Policies, procedures and guidelines
A POLICY reflects the "rules" governing the implementation of the organisation's processes. It governs or binds staff across the organisation. It may be used to support the organisation during legal action.
A PROCEDURE is a rigid statement of practice allowing little or no flexibility or variation. It is a standardised method of performing clinical or non-clinical tasks by providing a series of actions to be conducted in a certain order or manner to achieve a safe, effective outcome. This will ensure all concerned undertake the task in an agreed and consistent way.
A GUIDELINE is a set of systematically developed statements which assist the individual healthcare professional and patient in making decisions about appropriate health care for specific conditions. Guidelines are about best practices, and therefore variation may only be permitted on an individual case by explicit recording of the reason for non compliance in accordance with local requirements.
Guidance for writing a transfusion policy
All organisations involved in the transfusion process must have an approved document (i.e. a policy) for the management of risks associated with blood and blood component storage, handling and administration. The minimum requirements for the blood transfusion policy are:
- roles and responsibilities in the transfusion cycle
- process for request and collection of blood samples for pre-transfusion compatibility testing
- process for prescription of blood / blood products, including consideration of the appropriateness of allogeneic transfusion
- process for collection of blood or blood products and the delivery to the point of care
- process for administration of blood and blood products including the care and monitoring of patients
- process for reporting adverse events involving blood or blood product transfusion to the appropriate bodies
- staff training and competency assessment with regard to blood/blood products handling and administration, as reflected in the organisation's training needs analysis
- process for monitoring the policy (e.g annual / biannual audit)
As well as a policy for blood transfusion, organisations will need policies and guidelines for specific clinical/laboratory situations e.g massive haemorrhage. There is a wealth of existing guidance and supporting literature on this subject including:
- This website - Use the menu on the left to navigate to the appropriate page.
- The Handbook of Transfusion Medicine - Click here to go to the online Handbook
- BCSH Guidelines -The British Committee for Standards in Haematology is a sub-committee of the British Society for Haematology. BCSH provides information in the form of evidence based guidelines. These can be found on their website: www.bcshguidelines.com
- SHOT - Serious Hazards of Transfusion. Recommendations and Learning Points from their reports. Go to: www.shotuk.org.
- RTCs - Use the Regional Transfusion Committees to share knowledge and good practice. Click here to be taken to the RTC website.
Blood Transfusion in 'out of acute hospital' settings
A framework document was developed in 2005 to assist organisations that may be planning to introduce the administration of blood transfusions in non-acute hospital settings (or for organisations that already have such a service in place). Additional legislation and new guidance has emerged since then, and the document was updated in 2007 and again in 2012 to reflect this.
The framework highlights policy and service level agreements required and addresses personnel, training, transport, equipment and the practices for delivering an 'out of acute hospital' blood transfusion service to the patient. The out of acute hospital setting refers to:
- The patients own home
- Residential and nursing homes
- Renal satellite units
- Local treatment centres
- All other areas where blood components are administered that are not covered by local acute hospital protocols.
The 2012 document is available here
Jehovah's Witnesses and others who refuse transfusion of blood and/or blood products
There are individuals and religious groups who have principle objections to receiving a blood transfusion, such as the Jehovah's Witnesses. Hospitals should have a policy for treating patients who refuse a transfusion of blood or blood products.
For more information please see the following BBT Toolkit pages:
Pre Op Assessment for Jehovah's Witnesses
A Framework to Support Nurses and Midwives Making the Clinical Decision and Providing the Written Instruction for Blood Component Transfusion
This framework document has been developed to provide clearly defined guidance for nurses and midwives wishing to extend their role to include making the clinical decision for blood component transfusion and providing the written instruction for blood component transfusion.
As good governance is central to all role development, this document provides guidance on:
- patient selection
- selection criteria for nurses and midwives
- indemnity issues
- education and training
- clinical governance procedures
- staff responsibilities
- informed consent
- reviewing and monitoring practice
Further work is ongoing to develop an appropriate education provision for both nurses and doctors.
Click here to download the framework