ORIGINAL RESEARCH

Nursing challenges in responding to transfusion reactions

Emísia Maria da Silva^I; Creusa Alves Vieira^II; Flávio de Oliveira Silva^III; Edeilson Vicente Ferreira^IV

^I Nurse. Getúlio Vargas Hospital. Transfusion Agency. Recife, Pernambuco, Brazil. E-mail: emisia2008@hotmail.com
^II Nurse. Clinical Hospital of Pernambuco, Surgical Block. Recife, Pernambuco, Brazil. E-mail: creusaavieira@gmail.com
^III PhD. Defense and Agricultural Inspection Agency of Pernambuco. Animal Inspection. Recife, Pernambuco, Brazil. E-mail: foliveirasilva@gmail.com
^IV Nurse. PhD. Federal University of Pernambuco, Clinical Hospital, Bronchoscopy Ambulatory. Recife, Pernambuco, Brazil. E-mail: edeilsonvicente@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.11552

ABSTRACT

Objective: to evaluate nursing teams' knowledge with regard to responding to transfusion reactions at a hospital in Pernambuco State. Method: in this quantitative, descriptive study at hospital intensive care and emergency units, a semi-structured questionnaire was applied to 95 nursing professionals from these sectors, from January to June, 2013. The study was approved by the ethics committee of Restauração de Pernambuco Hospital (CAEE: 0081.0.102.000-10). Results: 93% of interviewees were women, 80% had graduated more than 10 years earlier, 49% had never monitored blood component or blood product transfusions; 59% were found not to know the maximum time for red blood cell concentrate infusion and 76% did not know the minimum time for this infusion. Regarding adverse reactions, 65% claimed to know how to identify them, and 19% did not know how to respond to transfusion reactions. Conclusion: nursing professionals need to receive continuing education in transfusion practice.

Keywords: Hemotransfusion; blood components; hemovigilance; transfusion process.

INTRODUCTION

Blood transfusion and techniques and strategies that avoid the need for blood are complementary activities of the clinical area of ​​transfusion medicine¹. The transfusion of blood components and blood products is a complex procedure associated with a significant risk of complications, and yet important as a support in the realization of treatments, transplants, chemotherapies and several surgeries. Reactions may occur during transfusions, which are defined as problems that happen during or after blood transfusion.

Transfusion therapy requires trained health professionals with technical competence especially to prevent transfusion reactions, which consist of intercurrences of any nature resulting from the transfusion of blood components during or after its administration. Rigorous investigation of transfusion reaction cases is essential to qualified health care practices ².

Observations made during the work routine in a health institution indicated that nursing professionals needed to improve their knowledge of blood transfusion. Thus, the objective of this study was to evaluate the nursing team's knowledge of transfusion reactions in a hospital in the State of Pernambuco.

LITERATURE REVIEW

Blood transfusion therapy is a science that has grown rapidly, continuously changed over time, and presents a great prospect of future development ¹. It is one of the most effective therapeutic alternatives in the treatment of certain diseases and in the replacement of blood components and blood products that are essential for maintenance of life ².

Transfusions of blood components represent a means of temporarily correcting red blood cell, platelet or coagulation factor deficiency ³, and may in some clinical situations represent the only way to save a life or to rapidly improve a serious disease. However, because of the complexity of the procedure, there is a significant associated risk of serious complications, because the blood has several intrinsic risks linked to its characteristics as biological product. Thus, like most treatments, blood transfusions can lead to complications involving a spectrum of adverse reactions that may occur during or after the procedure, with severity ranging from mild to fatal reactions⁴.

There are transfusion incidents in which the complications are mild and reversible, as in the case of mild urticarial reactions. On the other hand, there are also reactions that can lead to death, such as acute hemolytic reactions, bacterial contamination, and contamination by viral infections ⁵. The most frequent signs and symptoms are: malaise, tremors, chills, fever (above 38º C), sweating, skin paleness, myalgia, tachycardia, tachypnea, cyanosis, nausea, vomiting, among others⁶.

Transfusion therapy is a process that even when practiced with accurate indication, correct administration, and accordance with all the recommended technical norms, involves sanitary risk. Safety and quality of blood and blood components should be ensured throughout the process, from donor recruitment to administration. The involvement of nurses in all stages of the process, from donor recruitment to blood transfusion, contributes to ensuring the safety of the transfusions by providing quality products to donors and recipients with minimal risk to their health⁷.

Administration of blood and blood components requires knowledge of the application techniques and risks and ability to effectively intervene in complications. Institutionally, basic nursing care includes: checking whether patients or caregivers signed a consent form authorizing the procedure; checking the requested blood component, the blood type and the cross-test before the transfusion; comparing labels to make sure that the ABO group and RH type conform to the compatibility indicated in the registry; and examining blood for the presence of blisters, different staining, or turbidity. Air bubbles may indicate bacterial growth and abnormal color or turbidity may be signs of hemolysis ⁸.

Although the performance of this procedure in almost all clinics is linked to a greater or lesser extent to nursing professionals, they frequently feel little or completely misinformed about the procedure^9. This calls for the importance of quality of care in hemotherapy processes, although totally eliminating the possibility of human error is impossible. Specific knowledge and professional skills can minimize risks and avoid damage tough, if the entire process is efficiently carried out.

Quality and safety of blood transfusions are a constant concern of experts, health authorities, patients and society, making the safety of the blood used for transfusion a key to any modern healthcare system. Blood donation and transfusion require the involvement and commitment of the health team and a joint work to minimize the risks to the patients¹⁰.

Professionals of all the three nursing categories are responsible for administering blood transfusions, and they do so frequently. In Brazil, the competences and duties of nurses and nursing technicians in hemotherapy are regulated by the Resolution nº 511/2016 of the Federal Nursing Council, which establishes as their responsibility the planning, execution, coordination, supervision and evaluation of hemotherapy procedures in health units¹¹.

Regardless of the problems that affect this service, it is up to nursing professionals to integrate themselves into the various areas that make up the hospital complex and the hemotherapy service. On the one hand, the recipients need attention and redoubled care due to their receiving a transfusion, and on the other hand, the service is responsible for diffusion of the therapy. The nurses who work in the area become, therefore, the link between patients and the institutions, allowing for the constant exchange of information and the continuous search for improvement of the services provided¹².

Despite the advances in haemovigilance in Brazil, there are still many challenges to be overcome in the pursuit for the quality of hemotherapy assistance and reduction of health risks¹³. The absence of continuing education programs for nursing teams is a reality, making it necessary to promote permanent education aimed at the development of knowledge, skills and competences of the nursing team in the daily routine of intensive care and urgency/emergency sectors.

METHODOLOGY

This is a descriptive research with quantitative approach performed in a hospital in the Metropolitan Region of Recife. This health unit is a highly complex institution under public management composed of: emergency care service (ECS); general emergency service; intensive care units (ICUs), transfusion agency; laboratory; surgical ward; recovery room; material and sterilization center (MSC); medical clinic; surgical clinic; pediatric orthopedic clinic; neurological/neurosurgical clinic; traumatology clinic; vascular clinic; urology clinic; and hemodialysis clinic. The hospital provides practice field for undergraduate and intermediate level courses, offering residency in areas of medicine, physiotherapy and nursing.

The study population consisted of 95 nursing professionals, of whom eight were nursing assistants, 64 were nursing technicians and 23 were nurses who performed their activities in the ICUs and in emergency department of the hospital. The participants were randomly selected and all agreed to participate in the study. Before collecting data, the professionals were informed of the research objective, and also explained about their right to withdraw from the study at any time, and then they signed the Informed Consent Term.

Data collection occurred between January and June 2013. The inclusion criteria were: being a nursing professional, being assigned to the ICU or emergency care service. The exclusion criteria for selection of information were: being on legal leave during the period of the survey, and absent at the collection moment.

