WELCOME TO TRANSFUSION MEDICINE

1. Consent for Transfusion
   
   1. The patient must give written informed consent prior to transfusion.
   2. The clinician in charge of the patient shall explain to the patient the indication, benefits, risks and alternatives to transfusion therapy, and ensure that the patient understands the issues discussed.
   3. If for any reason, the patient is unable to personally give consent, a responsible family member of the patient shall be asked to do so. If no such family member is available, or in emergencies when the need for transfusion leaves no time for consent, the decision shall be made by two fully registered medical practitioners. This decision shall be clearly documented.
      
      
2. Patient Identification
   
   1. The phlebotomist shall ensure that the patient is correctly identified by:
   2. Asking the patient to state their full name and IC number (or use of at least 2 identifiers) in open-ended questions.
   3. Check the answers given against the information stated on the patient’s identification wristband and/or case notes.
   4. If it is not possible to identify the patient in the above manner, the phlebotomist shall identify the patient by asking the relative or career to name the patient and then check the answer given against the information stated on the patient’s identification wristband and case notes.
      
      
3. Patient's Blood Sampling
   
   1. The procedure shall be carried out as one process by one person at the bedside.
   2. Only one patient shall be attended to at any one time till completion.
   3. The phlebotomist shall clearly and accurately label the blood sample at the patient’s bedside immediately after blood taking.
   4. Use of HIS pre-printed label is allowed. The ward/clinic should implement a procedure to ensure that patients are correctly identified using the printed labels.
   5. Information on the label shall include, at the minimum, the patient’s full name, hospital registration number/ identity card number, the date and time of collection and the initial of the phlebotomist.
      
      
4. Blood Sample and Container for Red Cells Transfusion
   
   1. Collect the required amount of blood into the appropriate sample tube as below. Specimen collection with anticoagulant tube should be mixed gently and thoroughly for 1 minute by a rotary wrist movement.
      1. Infant up to 4 months old
         
         • The sample to be taken from the infant shall be in EDTA pediatric tube (volume is as per stated on the tube container).
         • Blood sample in EDTA tube shall be also taken from the mother (volume is as per stated on the tube container).
         • Both samples shall be sent to the TMU together under a single request.
         • No further sample is required for repeat transfusion of the same set of the paedipack. However, infant’s sample is required for subsequent transfusion if another set of paedipack is going to be issued. For this, crossmatching will be performed using the infant’s sample.
   2. Older than 4 months old
      
      1. • The sample to be taken shall be in EDTA tube (volume is as per stated on the tube container).
         • If a patient requires repeated red cell transfusion, each request for red cells shall be accompanied by a new request form and a new blood sample in EDTA tube (volume is as per stated on the tube container).
      2. Elective cases
         
         • For elective cases, samples should be sent to the TMU during office hours, at least 24 hours before the blood is required.
         • Except for rare blood groups and/or Rh(D) negative where the TMU should be informed at least 5 working days in advance
           
           
5. Blood Sample and Container (Other than Red Cells) Transfusion
   
   1. A new request for blood component other than red cells shall be accompanied by blood sample taken in EDTA tube.
   2. For a patient who has at least two previous blood grouping records at the TMU, a new blood sample need NOT accompany the request for blood component.

6. Borang Permohonan Transfusi Darah
   
   1. All requests for blood/blood components must be made using ‘Borang Permohonan Transfusi Darah’.
   2. The request form should be completely filled and contains relevant patient information.
   3. Write the name of staff that takes and labels the sample.
   4. The quantity and the approximate time when the blood and blood component would be required must be stated. Requests for blood to be made available ‘as soon as possible’ should be avoided as this would not assist the blood bank
   5. personnel in determining priorities.
   6. The clinician shall ensure that each request form is completed, sign and clearly state his name in block letters or stamped.
   7. A different request form must be used for different blood components.
   8. Crossmatched blood will be kept for a further 48 hours.
      
      
7. Group, Screen and Hold Cases (GSH)
   
   1. Tick the appropriate box for a GSH request.
   2. GSH is a procedure that consists of ABO and RhD grouping, and antibody screening for the patient’s sample.
   3. It is recommended only for cases where there is a higher chance of requiring a blood transfusion during admission.
   4. For elective clinical procedures, GSH shall be requested in accordance with the established Maximum Surgical Blood Ordering Schedule (MSBOS).
   5. Should the patient require transfusion following GSH, blood will be made available on time.
   6. In case of unexpected antibody was detected, the medical officer in charge will be informed. The laboratory will attempt to supply compatible blood for the patient if required.
   7. Preferably, the request for GSH is reached at the transfusion laboratory at least 24 hours prior to the operation.
   8. All GSH request are kept for 72 hours.
      
