COMPOSTELA VALLEY PROVINCIAL HOSPITAL

CVPH-PANTUKAN

Hospital Blood Transfusion

Committee
Standard Operating Procedure

Revised 2020
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Approval Sheet

Evangeline D. Hornido, MD
Chief of Hospital

Mary Grace C. Lim, MD, FPSMS

Chief of Hospital -OIC

Dr. Geli
Hospital Blood Transfusion Committee - Chairman

Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Hospital Blood Transfusion Committee - Vice Chairman

Administrative Officer

Chief Nurse

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Table of Contents

Approval Sheet 1
Table of Contents 2
Overview 3
Functions of the Committee 4
Appointment, Composition, Meetings, Record for Review 8

General Guidelines 9
Policy #1 Prescription of Blood/Blood Components 10
Policy #2 Informed Consent 11
Policy #3 Request to Secure Blood/Blood Component
12
Policy #4 Blood Cold Chain 13
Policy #5 Receiving Facility – Nurse Station/Laboratory 14
Policy #6 Crossmatching 15
Policy #7 Storage of Blood 17
Policy #8 Issuance of Compatibility Result 18
Policy #9 Releasing of Blood Unit 19
Policy #10 Blood Return, Standby/Unused Blood, Blood Replacement 21
Policy #11 Issuance of Pooled Blood 23
Responsibilities of Clinicians in Blood Transfusion…………………………….
Responsibilities of Nurses in Blood Transfusion
Policy #12 Pre-transfusion Checks on Blood/Blood Products 24
Policy #13 Identification of Patient and the Blood/Blood Product 26
Policy #14 Blood Component Administration 27
Policy #15 Monitoring and Observation of Transfusion 28
General Guidelines 31
Responsibilities of Laboratory Personnel in Blood Transfusion 32
Guidelines in the Management of Transfusion Reactions 33
Febrile Transfusion Reactions 35
Allergic Blood Transfusion Reactions 36
Hemolytic Blood Transfusion Reaction 37
Circulatory Overload Reaction 38
Blood Transfusion Reaction due to Contaminated Blood 39
Blood Transfusion Reaction from Rapid Infusion of Massive Amount of Stored
Blood 40
Hypothermic Blood Transfusion Reaction 41
Laboratory Procedures in the Investigation of Blood Transfusion Reactions 42
Interpretation of Laboratory Results of Examinations Done to Investigate Blood Transfusion
Reactions 44
Checklist for Signs of Deterioration of Blood or Plasma 46

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

References 47

Effectivity Date:

Subject: January 1, 2020 Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE Committee SOP,
Approval Date: Revised 2020
OVERVIEW
January 1, 2020

Background: Blood Transfusion is acknowledged to be a therapy that involves risks, so that the
organization’s performance, monitoring and improvement program must address the use of
blood and blood components. A cross functional group of medical and support staff is tasked
with the responsibility to take the leadership role in promoting safe and effective blood banking
and transfusion practices.

General Objective: To understand the importance of monitoring the blood transfusion practices
of the hospital and maintain quality standards in the area.

Specific Objectives:
 To formulate policies for blood transfusion therapy.
 To assess the usage and practices in blood component therapy.
 To review and analyze statistical reports of the Blood Station.
 To evaluate clinical and laboratory reports of adverse reactions to blood transfusion.
 To promote continuing education on blood donation and transfusion to all groups of
hospital staff.
 To provide safe and adequate supply of blood and blood products.
 To make recommendation and reports to the appropriate departments of the
laboratory, medical, nursing, and administrative services of the hospital.
 To implement established policies of the committee.

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE January 1, 2011 Committee SOP,
FUNCTIONS OF THE COMMITTEE Revised 2017
Approval Date:

January 2017

1. Establish policies for blood transfusion therapy. Formulate policies and guidelines, to be
approved by the Chief of Hospital and officers of the committee.

2. Enhance quality of patient care through objective assessment of on-going blood and
blood component therapy.

3. Review and analyze the statistical reports of the transfusion services.

4. Audit blood use. Special emphasis must be given to the following:

i. Blood Products transfused.
ii. Adverse reactions to transfusions.
iii. The transmission of infectious diseases.
iv. Adequate blood pool supply.

5. Promote continuing education in transfusion practices and guidelines to the hospital staff
for which they are intended.
- Indications for transfusion (Refer to Phil. Clinical Practice Guidelines for the
Rational Use of Blood & Blood Products)
- Component therapy (Refer to Phil. Clinical Practice Guidelines for the
Rational Use of Blood & Blood Products)
- Blood ordering schedule for elective surgery (Refer to Clinicians for the
MSBOS)
- Blood bank policies and procedures. (Refer to CVPH Blood Bank SOP)
- Quality Assurance (Refer to AABB Technical Manual 15th ed)

6. Assess the safety and adequacy of the blood supply, through Blood Usage Review
program to ensure all services and all major products are included in the review process.

7. Annual review of the written policies and procedures of the hospital transfusion services
to ensure they conform to the standards set by DOH.

8. Review the findings of problem areas and evaluate their improvement.

4

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE January 1, 2011 Committee SOP,
FUNCTIONS OF THE COMMITTEE Revised 2017
Approval Date:

January 2017

9. Facilitate active interaction among those involved in blood transfusion services.

10. Promote avoidance of unnecessary transfusion thus ensure appropriate utilization of blood
components.

11. Implement and monitor blood component therapy for appropriate use of blood.
a. Ordering of blood/blood components
i. Create policies on:
o Blood transfusion in general
o Number of units to be requested (Refer to Indications of Blood/Blood
Component Transfusion (p.28-62, DOH Manual, Phil. CPG for the
Rational Blood Use/MSBOS)
o Disposition/release of unused crossmatched units

b. Monitor data derived from records

- Source of blood
- Number of units expired / discarded under direct control of the laboratory
(inside laboratory loss) versus outside laboratory due to improper ordering or
handling (outside laboratory loss)
- Number of units crossmatched/transfused
- Number and kind of transfusion reaction
- Turnaround time of release of units / administration of blood

c. Utilization Review
Objectives:
o To maximize rational use of blood
o To minimize exposure to adverse effects of transfusion
o To minimize wastage of blood

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE January 1, 2011 Committee SOP,
FUNCTIONS OF THE COMMITTEE Revised 2017
Approval Date:

January 2017

Procedure:
i. Set indication for use of various blood components
ii. Request for blood must state indication for component therapy
iii. Select scope and period for review of requests for blood transfusion
iv. Review of medical records of cases without justifiable indications in
the requests by chairman of the committee
v. Letter to attending physician / resident requesting explanation for
unjustifiable request.
vi. Explanation of attending Physician discussed by BTC
vii. Recommendation of BTC to department head.
viii. Periodic report of findings, actions and recommendation to proper
authorities

d. Corrective actions after review of usage of blood

- Changes in the policies
- Improving in recording
- Continuing education of hospital staff
- Attention to clinician formally called
- Letter to concerned office / clinician for repeated offenses

12. Integrate a plan for the management of blood shortages (in coordination with the Regional
Blood Services Network), including planning for the management of patients based on
predetermined categories (e.g. patients in need of immediate resuscitation, patients in need of
urgent surgical supports, non-surgical patients who are anemic, scheduled but non-emergency
surgical patients- refer to p28-62 DOH Manual, Phil. CPG for the Rational Blood Use).

