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Original Article http://dx.doi.org/10.1590/0104-07072016002600015 NURSING CARE IN BLOOD TRANSFUSION: A TOOL FOR PATIENT MONITORING1 Daiana de Mattia2, Selma Regina de Andrade3 1 Paper taken from the thesis - Nursi...

Original Article http://dx.doi.org/10.1590/0104-07072016002600015 NURSING CARE IN BLOOD TRANSFUSION: A TOOL FOR PATIENT MONITORING1 Daiana de Mattia2, Selma Regina de Andrade3 1 Paper taken from the thesis - Nursing care in hemotherapy: designing tools for quality management, developed in the Programa de Pós-Graduação em Gestão do Cuidado de Enfermagem, Universidade Federal de Santa Catarina (UFSC), in 2014. 2 M.Sc. in Nursing Care Management. Nurse, UFSC University Hospital. Florianópolis, Santa Catarina, Brazil. E-mail: daimattia@ gmail.com 3 Ph.D. in Nursing. Professor, Departamento de Enfermagem, Programa de Pós-Graduação em Enfermagem, UFSC. Florianópolis, Santa Catarina, Brazil. E-mail: [email protected] ABSTRACT: Qualitative study, developed through discussion groups, with the objective to elaborate, along with nurses, a tool to monitor patients submitted to blood transfusion. Study participants were 11 nursing professionals, being three nursing technicians and eight nurses. Data were analyzed with the content analysis technique, resulting in two categories: Quality of nursing care for patients undergoing blood transfusion and monitoring of patients submitted to blood transfusion. It was identified that professionals are able to understanding the concept of quality and seek to implement actions to achieve a good standard of patient care. In line with the current regulations, the professionals have structured a tool for recording information on blood transfusion, serving as a tool to monitor patients who are receiving this therapy. This research is intended to help identify and intervene early in the onset of transfusion reactions. DESCRIPTORS: Nursing care. Quality management. Blood transfusion. CUIDADOS DE ENFERMAGEM NA TRANSFUSÃO DE SANGUE: UM INSTRUMENTO PARA MONITORIZAÇÃO DO PACIENTE RESUMO: Estudo de abordagem qualitativa, desenvolvido por meio de grupos de discussão, com o objetivo de elaborar, juntamente com profissionais de enfermagem, um instrumento de monitorização do paciente submetido à transfusão sanguínea. Participaram do estudo 11 profissionais de enfermagem, sendo três técnicos e oito enfermeiros. Os dados foram analisados com a técnica de análise de conteúdo, originando duas categorias: Qualidade no cuidado de enfermagem ao paciente submetido à transfusão sanguínea e monitorização do paciente submetido à transfusão de sangue. Identificou-se que os profissionais compreendem o conceito de qualidade e procuram implementar ações para alcançar um padrão ótimo de cuidado ao paciente. Em consonância com a norma vigente, os profissionais estruturaram um instrumento que permitirá o registro das informações sobre a transfusão de sangue, servindo como ferramenta para monitorar o paciente submetido a essa terapêutica. Espera-se contribuir para identificação e intervenção precocemente, no aparecimento de reações transfusionais. DESCRITORES: Cuidados de enfermagem. Gestão da qualidade. Transfusão de sangue. CUIDADOS DE ENFERMERÍA EN TRANSFUSIÓN DE SANGRE: UNA HERRAMIENTA PARA EL MONITOREO DEL PACIENTE RESUMEN: Estudio cualitativo, desarrollado a través de grupos de discusión, con objeto de elaborar, junto con las enfermeras, un instrumento de monitoreo de pacientes sometidos a la transfusión de sangre. Los participantes del estudio fueron 11 enfermeras, tres técnicos de enfermería y ocho enfermeras. Los datos fueron analizados con la técnica de análisis de contenido, lo que resultó en dos categorías: Calidad de la atención de enfermería para los pacientes sometidos a la transfusión de sangre y el monitoreo del paciente sometido a una transfusión de sangre. Se identificó que los profesionales entienden el concepto de calidad y tratan de poner en práctica acciones para lograr un buen nivel de atención al paciente. De acuerdo con la normativa vigente, los profesionales han estructurado un instrumento para registrar la información sobre las transfusiones de sangre, que sirve como una herramienta para monitorear el paciente sometido a esta terapia. Se espera ayudar a identificar e intervenir temprano en la aparición de reacciones transfusionales. DESCRIPTORES: Atención de enfermería. Gestión de la calidad. Transfusión sanguínea. Texto Contexto Enferm, 2016; 25(2):e2600015 Mattia D, Andrade SR 2/8 INTRODUCTION mental elements of patient care. Based on these records, multidisciplinary communication can Blood has always been present in the history be established, permitting the continuity of care. of humanity, in the belief that it sustained and They are also relevant to qualify the reporting of could save lives. Nevertheless, centuries of studies transfusion reactions by providing information on were needed to discover its true importance and the patient in the pre, trans and post-transfusion therapeutic role.