Haematology and Blood Transfusion User Handbook

Transcription

1 Haematology and Blood Transfusion User Handbook Subject Applicable to All personnel using QEW Haematology/Transfusion Services Date issued 01/10/2013 Next review date 01/10/2014 Author Owner Approved by Related documents John Wright Reza Mirza Reza Mirza Catherine Hawkins Pathology General Information Handbook (PP-MP-009) Location of copies Master Q-Pulse 1 Trust Intranet Please refer to Q-Pulse entry for record of change details and review history. When no amendment is made at review only the front page will need reprinting. Author John Wright Page 1 of 17

2 1. Introduction Key Personnel Anticoagulant Clinics Haematology Clinics Requesting Tests and Specimen Collection Urgent Requests Telephoning Results Blood Collection Tubes Specialised Tests Haematology Routine Tests Coagulation Studies Timing of Testing Special Tests Requesting Extra Tests Blood Transfusion Test Repertoire Blood Products Requesting Extra Tests Integrated Care Pathway (ICP) for Adult Transfusion Requesting Blood products Use of Emergency O RhD Negative Red Cells ("Flying Squad") Management of a Suspected Transfusion Reaction Blood Transfusion Policy References Laboratories Author John Wright Page 2 of 17

3 1. Introduction The Haematology and Blood Transfusion department at Queen Elizabeth Hospital provides a comprehensive consultant led diagnostic service to both hospital and primary care clinicians. The quality of the service is monitoring continuously by internal quality control and audit procedures and the department is fully accredited by Clinical Pathology Accreditation Ltd (CPA registration number 1014). The department participates in all relevant National External Quality Assurance Schemes for the range of analytes measured. 1.1 Key Personnel Contact Telephone Dr Nick Ketley nic.ketley@nhs.net Consultant Haematologist Dr Sara Stuart-Smith sarastuartsmith@nhs.net Consultant Haematologist Specialist Registrar Dr Bipin Vadher* b.vadher@nhs.net Consultant Haematologist Dr Corinne De Lord* cdelord@nhs.net Consultant Haematologist Dr Mansour Ceesay* mansour.ceesay@nhs.net Consultant Haematologist Dr Stella Bowcock* stella.bowcock@nhs.net Consultant Haematologist Reza Mirza reza.mirza@nhs.net Haematology Manager Catherine Hawkins catherine.hawkins1@nhs.net Joe Nanuck Transfusion Practitioner joe.nanuck@nhs.net * Contact for any enquires concerning patients in the care of GP practices within Bromley CCG. Out of their core working hours (09.00 to 17.00) laboratory clinical staff may be contacted via the hospital switchboard for advice on urgent matters. Author John Wright Page 3 of 17

4 1.2 Anticoagulant Clinics Anticoagulant Services Help Desk (answer phone during the clinic times below) Opening Times Monday Tuesday hr hr hr hr Wednesday hr hr Thursday Friday 1.3 Haematology Clinics Monday Tuesday hr hr hr hr hr hr hr hr Wednesday hr hr 1.4 Requesting Tests and Specimen Collection Refer to Pathology General Information Handbook. 1.5 Urgent Requests Clinicians requesting urgent tests MUST first telephone the Haematology or Blood Transfusion Departments on extensions 5723 and 5719 respectively to enable prompt handling of the sample on receipt. Some requests may need to be referred to a Haematology Clinican before the laboratory will proceed. There is a facility on HISS to request urgent work. URGENT work will always be given priority where practicable and appropriate. Ensure the sample is delivered directly to PATHOLOGY RECEPTION. Requests with the following clinical details will be prioritised: Anaemia, bleeding, chest pain, ITP, thrombocytopaenia, hyperkalaemia, temporal arthritis. Please try to avoid telephoning the laboratory for urgent results as this disrupts work and can cause delay. Author John Wright Page 4 of 17