13. Review operational effectiveness of the laboratory services (e.g. response time for
emergency request).

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

14. Review / evaluate transfusion reaction and medical errors with or without an adverse outcome.

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE January 1, 2011 Committee SOP,
FUNCTIONS OF THE COMMITTEE Revised 2017
Approval Date:

January 2017

a. BTC shall review periodically

- The types of transfusion reaction
- Magnitude of trends of transfusion reaction
- Causes and factors of transfusion reaction
b. BTC shall formulate recommendations and take actions
- To prevent or minimize occurrence of transfusion reactions
- Proper management of transfusion reactions
- To avoid wastage of limited blood resources

15. Set measure that defines effectiveness of the committee.

Regular Quarterly Meetings
Program Implementation Review
1. Blood Utilization Report and Inventory
2. Transfusion Reaction and Medical/Laboratory inaccuracies
3. Blood Services Network

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE January 1, 2011 Committee SOP,
APPOINTMENT Revised 2017
COMPOSITION Approval Date:
MEETINGS
RECORDS FOR REVIEW January 2017

APPOINTMENT:

The committee is appointed by the Chief of Hospital. Appointment is for at least three (3) years.

COMPOSITION:

The committee is headed by an Internal Medicine Physician and vice-chaired by the Pathologist.
Support group members are the following: Chief of Hospital, representatives from the Medical
Staff, Chief Nurse and the Nurse Station Heads, Chief Medical Technologist/Blood Station-in-
charge, and the Administrative Officer. The committee chair is a Physician who is
knowledgeable in transfusion medicine.

Responsibilities:

Chairman

Vice Chair

Clinicians

Nurses/Medical Technologists

Administrative Staff

MEETINGS:

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Meetings should be held at least quarterly or as often as necessary. Minutes of the meeting
must be written and maintained in detail to show date and time of convening, names of
members present and absent, business transacted, reports and their contents received, actions
taken, reports and recommendations to the Chief of Hospital, time of adjournment, and
signature of the chairman.

When liability issues are discussed, guests and other individuals who do not need to know
details are excused.

RECORDS FOR REVIEW:

As part of its role in quality assurance and medical audit, all selected records of patients
discharged subsequent to the last committee meeting should be reviewed. Members do not
review their own records. Rates of results are tabulated for each physician, and appropriate
reports and recommendations are made to the Chief of Hospital.

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE January 1, 2011 Committee SOP,
GENERAL GUIDELINES Revised 2017

Approval Date:

January 2017

Pre-established Criteria:

Guidelines for transfusion and blood banking, indications for transfusion, as well as guidelines
for ordering blood and its products and reporting, investigation and management of blood
transfusion reaction are pre-established in the hospital, approved by the Blood Transfusion
Committee.

Medical Records for Review:

All cases which are not consistent with the established criteria are reviewed by the Blood
Transfusion Committee as part of its role in quality assurance and medical unit.

The Committee shall review the following cases:

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

1. Medical errors (with or without an adverse outcome) and adverse patient events related
to transfusion (tracked, analyzed for cause, categorized and managed).
2. Partially crossmatched units issued/transfused.
3. Excessive transfusions or indiscriminate use of blood.
4. Wrong indications of blood components.
5. Excessive turnaround time prior to issuing blood units.
6. Units returned unused/expired and discarded.
7. Overnight transfusion.
8. Surgical cancellation due to unavailability of blood.
9. Late requests for pre-operative /elective cases crossmatching.
10. Excessive requests for crossmatching.
11. Excessive emergency requests for blood.
12. High outdate rate due to:
a. Failure to notify the blood bank of cancelled surgical procedures.
b. Excessive notices of postponed procedures.
c. Failure of blood bank to follow “first to expire-first out” (FEFO) principle.
13. Cases with complications resulting from transfusion.

Policy#1. Prescription of Blood/Blood Components

Subject: Policy Number: Hospital Blood
1 Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE Committee SOP,
Effectivity Date: Revised 2017
February
#1. PRESCRIPTION OF BLOOD/BLOOD COMPONENTS
January 1, 2017

Approval Date:
A. Crossmatching and Overnight Transfusion
January 2017

The prescription of blood and blood components shall be the responsibility of the attending
physician.
Blood and blood components shall be prescribed in the Blood request form.
The form should be legibly filled up completely with all the pertinent data and should specify:
 the urgency of the transfusion, including the date and time transfusion is to take place
 the blood type, amount, and the blood component to be administered.

Policy#1-A Crossmatching and Overnight Transfusion

10

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Routine blood transfusion shall commence only up to 10pm and shall be strictly implemented.
Cut-off time for routine blood unit withdrawal in the laboratory is at 6pm, and transfusion should
start within 30minutes from the blood unit withdrawal.

There are significantly increased risks to transfusing outside core hours so the transfusion
must be clinically ESSENTIAL. (Blood Transfusion Policy, Royal Cornwall Hospitals, 2014)
For WARD patients, if crossmatching and transfusion need to take place at night the reason for
this must be clearly stated in the patient notes, indicate in the request as “STAT Transfusion”
and a laboratory form on Acceptance of Responsibility (For Crossmatching and Transfusion
Beyond Core Hours) be signed by the requesting/attending physician and nurse-on-duty/nurse
attendant who will be responsible in closely monitoring the patient.

Subject: Policy Number: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE 2 Committee SOP,
Effectivity Date: Revised 2017

#2. INFORMED CONSENT February 1,

2017

Approval Date:

January 2017

Policy#2. An informed consent shall be signed by the watcher/relative prior to blood

transfusion.