¹ period.7 In the Brazilian hemotherapy system, the A direct mutual relation exists between confirmed first transmission of the Acquired Im- transfusion safety and quality management, as munodeficiency Virus (AIDS) in 1988 stands out as health service quality means offering less risk to the starting point to reorganize the National and the patient, based on the orchestration and search State Blood Policies.2 to maximize the care and benefit.8 Therefore, the Today, hemotherapy in the country is regu- establishment of planning and a risk management lated by a standard3 and decree4 on hemotherapy policy, such as consolidated protocols in the orga- procedures and best practices in the blood cycle, nization for example, contribute to the safety and ranging from the donor capitation process to the benefit the stakeholders: patients, collaborators and blood transfusion of blood, its components and the institutions.9 blood derivatives originating from human blood.3-4 In the health context, in which the consumer is Blood transfusion institutions are respon- the patient, a quality management system is intend- sible for maintaining registers related to the ed to improve the efficacy of the services provided, transfusion in patient’s records, such as date, in line with the patient’s requisites and satisfaction. start and end date of the blood transfusion, vital In that sense, it is highlighted that the professionals signs at the beginning and end, origin and identi- who work at these services should be trained and fication of the blood component bags, identifica- alert in order to prevent, identify, approach and treat tion of responsible professionals and records of possible transfusion reactions.10 At these services, transfusion reactions.4 In addition, the vital signs the nursing team is highlighted, considering that (temperature, breathing frequency, blood pressure its activities can significantly minimize the risks and pulse) of patients submitted to the procedure for the patient and avoid damage, managing the need to registered immediately after the beginning transfusion process efficiently.11 and after the end; monitoring during the first ten Although nursing plays a fundamental role minutes of the transfusion by a qualified health in hemotherapy, nursing research on this theme is professional; and patient monitoring throughout still limited. In a bibliographic study about scientific the transfusion.3 These actions permit not only the nursing production in Hemotherapy, Hematology early detection of any adverse reactions, but also and Bone Marrow Transplantation between 2000 their reporting. and 2004, 88 publications were found, of which The blood transfusion should be appropri- 73 came from congress proceedings. The studies ate to the patient’s health needs, delivered in time mainly came from the Southeast, with a predomi- and correctly administered. Even when delivered nance of the quantitative-qualitative approach and in accordance with the recommended standards, limited nursing production. This can be justified correctly indicated and administered, the blood by the fact that this is a recent nursing specialty in transfusion involves a health risk. This risk refers to Brazil that is still being consolidated.12 the transfusion reactions during or after the blood The search for texts in the Virtual Health transfusion, besides the fact of being related to it.5 Library, using the key words “nursing” and “he- The complications include those that are due to motherapy”, covering the period between 2005 and bacterial contamination, acute hemolytic reactions 2013, also revealed few publications. The findings caused by incompatibility of the ABO system, ana- were related to the nurses’ activities in blood donor phylactic reactions, fluid overload, among others. screening13 and risk management,14 being respon- These complications may be non-immune, and may sible for reporting transfusion reactions. Only two be associated with human error; or immune, linked studies were found that were specifically related to to the organic response mechanisms to the blood blood transfusion. One discussed the assessment of transfusion.6 nursing records in hemotherapy15 and the other the To avoid the possible damage caused by assessment of nursing professionals’ knowledge on blood transfusion, the nursing records are funda- hemotherapy and transfusion safety.11 This reality Texto Contexto Enferm, 2016; 25(2):e2600015 Nursing care in blood transfusion: a tool for patient monitoring 3/8 demonstrates that further research is needed in proved by Conselho Nacional de Saúde. The research hemotherapy nursing. participants were identified using the letter “P”, At the University Hospital (UH) where the followed by a sequence number, to guarantee the study was undertaken, professionals from the subjects’ anonymity. sector called Transfusion Agency take part in the The voices in the discussion groups were digi- transfusion process. This agency is responsible tally recorded with the participants’ authorization for selecting and installing the blood components. and then transcribed. The data analysis was based The responsibility for monitoring the transfusion on content analysis, in three phases: pre-analysis, and the patient is shared with the nursing team, analytic description and interpretation of the refer- which