5 1.6 Telephoning Results When a result is considered abnormal and may affect the clinical management of the patient, every attempt will be made to telephone the result either to the requesting Doctor, the Ward or the Consultant s Secretary. The values listed are based guidance provided by the Royal College of Pathologists and apply to new findings. Analyte Units Limit Haemoglobin g/l <60 <80 (GP and Out-patient) Platelets x10 9 /l <50 Neutrophils x10 9 /l <0.5 Clotting Ratio > Blood Collection Tubes Blood samples should be taken into one of the following containers: 3.5 ml BUFF Top No anticoagulant (with gel) 4 ml MAUVE Top With potassium EDTA (K EDTA) 1.8 ml LIGHT BLUE Top With sodium citrate For paediatric patients many tests can be performed on a smaller volume. Please take samples into Paediatric bottles provided. If in doubt about sample type or volume for any test please telephone ext before taking the sample. 1.8 Specialised Tests Where we do not provide a test on site, we will usually have in place arrangements for it to be carried out at a CPA, or equivalent organisation, accredited specialist reference laboratory. Tests that are referred are identified in the repertoire tables and a list of the laboratories used and their addresses are provided in Section 4. Reference laboratories are periodically reviewed to ensure they maintain accredited status, participate and perform to a satisfactory level in relevant external quality assessment (EQA) schemes and meet their stated turnaround times. Author John Wright Page 5 of 17

6 2. Haematology 2.1 Routine Tests Specimen Required Test Group Comments Turnaround - receipt to result available (85% reported within) 4ml blood in MAUVE 4ml blood MAUVE top bottle 4ml blood in MAUVE 4ml blood in MAUVE 4ml blood in MAUVE 4ml blood in MAUVE FBC, platelets, and differential ESR Reticulocytes Malarial parasites Malarial parasites Paul Bunnell Sickle Cell screen and Haemoglobin Studies (HPLC) Sickle Cell test - same day if urgent (with confirmation to follow). Haemoglobin- Studies Paternal (HPLC) (screening in ANC All positive results telephoned. Please give countries visited, recent malaria prophylactic drugs and contact number with request. If clinical details are not given, the test will not be processed. All positive results telephoned. Please give countries visited, recent malaria prophylactic drugs and contact number with request. If clinical details are not given, the test will not be processed. For investigation of abnormal haemoglobins. Telephone laboratory with urgent requests. Sickle Cell status available in 20 minutes. (Please telephone laboratory). Newborn screening Urgent/ED <=1 hr Routine in-patient <=4hr 2 days 6 hours during routine working day. 3.5 ml blood in BUFF 3.5 ml blood in BUFF Vitamin B12 and Serum Folate Ferritin Give ethnic origin Test performed in Biochemistry Dept. Test performed in Biochemistry Dept. 1 day 1 day Author John Wright Page 6 of 17

7 2.2 Coagulation Studies Specimen Required Test Group Comments Turnaround - receipt to result available (85% reported within) 1.8 ml blood in LIGHT BLUE 1.8 ml blood in LIGHT BLUE 1.8 ml blood in LIGHT BLUE 1.8 ml blood in LIGHT BLUE 1.8 ml blood in LIGHT BLUE Tested at patient's bedside 4 x 1.8 ml blood in LIGHT BLUE and 4ml MAUVE top bottle 1.8 ml blood in LIGHT BLUE top citrate bottle 1.8 ml blood in LIGHT BLUE 4 x 1.8 ml blood for 'coagulation studies' blood in LIGHT BLUE 4 x 1.8 ml blood for 'coagulation studies' blood in LIGHT BLUE PLUS 3.5 ml blood in BUFF 6 ml blood in MAUVE Clotting Screen Prothrombin time APTT for heparin control INR for oral Anticoagulant Control Fibrinogen Bleeding time PFA 100 screen D-Dimer (FDP) D-Dimer (DVT Screen) Thrombophilia Screen Includes the following: Free protein S Protein C Antithrombin APC Resistance Factor VIII Antiphospholipid Screen (including lupus anticoagulant) Includes the following: Anti Cardiolipin antibodies (IgG + IgM) Lupus anticoagulant by DRVVT and dilute APTT Factor V Leiden in cludes Prothrombin G20210A mutation Includes PT APTT INR Laboratory will do additional tests if indicated Please state if patient is on Anticoagulants Please give clinical details + details of Anticoagulation Contact Haematology Dept. to discuss. Contact Haematology Dept. to discuss Referred test (Ref. Lab. 2 ) For investigation of DIC? Please give clinical details. Please give clinical details. Inappropriate test for inpatients Should not be performed if patient is anticoagulated. If this is unavoidable then please contact haematologists as samples will need to be referred to alternative laboratory for testing. Referred test (Ref. Lab 2) Urgent/ED <=1 hr Routine in-patient <=4hr 2 weeks 2 weeks 3 weeks Author John Wright Page 7 of 17