Procedure:
1. The Attending Physician makes a dialogue with the patient/watcher and informs them of the
significant risks, benefits and alternatives to transfusion including the patient’s right to refuse the
transfusion. As a result of this discussion the patient should:
a) Understand what medical action is recommended.
b) Be aware of the risks and benefits associated with the transfusion.
c) Appreciate the risks, and possible consequences of not receiving the recommended
therapy.
d) Be given an opportunity to ask questions.
e) Give consent for the transfusion.
2. The informed consent is valid during the entire admission period of the patient.
3. The nurse-on-duty provides the consent form for signature of the watcher/patient.

11

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Subject: Policy Number: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE 3 Committee SOP,
Effectivity Date: Revised 2017

#3. REQUEST TO SECURE BLOOD February 1,

2017

Approval Date:

January 2017

Policy#3. All requests to secure blood shall be prepared by the attending physician or the nurse
on duty in the prescribed form and signed legibly by the attending physician.

Procedure:
1. Accomplish the blood request with the exact amount of blood needed, blood type, indication
for transfusion, and then given to the patient/watcher for them to secure.
2. Advise the patient/watcher to proceed to the laboratory for further instructions on the
necessary procedures to secure blood from the blood bank, amount needed and proper
handling of blood bags.

Policy#3-A. STAT requests for blood shall be accomplished in the same prescribed form and
must be sent immediately to the blood bank through the watcher.

12

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Subject: Policy Number: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE 4 Committee SOP,
Effectivity Date: Revised 2017

#4. BLOOD COLD CHAIN February 1,

2017

Approval Date:

January 2017

Policy#4. Proper Blood Cold Chain shall be strictly complied.

Defined as the maintained STORAGE and TRANSPORTATION of BLOOD
and BLOOD COMPONENTS at the appropriate storage temperature and
conditions from the point of collection to the point of use (vein of donor to vein
of recipient)

Transport Condition between Blood Banks

 Whole Blood and Red Cells
o Wet ice should not be allowed to come into direct contact with
the blood as the red cells nearest to the ice may freeze and
cause hemolysis.
o +2 oC to +10 oC

Issuance of Blood/Blood Components to Clinical Areas

 Record time of issue of blood
 Use an insulated carrier
o Whole blood or red cells (+2 oC to +10 oC)
o Platelets (+20 oC to +24 oC )
 Issue one unit at a time and remind the nurse withdrawing the blood unit of the
30-minute rule.
13

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

 Seal unit into insulated carrier.

For other blood components like the platelet concentrate, fresh frozen plasma and
cryoprecipitate, coordinate first with Blood Station/Laboratory Personnel.

Subject: Policy Number: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE 5 Committee SOP,
Effectivity Date: Revised 2017

#5. RECEIVING FACILITY-NURSE STATION/LABORATORY February 1,

2017

Approval Date:

January 2017

5. Receiving Facility

Hospital Blood Pool:

Blood Station/Laboratory
i. Medical Technologist-on-duty shall check and record the CVPH Pantukan
Blood Pool Units withdrawn at DRMC Blood Bank.
ii. Check the documentation slip (transmittal slip) with the following data:

 Serial number, and specific blood components labels.

 Time and temperature when blood was removed from the refrigerator
and placed into a box.
 Issuing staff.

iii. Store blood units in accordance to the DOH NVBSP Standards.

Nurse Station:
iv. The nurse-on-duty/nursing attendant withdraws the blood unit from the
laboratory for transfusion to the patient.
v. Observe proper transport, storage and documentation.

If the blood unit is secured by the watcher/patient:

vi. Watcher brings the secured blood unit to the blood station/laboratory.

14

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

vii. Medical Technologist observes proper documentation, stores the blood and
issues a proof of blood deposit to the watcher.
viii. Watcher submits the blood deposit form to the nurse station.

Subject: Policy Number: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE 6 Committee SOP,
Effectivity Date: Revised 2017

#6. CROSSMATCHING Febuary 1, 2017

Approval Date:

January 2017

1. The request for CROSSMATCHING shall be checked and all data shall be filled up correctly
and legibly including the serial number of the blood bag to be crossmatched and the name of
the physician and his signature checked.

2. Non-emergency request for blood must be sent to the blood bank/laboratory 24 hours prior to
the contemplated procedure.

3. Routine Crossmatching procedures are done during the morning and afternoon shift
only so that a co-identifier can re-check the processing and validate the result prior to release,
except for emergency cases.

4. Urgent request must be discussed directly by phoning the laboratory and the form should
then be labelled “URGENT” or “STAT”. All stat requests shall be attended to immediately.

5. In cases of extreme emergency, partially crossmatched blood may be released by the blood
bank only when the attending physician accepts responsibility for the risks involved in
transfusing such blood by signing the Acceptance of Responsibility form. The blood
bank/laboratory will notify the physician about the result once available. No compatibility label
should be attached upon release of the partially crossmatched blood pack.

15

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

6. The blood group of the patient must be determined using the ABO and Rh tube typing
method, and the results shall be validated by a co-identifier.

7. The patient and the donor shall be crossmatched using the 3-phase method.

8. All blood specimens for compatibility testing shall be extracted exclusively by any of the
laboratory personnel.

Subject: Policy Number: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE 6 Committee SOP,
Effectivity Date: Revised 2017

#6. CROSSMATCHING February 1,

2017

Approval Date:

January 2017

9. Plasma products (platelets, fresh frozen plasma, cryoprecipitate, cryosupernate) need not be
crossmatched, but retyped (using tube method) prior to release. Specific blood type products
shall be given. Please coordinate with the laboratory staff when plasma products are
needed so that specific instructions and further coordination with the Blood Center be
arranged.

10. Blood awaiting transfusion shall be kept in the blood bank refrigerator. For storage of whole
blood and packed red cells, it shall be kept at 1-6 OC. And the plasma freezer for storage of fresh
frozen plasma, cryoprecipitate, and cryosupernate at -30OC. Platelets are stored on a horizontal
shaker (agitator) with incubator. White cells “buffy coat” are used immediately and are not
refrigerated.

11. The blood station/laboratory staff shall be notified ASAP if surgery is cancelled/postponed.

12. The blood station/laboratory staff shall also be notified ASAP if the attending physician
decides that the blood transfusion is not needed anymore.

16

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Subject: Policy Number: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE 7 Committee SOP,
Effectivity Date: Revised 2017

#7. STORAGE OF BLOOD February 1,

2017

Approval Date:

January 2017

7. Storage of Blood

i. Any unit of blood obtained from outside (PNRC, or any other blood bank)
shall be brought directly by the watcher to the staff nurse in the ward who will
be responsible for delivering the blood to the blood bank/laboratory as soon
as possible or shall be brought directly by the watcher to the laboratory.
(Refer to Policy #5 on Receiving Facility-Nurse Station/Laboratory)

ii. The Medical Technologist-on-duty shall record all blood upon receipt after
checking the label which must contain the serial number, blood type, amount
of blood, extraction and expiration dates, and shall affix her signature after
noting the date and time the blood is received. Transmittal form which is
properly filled up by the Blood Bank Medical Technologist must be forwarded
together with the blood bag.

iii. Whole blood/PRBC must be stored only in blood bank refrigerator with

17

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

appropriate temperature monitor and not in wards or domestic refrigerator.

