Aim: The aim of this project was to align policies, processes, and practices around blood product transfusion reaction detection in five acute care hospitals with current synthesized evidence obtained from an Integrated Research Review methodology.
Background/Significance: 20,933,000 blood products transfused in the U.S. during 2011 with a 0.24% adverse event rate (Gehrie, Hendrickson, & Tormey, 2015; Sullivan et al., 2015). Reported blood transfusion reaction rates ranged from 0.14-2.1% in reviewed literature (Cortez-Gann, 2017; DeYoung et al., 2015; Gehrie, Hendrickson, & Tormey, 2015; Hardwick, Osswald, & Walker, 2013). Five acute care regional organizations located in the southwest United States recorded 51/12,077 (0.422%) transfusion-related adverse reactions in 2017, thus highlighting the importance of identifying evidence to support vital sign frequency to detect transfusion reactions. Blood transfusions may result in severe complications including death (Battard Menendez, 2016; Cortez-Gann et al., 2017). Adverse reactions may occur immediately or within several hours post transfusion according to reviewed literature (Battard Mendez, 2016; Cortez-Gann et al., 2017; Hardwick, Osswald & Walker, 2013; Goodall, 2014). Nurses enrolled in a Research Academy designed to increase confidence in research skills and research capacity conducted an Integrated Research Review of published peer-reviewed literature to identify what frequency of vital signs should be used to detect a blood product transfusion reaction. Due to lack of high level evidence and guidelines in peer-reviewed literature to inform nurses in how frequently vital signs should be monitored and what components should be included in “vital signs” to identify transfusion reactions, an answer to the clinical question was not found. Consistently throughout the literature, vital signs were noted to not be enough to detect blood transfusion reactions. Physical assessment changes occur prior to vital sign changes in reviewed literature. In one reviewed study, 40% of sample had vital sign changes after patient reported symptoms (DeYoung Sullivan et al., 2015). Current vital sign monitoring at start, 15 minutes after, and at the conclusion of a blood product transfusion do not detect delayed reactions.
Methods: Research Academy participants compared findings from a literature review using Integrated Research Review methodology to current blood administration policies and processes to ensure evidence-based practices are employed for early detection of blood product transfusion reactions. Stevens Star Model of Knowledge Transformation© was used to guide the Research Academy fourth cohort project work for translation of research into practice. Three clear themes emerged from synthesized literature review findings: inclusion of respiratory assessment, inclusion of a physical assessment, and engaging family and patients as partners in detecting blood product transfusion reactions. The three emerging themes were used to guide policy, process, and practice change recommendations by the group of direct care nurses with Research Academy faculty to guide and mentor them. Consensus was reached for changes to relevant policies, electronic health record, and implementation steps. Meetings were scheduled with nurse leaders from nursing informatics, nurse policy and procedure, compliance, laboratory, education, regional hospitals, and executive teams to present suggested changes for approval. Research Academy participants presented suggested changes to their peers for approval in the Staff Nurse Professional Practice Council.
Results: Two process changes associated with blood product administration were made based on literature findings. An assessment was added to be completed with every set of vital signs during transfusion and patient education will be printed with every blood administration consent automatically to be provided to patient and family. All five recommended electronic health record changes were approved through proper authorization channels. Numerous policy changes were approved. Primarily multiple policies for each hospital were combined into a regional blood administration policy. Three blood administration policies around administration, laboratory labeling, and reaction were combined into one policy. The direct care nurses shared their evidence-based practice findings and practice change work through two local and one national dissemination opportunities.
Discussion/Conclusion: More research needs to be completed to answer how often vital signs should be done to detect blood transfusion reactions to guide nursing practice. Early detection potentially prevents adverse outcomes, increased lengths of stay, higher costs to treat, and promotes customer satisfaction. Although a clinical question may not be answered in peer-reviewed literature and only low level of evidence may be found to address a clinical question, changes to policies, processes, and practices may be indicated based on additional findings in reviewed literature. Role-modeling research skills by nurse leaders in academic and acute care organizations empowers direct care nurses proficient application of research, evidence-based practice, and quality improvement concepts and promotes an increased research confidence and capacity. Mentoring and role-modeling how to be a change agent through evidence-based practice implementation should continue to the point of patient care by changing policy, protocols, and practice alongside direct care nurses.