General principles of home blood transfusion

INTRODUCTION — In the past decades, there has been increasing acceptance of administering some treatments in the home environment, a practice referred to as the "hospital in the home," to improve patient comfort and convenience, possibly lower hospital-acquired infection risks, and potentially decrease costs of care.

Although the concept of home infusion was introduced at least 40 years ago, the acceptance of blood and blood component transfusion in the home has been tentative but increasing in the United States and other countries [1]. Clinical indications for home transfusion should be evidence-based and follow patient blood management guidelines. (See "Indications and hemoglobin thresholds for RBC transfusion in adults", section on 'Hospital-wide oversight programs/patient blood management'.)

Concerns about safety distinguish home transfusion from transfusion in hospitals or outpatient clinics, including the availability of emergency care for managing significant complications. These inherent differences compound the usual and sometimes serious risks of transfusion. Thus, patient safety would be considered a higher priority than increased quality of life, possible cost savings, or other potential advantages.

Important aspects of home transfusion will be reviewed here, with a focus on recipient safety. Several key references that should be consulted prior to establishing a home transfusion program will be mentioned.

Specific procedures for enhancing the safety of home blood transfusion are presented separately. (See "Standard operating procedures (SOPs) for home blood transfusion: Operational framework".)

INDICATIONS AND GENERAL APPROACH

Uses — Transfusions typically involve red blood cells (RBCs) or platelets. The spectrum of patients who could potentially benefit from "hospital in the home" transfusion is broad. Essentially this includes patients with anemia or thrombocytopenia, hematologic and nonhematologic malignancies, and numerous chronic conditions associated with transfusion-dependent anemia, including hemoglobinopathies [1,2].

The potential benefits of "hospital in the home" transfusion are similar to those of other in-residence treatments and include:

●Improved patient comfort and convenience

●Lowered risk of hospital-acquired infections

●Potentially lower cost of care

●Reduced time and expense for travel related to the hospital for transfusion

●Fewer hours of lost work

●Proximity of loved ones

Accessibility and convenience of care would be particularly relevant for the patients who could be treated with home transfusion [1,2].

One of the rare reviews of home transfusion, performed by one community blood center, showed that more than 60 percent of RBC products were administered to patients with malignancies, HIV-related conditions, or non-specified anemias [3]. Less common indications were hemoglobinopathies, gastrointestinal bleeding, and kidney failure. Myelodysplastic syndromes comprised another group of disorders successfully managed by home transfusion [4,5].

Patient acceptance — Whether patients would accept home transfusion is important for the growth of this practice. Studies from 2021 and 2022 suggest growing patient acceptance of the home transfusion concept:

●A 2022 systematic review of 14 studies identified a study that evaluated patient acceptance of home transfusions and reported that 51 percent of hematology patients would be willing to have transfusions at home [6].

●A 2021 11-month survey of 385 patients treated at 17 hematology clinics demonstrated a similar acceptance level, with 52 percent of participating patients preferring home rather than hospital transfusion [7].

These studies demonstrate an overall greater acceptance of home transfusion compared with a 1996 survey of 29 patients in which 93 percent of participants chose not to consider home transfusion and 73 percent believed home transfusion posed greater safety risks than transfusion in a traditional facility [8].

Service models and personnel — A common model for providing transfusion services in a patient's home involves an arrangement between a home health agency (HHA) that transfuses the blood and a community blood center or hospital transfusion service that provides blood components [9,10].

Another model for home transfusion involves the direct provision of home services by the hospital transfusion service or community blood center without an intermediary organization such as an HHA. In this approach, the transfusionists are employees of the hospital or blood center.

Only transfusionists who have been trained and are experienced in transfusion therapy (usually a licensed nurse) should transfuse in nonhospital settings.

Home visit — After blood is ordered, the home health agency (HHA) transfusionist (usually a licensed nurse) visits the patient's residence, collects and labels blood specimens for pre-transfusion testing, and places a wrist band or other standard health care-specific type of identification on the patient.

