Transfusion Nurse Role

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The role of the transfusion nurse in the hospital and blood

centre

L. Bielby, L. Stevenson & E. Wood

Australian Red Cross Blood Service, Melbourne; and Blood Matters Program, Department of Health, Victoria, Australia

The transfusion process is complex, involving many interlinking chains of events,

and a multidisciplinary group of health professionals with different levels of aware-

ness and understanding of transfusion practice. In recent years, many measures

have been implemented to increase blood component safety and the clinical trans-

fusion process. Haemovigilance programs report the greatest risks to patients from

transfusion in many countries now relate to hospital-based steps in the process.

The role of the Transfusion Nurse (TN) is evolving as an integral part of efforts to

optimise appropriate use of blood components, reduce procedural risks and improvetransfusion practice generally. The TN position is a relatively recent specialist role

within hospitals and blood services, and continues to develop with growing experi-

ence of areas requiring intervention in the clinical setting, and increasing expecta-

tions for improvements in transfusion clinical governance.

The role typically includes activities to improve clinician and patient awareness

of transfusion issues and practical knowledge of blood product use, and therefore to

improve clinical decision-making and enhance blood administration processes,

along with responsibilities for education/training, auditing and adverse event fol-

low-up. Within the Blood Service in Australia the role also covers approval and

provision of specialised blood products along with many of the hospital-based TN

functions.

The TN serves as an expert resource and has been fundamental in development of

tools, resources and skills in the following areas:

- Patient blood management:

- Education

- Governance

- Professional development

- Research

Benchmarking across organizations has demonstrated that availability and

review of comparative data can be a powerful motivator of change. Reviews of the

TN role/programmes highlighted their effectiveness and resulted in ongoing sup-

port/funding. Skills and attributes such as confidence, persistence, energy, excellent

communication/ technical knowledge and clinical experience are key requirements

for the roles success.

Conclusion The specialist transfusion practitioner/Transfusion Nurse is an integralpart of a multidisciplinary team, supporting efforts at institutional and national

levels to reduce transfusion risks and improve practice.

Key words: transfusion practice, transfusion nurse, transfusion practitioner.

Correspondence: Linley Bielby, Blood Matters Program Manager, Australian Red Cross Blood Service ⁄ Department of Health, 50 Lonsdale Street,

Melbourne, Victoria, Australia

E-mail: [email protected]

ISBT Science Series (2011) 6, 270–276

STATE OF THE ART 2B-E1.6 ª 2011 The Author(s).

ISBT Science Series ª 2011 International Society of Blood Transfusion

270



Introduction

The transfusion process is complex, involving many inter-

linking chains of events, and a multidisciplinary group of

health professionals with different levels of awareness and

understanding of transfusion practice. In recent years,numerous measures have been implemented to increase

both the safety of blood components and the transfusion

process itself. However, haemovigilance programmes con-

tinue to report that the greatest risks to patients from trans-

fusion in many countries relate to hospital-based steps in

the process, particularly transfusion of the wrong blood

component.

Over the last decade, many countries have introduced

clinical transfusion practice improvement programmes to

optimize appropriate use of precious blood components,

reduce the procedural risks of transfusion administration

processes and improve transfusion practice generally. These

improvement activities typically involve a multidisciplin-

ary team, and the role of the Transfusion Nurse (TN) is

evolving as an integral part of these programmes and con-

tinues to develop with growing understanding of areas

requiring intervention in the clinical setting, and increasing

requirements for improvements in transfusion clinical gov-

ernance. The TN is (generally) a relatively recent specialist

position within hospitals and blood services. The role is

multifunctional, requiring diverse skills and attributes, and

incorporates a range of clinical, quality, risk management

and educational activities.

Drivers underpinning clinical transfusionpractice improvement programmes

A number of factors have prompted the development of

practice improvement programmes:

(1) Clinical governance : Many countries now have

requirements from healthcare quality accreditation

bodies that include standards for transfusion gover-

nance, and considerable resources may be required

to demonstrate compliance. For example in Australia,

both the Australian Commission for Safety and Qual-

ity in Healthcare (a national, standard-setting body)

and the Australian Council on Health Care Standards

(a hospital assessment and accreditation body) now

have detailed requirements for transfusion practice.

(2) Risk management : International haemovigilance data

indicate significant hazards associated with the trans-

fusion of incorrect or inappropriate blood components,

plus a substantial number of near misses with the

potential for harm.

(3) Demand : The demands for blood and blood products are

increasing each year in many countries for a variety of

reasons, such as ageing populations, changes in treat-

ment options, introduction of new technologies, and

improvements in supportive therapy. With increased

demands come associated costs, including costs associ-

ated with production, management and administration

of blood components and fractionated blood products.(4) Patient expectations : Patients are now much more

informed about treatments, including transfusion, and

their potential risks, and have expectations for more

information to make informed decisions about their

therapy.

