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, Norfolk Community Health and Care Trust (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.

The Blood Transfusion Departments at NNUH, QEH and JPUH are accredited by the United Kingdom Accreditation Service (UKAS) to ISO 15189:2012. The defined schedule of tests for which the laboratories are accredited can be found by clicking on the links below. 

20492 (NNUH) 

21363 (JPUH) 

20494 (QEH) 

Please note that the EPA transfusion services at NNUH, JPUH and QEH are currently in the process of completing a planned refresh of their equipment and a review of the related test methods. As a result, all tests performed by the transfusion departments on these sites, with the exception of the Kleihauer test, have been temporarily removed from their scope of UKAS accreditation until the new equipment and tests can be assessed by UKAS.

For a list of abbreviations please click here

Sample labelling and request forms

Samples

One 6 mL pink top EDTA sample is usually acceptable for the majority of transfusion testing. On occasions the laboratory may ask for additional samples.

Sample labelling

Accurate patient identification and sample labelling is critical and the laboratory 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 by the person performing the venepuncture, 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 will lead to the sample being rejected and a subsequent delay in availability of blood components.

There are 2 ways of labelling blood transfusion samples; via the Electronic Blood Tracking System (EBTS) PDA or by hand writing, it is preferable and safer to use the PDA if available.

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.

Patient consent:

 NOTE – All procedures carried out on a patient need the informed consent of the patient.

For most routine laboratory procedures, consent can be inferred when the patient presents himself or herself at a laboratory, or other suitable area, within a primary or secondary care setting, with a request form and willingly submits to the usual collecting procedure.

The laboratory infers informed consent has been obtained when samples are received. It is the responsibility of the clinician requesting the test to ensure that informed
consent has been obtained.

This consent includes notification to third parties where required by law for example under
the Health Protection (Notification) Regulations 2010: we are required to notify any infection
of public health significance to local public health department as mandated by the regulation.
Please ensure your patient is aware of this before submission of samples for testing.

Request forms

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)

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

QEH – Manual request forms (working towards implementation of ICE request forms)  

 

Guide to changing internet explorer margins for all ice forms

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 ensure all containers are 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.

NNUH  & QEH – The pneumatic tube systems are for the transport of Blood Sciences and Blood Transfusion specimens to the laboratories only – NO microbiology samples allowed. 

JPUH – The pneumatic tube systems are for the transport of Blood Sciences and Blood Transfusion, and microbiology samples to the laboratories only. 

The air-tube system should NOT to be used for:

  • Danger of Infection samples
  • Unrepeatable samples

“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 (CJD)
  • 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

All 3 transfusion laboratories provide the following blood components and products:

  • Red cells
  • Platelets
  • Fresh Frozen Plasma (FFP)
  • Cryoprecipitate
  • Anti-D Immunoglobulin (Ig)
  • Beriplex (Prothrombin Complex Concentrate – PCC) – not QEH – issued by pharmacy

In addition, NNUH and JPUH issue clotting factors e.g. Factor VIII, Factor IX and vWF.

In order to issue blood components 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

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.

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

If platelets are required, these need to be requested, by the transfusion laboratory, 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. One unit of “emergency” platelets is kept on site.

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

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 e.g. Irradiated blood products or CMV- products, it is important to ensure that the transfusion laboratory 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).

JPUH – Red Cells can be pre-ordered on the request form but for urgent red cells and all other components the laboratory 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.

Routine red cell transfusions should be one unit at a time with a check of Hb in between.

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. One unit of platelets, for emergency use, is kept on site.

If you require blood components for a patient with a known special requirement e.g. Irradiated blood products or CMV- products, it is important to ensure that the transfusion laboratory is aware of that patient’s needs.

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 red cell transfusions should be one unit at a time with a check Hb in between.

One unit of  emergency 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

If you require blood components for a patient with a known special requirements e.g. Irradiated blood products or CMV- products, it is important to ensure that the transfusion laboratory is aware of that patient’s needs.

 

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 group O units) 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 group O red cells.

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

If emergency group O blood is required, you must contact the laboratory and they will issue O positive in preference to O Negative, in line with patient blood management strategies, if appropriate.

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

NNUH

To collect blood components from the transfusion laboratory 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 laboratory staff who will issue the required components.

If emergency group O blood is required, you must contact the laboratory and they may issue O positive or O negative, in line with patient blood management strategies, if appropriate.

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.

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

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

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.

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”. Patient details are required; if the patient is unknown (out of hospital) then a generic trauma name must be provided.

All subsequent communications between the clinical area and the laboratory 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 laboratory.

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)

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

Full details can be found in the   Transfusion Policy Supplement 6: Major Haemorrhage: SUPP6/POL/TWD/JJ1220/02.1

You will need to call the laboratory on ext 2443 or 2050 and inform them you wish to Activate the Massive Blood Loss Protocol (if out of hours, a bleep is carried by the laboratory haematologist)

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

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 laboratory 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.

Referral laboratory sample requirements are varied and stated on the reverse of the NHSBT request forms, please check before bleeding the patient.

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, Transfusion Related Acute Lung Injury (TRALI), Neonatal Auto Immune Thrombocytopenia (NAIT).

International Blood Group Reference Laboratory (IBGRL): samples for cell free fetal DNA (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 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.

 

Advisory services

Clinicians

Clinicians may contact the duty consultant covering blood transfusion for clinical advice at any time via switchboard.

Details of national guidelines and local polices for blood transfusion can be found in Trust Docs via ‘The Beat’

The laboratory can also contact staff at NHSBT for advice, if required

 Patients

Patients already under the care of the NNUH Haematology Team should contact their consultant for any advice regarding their transfusion care. For other patients or members of the public, please contact the clinician involved with your care or your GP for any clinical queries related to blood transfusion. If required, your clinician will liaise with any relevant transfusion specialists.

Please note laboratory staff are not authorised to give results or provide advice 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 HTC is Chaired by a senior consultant from the group who is not a haematology consultant.

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 UKAS accredited 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)

EPA Network Blood Transfusion Manager: Eleanor Byworth

[email protected]

NNUH – Tracey McConnell or Sandra Ellis 01603 286906

[email protected]

[email protected]

JPUH – Marie Smith 01493 452102

[email protected]

QEH – Sandra Faloye 01553 613782

[email protected]

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 05/04/2024 (6)