During pre-transfusion and transfusion visits, patient identification is critical and should ensure accuracy of the identifying information and involve having the patient state their name and birth date (or another numeric identifier). These safety checks link the blood specimens, the patient, and the units intended for transfusion.

Preferably, the patient should confirm their identity and key information, such as date of birth, by presenting a government-issued or other official form positive identification, including a photograph. Systems that use forms of electronic identification such as a bar code should be approved by the US Food and Drug Administration (FDA).

At the time of this initial visit, the home should be assessed for its proximity to a hospital or urgent care facility. If the home is in a remote site and access to critical care could be delayed, consideration should be given to transfusing the patient in an outpatient facility or hospital. The room or space where the transfusion will actually take place should be evaluated to confirm that emergency personnel can access the patient for treatment and preparation for transport.

In the preliminary visit, the transfusionist can also determine whether the patient's physical and mental status are appropriate for home transfusion and confirm that a mobile device/cell phone or working land line telephone and another responsible adult are available for summoning emergency assistance if a serious transfusion reaction may be occurring.

Pre-transfusion specimens, transport, and transfusion — Pre-transfusion specimens are delivered to the community blood center or hospital transfusion service, where ABO and Rh typing, antibody screening, compatibility testing, and other necessary assays are performed.

Components are packaged for shipping according to specific federal and other regulations and transported by the transfusionist or other trained, qualified staff to the patient's home. During this visit, the nurse obtains informed consent (if not done previously), begins an infusion of physiologic saline, and transfuses the blood.

The nurse remains with the patient during the entire transfusion and for at least another 30 minutes afterwards to monitor for possible adverse events that can occur in the peri-transfusion period. All information about the transfusion should be documented in real time. Blood bags, tubing, and disposables are returned to the issuer for proper disposal.

Exclusion criteria — Inclusion and exclusion criteria for home transfusion should be established by the blood provider, hospital blood bank physician, ordering physicians, and medical personnel of the transfusing agency. The hospital transfusion committee and medical executive committee are also appropriate participants in these discussions.

Examples of exclusion criteria for home transfusion include the following [4]:

●Patient unable or refuses to give consent

●Patient unable to provide information for purposes of identification

●Inaccessibility to emergency services

●Physical layout of home inaccessible to emergency personnel

●No land line available; no cell phone signal

●Covering physician not available

●Responsible adult (beside transfusionist) not available

●Cardiovascular instability, major pulmonary compromise, or other severe underlying medical condition

●History of significant transfusion complication or repeated reactions

●Compatible RBC units are not available (eg, patient has autoantibody or alloantibody)

WHOM TO CONSULT AND WHY — Activities related to the collection, processing, issuing, and transfusion of blood and blood components are regulated by government agencies such as the US Food and Drug Administration (FDA) and possibly individual states or jurisdictions.

Applicable standards have been promulgated by organizations such as the Association for the Advancement of Blood & Biotherapies (AABB), College of American Pathologists (CAP), and The Joint Commission (TJC).

Physicians wishing to order home transfusions should be familiar with applicable standards and regulations. A blood center or hospital transfusion service should not issue blood to a health care provider or agency that does not have transfusion procedures meeting regulations and industry standards.

The foundation of the safety and regulatory infrastructures consists of detailed standard operating procedures (SOPs) for each aspect of the transfusion process, including but not limited to ordering blood, collecting pre-transfusion compatibility testing specimens, storing and transporting components, infusion, and proper handling of biohazardous materials such as blood bags and tubing. Documentation, retention of records, staff training, and periodic competency assessment are also required. (See "Standard operating procedures (SOPs) for home blood transfusion: Operational framework".)

Resources pertaining to transfusion regulations and/or practices include the following:

●The AABB Standards for Blood Banks and Transfusion Services [11]

●A recognized publication on transfusion and blood banking practices such as the AABB Technical Manual [12]

●The Circular of Information for the Use of Human Blood and Blood Components from the FDA [13]

Medical directors of community blood centers and hospital-based transfusion services frequently have specialty training in transfusion medicine and are knowledgeable about applicable regulations.