A semi-structured questionnaire based on the DRC 1353/11¹⁴ and in the consulted literature^1-15 was used for collection of sociodemographic information related to blood transfusion procedures, aspects of continuing education, including time elapsed after graduation, correct way of administering blood derivatives and blood components, identification of adverse reactions occurring during or after blood transfusion and participation in capacity building activities. The questionnaire was delivered during the work shift to be completed and subsequently returned.

Quantitative data were entered in a spreadsheet of the Microsoft Excel software, version 2007. Then, a descriptive statistical analysis of the categorical variables was performed by calculation of absolute and percentage frequencies. The results were presented in tables and discussed in light of the literature.

The object of the study was sent to the Ethics Committee of the Restoration Hospital of Pernambuco for evaluation and analysis and was approved under Opinion CAAE 0081.0.102.000-10, and is in compliance with the provisions of resolution 466/2012 of the National Health Council¹⁶.

RESULTS

The nursing team that participated in the study consisted of 88 (93%) female and 7 (7%) male professionals. The majority were nursing technicians 64 (67.3%). Regarding the time acting in nursing, most of the interviewed employees had more than 10 years after completion of undergraduate training. Regarding the frequency of transfusions, 46 (49%) reported never having monitored blood transfusions, as shown in Table 1.

TABLE 1: Characterization of the nursing professionals participating in the research. Recife, Pernambuco, 2013.

(*) Nursing assistants; (**) Nursing technicians; (***) Nurses

The knowledge of the professionals on aspects related to transfusion of blood components and blood products is presented in Table 2.

TABLE 2: Knowledge of the professionals on the aspects related to transfusion of blood components and blood products. Recife, Pernambuco, 2013.

(*) Nursing assistants; (**) Nursing technicians; (***) Nurses.

We verified that 91 (96%) professionals were not aware of the Resolution nº1353/11 that regulates hemotherapy procedures. They were also unaware of the time required for the most frequently performed blood transfusions. Regarding red blood cell concentrate, which is the most commonly used blood group in the hospital where the study was conducted, 56 (59%) professionals were unaware of the time required to infuse this blood component and 72 (76%) of the interviewees did not know which is the minimum time for infusion of this blood component. It was also verified that 62 (65%) of the interviewees stated that they knew how to identify transfusion reactions, yet 75 (79%) were unaware of the types of reactions that may occur after transfusion of blood components and blood products.

When questioned about the conduct before immediate transfusion reactions, 77 (81%) stated that they would discontinue the transfusion, but 18 (19%) of them did not know what to do if intercurrences occurred during the process, as shown in the data presented in Table 3.

TABLE 3: Distribution of professionals who participated in blood transfusion training and their respective conducts before transfusion reactions. Recife, Pernambuco, 2013.

(*) Nursing assistants; (**) Nursing technicians; (***) Nurses.

We verified that only 12 (13%) of the nursing professionals of the institution reported having participated in training related to the investigated topic and 83 (87%) were unaware of the form used to report transfusion reactions, as shown in Table 3.

DISCUSSION

Transfusion of blood and blood components is a relevant technology in modern therapy. When used properly, under conditions of morbidity or emergency, it can save lives and improve the patients' health. However, as any other therapeutic interventions, transfusions can lead to acute or late complications, such as transmission of infectious agents among other clinical complications¹⁶.

The nursing team is of great importance for the performance of this practice, being responsible for the blood transfusion procedure. Therefore, the nursing team should be able to identify possible problems arising from this procedure and provide to the patients qualified and accurate assistance, seeking to avoid or minimize complications¹⁷.

Blood transfusion is a process that involves risk even when performed within the prescribed norms, due indication, and correct administration. It is important to know the incidents related to transfusion therapy and its prevalence in order to introduce corrective and preventive measures and increase the safety of the practice, which is a major objective of haemovigilance systems. For proper functioning of this system, it is necessary that the events associated with preventable adverse reactions be clearly identified and distinguished from those that are not preventable ¹⁸.