(5) Availability of new clinical practice guidelines and

research findings, for example, in the areas of blood

conservation, including intra- and post-operative cell

salvage techniques and the development of pre-opera-

tive anaemia management clinics [such as from the UK

Better Blood Transfusion (BBT), and Canadian onTrac

programs].

Many governments and health agencies have considered

these factors and now place increased emphasis on appro-

priate use and management of blood, and as a consequence

some have provided direction and resources, including

financial support, to establish clinical transfusion practice

improvement initiatives.

What do these programmes look like?

Established clinical transfusion practice improvement

programmes and the activities within them vary signifi-

cantly both between and within countries; and are

strongly influenced by the local health care systemneeds and government expectations. Programmes gener-

ally involve a multidisciplinary team raising awareness

around transfusion to improve practical knowledge of

blood product use, and provide a basis to improve clini-

cal decision-making and enhance blood administration

processes and patient care. Data generated from audits

and other programme activities can be powerful motiva-

tors of change and tools for benchmarking within and

across organizations.

The individuals undertaking these roles have various

titles, such as TN, TN specialist or consultant, transfusion

safety officer, haemovigilance officer and specialist practi-

tioner of transfusion. In Australia, New Zealand and the UK

these specialist transfusion practitioner positions are now

well established and are predominantly nursing roles, while

in other settings, personnel with scientific ⁄ technical (e.g.

Canada) or medical (e.g. France) backgrounds may perform

some or all of these activities. In all cases, they work very

closely with other healthcare professionals in transfusion

support, patient blood management and blood conserva-

tion. Links to some established programmes and groups are

provided at the end of this article.

Role of the transfusion nurse 271

2011 The Author(s).

ISBT Science Series 2011 International Society of Blood Transfusion, ISBT Science Series (2011) 6, 270–276



Table 1 Examples of activities of some practice improvement programmes and the role of the TN in achieving results

Activities and achievements Key elements ⁄ skills of TN

Promote and participate in Patient Blood Management (PBM) programs:

• Support PBM including blood conservation practices (e.g. UK Better Blood Transfusion including

e-learning programme for cell salvage, see http://www.learncellsalvage.org.uk)• Provide tools and materials, such as patient information brochures (e.g. for management of iron

deficiency anaemia), fact sheets and other materials which are age and culturally appropriate.

(see BloodSafe and Blood Matters websites)

• Manage nurse-led clinics for anaemia management (see OnTrac website)

• Promote multidisciplinary team approach – e.g. involvement in clinical ward rounds enabling

real-time education or clinical intervention

Knowledge, preparation, implementation,

support and education,Clinical input, real-time education to

patients ⁄ staff and clinical intervention

Education

• Develop and implement programmes within health services and blood services, including: Online

e-learning ⁄ paper-based training ⁄ competency packages e.g.:

• BloodSafe (South Australia): see https://www.bloodsafelearning.org.au

• Bloody Easy (Transfusion Ontario): see http://www.transfusionontario.org

• Scottish National Blood Transfusion Service (SNBTS): see

http://www.learnbloodtransfusion.org.uk

• Develop templates to provide consistent transfusion information and assist new TNs

• Educational posters on indications, special requirements, identification, blood

sampling, transfusion reactions, etc. (see Better Blood transfusion tools).

Newsletters to highlight important messages

Knowledge, development and implementation,

support and education,

Understanding and working with technology,

Being a change agent,

Project management,

Communication with and across disciplines

Governance

• Develop and implement policies and procedures, manuals, clinical guidelines, charts and forms to

support safe and appropriate transfusion practice. For example:

• Policies and procedures to support new clinical practice guidelines and ⁄ or requirements, e.g.

for massive transfusion, or for specialised products such as intravenous immunoglobulin and

recombinant factor VIIa

• Institutional activities to support blood supply contingency planning strategies

• Patient identification – conduct audits and make recommendations for change, develop

policy, conduct trials and participate in implementation of technology, i.e.

radiofrequency identification system (RFID) for patient ID – e.g.‘Blood Track’

• Informed consent – develop and implement policy and procedures, patient

information (age appropriate and culturally sensitive) and forms to support increased

patient knowledge and understanding of risks. Establish and support hospital

transfusion committees, to provide authority and action change improvement

processes. Transfusion reaction follow-up and incident reporting internally and

externally, including to Haemovigilance programs

• Prepare reports to national and local governments, local institutions ⁄

organisations ⁄ departments and clinicians

Knowledge,

Change agent,

Auditing and monitoring,

Recording, analysing and maintaining data,

Literature review,

Education and training,

Communication with and across disciplines,

Working with multidisciplinary teams

Professional development

• Develop resources for new TNs e.g. UK BBT tools – ‘A drop of knowledge,‘A Wealth of Knowledge

and Blood Matters ‘Handbook for Transfusion Practitioners 2010’