Note: CVPH Laboratories are still not capable of proper storage for other
blood components such as fresh frozen plasma, cryopecipitate,
cryosupernate, and platelet concentrate.

Subject: Policy Number: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE 8 Committee SOP,
Effectivity Date: Revised 2017

#8. ISSUANCE OF COMPATIBILITY RESULT February 1,

2017

Approval Date:

January 2017

8. Issuance of Compatibility Result

i. For STAT examinations, the nurse-on-duty shall be informed through the

phone that the result is ready. The nursing attendant/urse-on-duty shall pick-
up the blood unit and receives the crossmatching result issued by the medical
technologist-on-duty.

ii. Duplicate copies of the result will be made. It shall be attached to the
patient’s chart, and presented to the laboratory when crossmatched blood is
needed for transfusion.

18

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Subject: Policy Number: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE 9 Committee SOP,
Effectivity Date: Revised 2017

#9. RELEASING OF BLOOD UNIT February 1,

2017

Approval Date:

January 2017

9. Releasing of Blood Unit

i. Upon the request of the attending physician, except for massive transfusion,
only one unit of blood shall be issued at a time. When the attending
physician finds it necessary to get more than one unit, he shall be required to
sign a waiver/acceptance of responsibility form.

ii. If blood is required before proper completion of crossmatch, a

waiver/acceptance of responsibility form will be obtained from the requesting
physician before a partially crossmatched blood unit will be released. The
blood bank personnel will complete the compatibility test to ensure that the
blood is safe for transfusion. Upon completion of compatibility test, the blood

19

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

bank personnel will make an official result and endorse it to the concerned
party.

iii. The nurse picking-up the blood for use in the ward or other areas shall
present a copy of the result of the compatibility test. The medical technologist
issuing the blood and nurse withdrawing it shall both sign in the logbook.
Patient’s relatives are not authorized to pick-up blood from the laboratory.

Subject: Policy Number: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE 9 Committee SOP,
Effectivity Date: Revised 2017

#9. RELEASING OF BLOOD UNIT February 1,

2017

Approval Date:

May 2016

iv. Before releasing the blood product, the laboratory staff shall check the
following:
 Expiry date
 ABO group
 Serial number
 Leaks at the ports and the seams
 Evidence of hemolysis in the plasma or at the interface between red
cells and plasma.
 Unusual discoloration or turbidity and the presence of large clots or
fibrin.

20

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

 Time of issue shall always be recorded with the signature of the

receiving staff affixed.
 Blood shall be transported in containers e.g. ice chest designated for
this purpose from the laboratory to the wards.

v. The transfusion form which is part of the compatibility result shall be signed
by the receiving nurse and the issuing medical technologist of the blood bag.
The necessary information will be completed in the ward by the nurse signed
by the resident-on-duty (ROD) and duplicate copy of which shall be sent to
the laboratory upon returning the used blood bag.

Subject: Policy Number: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE 10 Committee SOP,
Effectivity Date: Revised 2017

#10. BLOOD RETURN POLICY, STANDBY/UNUSED BLOOD, February 1,

BLOOD REPLACEMENT 2017

Approval Date:

January 2017

10. Blood Return Policy, Standby/Unused Blood, Blood Replacement

 Blood Return Policy

i. If not used, the blood issued to the ward shall be returned to the blood
bank/laboratory within 30 minutes (unhooked, no breach in the blood unit) -
30 minute RULE (and kept in an ice chest while at the ward) to prevent

21

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

bacterial contamination. Blood unit/s returned beyond the 30-minute rule

will be discarded.
ii. It is the responsibility of the nurse who withdrew the blood to comply with
the 30-minute rule, otherwise he/she will be held liable to replace the said
blood unit.
iii. It must be kept in quarantine for at least twelve (12) hours thereafter. The
blood shall be inspected for hemolysis and gross contamination before reissue.
Such return and reissue of the blood shall be recorded by the Medical
Technologist-on-duty.

 Untagging of Unused and “Standby” blood

i. Units of blood previously crossmatched to a particular patient but not
transfused within 48 hours are untagged and placed back in the blood pool.
This may be reassigned and crossmatched to another patient.
ii. Once confirmed from the attending physician/ward nurse that blood is no
longer needed for transfusion, the blood unit is untagged even before the 48 th
hour after crossmatch.
iii. Reassignment of blood to another patient shall be done up to twice/thrice as
long as there are still enough segment/tubing in the blood bag to be used for
crossmatching.

Subject: Policy Number: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE 10 Committee SOP,
Effectivity Date: Revised 2016

#10. BLOOD RETURN POLICY, STANDBY/UNUSED BLOOD, January 1, 2011

BLOOD REPLACEMENT
Approval Date:

May 2016

iv. This applies only to the Hospital Blood Pool units. (for unused blood secured
by watcher from outside blood bank, inform the watcher to sign waiver of
voluntary donation of the blood unit)

 Blood Replacement
22

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

i. Replacement of blood borrowed for use in emergency cases shall be the

shared responsibility of the relatives, physicians, the nurses, and the social
worker.
ii. Physicians borrowing blood for their patients shall sign an Acceptance of
Responsibility Form (Request to Borrow Blood Unit from the Blood Pool for
Emergency Use of the Patient)
iii. Transfer of blood from patient to patient may be allowed provided two copies
of a signed agreement/consent from both parties is made in coordination with
the laboratory staff and a copy is provided to be attached in the patient’s
chart.

Subject: Policy Number: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE 11 Committee SOP,
Effectivity Date: 2017

#11. ISSUANCE OF POOLED BLOOD February 1,

2017

Approval Date:

January 2017

11. Issuance/Utilization of pooled blood

i. Pooled blood units are the property of CVPH.

