A member asked a question about the change in the recommendation to monitor patients during transfusion that has occurred between the 12^th and 13^th editions of the Technical Manual. According to the member, in the 13^th edition of the Technical Manual, it states that "The transfusionist should remain with the patient for at least the first 15 minutes of the infusion." (Chapter 22, page 491). This is an increase in the actual amount of time that the transfusionist should spend with the patient, when compared with the previous technical manuals. The inquiring member is wondering what impact this has had on hospitals and in the updating of nursing procedure, and how well this change was received by the RN's.

So that you all have a frame of reference, the 12^th and 13^th editions of the Technical Manual state:

12^th edition - Patient Care During Transfusion

The transfusionist should remain with the patient for the first few minutes of the infusion, which should be started slowly. Catastrophic reactions from acute hemolysis, anaphylaxis, or bacterial contamination can become apparent after a very small volume enters the patient's circulation. After the first 15 minutes, the patient should be observed and the vital signs recorded; if the patient's condition is satisfactory, the rate of infusion can be increased to that specified in the clinical order. Clinical personnel should continue to observe the patient periodically throughout the transfusion (e.g., every 30 minutes) and up to an hour after completion.

13^th edition - Patient Care During Transfusion

The transfusionist should remain with the patient for at least the first 15 minutes of the infusion. The transfusion should be started slowly. Catastrophic reactions from acute hemolysis, anaphylaxis, or bacterial contamination can become apparent after a very small volume enters the patient's circulation. After the first 15 minutes, the patient should be observed and the vital signs recorded; if the patient's condition is satisfactory, the rate of infusion can be increased to that specified in the clinical order. Clinical personnel should continue to observe the patient periodically throughout the transfusion (e.g., every 30 minutes) and up to an hour after completion.

In response to this question, the following opinions were submitted:

1. The 12^th and 13^th editions of the Technical Manual provide essentially the same recommendation, which is to observe the patient for the first 15 minutes of the blood transfusion.

2. The wording in the 12^th edition of the Technical Manual describes a clinically appropriate practice that is feasible. The Wording in the 13^th edition of the Technical Manual is unrealistic. There is no way that a nurse can afford the time to stay at the bedside of a transfusion recipient for a full 15 minutes for every transfusion.

3. The amount of time that a nurse must observe a patient at the start of a transfusion, according to the 13^th edition of the Technical Manual, has had a significant reaction on our campus which transfuses over 50,000 RBC/yr. In view of the ongoing appropriate concern over errors and safety, this minimal time seems appropriate and should be strictly observed.

4. On the oncology unit at a major institution in Washington state, this has been a topic that has been discussed before. On that particular unit the nurses are very sensitive to issues surrounding transfusion and usually find a way to be in the room for about 10 minutes when the transfusion is first started. The nurse there thought that a 15 minute observation time would be a stretch, but they would comply. The member who submitted this opinion had doubts about other wards where the patient-nurse ratio was higher.

5. This individual was not sure where the 15 minute time frame came from, and hypothesized that there must have been some study that indicated that adverse reactions to transfusions are seen within the first 15 minutes. Interestingly, the JCAHO CAMH manual merely states that the patient needs to be monitored for vital signs and clinical signs during the procedure (TX.5.4 and IM.7.3.3). Most hospitals have defined the appropriate time (like 15 minutes) for a second check after starting the infusion. Stating a time frame allows the process to be measured (if people follow policy or not).

6. According to this individual, people should remember that the Technical Manual is simply someone's best opinion, and that this text is not a required standard! Over the years, there have been several statements in the Technical Manual that were contrary to usual practices. In some cases, what appeared in the Technical Manual was an outright error. Therefore, it is recommended to take what appears in the Technical Manual with a grain of salt. This individual stated that serious transfusion reactions (eg, acute hemolysis, bacterial shock, TRALI, etc) usually begin early during a transfusion. Therefore, institutions should set up policies to detect transfusion errors and to care for patients who suffer transfusion reactions. Nurses should follow the Golden Rule and ask "How would I want a transfusion to be given to me?"

7. The first point is that the Technical Manual does not represent the official policy of any organization. No one should consider any statement in the Manual to be a requirement. This individual believes that the standard of practice is, and should be, to observe the patient "closely" during the first 15 minutes of a transfusion. The type of monitoring must ensure that acute hypotension and/or angioedema would be recognized promptly. Each hospital should be free to use its own wording in its policy statement.

8. This member doubted if anyone noticed, especially the nurses. In the hospitals around this member's practice, they are lucky to have enough staff available to get pre vital signs, post at 15 min. and again at the completion of the transfusion. It is what is in the Standards which counts and this is not specified.

9. According to this individual, he would be surprised if the nurse is actually at the bedside for the full 15 minutes. And, in ICU's - - where there is more monitoring going on at any given time - - is probably even more lax about "remaining at the bedside the first 15 minutes. From a cost-effective standpoint this individual thinks that the question is a good one, and it would be interesting to see some data in this regard. From a practical standpoint, this individual asks if there are data to support the requirement to remain at the bedside for the first 15 minutes. How many transfusion reactions actually occur in the first 15 minutes? These days, one is lucky to even get the vital signs recorded on the transfusion slip, or the start and stop times, let alone making sure a nurse is on-site for 15 minutes.

10. This individual has noted the change in the Technical Manual and has used it as an indicator for the transfusion process. This member states that one would not believe how often the patient is left alone. RNs do not seem to understand the importance of this process. Lab supports the change and Nursing has begun to take note of the difference in Standards.

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator