in patients with destruction of endogenous or transfused platelets, such as TTP or ITP, unless the patient has a life threatening hemorrhage. VI. APPROPRIATE USE OF CRYOPRECIPITATE Bleeding patients with: Hypofibrinogenemia (less than 150 mg/dl) Hemophilia A (Factor VIII:C) Von Willebrands Disease (vWF) Stuart Prower Factor X Deficiency VII. APPROPRIATE USE OF Rh IMMUNE-GLOBULIN 1. Delivery of an Rh-positive infant to a Rh-negative woman. 2. Ectopic pregnancy in a Rh-negative women. 3. Antepartum fetal-maternal hemorrhage (suspected or proven) resulting from antepartum hemorrhage (eg. placenta previa), amniocentesis, chorionic villus sampling, percutaneous umbilical blood sampling, other manipulative procedures (eg. version) or abdominal trauma in a pregnant Rh-negative women. 4. Transfusion of Rh incompatible blood or blood products (platelets) in a Rh- negative woman of child bearing age. VIII. TRANSFUSION REACTIONS Transfusion reactions are defined as a variety of reactions that can occur as a result of a blood transfusion. In general, one should consider any adverse manifestation occurring at the time of the transfusion to be a transfusion reaction until proven otherwise. 1. Fever with or without chills (generally defined for surveillance purposes as a 1C (1.8 F) increase in body temperature) associated with transfusion. Fever is the most common symptom of a hemolytic transfusion reaction (HRT). but more frequently it has other causes. 2. Shaking chills (rigors) with or without fever. 3. Pain at the infusion site or in the chest, abdomen or flanks. 4. Blood pressure changes, usually acute, either hypertension or hypotension. Circulatory shock in combination with fever, severe chills, or high-output cardiac failure suggests acute sepsis but may also accompany an acute HTR. Circulatory collapse without fever and chills may be the most prominent findings in anaphylaxis. 5. Respiratory distress, including dyspnea, tachypnea, wheezing, or hypoxemia. 6. Skin changes, including urticaria, pruritis (itching), flushing, or localized edema (andioedema). 7. Nausea with or without vomiting. 8. Darkened urine or jaundice. Dark urine may be the earliest indication of an acute hemolytic reaction in anesthetized patients. 9. Bleeding or other manifestations of a consumptive coagulopathy. IX. TRANSFUSION REACTION STAFF RESPONSIBILITIES 1. Responsible staff will monitor blood administration to detect adverse reactions. 2. There will be documentation of monitoring of patients receiving blood. 3. Clinical Nursing Services and the Laboratory will have written policies and procedures that include detailed criteria for recognizing a suspected transfusion reaction. 4. All suspected transfusion reactions are reported immediately to the responsible physician. 5. In all instances, the laboratory is notified immediately of suspected transfusion reactions whether or not the physician responsible for the patient deems it necessary. 