23

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

ii. Issuances of blood unit/s shall observe the FEFO (First-to-expire-first-out)

policy.
iii. FEFO policy will not exempt the patient to paying charges related to blood
transfusion and compatibility testing.
iv. Blood needs of CVPH patients shall be the responsibility of the Hospital
Blood Station.
v. The Hospital Blood Station shall provide the blood units needed for
transfusion to all Emergency cases (regardless of residence) and CVPH
patients who are residents of the province, provided the following
documents are complied and submitted to the blood station: Certificate of
Residency issued from the Purok/Barangay and a withdrawal slip from the
Barangay/Municipal Blood Program Coordinator.
vi. For non-ComVal residents, provision of blood units may depend upon the
availability of blood supply.
vii. For non-ComVal residents who were given blood units used for emergency
transfusion, are required to replace the blood unit transfused to ensure
adequate blood supply in the Hospital Blood Pool.
viii. Should there be more than enough supply in the Hospital Blood Pool, may
provide blood units even to non-ComVal residents who need blood but will
have to be charged for the blood processing fee as provided in the Tax Code,
EXCEPT for PHIC NBB patients.

Subject: Policy Number: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE 12 Committee SOP,
RESPONSIBILITIES OF NURSES IN BLOOD TRANSFUSION 2017
Effectivity Date:
#12. PRE-TRANSFUSION CHECKS
February 1,
2017

Approval Date:

January 2017

1. Pre-transfusion checks on blood/blood products

All the following checks should be carried out at the bedside or otherwise adjacent to
the patient being transfused. Checking away from the patient/bedside, e.g. at the
Ward Office or desk, is a common and avoidable cause of transfusion accidents.

24

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

1.1 Inspect the blood or blood product component for:

 Leakage
 Unusual color e.g. black or purple (may indicate hemolysis)
 Unusual cloudiness or particulate matter
 Presence of large clots (if any of the above present, the unit must not be used
and should be returned to the Blood Bank).

1.2 Identification of the Blood Product

Read and take note of any special labels or instructions attached to the blood
pack or printed on the accompanying report.

1.3 Positively identify the patient before transfusion

Ask his/her surname, first name and date of birth whenever possible and make
sure this is the same as on the ID wristband. It is essential that any patient
having a blood transfusion has an ID wristband.

The surname, first name, date of birth and patient identification number should
be checked and found to be identical on:

 The patient’s ID wristband

 The blood transfusion compatibility report form
 The compatibility label attached to the blood pack
 The IV prescription chart
 The medical notes

Subject: Policy Number: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE 12 Committee SOP,
RESPONSIBILITIES OF NURSES IN BLOOD TRANSFUSION Effectivity Date: 2017

#12. PRE-TRANSFUSION CHECKS February 1,

2017

Approval Date:

January 2017

25

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

1.4 Review on Pertinent Records

 The blood group and donation number label by the National Blood
Service on the blood component must be checked and found to be
identical to that on the compatibility report form and the compatibility label
attached to the blood pack.
 The blood group on the unit must be compatible with the blood group of
the patient indicated on the compatibility label attached to the blood pack
(if in doubt, verify with the Blood Bank)
 The unit must be checked to ensure it has not passed its expiry date or
expiry time.
 The blood transfusion compatibility report form and/or the IV prescription
sheet must be signed by the members of staff carrying out the identity
check and the date and time of commencement of transfusion of each
unit indicated in the appropriate space together with the donation number
of the blood pack
 If any discrepancy not covered by a comment on the blood transfusion
compatibility report form is found during the bedside identity check, the
unit must not be transfused and the Blood Bank must be contacted.
 The blood transfusion compatibility report form should, wherever possible,
be readily available during the transfusion. When the transfusion is
completed it must be fixed in the patient’s medical folder as a permanent
record of the transfusion.

Subject: Policy Number: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE 13 Committee SOP,
RESPONSIBILITIES OF NURSES IN BLOOD TRANSFUSION Effectivity Date: 2017

#13. IDENTIFICATION OF PATIENT AND THE BLOOD PRODUCT February 1,

2017

Approval Date:

January 2017

2. Identification of Patient and the blood product

26

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Before beginning the transfusion, it is extremely important to identify CORRECTLY

the patient and the blood product.

2.1 Check the ABO and Rh group on the label of the blood container to be
certain that it also agrees with the Transfusion Record.

2.2 Check the number on the label of the blood container to be certain it agrees
with the Transfusion record.

DO NOT begin the transfusion until any discrepancy in the above information is
resolved.

Subject: Policy Number: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE 14 Committee SOP,
RESPONSIBILITIES OF NURSES IN BLOOD TRANSFUSION Effectivity Date: 2017

#14. BLOOD COMPONENT ADMINISTRATION February 1,

2017

Approval Date:

January 2017

3. Blood Component Administration

Transfusion Set
Blood or components must be administered safely through a peripheral or central
venous access device. Peripheral intravenous access should be sufficient to maintain an
adequate rate for the transfusion without causing a risk of hemolysis. The size of
cannula chosen depends on the size and integrity of the vein. Blood components
particularly red cells and whole blood should be mixed thoroughly by gentle inversion
27

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

before use and then transfused through an intravenous line approved for blood
administration incorporating a standard 170-200 micron filter. A peripheral vein cannula
18-20G size is recommended for adults while 22-24G is recommended for pediatric
patients. (Grade A; Level 2) Smaller gauge devices can be used but restrict the flow rate
of the transfusion and result in a much longer time to infuse a component. When blood is
being administered by syringe to small infants or neonates, the blood should be drawn
into the syringe via a 170-200 micron filter. (ANZSBT, 2004).

A new transfusion set should be used for every new unit of blood product. In an
emergency or operating room procedure where several units may be administered in a
short time, the transfusion set should be changed every 6 hours. A transfusion set used
for red cells should NOT be re-used for platelet transfusion since red cell debris trapped
in the filter would trap the platelets. (ANZSBT, 2004) (Grade A; level 3) (p71 Phil. CPG
for the Rational Use of Blood/Blood Products)

Intravenous Fluids
The standard set to be used in a blood transfusion should be primed with normal
saline (0.9 NSS) or the blood component. Dextrose containing solutions should
not be used for priming the blood transfusion set. The only fluids that can be
given concurrently through the same IV device as a red cell transfusion are: 1.
Normal saline, 2. 4% albumin, 3. Plasma protein fractions, or 4. ABO-compatible
plasma. Electrolyte and colloid solutions containing calcium or 5% dextrose
should not be given with blood components. (ANZSBT, 2004) (Grade A, Level 2)
Blood transfusion sets should not be ‘piggy-backed’ into other lines. Similarly
medication should not be added to any blood component prior to its transfusion.

Subject: Policy Number: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE 14 Committee SOP,
RESPONSIBILITIES OF NURSES IN BLOOD TRANSFUSION Effectivity Date: 2017

#14. BLOOD COMPONENT ADMINISTRATION Febuary 1, 2017

Approval Date:

January 2017

General Blood Transfusion Rates

Unless otherwise indicated by the patient’s clinical condition, the rate should be no greater than
5 mL/minute for the first 15 minutes. All blood components should be infused within 4 hours
unless otherwise specified. (ANZSBT, 2004) (Grade A; Level 3)

28

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

The transfusion should be completed in less than 4 hours because of the dangers of bacterial
proliferation and red blood cell hemolysis at room temperature.