Safety in blood administration depends on trained and competent professionals. The nursing team members play a key role in the safety of transfusions; they must not only administer the transfusions, but also know their indications, provide important data for prevention of errors, guide patients about transfusion;, detect, communicate and act in the treatment of transfusion reactions and document the whole process. The performance of these professionals can significantly minimize the risks of complications of patients receiving transfusions and avoid damages, as assuring that the management of the transfusion process takes place with the necessary effectiveness¹⁹.

Transfusion therapy is a complex process that depends on several professionals. To ensure safety, each professional relies not only on his own knowledge and skills, but also on the knowledge and skills of the entire team and the efficiency of the system²⁰.

Among the signs that arise during a transfusion reaction, the most cited by the participants of this study were fever, trembling and tachycardia. However, it was observed that the nursing team studied did not know much of the signs presented by the patients.

Adverse reactions to transfusion or transfusion incidents are defined as disorders occurring during or after and associated with the blood transfusion and may be classified as immediate (up to 24 hours after the start of the transfusion) or late (after 24 hours) reaction. Adverse reactions should involve the medical and the nursing teams, since these are unwanted events that can often be prevented²¹.

Transfusion reactions can be represented by any sign or symptom caused by the hemotherapy procedure, such as: an increase equal or higher than 1ºC in the basal temperature​​ after the initiating the transfusion; chills, with or without fever; pain in the chest, abdomen or lower back; changes in blood pressure; respiratory discomfort; nausea, with or without vomiting; hives or other skin allergies; anaphylaxis. These may occur at the beginning, during or after receiving the blood²². These symptoms may be unnoticed by health professionals due to the severity of patient's health status in ICUs, as well as in the emergency sectors.

Complications related to transfusions may occur and some of them cause serious harm to patients, including death. Several factors may contribute to increase the chances of complications related to transfusion, such as the type of component being transfused, the characteristics and clinical conditions of the patient, the use of inappropriate equipment, incompatible intravenous solutions, inadequate procedures, and errors or omissions by the responsible health care team. Although some reactions are unavoidable, most transfusion reactions are attributed to human error¹⁹.

Red blood cell concentrate was the most commonly used in transfusions during the development of this study. Similar results have been observed by other authors. In a study carried out in a university hospital, researchers analyzed 1,462 transfusion reaction reports and found that 71.8% were related to the therapeutic use of red blood cell concentrate. They also found that non-hemolytic fever reaction and allergic reaction were the most frequent (86.8%), and the severity was considered mild. Moderate to severe events occurred in 13.2% of the patients²³.

In a study conducted in Ceará, the authors analyzed 4,899 transfusions and found that red blood cell concentrate was the main used in blood transfusions (48.6%) and also the one that had the highest percentage of transfusion reactions, accounting for 70.7% of the notifications ²⁴.

A study in a university hospital in the countryside of São Paulo, which sought to determine the knowledge about transfusion practices of nursing professionals, verified that not always the professionals who work in the hemotherapy are enabled to act in the transfusion process neither in cases of adverse reactions. The study concluded that a team with adequate level of knowledge is essential for patient's safety and that mechanisms should be established to detect this knowledge, because the transfusion process is complex and requires specific knowledge in all its stages. Qualified and trained professionals are fundamental to make sure that procedures will be carried out with maximum safety⁹. Other authors also pointed out the lack of preparation of the nursing team and the need to invest in continuing education to overcome this deficiency²¹.

Competent nursing performance is an essential requirement in blood transfusion in order to prevent possible complications and reactions. Nursing professionals must not only administer the transfusions, but also know their indications, guide and clarify the patients concerning doubts about the transfusion procedure, and be able to detect any type of adverse event.

Professionals involved in transfusions (physicians, nurses, nursing technicians, blood bank technicians) need to understand the importance and seriousness with which this procedure should be treated, since any error can cause irreversible damages to patients undergoing this therapy. These professionals must understand that part of the safety and efficiency of the transfusion process depends on them.

The high percentage of professionals who have never received training on the transfusion process demonstrates the need to implement a continuing education program in the institution. A survey carried out to evaluate the knowledge about hemotherapy and transfusion safety of nursing professionals showed that most professionals (58.8%) felt little informed or completely misinformed about the subject⁹.

