Departments

Blood Transfusion

EPA Blood Transfusion Laboratories

The Transfusion Laboratory at the Norfolk and Norwich University Hospital provides blood components for transfusion at the Norfolk and Norwich University Hospital, Cromer Hospital, Priscilla Bacon Lodge (NCHC, Spire Norwich, Bowthorpe Kidney service and Health Care at Home.

They are also responsible for the supply of routine and prophylactic Anti-D, Prothrombin Complex Concentrate (Beriplex) and clotting factors.

The Transfusion Laboratory at the James Paget Hospital provides blood components for transfusion at the James Paget Hospital and Beccles Community Hospital.

They are also responsible for the supply of routine and prophylactic Anti-D, Prothrombin Complex Concentrate (Beriplex) and clotting factors.

The Transfusion Laboratory at the Queen Elizabeth Hospital provides blood components for transfusion at the Queen Elizabeth Hospital and North Cambridgeshire Hospital in Wisbech.

They are also responsible for the supply of routine and prophylactic Anti-D.

Sample labelling and request forms

Sample labelling

Accurate patient identification and sample labelling is critical and the lab operates a zero tolerance policy for samples that are incorrectly labelled or are missing the minimum patient identifiers.

The minimum information on all samples are:

  • Surname
  • Forename
  • Date of birth
  • Hospital number

Samples must also be signed, dated and timed.

It is the responsibility of the person taking the blood sample to positively identify the patient and label it correctly at the patient’s side. Incorrect or missing information can lead to the sample being rejected and therefore there will be a delay in blood components being available.

There are 2 ways of labelling blood transfusion samples, either by hand or using the PDA device in association with the Electronic Blood Tracking System (EBTS). Samples labelled by the PDA must not have any amendments on the PDA printed label – the date/time and signature of the person taking the blood is recorded electronically.

Request forms

JPUH – Manual request forms (ICE request forms being implemented Summer 2021)

NNUH – all samples must be accompanied by a WebIce generated request form (or manual request forms if WebIce is down).

See Blood Transfusion ICE Requesting User Guide (Trust Docs ID:13770)

QEH – For further information on taking and labelling samples and request forms please see Section B04.1 of the Trust Transfusion Policy available in either the guidelines section of the Intranet or the Intranet Blood Transfusion page.  

Packaging and Transport of Samples 

Samples are a potential source of infection and should be treated accordingly. Please fill all sample bottles with the correct volume of blood to ensure correct anticoagulation, and all containers must be securely closed. Leaking samples with gross contamination of contents and containers are discarded. Pocket bags are available for sample transport. Samples should be placed in the appropriate container, which must be securely fastened. This must be placed in a clear plastic bag and sealed. Samples accompanied by forms without specimen bags must be put into marsupial bags with the request form being placed in the side pouch.

Refer to local Trust policies.

Sending Samples

The transport of samples from GP surgeries or other primary care locations is carried out by the Logistics service staff who will collect all samples from dedicated collection points. Samples from within the hospital can be transported to Pathology either by the Pneumatic Tube System (PTS) if suitable or by a porter. For urgent samples ward staff are required to arrange delivery to the laboratory. Samples must first be placed in the plastic sample bags together with the completed request form.

The safe transport of specimens to the laboratory is the responsibility of the requesting doctor or carrier. Laboratory responsibility for the sample begins when it has arrived at the laboratory.

Sending sample via the pneumatic tube system

  • All items MUST be sent in the carriers provided.
  • Samples MUST not be placed directly into the carriers. ALL Pathology samples MUST be placed in specimen bags and the lids of all items with the potential to leak (fluids etc.) tightly secured BEFORE placing them in the carriers.
  • Do not cram samples/items into the carrier as this may lead to breakage/leakage and system failure.
  • Only one carrier at a time should be placed in a delivery station.
  • Ensure that carriers are closed securely at both ends to avoid them jamming in the tube network.
  • If any defect is noticed with the operation of the air-tube systems please notify the laboratory at the earliest opportunity.

The air tube systems are for the transport of Blood Sciences specimens to the laboratories only.