assists the patient at inpatient and outpatient ence framework.17 In the pre-analysis, the material services. To put these actions in practice, the need transcribed with the participants’ statements was was identified for a standardized blood transfu- transcribed. In the analytic description, this material sion registration tool that provides the patient data was analyzed in depth, looking for central themes throughout the transfusion process. At the UH, the participants had transmitted, revealing the however, no specific tool is available yet for this following categories: Quality in nursing care for purpose in the patient history. patients submitted to blood transfusion and Moni- In view of the above, the objective in this study toring of patients submitted to blood transfusion. In was to elaborate, together with nursing profession- the interpretation phase of the reference framework, als, a tool for monitoring the patient submitted to these categories were analyzed based on the theo- blood transfusion. retical framework of quality management.18 Based on the discussions, the tool to monitor patients sub- METHOD mitted to blood transfusion was structured, which was validated in group. This qualitative study was developed based on discussion groups and was intended to collect data in order to analyze the context the interviewees RESULTS AND DISCUSSION are part of, as well as their world view. The group’s Quality in nursing care for patients submitted opinion is not the sum of all individual opinions, to blood transfusion but the collective construction of ideas.16 Over time, the health institutions have ad- The study population involved 11 nursing opted quality management using efficient manage- professionals, including three technicians and eight ment models, which optimize the resources applied, nurses. The inclusion criteria were: nursing team contributing to better productivity and satisfaction professionals working at the services, chosen inten- for users and health care professionals.19 tionally, due to the care particularities they present; In the discussion groups, the participants who agreed to participate voluntarily by signing the manifested some concepts of health quality man- Free and Informed Consent Form. agement. The data were collected in three discussion Doing well what one does, with scientific knowl- groups that took approximately two hours. One edge and with the smallest possible error margin, fulfill- of the researchers conducted the groups through ing the requisites needed to be as good as possible (P3). guiding questions. The guiding question for the first group was: how do you observe the quality Satisfying the patient, aiming for safe, respectful, in nursing care for patients submitted to blood efficient and competent care (P2). transfusion? In the second group: what should be The care quality concept Pan American Health the structure of a tool to monitor blood transfusion Organiztion20 proposes corresponds to the degree of patients? The third group: does the constructed satisfaction of the service users, guaranteeing that tool permit monitoring patients submitted to blood they receive effective and safe care, with a level of transfusion? professional excellence, in view of existing social The data were collected in October and No- and cultural values. vember 2013, with the authorization of the Ethics Thus, it was observed that the participants Committee for Research Involving Human Beings have background knowledge on the theme, as their (protocol 388.010/2013). In the development of perceptions are in accordance with the concept of the research, respected the Resolution 466/12, ap- health care quality. Texto Contexto Enferm, 2016; 25(2):e2600015 Mattia D, Andrade SR 4/8 The concepts refer to the pillars of quality in activities tend to guarantee transfusion safety and health,18 as follows: efficiency, corresponding to if the transfusion process is managed efficiently. the ability to obtain the best result at the lowest Nevertheless, professionals with limited knowledge cost: efficacy, the ability of medical science to offer on this specialty and without sufficient skills can improvements in individuals’ health and wellbeing; cause important damage.10-11 effectiveness, with a relation between the actual ben- Transfusion reactions are problems that can efit the health system or care offers and the potential happen during or after the blood transfusion. The result of an ideal system; optimization, corresponds signs and symptoms are perceived at the beginning to the maximization of the benefit in relation to the or within 24 hours after the end of the transfusion. economic cost of its resources; acceptability, which 6 They require immediate action from these profes- is the adaptation of medical and health care to the sionals, with decision making and priority setting, expectations, desires and values of the patients and in order to minimize the damage and discomfort their families; legitimacy, refers to the possibility the reaction causes.22 to satisfactorily adapt a service to the community For the early detection of these reactions, or to society as a whole; equity, corresponds to the during the transfusion