6. If signs and symptoms of a transfusion reaction are detected during the infusion of a blood product, the infusion of that unit must be stopped and can be resumed if the only symptom was a mild allergic reaction that shows improvement with antihistamine. X. MANAGEMENT OF ACUTE TRANSFUSION REACTION 1. Immediate steps for all reactions: A. Stop transfusion; document time on Transfusion Form B. Keep IV open with 0.9% NaCl. C. Verify correct unit was given to the correct patient. D. Notify attending physician and the Blood Bank (x3653) that the transfusion was terminated due to signs and symptoms of a transfusion reaction. E. After transfusion is terminated (except Mild allergic reaction, see below), send urine sample with blood unit and administration set to the Laboratory Blood Bank. F. Laboratory will draw post-transfusion blood specimens upon notification of possible Transfusion Reaction... REACTION TYPESIGNS AND SYMPTOMSAABB SUGGEST CLINICAL ACTION (Administer meds by Physician order only)Allergic (mild) Pruritis, Urticaria (hives)Steps 1-4 above; administer antihistamines (PO, IM or IV); resume transfusion if improved; if no improvement in 30 minutes treat as belowAllergic (moderate to severe)Hives and dyspnea, abdominal pain, hypertension, nausea, anaphylaxisSteps 1-6 above; administer antihistamines, epinephrine, vasopressors, and corticosteroids as needed; avoid future reactions by premedication and use of washed red cellsFebrile (mild to moderate)Fever, chills, rigors, anxiety, respiratory failureSteps 1-6 above; mild administer antipyretics as needed; avoid future reactions by premedicationAcute Lung InjuryFever, chills, rigors, anxiety, mild dyspneaSupportive therapy for respiratory failure, oxygen, mechanical ventilationAcute HemolyticAnxiety, check pain, flank pain, dyspnea, chills, fever, shock, unexplained bleeding, hemoglobinemia / hemoglobinuria, cardiac arrestSteps 1-6 above, treat shock with vasopressors, IV fluids, corticosteriods as needed; maintain airway; increase renal status for acute renal failure. Monitor coagulation status for IC; administer blood components as needed after etiology is clear.Septic/ToxicChills, fever, hypotensionSteps 1-6 above; treat shock with vasopressors, IV fluids. Culture patient and blood bag.Reference: Darrell J. Triulzi, MD (ed.), American Association of Blood Banks, 9/99 Questions concerning any aspect of this policy/guideline should be referred to Administration. This policy/guideline replaces and supersedes all previous policies/guidelines and is effective immediately. ATTACHMENT A EMERGENCY RELEASE OF BLOOD OR BLOOD COMPONENT BEFORE COMPLETION OF COMPATIBILITY TESTING TO BE COMPLETED BY LAB PATIENTS NAME: _______________________________ ID #: _____________________ DATE: ___________________________ TIME: ________________________ SERVICE: ________________________________________________________________ PATIENTS ABO GROUP: ______________________ Rh (D) TYPE: _________________ UNIT #: __________________ ABO GROUP: ___________ Rh (D) TYPE: _____________ UNIT #: __________________ ABO GROUP: ___________ Rh (D) TYPE: _____________ UNIT #: __________________ ABO GROUP: ___________ Rh (D) TYPE: _____________ UNIT #: __________________ ABO GROUP: ___________ Rh (D) TYPE: _____________  PHYSICIANS STATEMENT: I believe this patients life will be in jeopardy without an emergency transfusion, therefore, I accept the responsibility for any adverse reaction resulting from this tra