8 2.3 Timing of Testing Prothrombic testing is best performed when the coagulation system is in a steady-state, and is best avoided: in an acute thrombotic state during anticoagulant treatment during pregnancy or the puerperium when taking oestrogen containing contraceptive pills or hormone replacement therapy There will be occasional situations where testing during the above is beneficial, but these should be discussed to ensure that the interpretation reached and advice given are valid. 2.4 Special Tests Specimen Required Test Group Comments Turnaround - receipt to result available (85% reported within) 3 x 6 ml in large HLA B27 typing Monday to Friday only 1 week MAUVE Referred test (Ref. Lab. 5) 3 x 6 ml in large HLA B5701 typing Monday to Friday only 1 week MAUVE * Chromosome Studies 4 ml blood in MAUVE PLUS ml BUFF 2 X 3.5 ml blood in BUFF Platelet Antibodies Erythropoietin * Bone marrow Investigation 4 ml blood in MAUVE CytochemistryLeu cocyte Alkaline Phosphatase Periodic Acid Schiffs (PAS)Dual EsteraseSudan Black Referred test (Ref. Lab. 6) By arrangement with Haematologist Referred test (Ref. Lab. 4) By arrangement with Haematologist Referred test (Ref. Lab. 7) By arrangement with Haematologist Referred test (Ref. Lab. 1) By arrangement with Haematologist Discuss with Haematologist 2-3 weeks 2-3 weeks 1 week Early morning urine Haemosiderin 1 day 4 ml blood in MAUVE Heinz bodies 1 day 2 x 1.8 ml blood in LIGHT BLUE and 1 x 3.5 ml BUFF top bottles HIT Screen Discuss with Haematologist Referred test (Ref. Lab. 3) 1 week N.B. * Containers available from Haematology Laboratory extension 5731 The above is not a complete list of all tests performed and other less common tests can also be provided by consultation with the Haematologist. We are readily available to help and advise. 'Lab turn-around time' indicates the time by which results will be available within the laboratory. Author John Wright Page 8 of 17

9 2.5 Requesting Extra Tests Requests for additional tests to be performed on samples in transit or already received should be made by phoning the laboratory on extension Full blood count samples are retained under temperature controlled conditions for up to 3 days. The integrity of the sample is no longer valid after a period of 24 hours. Anticoagulant samples are stored for 24 hours under temperature controlled conditions after which time they are no longer suitable for retesting. In circumstances where further or more specialised testing is required, a request must be made as soon as possible within 24 hours after specimen collection so that arrangements can be made for the plasma to be aliquoted and frozen at -20 C. Additional tests may be added by laboratory clinical staff if very abnormal results are seen at authorisation. Some additional tests are also added by reflex depending on predefined test value limits. Author John Wright Page 9 of 17