period, the patient should appropriate and fair distribution of the services and be observed, during the first ten minutes of the benefits to all members of the community, popula- transfusion, by a professional trained for this end, tion or society.18 who stays at his/her side to observe possible reac- As a part of the health system, nursing under- tions.3 In case of one or more signs and symptoms stands that an excellent patient care level can only of a transfusion reaction, the nursing team should be achieved if quality is sought in care.21 Concern- be at least capable of taking the measures needed ing the quality in hemotherapy nursing care, some for each of the reaction types.22 aspects are essential for safety and quality in blood Transfusion safety and quality management transfusion. Among these, the participants high- are directly related with the professionals’ engage- lighted specific nursing care in their statements, ment in this process, taking into account their which should be provided to patients submitted to qualification and knowledge in the area. Tools to blood transfusion. help and provide appropriate support on how to Checking the patient’s vital signs, knowing that proceed in care for blood transfusion patients are he may experience a transfusion reaction, what to do in fundamental.7-11 case of a reaction. I take care, check the vital signs, if they are stable. Every 30 minutes, I end up checking the vital signs. He may present a transfusion reaction as early as Monitoring of patients submitted to blood in the first 10 minutes (P3). transfusion Nursing needs to know the care that guides Registering information related to the blood the blood transfusion and the possible complications transfusion is extremely important, as it serves to this treatment may cause for the patient. verify whether the transfusion took place in accor- Quite some time ago we had an employee who was dance with the standards in force. returning from her holidays and, on that day, they did Monitoring the entire transfusion process 54 transfusions, including cry, platelets. She was a very is intended to detect complaints, signs and experienced professionals, very careful, but she exchanged symptoms that can reveal transfusion reactions. the blood bag. The patient started with a burning feeling Registering and monitoring the adverse events in the arm, chest pain and, as soon as she noticed, she associated with the transfusion contribute to called the staff and they were able to revert the condition. guarantee the safety and quality control of hemo- Exchanging a blood bag is lethal (P1). therapy services.6 What I notice is that the reactions happen later. The For the nursing team, this registry provides care we didn’t take before and we do now is to send the legal support concerning the quality of patient care. patient away only half an hour after the transfusion (P4). Therefore, the more and the better the nursing team The professional should know the main indi- registers its actions, the more it is valuing its work, cations of blood transfusion, verify important data besides favoring patient safety.15 to prevent errors, advise relatives and patients about In the course of the discussion groups, based the transfusion, attend to transfusion reactions and on the participants’ statements, a tool was structured register the entire process. These professionals’ to monitor patients submitted to blood transfusion. Texto Contexto Enferm, 2016; 25(2):e2600015 Nursing care in blood transfusion: a tool for patient monitoring 5/8 Using guiding questions, topics were listed that routines were discussed in accordance with the 2011 should be present in the tool, as well as the content standard, in force when the discussion groups were each topic should present, as described in Table 1. It held, and which was not changed in the legislation should be clarified that the topics on the transfusion currently in force.3-4 Table 1 – Topics and contents of monitoring tool for patients submitted to blood transfusion. Florianópolis-SC, 2014 Topics Content Patient identification Patient name, mother’s name, age, birth date, diagnosis, file number, room/bed, inpa- tient service, blood type, transfusion data: previous transfusion, transfusion reaction, need for preparation for the transfusion, result of irregular antibody test, identifica- tion of irregular antibodies, erytrocytary phenotyping when performed, compatibil- ity test, result of laboratory tests. Pre-transfusion Number of blood component bag, type of blood component, verification of double checking, vital signs, start date and time of transfusion, access route (peripheral, cen- tral, port cath), access site, orientation to patient or responsible caregiver about proce- dure and space for observations. Transfusion Vital signs Post-transfusion Vital signs, end time of transfusion, removal of access, space for observations. Complementary observations Observations related to quantity of blood components, transfusion reactions: orienta- tions, transfusion recommendations. The participants considered the content of the service found it important to have available infor- patient identification topic as