      
8. Group and Crossmatch (GXM)
   
   1. GXM consists of checking ABO & RhD grouping and antibody screening for the patient’s sample and crossmatching patient and donor unit for compatibility.
   2. GXM shall be requested for cases with high certainty for transfusion at that time.
   3. Requests for non-urgent cases such as thalassemia, leukemia, and anemia should be sent preferably before 3.30 pm during normal office hours. This is to ensure that the Medical Laboratory Technologist (MLT) on-call can attend promptly
   4. and properly to the urgent requests.
   5. The approximate time when the blood is needed should be stated on the request form.
   6. Crossmatched blood will be kept for a maximum of 48 hours only. The blood will be automatically canceled on the third day of the request, unless the ward staff or medical officer informs for further reservation.
      
      
9. Transfusion in Cases of Life-Threatening Bleeding
   
   1. Phone call to TMU is required to facilitate the process for Safe O, uncrossmatch or emergency blood request.
   2. The choice of blood for transfusion in cases of life-threatening bleeding is dependent on the urgency for transfusion and the time available
      
      1. Uncrossmatched Group O RhD positive packed red cells (Safe O)
         
         • In Transfusion Medicine Unit, commonly Group O RhD positive packed cells are used as Safe O. Safe O can be used for resuscitation in a dire emergency while waiting for group-specific or crossmatched blood to be available.
         • Any decision to use Safe O shall only be made after the clinician has carefully assessed the urgency of the patient’s need for blood. The requesting doctor shall clearly state the reasons for the transfusion in the patient’s records and in the
         • request form.
         • Tick ‘serta merta tanpa ujian keserasian darah’ box in the request form.
         • A pre-transfusion blood sample must be collected from the patient before starting transfusion with ‘Safe O’. Send this sample together with the request form.
      2. Uncross matched group specific packed cells
         
         • If the blood group of the patient is known, uncrossmatched group specific blood may be given.
      3. Emergency crossmatch
         
         • If the blood is required urgently (within 30 minutes), tick ‘Segera’ box on the request form.
         • The laboratory will issue units of blood that are found to be compatible at immediate spin at room temperature.
   3. For Safe O, uncrossmatch and emergency crossmatch request,
      
      1. The laboratory will proceed to completion of the compatibility testing and antibody screening of the units of blood issued, at 37 °C and in the AHG phase.
      2. If there is any incompatibility detected, it will be immediately informed to the clinician concerned for appropriate action.
         
         
10. Neonatal Transfusion
    1. Blood used for neonatal transfusions shall be compatible with the mother’s blood. For that reason, samples from mother and neonate should be obtained.
    2. The volume of blood to be transfused is calculated based on the neonate’s body weight.

1. Discontinued Transfusion
   
   1. Any blood remaining from a discontinued transfusion shall not be used.
   2. Remnants of blood shall be returned to the TMU immediately together with completed form of ‘Borang Pemulangan Darah Yang Tidak Digunakan’.
      
      
2. Return of Unused Blood / Blood Component
   
   1. The ward shall return all un-transfused blood immediately to laboratory accompanying with completed form of ‘Borang Pemulangan Darah Yang Tidak Digunakan’.
   2. The ward shall inform the laboratory if any of the un-transfused blood returned to the laboratory has not complied with the storage or transportation temperature.
      
      
3. Return of Used Blood Bag
   
   1. Upon completion of blood transfusion, the ward staff must ensure that the BHT tag / compatibility label attached to each bag of blood component is filled completely and returned to laboratory together with the used blood bag.
      
      
4. Transfusion Reaction
   
   1. If an adverse transfusion reaction is detected or suspected, the transfusion shall be stopped immediately. A doctor shall immediately assess and stabilize the patient. Further management depends on the type and severity of the reaction.
   2. All transfusion reaction must be investigated. The request must be made using ‘Transfusion Reaction Request Form’.
   3. To facilitate investigation of an adverse transfusion reaction, follows ‘NOTES’ on the Transfusion Reaction Investigation Request form.
   4. Preserved the blood bag and tubing set with all attached labels.
   5. Label specimens as “Post-transfusion”, patient’s name and identifying data.
   6. For urticarial cases, please send blood bag and transfusion reaction form only.
   7. Send all investigations sample and request form to TMU immediately.
   8. Prior to sending the Transfusion Reaction Request Form to TMU, the ward shall keep the transfused blood bag and its transfusion set under appropriate conditions to ensure the integrity and to avoid microbial contamination.

Immunohaematology Test Request

• Request for Immunohematology test (other than transfusion request) shall be made only via online, through HIS Care2X.
• The sample to be taken from the infant shall be in EDTA pediatric tube (volume is as per stated on the tube container)
• The sample to be taken for a patient older than 4 months shall be in EDTA tube (volume is as per stated on the tube container).

1. Acceptance Criteria for Verbal Requests
   
   1. Other than urgent request, the verbal request can be made to add-on blood components, additional testing or to inform cancellation of the test on the previous request.
   2. For blood component add-on, new hardcopy request form must be sent to TMU.
   3. Acceptance of verbal request depend on
      • Request made less than 24 hours after the sample is received.
      • The request can only be accepted if the sample is sufficient.
      • The requested test is suitable to sample.
      • Request made by / on behalf of the medical officer.
      • Order the test / blood component in HIS Care2X

Rejection Criteria