The AABB issues standards for transfusion activities and publishes guidelines for home transfusion and standards for out-of-hospital transfusion [11,14,15]. Although the FDA does not regulate the clinical practice of transfusion medicine, it exercises regulatory oversight of blood collection, processing, quality assurance, and relevant current Good Manufacturing Processes (cGMPs) through the publication of the Code of Federal Regulations and various guidance documents, memoranda, and recommendations [16]. There is also a small body of peer-reviewed home transfusion literature [3,17-19].

PHYSICIAN ROLE — Transfusion outside the hospital setting offers physicians a unique patient care opportunity that by its novel nature may require more involvement than hospital-based transfusion.

Because patient safety could potentially be compromised by limited availability of emergency care services, the responsible physicians must anticipate and plan for off-site management of acute transfusion-related medical emergencies. Physician preparedness involves availability to personnel administering the transfusion. Many HHAs require that the responsible physician be notified just prior to infusion and be available at all times during blood administration.

The physician must be familiar with each agency's procedures for recognizing and managing acute reactions, and they may determine that it is a priority to participate in developing such procedures.

The physician should also decide what medications should be available on-site for treating complications. Examples are:

●Antipyretics

●Antihistamines to treat minor allergic reactions

●Epinephrine to treat rare but potentially catastrophic anaphylaxis

Physicians should ascertain that the competence and experience of the transfusionist are commensurate with the risk of out-of-hospital transfusion.

PATIENT PROFILE — Underlying conditions for which patients might receive a transfusion at home are discussed above. (See 'Uses' above.)

The prospective recipient must be medically stable. Patients with compromised cardiac or pulmonary function or who have other serious conditions should be transfused in a hospital or outpatient facility. If the patient has an autoantibody or alloantibody and compatible blood is not available, transfusion should take place in a hospital setting where the patient can be closely monitored. (See 'Exclusion criteria' above.)

Transfusion in the patient's home is an appropriate service if patients have physical or emotional impediments to leaving their homes or difficulty traveling but should not necessarily be offered exclusively for the sake of convenience.

Patients must be alert and oriented so that they can give informed consent and communicate symptoms of a possible reaction. Some children are candidates for home transfusion [20,21]. However, children should be mature enough to demonstrate an understanding of the process and able to communicate symptoms that could be related to the transfusion.

Patients who are possible candidates for home transfusion should have a history of previous transfusion without severe or repeated reactions. Although this has been the subject of debate, it is an AABB patient selection criterion that should be considered when making home transfusion decisions. (See 'Uses' above.)

COMPONENTS — For the sake of this article, blood components are defined as products manufactured from whole blood such as red blood cells (RBCs), plasma, platelets, or Cryoprecipitate, or those collected by apheresis such as platelets, plasma, or RBCs. Pharmaceutical products such as albumin, intravenous immune globulin, and clotting factor concentrates are not included in this discussion. (See "Cryoprecipitate and fibrinogen concentrate".)

Blood components may be ordered from community blood centers or hospital transfusion services that have an established arrangement with a specific physician's office or home health agency. RBCs are most frequently ordered, but platelets or plasma may also be requested [22].

Some facilities limit the total number of components for each transfusion event to two products, (eg, two units of RBCs or a unit of RBCs and an apheresis platelet unit). The reason for these limits is to avoid fluid overload or transfusion-associated circulatory overload (TACO). The appropriateness of home transfusion for patients requiring more than one or two units should be questioned as well. (See "Transfusion-associated circulatory overload (TACO)", section on 'Prevention'.)

Cryoprecipitate could be appropriately transfused in a nontraditional setting if a patient has a specific clotting factor deficiency for which a factor concentrate is not available.

Patients needing granulocyte transfusions are septic and usually severely neutropenic and would be considered too ill to be transfused anywhere other than a hospital. (See "Granulocyte transfusions".)