  • The air-tube system should NOT to be used for:
  • Danger of Infection samples
  • Blood gases
  • Blood cultures
  • Unrepeatable samples
  • CSFs (for culture, protein, glucose or xanthochromia)

“High Risk” samples

Medical officers responsible for the care of patients have a duty of care towards other members of staff – therefore all samples from patients who are known to have, or strongly suspected of having the conditions noted below must be identified. 

  • Creutzfeldt – Jakob disease
  • Viral haemorrhagic fever (VHF) of any type
  • Microorganisms, (biological agents) in Hazard Group 3 or 4
  • Pyrexia of unknown origin (PUO) recently returned from Africa
  • Hepatitis B and/or C, and HIV

Medical staff should ensure that appropriate information, including relevant travel history, is provided in order to alert laboratory staff of potential dangers. Clinical details supplied on sample request forms must contain clear information regarding the nature of the test being requested and sufficient detail to inform laboratory staff upon the safety precautions they need to take in order to process the sample without risk of infection.

If, during patient intervention, further information becomes available that has implications for the safety of laboratory staff this must be communicated immediately to the laboratory so that appropriate steps regarding containment can be taken.

Blood Component Requesting

In order to issue blood components for a patient the laboratory must have a valid sample for the patient. A sample is suitable for issuing components for up to 7 days after the sample was taken unless the patient has been pregnant or received a transfusion within the previous 3 months when a sample must be taken and sent for testing within 72 hours of the planned transfusion.

The check group: in line with national guidelines a check group sample may be required. If the patient has no previous transfusion records at the hospital then a second sample will be needed to confirm that the correct patient has been bled. If this sample is required then it should be taken by a different person to the initial sample and must be taken from a separate venepuncture.

When two samples arrive together, or in quick succession, a sample will be regarded as a suitable second sample if it was either:

  • taken by a different phlebotomist than the first sample or
  • the sample was taken at least 5 minutes after the first sample

JPUH – Red Cells can be pre-ordered on the request form but for urgent red cells and all other components the lab must be telephoned on extension 2443 or 2050, in all cases you will need patient ID and reason for transfusion (for platelets the National Indication (P) Code available on the Authorisation sheet must be provided).

Once a unit of red cells has been issued it will remain available in the issue fridge for 24- 48 hours, dependent on recent transfusion history, before being returned to stock. All other components are returned to stock after 24 hours. If you require a component to continue to be available this must be discussed with the laboratory.

When requesting Platelets please ensure that you try to telephone your request to enable delivery within the required time frames. Please click here for JPUH Platelet time frames.

NNUH – Requests for red cells must be made through ICE which has been designed to guide appropriate requesting. All urgent requests must be phoned to the laboratory. Once a unit of red cells is issued for a patient it will be available for 24 hours after the date and time required. All other requests for blood components and products are taken over the phone.

If platelets are required then these may need to be requested from NHSBT specifically for the patient. In order to allow for delivery on the routine transport please contact the transfusion laboratory before the order cut off time.

Platelets will be returned to stock 8 hours after the date and time requested has passed.

If you require blood components for a patient with a known special requirement it is important to ensure that the transfusion lab is aware of that patient’s needs. If the requirement is new or if the patient has not been treated at the hospital before then the appropriate special requirements request form must be completed and sent to the lab to allow an alert to be created for previous attendances (Trust Docs ID: 1286).

For order cut off times and expected times of delivery click here

QEH – All requests for blood components at QEH must be made by telephone on x3782. The laboratory staff will always ask specific questions about your request including the patient’s weight. This is so that patients are ensured the correct components and interventions.

Routine transfusions should be a unit at a time with a check Hb in between.

One unit of stock platelets is kept on site. For other routine platelet orders they should be requested by clinicians via the Transfusion Laboratory before the cut off time to allow for routine delivery. We have one delivery per day.

Please click here for QEH Platelet time frames

Donor Unit Collection and Administration

JPUH

Only staff who have been trained have access to the Blood Fridge to collect donor units, in an emergency (if no trained person available) a person who has not been trained can come down and ask the BMS for help.