necessary, includ- mation on the blood type in the patient history.7 ing specific data (patient name, mother’s name, Concerning the pre-transfusion data, the need age, birth date, diagnosis, file number, room/bed, was addressed to include, besides the vital signs inpatient service and blood type) and the transfu- (blood pressure, cardiac frequency, respiratory sion data, such as: previous transfusion, previous frequency and temperature), start date and time of reaction; need to prepare for the transfusion, test the transfusion, access route (peripheral, central, result of irregular antibodies, identification of ir- port cath), access site, device used (single, shared), regular antibodies, eritrocytary phenotyping when orientation to patient or responsible caregiver about performed, compatibility test, laboratory test result. the procedure and space for observations. The patient identification is part of safe care. The data the participants listed are included in This initiative establishes actions for the patients’ the legislation, which recommends the verification safety in health services. Thus, all patients need to and registration of the patient’s vital signs at least be identified in a unique manner, using at least two before the start and at the end of the transfusion.3 distinct markers.8 The reporting system of transfu- This action is fundamental to direct the care during sion reactions in the United Kingdom identified that the transfusion process, besides helping in case of a approximately 66.7% of the transfusion reactions transfusion reaction, either to establish the diagnosis reported in that country are associated with errors or care for the patient.14 in the receivers’ identification.23 This fact evidences the importance of considering this information in Concerning the access route used for the trans- the tool. fusion, it should be compatible for this end, as an Knowledge on the patient’s transfusion his- inappropriate access causes delay in the transfusion tory in the tool is useful, as patients with a history and even the discarding of the blood component if of transfusion reactions, antigens and eritrocitários the infusion period exceeds four hours. The high antibodies may be at an increased risk of a transfu- pressure of the flow through the small-lumen cath- sion reaction.6 In these cases, professionals assisting eter can cause the hemolysis of the erythrocytes.24 patients submitted to blood transfusion should be Registering the access site and the device use alert to any report and signal the patient may pres- is essential as, when a pre-existing venous access is ent during or after the blood transfusion. In addi- chosen, it is important to assess signs of infiltration, tion, in a study developed in 2012, it is appointed inflammation, infection, interaction with parenteral that the professionals from an adult intensive care solutions, duration of medication therapy, compat- Texto Contexto Enferm, 2016; 25(2):e2600015 Mattia D, Andrade SR 6/8 ibility for infusion of blood component. No drug can the signs and symptoms early, as this can determine be infused together with the blood component bag, the type of transfusion reaction and decision mak- nor infused in parallel. Five percent glucose solu- ing for the therapeutic conduct.22 The transfusion tions can cause hemolysis of the blood cells, while reactions that happen during and until 24 hours ringer lactate solutions can cause clots due to the after the blood transfusion still represent almost all presence of calcium.6 reported transfusion reactions.25 That demonstrates Including the start date and time of the trans- the need to monitor the patient throughout the fusion is fundamental as the infusion time of each transfusion period. blood component cannot exceed four hours. Thus, As regards the topic associated with the post- writing down the start time of the transfusion transfusion period, the participants appointed the provides information to control how long the bag importance of maintaining records on the vital signs, remains at room temperature.14 In the same topic, an- the end time of the transfusion, space for observa- other suggestion made was to include specific space tions to describe possible adverse reactions and to register the bag number and type of the blood conducts. These data are important, as they permit component. Each stage of the hemotherapy process observing whether the transfusion was concluded should be registered. The bag number is essential, within the legally established deadline (maximum as it permits tracking the blood component that of four hours) and the identification of a possible was transfused. Tracking any blood component is transfusion reaction. a possibility established by law, as it should permit The administration time of the blood compo- the investigation of adverse events that may occur nent is fundamental as, if it is exceeded, the blood during or after the transfusion.3 component loses its properties due to the exposure Double checking, when the technician from to uncontrolled temperature.26 That can also increase the transfusion agency and the nursing technician the risk of bacterial growth.6 check that the correct blood