Continuing education is a fundamental tool to improve the care provided by health professionals. The objective of this study was to analyze the knowledge of health professionals about the occurrence of adverse events (AE) in the intensive care units of a teaching hospital. It was found that the professionals have a superficial knowledge about the concept of AE, although they identify and recognize the event as part of health care when it is not performed with quality. Specialists evidenced the underreporting of adverse events in the practice context and the existence of gaps in the institutional educational processes, demonstrating flaws in patient safety ²⁵.

The importance of an educational intervention in the knowledge of the nursing team on aspects of wound care was investigated in a study, demonstrating that this methodology bolstered an improvement in the knowledge of the subjects evaluated, namely, the management and topical treatment of wounds²⁶. Thus, educational interventions are essential for professional improvement in any area of ​​nursing practice, including in hemotherapy.

The American Nursing Association believes that health institutions should provide continuing education in specific areas, which are training programs aimed at moving the professional practice forward. Organizations need trained and competent professionals to reach their goals and objectives ²¹. Training of all team members, regardless of their working area, is paramount to prevent complications. Knowledge of the equipment handled, familiarization with the procedure, and teamwork are parts of the training²⁷.

It is necessary to raise awareness among professionals of the proper monitoring of patients receiving transfusions, prepare them to make the necessary decisions if there is any transfusion reaction, and notify the observed incidents, a practice that is also not stimulated in the researched institution.

Permanent education at work, in this perspective, seeks to transform professional practices through answers built from the reflections on the work environment. Thus, continuing education can be understood as learning-at-work process, since it happens rooted in the daily work routine of people and organizations. It is in the work process that such education is built, and becomes feasible and effective. For that, educational needs stem from the reality of the work, being these mediated by the knowledge and experiences of the subjects. Education, therefore, consists of implementing activities that can combine theoretical precepts with the experience of workers, in order to strengthen their practices ⁸.

After the results analyzed, the students and the supervisor of this research carried out an update course on the subject.

CONCLUSION

We observed in this study that the nursing team was composed mainly by female workers, nursing technicians, and with more than 10 years elapsed after completion of undergraduate training. About half of the professionals who participated in the study have already monitored blood transfusions, but incipient knowledge about the aspects of the transfusion of blood components and blood products was evident, emphasizing the importance of further training courses related to this topic.

The implementation of a continuing education program as well as measures to promote the development of the health professionals of the team are indispensable for helping those involved in the transfusion process to identify abnormalities that may occur during or after the process, aiming at safer care to patients.

It is worth mentioning that, after analyzing the results, the students and the supervisor of this research organized courses with the objective of updating the nursing professionals on transfusion reactions and haemovigilance.

As a limitation of the study, there was no observation of the administration of blood components and blood products, which did not compromise the achievement of the proposed objectives. We suggest that further research be done in this area, including the observation of the conduct of professionals during the transfusion process, including aspects related to administration, correct monitoring, and filling of medical records.

REFERENCES

1.Razouk FH, Reiche EMV. Characterization, production and clinical indication of the main blood components. Rev Bras Hematol Hemoter. 2004; 26(2):126-34.

2.Cherem EO, Alves VH, Rodrigues DP, Guerra JVV, Souza FDL, Maciel VL. Post-transfusional care in neonatal intensive care units.Rev baiana enferm. 2016; 30(4): 1-8.

3.Callera F, Silva ACO, Moura AF, Melo DB, Melo CMTP. Descriptions of acute transfusion reactions in a Brazilian Transfusion Service. Rev Bras Hematol Hemoter. 2004; 26(2):78-83.

4.Sousa Neto AL, Barbosa MH. Immediate transfusion incidents: integrative literature review. Acta Paul Enferm. 2012; 25(1);146-50.

5.Chamone DAF, Novaretti MCZ, Dorlhiac-Llacer PE. Blood Transfusion Manual. São Paulo: Manole; 2001.

6.Ludwig L, Zilly A. Transfusion reactions linked to ABO system. NewsLab. 2007; 84(1):102-12.

7.Barbosa SM, Torres CA, Gubert FA, Pinheiro PNC, Vieira NFC. Nursing and hemotherapy practice in Brazil: an integrative review. Acta Paul Enferm, 2011; 24(1):132-36.

8.Silva LAA,; Somavilla M B. Knowledge of the nursing team on transfusion therapy. Cogitare Enferm. 2010; 15(2):327-33.

9.Ferreira O, Martinez EZ, Mota CA, Silva AM. Assessment of the knowledge of nursing professionals on hemotherapy and transfusion safety. Rev Bras Hematol Hemoter. 2007; 29(2):160-7.

10.Schöninger N, Duro CLM. Performance of nurses in hemotherapy services. Ciênc Cuid Saúde. 2010; 9(2):317-24.

11. Federal Nursing Council (Br). Resolution nº 511 of March 29, 2016. It approves the technical standard that regulates the performance of nurses and nursing technicians in hemotherapy. Brasília (DF): COFEn;2016.

12.Silva PS, Nogueira VO. Hemoterapia: difficulties faced by nurses. ConScientae Saúde. 2007; 6(2):29-334.

13. National Health Surveillance Agency (Br). Hemovigilance Bulletin, nº4. Brasília (DF): Ministry of Health; 2011.

14. National Health Surveillance Agency (Br). Resolution nº 113 of June 14, 2011. Technical regulation of hemotherapy procedures. Brasília (DF): ANVISA; 2011.

15. Ministry of Health (Br). Guide to the use of blood components. Brasília (DF): Ministério da Saúde; 2010.

16. National Health Council (Br). Resolution nº 466 of June 2012. Guidelines and norms regulating research involving human beings. Brasília (DF): CNS;2012.

17.Boneares CSN, Oliveira CC, Martins KD, Rufino MPB, Dias RAA. Importance of nursing care in blood transfusion. [nursing graduation end-of-course thesis]. Governador Valadares. (MG): Universidade Vale do Rio Doce; 2008.

18.Costa FV. Study of the immediate transfusion incidents occurred at the University Hospital of the Federal University of Santa Catarina. [graduation end-of-course thesis]. Florianopólis (SC): Universidade Federal de Santa Catarina; 2006.

19.Mendes MN, Souza SROS. Dimensions of transfusion of blood components in an adult intensive care units. Revista Hospital Universitário Pedro Ernesto. 2011; 10(2):83-90.

20.Ferreira O, Martinez EZ, Mota CA, Silva AM. Assessment of the knowledge of nursing professionals on hemotherapy and transfusion safety. Rev Bras Hematol Hemoter. 2007;29(2):160-7.

21.Silva KFN, Soares S, Iwamoto HH. Transfusion practice and training of health professionals. Rev Bras Hematol Hemoter. 2009; 31(6):421-6.

22.Durães ATG, Pereira LB, Ponciano MM, Versiani CC. The incidence of immediate transfusion reactions in recipient patients in a university hospital. EFDeportes.com, Digital Magazine. 2013; 176(1):1-1.

23.Grandi JL, Grell MC, Barros MO, Chiba AK, Barbosa DA. Frequency of immediate transfusion incidents in blood component recipients. Vigil sanit Debate. 2017;5(2):83-8.

24.Beserra MPP, Portela MP, Monteiro MP, Façanha MC, Adriano LS, Fonteles MMF. Transfusion reactions in an accredited hospital in Ceará: a haemovigilance approach. Arq med. 2014;28(4):99-103

25.Moreira IA, Bezerra ALQ, Paranaguá TTB, Silva AEBC, Azevedo Filho FM . Knowledge of health professionals about adverse events in intensive care units. Rev enferm UERJ. 2015; 23(4):461-7.

26.Frota OP, Constanci JGO, Loureiro MDR, Ferreira AM. Impact of an educational intervention about wounds on the knowledge of nursing technicians. Rev enferm UERJ. 2015; 23(5):603-9.

27.Nogueira VO. Online information on intra-hospital transport of critical adult patients. [Master thesis]. São Paulo: Federal University of São Paulo; 2003.