In all cases full patient ID (unless collecting emergency O Neg) and the red box must be brought down. Failure to do so will result in delay and without patient ID the only product that can be collected are Emergency O Neg red cells.

Never give your barcode to someone else and ask them to collect – this could result in disciplinary measures being taken.

If emergency O Neg is removed, you must contact the laboratory.

For prophylactic anti-D, Beriplex, and Coagulation factors a completed drug chart must be brought down.

NNUH

To collect blood components from the transfusion lab an EBTS pick up slip must be used. This should be taken to the transfusion issue hatch (East Block, Level One) and given to the Lab staff who will issue the required components.

Emergency O negative blood is available at all times to collect from the laboratory, please contact the laboratory first to check if the patient has any blood issued.

For areas that have a satellite blood fridge only staff who have been appropriately trained can put units in or remove them as per the Trust Guideline for the Storage of Blood Components in and Maintenance of Satellite Blood Fridges ( Trust Docs ID: 1074)

For further information on collection and administering blood components please see Trust Policy for the Collection and Return of Blood Components/Products from the Norfolk and Norwich University Hospital Transfusion Laboratory (Trust docs id 1077)

Trust Clinical Policy for Checking Blood Components/Products prior to Administration (Trust docs ID No: 1094)

QEH

Blood components can only be collected using the Blood Track kiosks in the Blood Bank Issue room through the Pathology waiting area. Only staff assessed as competent to do so may collect blood using a patient pick up sticker and their own barcode.

Blood should be removed one unit at a time from the issue fridge, scanned out and placed in a blood transport bag available next to the Kiosk.

In an emergency, the laboratory should be notified of the need for Emergency O negative, if no blood is available for the patient, Emergency O negative blood should be taken from the Issue fridge. This does not require a pick up slip as it has not been allocated to an individual, but patient’s details must be recorded on the blood collection report.

There are no satellite blood fridges at the QEH but the QEH maintains a Blood Bank refrigerator at North Cambridgeshire Hospital for use in their Macmillan Alan Hudson Palliative Care Centre.  

Transfusion Reactions

If you suspect a transfusion reaction, stop the infusion and assess the patient. Call a Dr to see the patient, who can take advice from the clinical haematology team.

Each hospital will have their own Trust policies to follow, which are available on the staff intranet. You must inform the laboratory on the relevant site of the suspected transfusion reaction.

JPUH – Supplement 5: Transfusion Reactions/Complications: SUPP5/TWD/JJ0106/02

NNUH – Trust Guideline for the Management of Reactions to Blood and Blood Products (Trust docs ID 1281).

QEH – Trust Transfusion procedures and Managing reactions – B04.5 Procedure for managing and reporting adverse events in transfusion

Massive Blood Loss Protocol

Massive blood loss is defined as ≥40% loss of total blood volume, blood loss of 4000mls within a 24hr period, blood loss of 2000mls in a 3hr period, or blood loss at a rate of >150mls/min. In recent years a more practical approach is that patients suspected of bleeding (especially if it is internal) will demonstrate a pulse of >110 bpm and a systolic blood pressure of < 90 mmHg.

JPUH – Supplement 6: Major Haemorrhage: SUPP6/POL/TWD/JJ1220/02.1

NNUH – The NNUH uses the treatment algorithm developed by the East of England Trauma Network and agreed by the East of England Transfusion Committee.

To activate the protocol phone the transfusion lab on ext. 2905/2906 and state “I want to trigger the massive blood loss protocol”.

All subsequent communications between the clinical area and the lab staff should be started with “This call relates to the massive blood loss protocol”. A specific member of the clinical team should be nominated to co-ordinate communication with the transfusion lab.

Full details can be found in the Guideline for the Management of: Massive Blood Loss in Adults (MBL) (Trust Docs ID: 1175) and Massive blood loss in children (Document ID 9960 and Flow chart ID 10828)

QEH – Massive Blood loss Flow Chart on The Trust Transfusion policy – B07.2 Massive Blood loss and B10.5 MBL in children protocol EoE RTC

To activate the protocol the transfusion lab must be contacted on ext 2330 or 3782 ask Transfusion to ‘’Initiate Massive Blood Loss Protocol’’.

