Home transfusions-balancing safety with individualised care

ABSTRACT

Blood transfusions are an essential part of supportive care for certain patient cohorts, particularly those on palliative care. Most transfusions occur in the hospital setting, including community hospitals. Transfusion in the patient's home supports individualised care, reduces demand on acute services and inconvenience for patient travel to hospital. Decision to undertake home transfusions requires assessment of risks and benefits, with regular review. Risk of acute transfusion reaction in any setting is rare but can result in major morbidity or death. This review looks at adverse events and reactions reported to Serious Hazards of Transfusion (SHOT), the UK haemovigilance scheme, where the transfusion was performed in the patient's home. SHOT cases submitted 2010-2020 were identified using the terms 'home', 'home transfusion' and 'patient's home'. Data were manipulated in MS Excel identifying reactions (febrile, allergic and hypotensive [FAHR], transfusion-associated circulatory overload [TACO]) and events (right blood right patient (RBRP), avoidable, delayed and over/under-transfusion [ADU], incorrect blood component transfused-specific requirements not met [IBCT-SRNM]). 20 cases of home transfusion were identified. FAHR accounted for 10/20 cases, IBCT-SRNM (3/20), HSE (3/20), RBRP (2/20), TACO (1/20) and ADU (1/20). Where patient sex was recorded, 12/19 were male. Age range 3-90 years (median 66, SD 24.9). Red cell components were implicated in 12/20 cases, platelet concentrates in 7/20 cases and one fresh frozen plasma. Patient underlying condition was haematological in 12/20 cases, others included pancytopaenia, angiodysplasia, metastatic cancer and anaemia. Chronic anaemia was the indication in 8/12 red cell transfusion cases and prophylaxis for 4/7 of platelet transfusions. Reactions ( n -11) were febrile (5/11), allergic reactions (3/11), TACO (1/11), 1 anaphylaxis and 1 unclassified. 7/11 patients (6 FAHR and 1 TACO) required hospital admission as a result of the reaction. Four patients were identified as not suitable for home transfusion after the event, SHOT expert review noted one patient should have been ineligible in the first place due to risk of TACO. Adverse events ( n = 9) included cold chain failures (2/9), one failure to inform the laboratory of home transfusion, failure to provide irradiated red cells (2/9), errors in labelling (2/9), incorrect administration rate, failure to provide antigen-negative blood and delay due to an incorrect Hb result. There are no data regarding the number of home transfusions in the UK, therefore it remains unclear whether reactions and errors are over-represented in these cases. Careful consideration should be given to the eligibility of patients to receive home transfusion, particularly the risk of TACO and previous transfusion reactions, before this regime is implemented. No data were available regarding staff performing the transfusions, nurses administering home transfusions must be transfusion trained and competent in identification and management of reactions. There must be robust processes for urgent transfer to hospital. There are no national guidelines for safe practice for home transfusions, including informed consent. Home transfusion is an increasingly important component of patient care, particularly during the COVID-19 pandemic to minimise risk for vulnerable patients, the infrastructure supporting this must have patient safety at its core.