Action 7.06

Consider developing local protocols for prescribing and administering blood and blood products in accordance with national guidelines and national criteria. Further guidance regarding the administration of a blood transfusion, as well as documentation of the transfusion, is in the ANZSBT guidelines for the administration of blood products.

Provide orientation and training to all clinicians involved in the clinical administration or prescription of blood or blood products, to ensure that they have appropriate skills and expertise.

Ensure that policies, procedures and protocols are in place that accord with national evidence-based guidelines for:

• Prescribing practice and clinical use of blood and blood products – decisions to use blood and blood products including any specific requirements (for example, irradiated products)
• Administration of blood and blood products, including venous access; the use of equipment, concurrent fluids and medicines; pre-administration identity check of patient and blood product; infusion rates; and observations and monitoring.¹

Where there are no national evidence-based guidelines, develop a local policy, process or procedure that communicates the appropriate practices, or rely on clinical judgement.

Improving the consistency of policies, procedures and protocols with evidence-based guidelines should be part of the blood management quality improvement system (refer to actions for the Clinical Governance Standard and Action 7.02). This includes actions such as developing or reviewing policies, procedures and protocols to ensure alignment with national evidence-based guidelines, and amending such documents as required.

Health service organisations are required to monitor the use of the policies, procedures and protocols. Ensure that these policies, procedures and protocols are readily available to the workforce. Members of the workforce should be trained in the use of such documents and procedures, where appropriate.

Strategies to change clinical practice are more likely to be effective if they use a multifaceted approach that includes a range of the following features:

• Evidence-based content
• Adaptation for local use
• Effective data collection systems to assess and feed back statistics by specialty and clinician
• Clinician involvement in clinical pathway development
• Use of an implementation team (for example, local clinical change team at the local level); in PBM programs, identifying and engaging multiple disciplines (for example, anaesthetists taking a major role in perioperative care) has been particularly successful
• Identification of the evidence–practice gap before implementation
• Identification of potential barriers to change
• Incorporation of reminder systems
• Use of ongoing education and communication
• Use of effective clinical leadership, including local opinion leaders, as part of a structured program.

Provide education, training and tools to the workforce to support the introduction of PBM practices in the clinical setting.

All members of the workforce involved in transfusion of blood and blood products are expected to receive orientation or training for the prescription and administration of blood and blood products.

Applicability of actions

The actions in the Blood Management Standard will not be applicable for day procedure services that do not use blood or blood products. These services should provide evidence that they do not use, receive, store, collect or transport the blood or blood products governed under this standard.

Services using blood or blood products should refer to the information provided for hospitals for blood management.

MPSs and small hospitals may need to:

• Develop and implement policies, procedures and protocols that are evidence based, and in line with national guidelines and criteria for the prescription and administration of blood and blood products
• Ensure that clinicians have the necessary skills to prescribe and administer blood and blood products
• Develop and implement education activities for the prescription and administration of blood and blood products.