Subject: Policy Number: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE 15 Committee SOP,
RESPONSIBILITIES OF NURSES IN BLOOD TRANSFUSION Effectivity Date: 2017

#15. MONITORING AND OBSERVATION OF TRANSFUSION February 1,

2017

Approval Date:

January 2017

4. Monitoring and Observation of Transfusion

29

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Monitoring the Patient

For each unit of blood transfused, monitor the patient at the following stages (Grade A; Level 3)
(WHO, 1997)
 Before starting the transfusion
 As soon as the transfusion is started
 Every 15 minutes after starting the transfusion for first hour
 Every 30 minutes during transfusion
 On completion of the transfusion
 Four hours after completing the transfusion

In each of these stages, record the following information on the patient’s chart:

1. Patient’s general appearance

2. Temperature
3. Pulse rate
4. Blood pressure
5. Respiratory rate
6. Fluid balance of oral and IV fluid intake and urine output
(WHO, 1997)
7. Patient’s subjective complaints

The following should also be recorded in the patient’s medical chart:

1. Time the transfusion is started

2. Time the transfusion is completed
3. Volume and type of all products transfused
4. Unique donation numbers of all products transfused
5. Any adverse effects (WHO, 1997)

Subject: Policy Number: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE 15 Committee SOP,
RESPONSIBILITIES OF NURSES IN BLOOD TRANSFUSION Effectivity Date: 2017

#15. MONITORING AND OBSERVATION OF TRANSFUSION February 1,

2017

Approval Date:

30

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

January 2017

Unconscious or anesthetized patients

Unconscious or anesthetized patients are more difficult to monitor for signs of

transfusion reactions. Routine observation patterns should continue. Transfusion
reactions should be considered when assessing a change or deterioration in the
patient’s condition, particularly during the first 15-20 min following the start of a unit of
blood or blood component.

Closer observation should take place for infants, unaccompanied children and patients
who are unable to verbalize symptoms or use the call bell due to mental or physical
limitations.

Hypotension, uncontrolled bleeding or generalized oozing during surgical procedures

may suggest a coagulopathy, e.g. disseminated intravascular coagulation. However,
these symptoms may indicate the possibility of an acute hemolytic reaction due to an
incompatible red cells transfusion.

Hemoglobinuria or oliguria may also be an early sign of an acute hemolytic transfusion

reaction due to an incompatible red cell transfusion.

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE February 1, Committee SOP,
2017
RESPONSIBILITIES OF THE NURSING STAFF IN BLOOD 2017
TRANSFUSION Approval Date:

GENERAL GUIDELINES January 2017

31

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

1. Make sure that requests to secure blood and compatibility test are properly and
completely filled up.
2. Take baseline vital signs.
3. Assure that blood is properly transported from the laboratory to the ward/unit and
observe the 30-minute rule.
4. Check label of blood bag against transfusion sheet.
5. Inspect thoroughly the blood pack of its general appearance and quality.
6. Set-up the transfusion.
7. Sign the transfusion sheets together with the attending physician
8. Recheck labels, type, compatibility results, expiry dates, and other pertinent data.
9. Should there be delays in hooking up the blood unit for transfusion, and the blood unit is
already in the ward, carefully monitor the time and adhere to the 30-minute rule for
blood unit/s taken out from the Blood Bank.
10. Ensure careful infusion.
11. Monitor patient during transfusion.
12. Report untoward reaction to attending physician.
13. Fill-up the report of blood transfusion reaction signed by the attending physician and
send this to the blood bank.
14. Keep records of progress of transfusion.
15. Keep records of number of blood units used by each patient.
16. Monitor wastage and improper use and handling of blood and report this to the Blood
Transfusion Committee.
17. Notify the laboratory if scheduled procedures are postponed or cancelled and when
reserved units are no longer needed.

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE February 1, Committee SOP,
2017
RESPONSIBILITIES OF LABORATORY PERSONNEL IN BLOOD 2017
TRANSFUSION Approval Date:

GENERAL GUIDELINES January 2017

32

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

1. Perform accurate compatibility testing and provide properly filled up result forms.
2. Assure that blood cold chain policy is implemented and blood units are properly stored
and transported from the laboratory to the ward/unit using an ice chest.
3. Inspect thoroughly the blood pack for its general appearance and quality before
issuance to the nurse.
4. Refer to the Pathologist for cases with difficult crossmatching and ABO/Rh typing
discrepancies.
5. Pathologist consults the clinician to further discuss the management of difficult typing,
crossmatching and transfusion cases.

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE February 1, Committee SOP,
2017 2017
*GUIDELINES IN THE MANAGEMENT OF TRANSFUSION
REACTION* Approval Date:

January 2017

33

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

1. Any change in the patient’s condition while undergoing blood transfusion should be
recognized and evaluated. The nurse should remain with the patient while transfusing the
first 50mL of blood.
2. If a change in patient’s condition occurs, the flow of blood or component being administered
should be stopped, and the amount of blood which has been infused should be noted.
3. The vein should be kept open with starter solution (NSS) at a rate of 10-12 drops/minute, or
as directed.
4. Referral to the attending physician should be made immediately.
5. The reaction should be reported to the blood bank without delay.
6. The hospital form “Report of Transfusion Reaction” should be immediately filled up and
brought to the laboratory.
7. The blood bank number (serial number) on the blood bag should be checked with the
number on the blood transfusion sheet. The identification of the patient and other data
should be checked.
8. The remaining blood should be sent to the laboratory together with the blood transfusion set,
with the tubing clamped shut.
9. Any adverse symptoms or physical sign occurring during transfusion of blood or its’
components should be considered life-threatening. An adverse reaction is defined as any
unexpected outcome resulting either during or within several hours following the
blood transfusion. This includes, but it not limited to, any of the following:
a. Fever (rise of 1◦C or more)
b. Chills
c. Back pain
d. Dyspnea, including wheezing
e. Hypotension
f. Hemoglobinuria
g. Bleeding

34

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE February 1, Committee SOP,
2017 2017
*GUIDELINES IN THE MANAGEMENT OF TRANSFUSION
REACTION* Approval Date:

January 2017

When a transfusion reaction is suspected:

9.1 IMMEDIATELY STOP THE TRANSFUSION. Record the amount of blood which has
been infused.
9.2 Notify responsible physician
9.3 Keep I.V. line open with infusion of normal saline at a rate of 10-12 drops/minute or as
indicated.
9.4 Check all forms, labels, and patient identification to determine if the patient received the
correct blood or component.
9.5 Report the suspected transfusion reaction to blood bank personnel immediately
9.6 Send completed transfusion reaction form, discontinued bag of blood, administration set,
and all of the IV solutions to the blood bank.
9.7 The blood bank shall collect a blood sample for repeat crossmatching and other studies
for blood transfusion reaction, especially when a hemolytic blood transfusion is
suspected.
9.8 The nurse attendant should collect sample of the next urine and send it to the laboratory
for hemoglobin determination.