• Clinical support networks to facilitate information and resource sharing and provide support to

TNs (e.g. Australia ⁄ NZ ‘AUSPOTS’ and UK SPOT networks

• Participate in post-graduate specialist qualifications: e.g. Blood Matters ⁄ University of

Melbourne Graduate Certificate in Transfusion Practice. TNs have played a major part in

designing and delivering this course• Participate in local, national and international professional meetings and conferences

to share knowledge

Knowledge, development and implementation,

support and education,

Communication with and across disciplines and

organisations,

Project management,

Contract management,

Multimedia presentation skills,Facilitating change

Audit and research

• Plan and conduct audits of clinical practice (e.g. administration practice, overnight transfusion,

sample collection and compliance, appropriateness of transfusion against guidelines, patient

identification and storage and handling).

• Use audit data to support practice change and benchmarking. Participate in research, including

clinical trials

Auditing, monitoring maintaining and

interpreting data,

Implementing change,

Understanding and working with technology,

Communication with and across disciplines,

Working with multidisciplinary and

international teams

272 L. Bielby et al.

2011 The Author(s).




Skills and attributes of the TN

The skills and attributes of TNs ⁄ practitioners are impor-

tant factors in the success of the role and their contribu-

tion to clinical transfusion practice improvement

programmes.Transfusion nurses are vital connections between the dif-

ferent health professionals engaged in the transfusion

chain, in particular, those beyond the transfusion labora-

tory. They act as educators, trainers, co-ordinators, data

collectors, project managers and change agents. They are

critical components of hospital transfusion teams, and pro-

vide invaluable support for the efforts of the hospital trans-

fusion committee (or equivalent).

The TN skills should include comprehensive and current

knowledge of transfusion practice, excellent communica-

tion skills, an ability to interact with a broad range of peo-

ple from hospital executives, quality co-ordinators, senior

and junior medical officers, scientists and nurses, to

patients and relatives. The ability to understand and work

with the local hospital ⁄ health service ‘politics’ is a definite

advantage when implementing change. Skills such as effec-

tive project management and coordination, and attributes

such as confidence, energy and persistence are necessary to

see ideas through implementation and to fruition. As prac-

tice change is often achieved slowly, a coordinated and per-

sistent approach is required for truly ‘embedded’ long term

changes.

AchievementsThe TN has been fundamental in the development and

implementation of many improvements; however, it

must be noted that while the TN is the driver and agent

of many of these changes, strong local leadership and

support from management is also essential to the pro-

cess, and especially required to ensure there is a contin-

uous cycle of improvement. Depending on the role and

the organization, this support could be provided by a

number of sources including hospital clinical champions,

transfusion team and transfusion committee, the blood

service transfusion medicine team, and professional TN

networks and specialty societies. Where practice improvement programmes are well estab-

lished and have been evaluated they have demonstrated

increased awareness and knowledge to support decision-

making and appropriateness of transfusion, ultimately

resulting in improved outcomes in patients [1].

Table 1 demonstrates the complexity and diversity of

some of the achievements that have been possible within

these programmes and also outlines key elements and skills

of the TN required to achieve these results.

The Australian experience

A number of transfusion practice improvement pro-

grammes have been established over the past decade in

Australia, generally constructed as formal collaborations

between state ⁄ territory health departments and the Austra-lian Red Cross Blood Service and in partnership with local

hospitals. Their activities, and those of the TNs employed

within them, reflect both national and local state or terri-

tory government priorities, resulting in variation in activity

and responsibility depending on the context and location

of their work. For example, some TNs oversee activities in a

large area health service (either metropolitan or regional)

covering many hospitals and health services, whereas oth-

ers are based at one hospital, such as a large metropolitan

university teaching hospital. At the time of publication,

there were approximately 75 specialist nurse positions

across Australia. A review of the TN role and the Blood

Matters program conducted in 2007 highlighted the effec-

tiveness and resulted in ongoing support ⁄ funding.

A Graduate Certificate in Transfusion Practice was devel-

oped by the Blood Matters program and is now offered

entirely on line for Blood Matters by the University of Mel-

bourne. This specialist qualification is recommended for

TNs undertaking this role in Victoria. Since 2003, a total of

70 students across Australia have successfully completed

the course, including a number of international and non-

nursing background participants.