component is given to In the additional observations, the participants the correct patient, was another content the partici- suggested some informative topics useful for their pants suggested. This verification procedure of the daily practice, such as the blood components the data by two technicians, one at a time and at distinct institution uses, the standardized abbreviation of moments, comparing the data, tends to minimize each blood component and the infusion time of each. error risks, enhancing the transfusion safety.6 In addition, an observation was included that no Advising the patients or their responsible medication should be administered concomitantly caregivers about the transfusion is also part of the with the blood component and a flow chart was con- transfusion safety recommendations and is the structed in case of suspected transfusion reactions. role of the entire nursing team, so as to appoint A version of the tool for nursing care to moni- the benefits and possible reactions the transfusion tor blood transfusion patients, resulting from this can cause. A study shows that, in the orientation to study, is under evaluation at the component sector patients submitted to blood transfusion, the nurs- of the place of study with a view to future imple- ing team emphasizes the aspects regarding the mentation. benefits of the transfusion, providing little clarifi- cation on its risks. That is a problem, as the patient or responsible caregiver’s cooperation, informing FINAL CONSIDERATIONS on any abnormality suggesting a reaction, leads to Nursing care to monitor patients submitted the early detection of a transfusion, contributing to to blood transfusion requires a registration tool to minimize any damage.11 guarantee the quality of this procedure. This moni- In the topic related to the transfusion period, toring tool was constructed in discussion groups the participants listed information on the vital signs based on the experience of professionals who under- as necessary. These data permit monitoring the stand the concept of quality and work to implement patient throughout the transfusion and identifying actions to achieve an excellent patient care standard. possible transfusion reactions early, as this treat- In line with established standards, the profes- ment is not free from causing health damage.11 sionals structure the tool in view of the particulari- The causes of these reactions may be linked ties of their place of work, listing fundamental data with the immunological and non-immunological that contributed to quality care. Thus, in a broad response. Therefore, the nursing team needs to sense, the data in the tool can cover all specificities of know about this possible problem and to identify inpatient and outpatient services at the institution. Texto Contexto Enferm, 2016; 25(2):e2600015 Nursing care in blood transfusion: a tool for patient monitoring 7/8 The researchers hope that, based on the tool, Universidade Federal de Santa Catarina, Programa all information on the blood transfusion can be de Pós-Graduação em Enfermagem; 2012. registered, ranging from blood component data to 8. Ministério da Saúde (BR). Agência Nacional de the patient’s clinical parameters. Its main contribu- vigilância sanitária. Programa Nacional de Segurança tion is the early identification and intervention in do Paciente. Anexo 2: Protocolo de Identificação do situations of transfusion reactions, minimizing the Paciente. Brasília (DF): MS; 2013. damage and discomfort for the patient. In addition, 9. Sociedade Beneficente Israelita Brasileira Albert the importance of nurses’ activities and the incipient Einstein (SBIBAE). Qualidade e segurança do paciente. São Paulo (SP): SBIBAE; 2014. nature of nursing studies on quality management in transfusion practices in Brazil and internationally 10. Mattia D. Assistência de enfermagem em hemoterapia: construção de instrumentos para a gestão da qualidade are underlined. [dissertação]. Florianópolis (SC): Universidade Federal The scarce literature and the small number de Santa Catarina, Programa de Pós-Graduação em of professionals who participated in the discussion Gestão do Cuidado em Enfermagem; 2014. groups were limiting factors, but they did not make 11. Ferreira O, Martinez EZ, Mota CA, Silva, AM. it impossible to produce a tool to monitor blood Avaliação do conhecimento sobre hemoterapia transfusion patients, the focus of this research. This e segurança transfusional de profissionais de tool will contribute to the safety of transfusions, the enfermagem. 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Boletim de Hemovigilância nº 5. Koogan; 2005. Brasília (DF): MS; 2012. 24. Achkar R, Arap SS, Arrais C, Biagini S, Callas SH, 26. Fidlarczyk D, Ferreira SS. Enfermagem em Cardoso LF, et al. Guia de condutas hemoterápicas. 2ª hemoterapia. Rio de Janeiro (RJ): MedBook Editora ed. Sociedade Beneficente de Senhoras Hospital Sírio Científica Ltda; 2008. Correspondence: Daiana de Mattia Received: July 13, 20115 Rua Lauro Linhares, 1314, Bloco C, ap 206 Approved: November 03, 2015 88036002 – Trindade, Florianópolis, SC, Brasil E-mail: [email protected] Texto Contexto Enferm, 2016; 25(2):e2600015