Neonatal Blood Transfusion Care Bundle

Implementing Neonatal Blood Transfusion Bundle into a Local Neonatal Unit (LNU) within the Thames Valley and Wessex Operational Delivery Network.

The Problem

Most neonatal transfusions are carried out on low birth weight preterm infants treated on Neonatal Intensive Care Units/ Neonatal Units. Documentation that can provide a clear audit trail is an important part of the transfusion pathway.

It was identified that this Neonatal Unit did not have a standardised blood transfusion documentation form.


It was decided to produce a combined transfusion, prescription and monitoring chart (care pathway).

This can then be used to record the information in one place and to provide a clear audit trail each time the infant receives blood.

Making the Case for Change

  • Stage 1: Preceptees from within Wessex shared Blood Transfusion Care Pathway documentation charts.
  • Stage 2: A blood transfusion document was adapted and produced which included key information on three elements:
    • Pre-transfusion.
    • During transfusion.
    • Post transfusion

This is in line with National Blood Transfusion guidance.

The pilot document was disseminated to all staff through the unit’s staff communication/changes folder and daily handover.

All staff were asked to comment and suggest ideas for improvement.

Our Improvement

The document was tested with a sample of nursing and medical staff on four infants requiring a blood transfusion (the sample was small due to Local Neonatal Unit). Staff were asked to comment on the three key elements and ease of use.

Changes were made to the document incorporating staff feedback. The finalised version was presented at the Neonatal Governance meeting where it was ratified and approved and added as an appendix to the Trust Neonatal Blood Transfusion Guideline and is now in use on the unit.

Learning and Next Steps

Success of the project was dependent on the following:

  • Support from the neonatal unit.
  • A multi-professional team.
  • Trust in the Blood Transfusion Team.

The bundle was ratified against National Blood Transfusion Standards and local Neonatal Governance Forum.


Project lead: Kim Edwards, Wessex Neonatal Preceptorship Programme Director.

Organisation: Health Education Wessex


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