35

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE February 1, Committee SOP,
2017 2017
MANAGEMENT OF FEBRILE BLOOD TRANSFUSION REACTION

Approval Date:

January 2017

Signs and Symptoms: Chills, fever, headache, myalgia, nausea, and non-productive cough.
Onset: During transfusion or up to 24 hours post-transfusion.
History: Patients with multiple transfusion or pregnancies.
1. Stop the transfusion and note the amount of blood transfused.
2. Keep the vein open with NSS.
3. Notify physician
4. Give acetaminophen or aspirin if necessary. Treatment is generally not required
since symptoms resolve in a short period.
5. Report to the blood bank. Refer to CVPH HBTC SOP, p33, Guidelines for
Management of Transfusion Reaction.
6. The transfusion may be continued if the clinical signs and symptoms and
laboratory tests were able to rule out a hemolytic blood transfusion reaction.

36

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE February 1, Committee SOP,
2017 2017
MANAGEMENT OF ALLERGIC BLOOD TRANSFUSION
REACTION Approval Date:

January 2017

Signs and Symptoms: Skin rashes, flushing, and for extreme cases of anaphylaxis: nausea,
vomiting, and hypotension.
Onset: During transfusion or up to 24 hours post-transfusion.
History: Allergies
1. Stop transfusion and note the amount of blood transfused.
2. Keep vein open with NSS.
3. Notify physician.
4. Treatment is generally with antihistamine given orally or IM. Epinephrine or
steroid may be given for symptoms of acute asthma or anaphylaxis.
5. Report to the blood bank. Refer to CVPH HBTC SOP, p33, Guidelines for
Management of Transfusion Reaction.

37

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE February 1, Committee SOP,
2017 2017
HEMOLYTIC BLOOD TRANSFUSION REACTION
Approval Date:

January 2017

Signs and Symptoms: Apprehension, fever, chills, chest pain, headache, shock, nausea,
vomiting, dyspnea, flushing, oozing from minor wounds, or any
abnormal oozing of blood.
Onset: Immediate or delayed until up to 4th day or until several days after transfusion.
1. Stop the transfusion and note the amount of blood transfused.
2. Keep the vein open with NSS.
3. Notify the physician.
4. Treatment is aimed at preventing renal failure. Give mannitol IV push over 10-15
mins, followed by continuous infusion of 5% mannitol regulated to maintain urine
output at 100-150 cc/hr. Normal saline with Na bicarbonate may also be given.
5. Patients with suspected disseminated intravascular coagulopathy (DIC) may be
given heparin at 40-50 units IV/ lb. body weight over 4 hours.
6. Give ventilator support and intubation if indicated by hypotension and shock.
7. Report to the blood bank. Refer to CVPH HBTC SOP, p33, Guidelines for
Management of Transfusion Reaction.

38

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE February 1, Committee SOP,
2017 2017
MANAGEMENT OF CIRCULATORY OVERLOAD REACTION
Approval Date:

January 2017

Signs and Symptoms: Cough shortness of breath, neck vein engorgement, rales, pulmonary
congestion and edema.
Onset: Gradual, within increasing severity of symptoms as more blood is infused.
History: Chronic anemia, infusion of massive volume of blood and/or fluid over a short period.
1. Stop the transfusion and note the amount of blood infused.
2. Keep vein open with NSS.
3. Notify physician.
4. Give oxygen if necessary.
5. Give diuretics.
6. Report to the blood bank. Refer to CVPH HBTC SOP, p33, Guidelines for
Management of Transfusion Reaction.

39

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE February 1, Committee SOP,
2017 2017
BLOOD TRANSFUSION REACTION DUE TO CONTAMINATED
BLOOD Approval Date:

January 2017

Signs and Symptoms: Chills, fever, and shock

Onset: Rapid, with increase in pulse rate, hypotension with temperature elevation.
1. Stop the transfusion and note the amount of blood infused.
2. Keep vein open with NSS.
3. Notify physician.
4. Treatment is symptomatic.
5. Report to the blood bank. Refer to CVPH HBTC SOP, p33, Guidelines for
Management of Transfusion Reaction.

40

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE February 1, Committee SOP,
2017 2017
MANAGEMENT OF BLOOD TRANSFUSION REACTION
RESULTING FROM RAPID INFUSION OF MASSIVE AMOUNT OF Approval Date:
STORED BLOOD
January 2017

Signs and Symptoms: Coagulation changes and bleeding, acidosis, and hypocalcemia.
History: Transfusions of blood near expiry date or near outdate.
1. Stop the transfusion and note the amount of blood infused.
2. Keep vein open with NSS.
3. Notify physician.
4. Check platelet count, PT, PTT. May give platelet concentrate and fresh frozen
plasma
5. Give NaHCO3 IV.
6. Check calcium level, do ECG and give CaCl2.
7. Report to the blood bank. Refer to CVPH HBTC SOP, p33, Guidelines for
Management of Transfusion Reaction.

41

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE February 1, Committee SOP,
2017 2017
MANAGEMENT OF HYPOTHERMIC BLOOD TRANSFUSION
REACTION Approval Date:

January 2017

Signs and Symptoms: Cardiac arrhythmias, cardiac arrest.

Onset: Occurs after infusion of large amount of cold blood.
History: Large volume replacement with blood which were not previously warmed.
1. Stop the transfusion and note the amount of blood infused.
2. Keep vein open with NSS.
3. Notify physician.
4. Treatment is symptomatic.
5. Report to the blood bank. Refer to CVPH HBTC SOP, p33, Guidelines for
Management of Transfusion Reaction.

42

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE February 1, Committee SOP,
2017 2017
LABORATORY PROCEDURES IN THE
INVESTIGATION OF BLOOD TRANSFUSION Approval Date:
REACTIONS
January 2017

1. Clerical check should be done to verify patient identification.

a. Check the identification of patient and donor blood.
b. Review pre-transfusion testing records.