In some Australian states, funding has been secured to

introduce additional resources in the form of non-specialist

nurse transfusion trainers (TT) and ‘link’ nurses to imple-ment quality activities at regional and rural hospitals. These

roles are typically undertaken on a part-time basis, 1 day ⁄

week or fortnight, depending on the number of transfusion

episodes in their hospital.

The TN role is also an integral part of the Transfusion

Medicine Services (TMS) team at the Australian Red Cross

Blood Service. The TMS team provide clinical and technical

transfusion advice and support to clinicians, hospitals and

laboratories nationally.

Currently, 14 TNs are employed within the Blood Service

across Australia to cover each state and territory. The Blood

Service TN role includes approval and provision of specia-lised blood products with particular reference to intrave-

nous immunoglobulin (IVIG) and specialised platelet

support, along with assistance with clinical advice, educa-

tion and support. In Australia, IVIG is an intensively man-

aged blood product, with the Blood Service designated as

one of the key authorized approvers; as such the Blood Ser-

vice TNs are key facilitators of these approvals, along with

other members of the TMS team. The Blood Service TNs

have assisted governments with the implementation and


2011 The Author(s).




ongoing education and support of the ‘Criteria for clinical

use of IVIG in Australia’ (Commonwealth of Australia

2007) and provided input to the recent review of this docu-

ment. The Blood Service TN role also incorporates the co-

ordination and provision of specialised platelet support (i.e.

HLA-matched and directed products). The Blood ServiceTNs work closely with the hospital-based TNs and the role

also includes clinical audit and research (see below).

The TNs in Australia are actively involved in all aspects

of transfusion practice improvement as outlined in Table 1.

Some additional interesting aspects of the TN role in Aus-

tralia include participation in a range of clinical research

projects, such as:

(1) Data linkage activities, where hospital admission data

are linked with laboratory data to help understand

usage patterns at institutional and regional levels.

(2) A study of hospital intern knowledge of blood and

blood transfusion, which has been helpful in planning

further educational interventions.

(3) Collecting patient data for a number of clinical regis-

tries such as the Australian and New Zealand Haemo-

stasis Registry (to capture non-haemophilia-related use

of recombinant factor FVIIa), and the new national reg-

istries for neonatal alloimmune thrombocytopenia and

thrombotic thrombocytopenic purpura.

(4) National coordinator role for the Australian arm of the

international ‘TOPPS’ study (a randomized controlled

trial examining the use prophylactic platelet transfu-

sions in patients with haematological malignancies).

(5) Mapping and costing studies of red cells and platelets.

Within Australia, each clinical transfusion practiceimprovement programme regularly uses an email network

or online forum at regional (e.g. Blood Matters – Transfu-

sion Interest Group) or national (Australian Specialist Prac-

titioners of Transfusion – AUSPOTS) level to interact, and

share resources or information from colleagues, including

through national networks in other countries such as the

UK Specialist Practitioner of Transfusion (SPOT) group.

Challenges for the TN role

(1) Facilitating change and maintaining the drive and

enthusiasm to continue to promote and support change

where in some settings there is little evidence and con-

flicting clinical and other priorities.

(2) The complexity of the transfusion chain and the num-

ber of staff involved, with frequent turnover, which

creates sustained pressure on the number and fre-

quency of education requirements.

(3) Maintaining funding to support and maintain pro-

grammes in the setting of tight healthcare budgets is a

constant challenge and requires proactive managers

and the use of data to demonstrate the value and need

for such programmes. In Australia, support and funding

has generally been focused at hospitals in the public

sector to date but it is hoped to expand this further to

the private sector and rural areas in the future.

Where to from here?

In the current healthcare climate, and with imperatives to

reduce costs and risks, it is important that the outcomes

and achievements from these clinical transfusion practice

improvement programmes continue to be circulated and

published, to share results, celebrate achievements, identify

problems, minimize duplication of effort and assist with

benchmarking. Collaboration between programmes can

both maximize results and reduce workloads, generating

cost efficiencies and serving to provide a variety of addi-

tional skills and experiences for TNs, including opportuni-

ties for exploration of new technologies and their

implementation. Where institutions, regions or countries

are exploring or establishing new programmes, established

programmes could provide valuable support and direction

by sharing knowledge and experiences.

Summary ⁄ conclusion

Specialist transfusion practitioners ⁄ TNs have played sig-

nificant roles in delivering the many achievements of

the transfusion practice improvement programmes estab-

lished to date, working as part of multidisciplinary teams

at institutional and national levels in hospitals and

blood services to reduce transfusion risks and improvepractice. Sustaining improvements in transfusion practice

requires the continued support and co-ordination of

these efforts.

Disclosures

The authors declare that there are no potential conflicts of

interest.

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Documents

Transfusion Nurse Role