hklmn̾߶{{sh`XMhvhjVCJ aJ hQuuCJaJhvCJ0aJ0hQuuhiCJ0aJ0hCJ0aJ0hsZoCJ0aJ0hr_CJ0aJ0h,8CJ0aJ0hI&CJ0aJ0hjVCJ0aJ0h+CJ0aJ0h+h+CJ(aJ(hE&OCJ(aJ(hE&OB* OJQJ^Jphf$jhE&OB* OJQJU^JphfhE&OB*OJQJ^Jph333$jhE&OB*OJQJU^Jph333mnZ [ t $a$gd{8$a$gdv$a$gdsZo$a$gdjV U V W X Y Z [ l s t u ˽˪ˁxocXL@huh?H5CJaJhuh5CJaJhuh{8CJaJh{8h5CJaJhr_5CJaJh,E5CJaJhYhCJ4aJ4$jhE&OB* OJQJU^JphfhE&OB* OJQJ^Jphf$jhE&OB* OJQJU^JphfhE&OB*OJQJ^Jph333$jhE&OB*OJQJU^Jph333hvCJ4aJ4h,E6CJ4aJ4hjV6CJ4aJ4hjVCJ4aJ4t u 2 4 A B u 0 1 ? @  gd@ugd{8 & F gd{8gdQuugd'gdQgd;~gd9Sdgdgd$a$gd{8 N O  % / 0 1 2 4 = > @ A B s ¶Չ݉ݙ~riri]Rhuh'CJaJhuhv[5CJaJh'5CJaJhuh'5CJaJhuhCJaJhQCJaJhv[CJaJhv[hv[CJaJhv[5CJaJh5CJaJhuh5CJaJh;~h;~CJaJhgCJaJhCJaJhJ_CJaJh,ECJaJh9SCJaJh;~h?HCJaJ s t u   ) . / 0 1 ? @ B C G X } ~  𽱥vmd[hQuu5CJaJhu5CJaJh5CJaJhuh@uCJaJhdCJaJh CJaJh@u5CJaJhuhCJaJhuh5CJaJhuh5CJaJh'h{8CJaJhXCJaJhCJaJhJ_CJaJh*QFCJaJh,ECJaJhQuuCJaJh{8CJaJ" " # $ 0 1 2 @ _ ABCDEFGHIgd\r & FgdQ & Fgd| & Fgddgd   " # $ ( ) / 0 1 2 @ L W X ^ p x y z ̵ynf^VV^VhQuuCJaJh*QFCJaJhE&OCJaJhuhdCJaJhuCJaJhCJaJhuhCJaJhE&O5CJaJhuh5CJaJhuhd5CJaJhuh5CJaJhbhCJaJhbhbCJaJhbh*QFCJaJhbCJaJh*QFhQuuCJaJh*QFh*QFCJaJ! +678?@AJKTXĹ~ul~aXOFBhdh>*CJaJh\r>*CJaJh\r>*CJaJh*QFhQCJaJhb>*CJaJh*QF>*CJaJh]hQ>*CJaJhQ>*CJaJhvCJaJh*NCJaJhx,hx,CJaJhx,h|CJaJhx,hdCJaJhuhdCJaJhuhd>*CJaJh CJaJh*QFCJaJh h CJaJh >*CJaJIJKLMNOPQRSTUVWXYZ[\]^_`$a$gd3gd*gd\rXYZ^_`a~n'AEGSV[\ ¸©xnnnnhh35CJhqh3>*CJhqh35>*CJ h3CJ h35CJh35>*CJ h35j)hE&OB* U^JphfhE&OB* ^JphfjhE&OB* U^JphfhE&OB*^Jph333jhE&OB*U^Jph333h3B*^Jph333hhdhX+n :$Ifgdv d$Ifgdv^gd3gd3$a$gd3$a$gd3ujjuj :$Ifgdv d$Ifgdv~kdC>$$Ifx4FF&:`  `'    4 xaf4pyt3ujjuQ `0JJ:$If^Jgdv :$Ifgdv d$Ifgdv~kdi?$$Ifx4FF&:   `'    4 xaf4pyt3  "#rrfSSSSf `0J$Ifgdv d$Ifgdv `0Jgd3~kd@$$Ifx4FF&:   `'    4 xaf4pyt3 #%2B<A,1 .343457g#  !!"""(#)######<$$$&&&&''(((((())ʹʹh3 h36CJhY^h35CJ h3>*CJhY^h3CJh3CJaJhlEh35CJaJhlEh3CJaJ h3CJ h35CJD#%&<QkdA$$Ifx4F6&`0*H    4 xaf4yt3 d$Ifgdv `0J:$Ifgdv <=>?AB,rffQfQ `0J:$Ifgdv d$Ifgdvkd_B$$Ifx4KF6& 0*H    4 xaf4yt3,-./12rffQfQ `0J:$Ifgdv d$Ifgdvkd%C$$Ifx4jF6& 0*H    4 xaf4yt3rffQfQ `0J:$Ifgdv d$IfgdvkdC$$Ifx4KF6& 0*H    4 xaf4yt3rffS>f> `0J:$Ifgdv `0J$Ifgdv d$IfgdvkdD$$Ifx4F6& 0*H    4 xaf4yt3.rffSf> `0J:$Ifgdv `0J$Ifgdv d$IfgdvkdwE$$Ifx4F6& 0*H    4 xaf4yt3./013445riiiiii $Ifgdvkd=F$$Ifx4F6& 0*H    4 xaf4yt3567BEQfgrfSS>>f `0J:$Ifgdv `0J$Ifgdv d$IfgdvkdG$$Ifx4F6&0*H    4 xaf4ytvgijzckdG$$Ifx4F6&`*H    4 xaf4yt3 d$Ifgdv `0J:$Ifgdv zz d$Ifgdv `0J:$IfgdvckdH$$Ifx4F6& *H    4 xaf4yt3 "#( zzq $Ifgdv d$Ifgdv `0J:$IfgdvckdI$$Ifx4F6& *H    4 xaf4yt3( ) * + - . 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I understand that the Laboratory will subsequently perform the Crossmatch and that they will report to me immediately any results they may find. Nurses can sign this form as a verbal order, but it must be signed, dated and timed by the physician within 24 hours of transfusion. __________________________________________ _______________ ________ PHYSICIANS SIGNATURE DATE TIME The blood or blood components(s) shall not be transfused until this form is completed in full. The patients chart shall indicate the justification for the emergency transfusion and the results of the compatibility testing.     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