2. Examination of serum, for hemolysis and a direct Coomb’s test done on the post-
transfusion specimen for antibody coating of red cells.

3. The pre and post-transfusion samples are rechecked for blood group and immune
antibodies, and compatibility testing is repeated.
a. Repeat ABO and Rh test on both pre and post-transfusion samples, and on
blood taken from the bag or from a segment still attached to the unit.
b. Repeat the crossmatch on both the pre and post-transfusion samples against a
sample of red cells form the bag or from a segment still attached to the unit.

4. Bacteriologic studies are performed.

a. Examine the unit for signs of bacterial growth, i.e. purple color, clots in the bag,
or hemolysis.
b. Take specimen from the bag for cultures at 4◦C, at 20-24◦C, and at 35-37◦C.
c. Examine the smear of blood stained with Gram stain.

5. Determination of free hemoglobin.

a. Determine by visual or photometric methods the presence of free hemoglobin
(pink or red) and bilirubin (yellow or brown) in the serum of the pre and post-
transfusion specimens.
b. Examine the supernatant plasma of blood from the donor blood container for
presence of free hemoglobin.
c. Examine the blood remaining in the administration tubing for presence of free
hemoglobin.

43

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE February 1, Committee SOP,
2017 2017
*LABORATORY PROCEDURES IN THE
INVESTIGATION OF BLOOD TRANSFUSION Approval Date:
REACTIONS*
January 2017

6. Post-transfusion urine is evaluated for hemoglobin

7. The patient’s history and the results of tests are evaluated by the blood bank physician
who makes an interpretation.

8. The blood bank physician notifies the physician-in-charge of the results and
interpretation of the investigation as soon as possible.

44

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE February 1, Committee SOP,
2017 2017
INTERPRETATION OF LABORATORY RESULTS OF
EXAMINATION DONE TO INVESTIGATE BLOOD Approval Date:
TRANSFUSION REACTIONS
January 2017

1. Determination of patient’s samples and/or donor units which have been

misidentified or incorrectly issued.

a. When ABO and Rh typing on the patient’s pre- and post-transfusion samples do
not agree, an error in either the patient identification, typing, or blood drawing is
considered.
b. When the ABO group of the blood specimen does not match with the ABO group
on the bag, an error in labelling is considered, and thus, an error in compatibility
test is also considered as well.
c. When results of pre- and post-transfusion specimens are not compatible, an error
during pre-transfusion testing is considered. (The donor specimen used for
compatibility test may have been taken from a different unit.)

2. Determination of free hemoglobin/bilirubin

a. When there is a pink or red discoloration in the post-transfusion specimen but

none in the pre-transfusion specimen the presence of free hemoglobin and
therefore a destruction of red blood cells is considered.
b. When there is yellow or brown discoloration in the post-transfusion specimen and
there is none in the pre-transfusion specimen, an increase in bilirubin and other
hemoglobin breakdown products is considered.
c. When there is pink or red discoloration in the supernatant plasma of the blood
from the donor blood container, damage of the unit by improper temperatures in
storage or during administration, damage due to injection of drugs or hypotonic
solutions, or bacterial contamination are considered.
d. When there is pink or red discoloration in the blood remaining in the tubing, a
hemolysis in the tubing but not in the blood bag is considered. This is particularly
true when the administration set has been previously used for hypotonic
solutions or dextrose.

45

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE February 1, Committee SOP,
2017 2017
INTERPRETATION OF LABORATORY RESULTS OF
EXAMINATION DONE TO INVESTIGATE BLOOD Approval Date:
TRANSFUSION REACTIONS
January 2017

3. Determination of antibody coating of red cells by Coomb’s test

a. If Coomb’s test is positive, a delayed destruction of antibody or complement-

coated incompatible cells is considered.
b. If Coomb’s test is negative, a non-immune hemolysis is considered. A delay in
drawing specimen for hemolytic study is also considered.

4. Determination of hemolysis using both Coomb’s and free hemoglobin test.

a. If the free hemoglobin and bilirubin tests are both negative and the Coomb’s test
is positive, an acute immune hemolytic reaction is not considered. However, if
the patient’s clinical condition strongly suggests a hemolytic reaction, further
investigation is warranted.
b. If free hemoglobin is positive, bilirubin is negative, and the Coomb’s test is
positive, a conclusive interpretation is not possible, and the situation requires
further investigation. If free hemoglobin is negative, bilirubin is positive and
Coomb’s test is negative, a conclusive interpretation is likewise not possible, and
the situation also requires further investigation.
c. If free hemoglobin is positive, bilirubin is positive, and Coomb’s test is positive,
and acute immune hemolytic reaction is highly considered.

5. Determination for alloantibodies

a. When the post-transfusion sample for ABO and Rh tests show a mixed field
pattern, the presence of incompatible donor cells is considered.
b. When the crossmatch is incompatible with the post-transfusion specimen but
compatible with the pre-transfusion specimen, an anamnestic response is
considered.

46

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE February 1, Committee SOP,
2017 2017
CHECKLIST FOR SIGNS OF DETERIORATION IN
BLOOD OR PLASMA Approval Date:

January 2017

Before blood/blood product is issued from the blood bank to end-users, it should always be
inspected for any signs of deterioration, including:

1. Any sign of hemolysis in the plasma indicating that the blood has been contaminated,
allowed freezing or becoming too warm.

2. Any sign of hemolysis on the line between the red cells and plasma. If you suspect this,
gently mix the unit and allow in to “settling out” before being issued.

3. Any sign of contamination, such as a change of color in the red cells, which often look
darker or purple/black when contaminated.

4. Any clots, which may mean that the blood was not mixed properly with the anticoagulant
when it was collected.

5. Any signs that there is a leak in the bag or that it has already been opened.

47

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
 Republic of the Philippines
Provincial Government of Compostela Valley
PROVINCIAL ECONOMIC ENTERPRISE MANAGEMENT OFFICE
COMPOSTELA VALLEY PROVINCIAL HOSPITAL
Pantukan

Subject: Effectivity Date: Hospital Blood

Transfusion
HOSPITAL BLOOD TRANSFUSION COMMITTEE February 1, Committee SOP,
2017 2017
REFERENCES
Approval Date:

January 2017

Safe Blood and Blood Products, Introductory Module: Guidelines and Principle for Safe Blood
Transfusion Practice, World Health Organization, pages 58-59.

Philippine Clinical Practice Guidelines for the Rational Use of Blood and Blood Products and
Strategies for Implementation, Department of Health, 2010

JRRMMC Hospital Blood Transfusion Committee Standard Operating Procedure

AABB Technical Manual, 15th Ed

48

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist