Blood Bank has a unique importance in a healthcare facility.
It provides the life-saving resource, blood and blood components, which is collected
from donors and has limited availability. It is of high importance that this
precious resource is used rationally and is not wasted. Blood bank is also
considered a high risk area for patient safety as any error or infection in
blood can be potentially lethal for the patient. Hence policies and procedures
in blood bank should be aimed at achieving the highest level of safety, rational
use of blood and blood products and reduction of wastage. The checklist given
below which takes into account NABH standards for blood bank can be used as a framework
to achieve these objectives. This checklist may not be sufficient for a separate accreditation of Blood Bank, under
NABH accreditation for Blood Banks’.
Legal
1. The blood bank should possess a license under
Drugs and Cosmetics Act. The license should be renewed periodically. For establishing
a new Blood Bank, the ‘No Objection Certificate’ should be obtained from ‘State
Blood Transfusion Council (STBC)’ . (Check - Licenses and permits for hospital)
Building facility
1.
The blood bank area should be hygienic and well
ventilated. Screens or mesh should be provided in windows to avoid entry of
insects and rodents
2.
The blood bank should have dedicated room for
carrying out its functions. This include
a.
Registration and examination room with adequate furniture
for desk work, donor screening. Adequate seating arrangements for blood donors
should be provided
b.
Donor counselling section – this should be separate
from registration and examination room and should provide privacy
c.
Blood collection area – The size should be as
per the number of couches. This area should be air-conditioned
d.
Refreshment and rest room for donors – should be
air-conditioned
e.
Laboratory for testing blood for hepatitis,
syphilis, malaria, TB and HIV antigen – should be air-conditioned
f.
Laboratory (separate section) for doing blood
group serology. This should be air-conditioned
g.
Blood component preparation area with
air-conditioning that maintains temperature between 20 and 25 degree Celsius
h.
Blood component preparation area (if component
preparation is undertaken)
i.
If apheresis is conducted then a separate air-conditioned
area for this should be provided
3.
All the above areas should be clearly distinct with
effective separation between them
4.
The areas should be adequately equipped with furniture,
storage space and work desks
5.
The areas should be well maintained and clean
6.
Electricity back-up facility should be available
for blood bank
Human Resources
1.
The HR should meet the minimum regulatory
criteria for blood bank. The HR of blood bank should include following
a.
Blood bank should have an identified in-charge
who should fulfil any one of the given criteria
i.
MD - Transfusion medicine
ii.
MD – Immunohematology and Transfusion Medicine
iii.
MD – Pathology
iv.
MBBS with diploma in clinical pathology or
transfusion medicine
v.
MBBS with at-least one year experience in blood
bank
b.
Technical supervisor with and full time
technicians with one of the following qualifications
i.
D.M.L.T with six months experience in testing of
blood or its components
ii.
Diploma should be from an institution recognized
by central or state government (UGC or AICTE approved)
c.
Nurses with appropriate qualification from
Nursing Council of India and registered with state/central nursing council
d.
Counselor – suitably qualified or experienced
and trained for counselling
2.
Written job description and responsibilities for
each staff category should be available
Equipment
1.
All equipment that is required for blood
collection, testing, component preparation and storage should be available
2.
Each equipment should have an equipment log,
that records its identification, manufacturer’s details, calibration and maintenance
history
3.
Each equipment should have a label that identifies
the equipment, calibration status and due date of next calibration
4.
Blood storage equipment (refrigerators) with
necessary temperature control and monitoring devices should be available. Storage
refrigerators should have continuous temperature monitoring system installed. The
temperature should be checked and recorded every 8 hours.
5.
Back-up arrangement should be there in case of
equipment breakdown or power shutdown situation
Policies and Procedures
1.
SOPs for following function
a.
Donor screening (including criteria for donor
selection)
b.
Blood collection
c.
Blood testing – SOP for each test
d.
Labelling of blood and blood component bags
e.
Blood storage (including Quarantine
requirements)
f.
Component preparation
g.
Compatibility testing
h.
Issuance of blood/blood component
i.
Disposal of waste blood
2.
Policy on rational use of blood and blood
products. The policy should describe clinical criteria to determine whether or
not blood or blood component should be used on a particular patient
3.
Procedure of transfusion of blood and blood component.
The procedure should include instructions on following
a.
Written order for transfusion, with details of
pre-medications if any and rate of transfusion in case of paediatric patients
b.
Temporary storage in patient area before
transfusion
c.
Verification of blood/component before
transfusion
d.
Identification of patient
4.
Policy on informed consent and its validity. Procedure
to obtain informed consent from patient before transfusion
5.
Procedure for traceability of blood/component
from blood collection to its issuance
6.
Procedure to identify the recipient of blood
from a donor who subsequently was found to be suffering with transfusion
transmitted infection
7.
In above situation policy of immediately
reporting this to the patient and his/her physician and discarding of unused
blood from that recipient
8.
Procedure for obtaining blood/component in
emergency situation. The procedure should describe ‘what constitute an
emergency transfusion’
9.
Monitoring of patient during and after
transfusion
10.
Post-transfusion recording of details, including
reactions if any
11.
Procedure for conducting transfusion reaction
analysis and taking corrective/preventive actions
12.
Quality Control Process for testing of blood
Quality Indicators for blood bank and transfusion services
1.
Percentage of blood wastage (whole blood and
component-wise)
2.
Adverse transfusion reaction rate
3.
Turn-around time for blood issuance
4.
Percentage of component quality control failure
(for each component)
5.
Adverse reaction rate with donors
6.
Percentage of components in blood bank