10 3. Blood Transfusion 3.1 Test Repertoire Specimen Required Test Group Comments Turnaround - receipt to result available (85% reported within) 6 ml blood in large MAUVE 6 ml blood in large MAUVE 6 ml blood in large MAUVE 6 ml blood in large MAUVE. 6 ml blood in large MAUVE 4 ml blood in MAUVE 4 ml blood in MAUVE 6 ml Cord blood in PINK PLUS 6 ml maternal blood in MAUVE Full Blood Group and/or antibody screen Routine Crossmatch Emergency Crossmatch Emergency O RhD negative red cells Cold Agglutinins Antibody Titration Sample must be labelled with Patient's full name (surname and forename), Date of birth, hospital number OR NHS number. Sample should also be labelled with date and time of collection and signature of collector. Preprinted labels MUST NOT be used for transfusion on the sample. Phone laboratory ext Phone laboratory ext Phone Laboratory ext Labelling as above. Sample must be kept at 37 o C and taken directly to laboratory. Ring the laboratory ext Referred test (Ref Lab. 7) 1hr-12hr depending on sample urgency. 2 hours 1hr Immediately available. 1-2 days 7 days Direct Antiglobulin Labelled as above. 2-3hrs. Test (DAT) Kleihauer Labelled as above. 1hr-12hrs Cord blood / New Born ABO post delivery Within 72 hrs of delivery. Author John Wright Page 10 of 17

11 3.2 Blood Products Specimen Required Test Group Comments Turnaround - request to available (85% within) 6 ml blood in large MAUVE Issue of anti-d immunoglobulin Sample must be labelled with Patient's full name (surname and forename), Date of birth, hospital number OR NHS number. Sample should also be labelled with date and time of collection and signature of collector. Pre-printed labels MUST NOT be used for transfusion on the 1 hour (available on site) None 6 ml in large MAUVE -no sample required if historical blood group is available. 6 ml blood in large MAUVE -no sample required if historical blood group is available 6 ml blood in large MAUVE Top bottle-no sample required if historical blood group is available None Issue of Human Albumin solutions 4.5% & 20% Issue of PLATELETS Issue of FRESH FROZEN PLASMA Issue of CRYOPRECIPITAT E Issue of PCC (Beriplex) sample. Telephone the laboratory on ext 5719 Requests must be phoned if patients blood group is known by Blood Transfusion Department, no sample is required Requests must be phoned if patients blood group is known by Blood Transfusion Department, no sample is required Requests must be phoned if patients blood group is known by Blood Transfusion Department, no sample is required Telephone the laboratory on ext hrs (available on site) 2-8 hours Ordered from NBS minutes minutes (available on site) 15 min. 3.3 Requesting Extra Tests All blood transfusion samples are stored under temperature controlled conditions for seven days. Requests for further analysis must be received within this time frame. Requesting of extra products will depend on the sample validity rules. Author John Wright Page 11 of 17

12 3.4 Integrated Care Pathway (ICP) for Adult Transfusion An evidence based ICP must be used by all healthcare staff for each episode of transfusion of up to six units of blood and blood components (four units for paediatric patients). The ICP is collected from the clinical area prior to collection of blood or blood components. For further information please contact the Specialist Practitioner of Transfusion on extension 5707 or bleep Requesting Blood products Red Blood Cells All requests for blood and blood products must be accompanied by a telephone call to the laboratory ext 5719(bleep 271 out of hours). Requests for red blood cells must be made by a clinician. Order on HISS and send flimsy with a 6mL EDTA sample to the laboratory. Requesting a cross match from a previously sent 'group and save' sample, place the order on HISS and telephone the laboratory on 5719 (bleep 271 on-call). Cross matched blood will be available from the Transfusion laboratory blood bank within the stated turnaround times depending on the urgency of the situation. Collect blood following collection procedure Platelet Concentrates All requests for blood and blood products must be accompanied by a telephone call to the laboratory ext 5719 (bleep 271 out of hours). Requests for Platelet Concentrates should be discussed with the Consultant Haematologist. Order on HISS then send flimsy to the Transfusion Laboratory or telephone on ext (bleep 271 on-call). Platelet Concentrates should be stored at room temperature (20 C to 24 C) and continuously agitated. DO NOT refrigerate as this will impair platelet function. Use Platelet Giving Set when infusing platelets (issued with platelets). Platelets will be available from the blood bank hatch and should be scanned out through Blood Track. Author John Wright Page 12 of 17