Referral Laboratories

The transfusion laboratories use the reference services of the NHS Blood and Transplant (NHSBT). The EPA laboratories hold the specialist request forms for these investigations, and some require haematology consultant advice before referring.

Red Cell Immunohaematology (RCI): for blood grouping and antibody investigations that cannot be resolved in the laboratory.

Histocompatibilty and Immunogenetics (H&I): for investigations of platelet refractoriness, TRALI, HIT, NAIT.
International Blood Group Reference Laboratory (IBGRL): samples for cffDNA to guide antenatal anti D prophylaxis.

Results

Authorised results are available on the ICE system, which is updated regularly throughout the day.

Results of urgent requests if ICE access or electronic delivery is not available and unexpected results, which may aid the immediate patient management, will be telephoned.

In the event that the laboratory is unable to deliver the required service due to equipment failure we will endeavour to contact all relevant users.

Due to IG compliance requirements, results cannot be communicated directly to patients. 

Quality and Governance

Each Trust has a Hospital Transfusion Committee (HTC), which is a multi-disciplinary team which meets 4 times a year and is made up of a variety of specialities with an interest in transfusion.

The Hospital Transfusion Team (HTT) meets more frequently and is comprised of representatives from the Medical staff, BMS staff and the Transfusion Practitioner team. The HTT is a subcommittee of the HTC and issues can be feedback to the full committee when required.

All 3 laboratories participate in the external quality assurance scheme run by UK NEQAS (National External Quality Assurance Scheme).

All 3 laboratories are accredited with UKAS to ISO 15189 standards.

All 3 laboratories comply with the Blood Safety and Quality Regulations 2005/50, under the guidance of the Medicines and Healthcare products Regulatory Agency (MHRA). As part of the MHRA compliance all laboratory incidents, errors and near misses are reported via the Serious Adverse Blood Reportable Events (SABRE) website.

All 3 laboratories report to the UK’s independent, professionally-led haemovigilance scheme SHOT (Serious Hazards Of Transfusion).

Contacts

EPA Network Blood Transfusion Manager:
Carol Harvey: 01603 286286 or 07562322164

JPUH 
Sarah Parsons : 01493 452102

NNUH
Tracey McConnell and Sandra Ellis : 01603 286906

QEH
Frank Baiden : 01553 613782

Opening Times

JPUH

The Transfusion laboratory is available 24 hours a day

 For Urgent samples the laboratory can be contacted internally on 2443. Outside hours contact the Haematology BMS via the Switchboard.

The laboratory can be found at the rear of the building on the ground floor sign posted ‘Pathology – Blood Tests’

Monday08:00 - 17:00
Tuesday08:00 - 17:00
Wednesday08:00 - 17:00
Thursday08:00 - 17:00
Friday08:00 - 17:00
Saturday08:00 - 13:00
Sunday08:00 - 13:00
Bank Holiday08:00 - 13:00

NNUH 

The Transfusion laboratory is available 24 hours a day and can be contacted on Ext 2905/2906.

The laboratory can be found in East Block Level 1  at the rear of the building on the ground floor sign posted ‘Pathology – Blood Tests’

Monday08:00 - 17:00
Tuesday08:00 - 17:00
Wednesday08:00 - 17:00
Thursday08:00 - 17:00
Friday08:00 - 17:00
Saturday08:00 - 13:00
Sunday08:00 - 13:00
Bank Holiday08:00 - 13:00

QEH

The Transfusion Laboratory is open 24 hours a day. 

For Urgent samples the laboratory can be contacted internally on 3782. Outside hours contact Haematology by bleep 2475.

The laboratory can be found at the rear of the building on the ground floor, in area 4, the green section sign posted “Pathology & Blood Tests”. Urgent samples should be handed to a member of laboratory staff after contacting them by telephone. It is a locked department and so can only be contacted in this way.

Monday08:00 - 18:00
Tuesday08:00 - 18:00
Wednesday08:00 - 18:00
Thursday08:00 - 18:00
Friday08:00 - 18:00

EWT-D-001 Last updated 07/06/2021 (1)