13 3.5.3 Fresh Frozen Plasma (FFP) All requests for blood and blood products must be accompanied by a telephone call to the laboratory ext 5719 (bleep 271 out of hours). All requests for Fresh Frozen Plasma have to be made by a Clinician. Order on HISS then send flimsy to the Transfusion Laboratory or telephone on ext (bleep 271 on-call). Fresh Frozen Plasma should be infused as soon as possible (within 4 hrs at room temperature) and within 24 hours after thawing if stored in the blood bank fridge. If the blood group of the patient is known then a telephone order is sufficient. It takes 30 minutes to process the order. If the blood group is not known then a sample for group and screen should be sent to the laboratory. FFP will be available from the blood bank hatch and should be scanned out through Blood Track Issue of Cryoprecipitate All requests for blood and blood products must be accompanied by a telephone call to the laboratory ext 5719 (bleep 271 out of hours). All requests for Cryoprecipitate must be authorised by a Haematology Consultant. The order can then be placed on HISS and telephoned through to the laboratory on ext 5719 Cryoprecipitate should be infused as soon as possible (within 4 hrs at room temperature) If the blood group of the patient is known then a telephone order is sufficient. It takes 30 minutes to process the order. If the blood group is not known then a sample for group and screen should be sent to the laboratory Cryoprecipitate will be available from the blood bank hatch and should be scanned out through Blood Track Prothrombin Complex Concentrate (PCC) (Beriplex) All requests for blood and blood products must be accompanied by a telephone call to the laboratory ext 5719 (bleep 271 out of hours). All requests for PCC must be authorised by a Haematology Consultant. The order can then be placed on HISS and telephoned through to the laboratory on ext PCC is provided as a freeze dried product and once reconstituted on the ward should be administered immediately. Author John Wright Page 13 of 17

14 3.5.6 Human Albumin All requests for blood and blood products must be accompanied by a telephone call to the laboratory ext 5719 (bleep 271 out of hours). All requests for Human Albumin Solution have to be made by a Clinician. Order on HISS and then telephone the Transfusion Laboratory on ext Store all Human Albumin solutions in the dark between 20 C and 25 C. Requested Human Albumin Solutions will be placed for collection at the blood bank hatch. Return unused bottles to the Transfusion Laboratory. Never use Human Albumin Solution for a patient that it has not been specifically assigned to. Only use it for the assigned patient Anti-D Immunoglobulin All requests for Human Albumin Solution have to be made by a Clinician. Order on HISS and then telephone the Transfusion Laboratory on extn Anti-D is stored at 2 C-8 C and should be administered immediately after collection from the Blood Transfusion Department. Anti-D immunoglobulin is issued automatically post delivery of a RhD positive baby by a RhD negative mother. Anti-D is issued for any sensitising event experienced by a RhD negative pregnant lady. Anti-D must be administered within 72hr of any sensitising event. 3.6 Use of Emergency O RhD Negative Red Cells ("Flying Squad") Flying squad blood should only be requested when blood is required immediately. a) Telephone the Transfusion Department on 5719 or bleep 271 for the Biomedical Scientist on call when the 'Flying Squad' blood is required. b) A fully labelled specimen (with the surname, first name and hospital number /NHS number and date of birth) should be sent to the Transfusion Department as soon as possible to be screened for atypical antibodies and provide group specific blood. In the case of the unconscious patient a sample labelled with Unknown Male or Unknown Female with a hospital number will be accepted. c) The Transfusion Laboratory MUST be informed of the fate of 'Flying Squad' units, i.e. name of patient transfused, sent to another hospital, etc. Author John Wright Page 14 of 17

15 WHEN TELEPHONING URGENT CROSS MATCH REQUESTS, PLEASE STATE THE FOLLOWING: 1. NAME AND UNIT NUMBER 2. CLINICAL PROBLEM 3. URGENCY OF REQUEST 4. NUMBER OF UNITS REQUIRED N.B. THESE REQUESTS MUST BE PLACED ON HISS. 3.7 Management of a Suspected Transfusion Reaction If a transfusion reaction is suspected, STOP the transfusion IMMEDIATELY. Symptoms/signs of an acute transfusion reaction: rise in temperature, urticarial rash, rigor, broncho-spasm, O2 de-saturation, angioedema, difficulty in breathing, tachycardia, hypotension, hypertension, loin pain, chest pain or agitation. Check patient details: It must be established that the identity of the recipient is the same as that stated on the compatibility label of the unit being transfused. Seek medical advice: The treatment will depend on the cause, symptoms and severity of the reaction. A doctor must attend to assess the patient if there are any of the above symptoms. Check storage conditions: Check that the blood has been correctly stored in a designated blood bank fridge, has not been out of the controlled temperature environment for too long and is not contaminated by additives. Inform the blood transfusion staff: If a transfusion is discontinued due to a suspected transfusion reaction the blood transfusion laboratory staff must be informed. A transfusion reaction form is available to download from the intranet at and must be completed and returned to the laboratory with the unused portion of the implicated unit and relevant blood samples. Mild Reaction A mild reaction is described as a rise in temperature of less than 1.5 C from the baseline and/or an urticarial rash occurring at any time during the transfusion. If any other symptoms are present this would be classified as a severe reaction. Do not take the unit of blood down immediately; however stop the transfusion, by closing the giving set, until you have confirmed the actions needed. The patient must be assessed by a doctor. If symptoms resolve following treatment the transfusion can be restarted at a slower rate with increased frequency of observations. Author John Wright Page 15 of 17

16 Severe Reaction A rise in temperature of greater than 1.5 C from the baseline and/or any of the above symptoms (with the exception of an isolated urticarial rash) occurring at any time during the transfusion. Stop and disconnect the transfusion immediately. The patient must be assessed by a doctor urgently. Keep the IV line open with a 0.9% sodium chloride infusion and return the remainder of the unit with the attached giving set to the laboratory. Complete a transfusion reaction form and send blood samples to the laboratory. A DATIX incident report must be completed. 3.8 Blood Transfusion Policy For further information on clinical indications of products issued by the department please refer to the SLHT Blood Transfusion Policy on the SLHT intranet site. Author John Wright Page 16 of 17

17 4. References Laboratories Ref Lab Number Laboratory Address 1 Biochemistry Department 1 st Floor Bessemer Wing, Kings College Hospital, Denmark Hill, London, SE5 9RS 2 Haematology Department 3 rd Floor, St Bart s & London NHS Trust, Pathology & Pharmacy Building, 80 Newark Street, Whitechapel, London, E1 2ES 3 Haemostasis Laboratory 4 th Floor, St Bart s & London NHS Trust, Pathology & Pharmacy Building, 80 Newark Street, Whitechapel, London, E1 2ES 4 Cytogenetics Department Cytogenetics Laboratory, 5th Floor Tower Wing, Great Maze Road, Guy s Hospital, London SE1 9RT 5 Histocompatability Laboratory Clinical Services, The Anthony Nolan Trust, Histocompatability Laboratory, The Royal Free Hospital, Pond Street, London, NW3 2QG 6 Pathology Lab 21 Ltd, 184 Cambridge Science Park, Cambridge, CB4 0GA 7 Transfusion Department National Health Service Blood & Transplant (NHSBT), Cranmer Terrace, London, SW17 0RB Author John Wright Page 17 of 17