Leukoreduction — To avoid febrile nonhemolytic transfusion reactions (FNHTRs), platelets and RBC components should undergo pre-storage leukoreduction. It is standard practice for blood centers in the United States to manufacture leukoreduced apheresis platelets and RBCs. If RBCs are derived from whole blood, leukoreduction should take place shortly after collection (pre-storage). The reduction in white blood cell (WBC) content decreases the accumulation of WBC-derived cytokines associated with FNHTRs [23,24]. (See "Immunologic transfusion reactions", section on 'Febrile nonhemolytic transfusion reactions' and "Practical aspects of red blood cell transfusion in adults: Storage, processing, modifications, and infusion", section on 'Pre-storage leukoreduction'.)

If the transfusing agency does not know whether the regional blood center or collecting hospital provides leukoreduced apheresis platelets RBCs or pre-storage leukoreduced whole blood-derived RBCs, the requesting physician or health care worker should order leukoreduced products.

If leukoreduced RBCs are not available, bedside filtration is another, although not optimal, alternative. This may be associated with an increased risk of FNHTRs relative to pre-storage leukoreduced products, due to higher concentrations of cytokines that have accumulated during storage and are not removed by filters. Transfusing staff should follow the manufacturer's instructions for use of the filter and not manipulate the blood bag or filter to initiate the transfusion or increase the infusion rate.

For platelet transfusions, single donor apheresis platelets are preferable to pooled whole blood-derived platelet concentrates; the latter are associated with an increased number of allogeneic blood exposures. WBC content is significantly decreased during apheresis collections, and use of bedside filtration would not be necessary. (See "Platelet transfusion: Indications, ordering, and associated risks", section on 'Whole blood derived (WBD) versus apheresis platelets'.)

FREQUENCY OF TRANSFUSION REACTIONS — Literature dealing with home transfusion complications is limited. Complications have been reported, although they are generally rare.

●Severe reactions are rare [6].

●Febrile nonhemolytic transfusion reactions (FNHTRs) are most common, and serious complications including transfusion-associated circulatory overload (TACO) have been reported [25-31].

In an Italian study of 211 patients with myelodysplastic syndromes who received red blood cell (RBC) transfusions, only six non-venipuncture-related complications were reported in 4980 home transfusion encounters involving 7766 transfused units [4]. All transfusions were performed by physicians. Two temperature elevations and one cutaneous reaction were noted. Reactions that may have been more significant and serve as a reminder that these can indeed occur in the home setting were cardiovascular symptoms due to fluid overload and one episode of nausea and vomiting that was not characterized further but is observed in ABO incompatibility and other types of hemolysis. FNHTR rates as high as 28.6 percent have been reported in other studies [30,31].

Older adult patients likely comprise most people undergoing home transfusion and represent a cohort of patients who are potentially at increased risk for some types of significant reactions.

In a study by the US Food and Drug Administration (FDA) and the Centers for Medicare and Medicaid Services (CMS) that used International Classification of Diseases (ICD)-9-CM diagnosis codes from CMS databases to report on the rates of major transfusion reactions in 492,339 older adult outpatients receiving transfusions over a two-year period, the major reactions assessed were transfusion-related acute lung injury (TRALI) and ABO incompatibility [22]. The percentage of transfusions that were given in the home (rather than hospital) setting was not stated. The following findings were reported:

●TRALI rates were higher among patients who received a combination of leukoreduced RBCs and leukoreduced platelets (14.5 per 100,000) compared with leukoreduced RBCs alone (1.5 per 100,000).

●TRALI rates for irradiated RBCs were 36.4 per 100,000 and for irradiated platelets 14.5 per 100,000.

●The ABO incompatibility rate was higher for irradiated, leukoreduced RBCs (44 per 100,000) versus leukoreduced RBCs (1.2 per 100,000) during the first year of observation).

Clinical and laboratory data for each reaction were not described, and mistransfusion or other errors that could result in ABO incompatibility were not discussed [22]. The authors hypothesized that irradiation-induced cellular membrane changes; underlying patient conditions, including ABO group changes or complications associated with hematopoietic stem cell transplantation; and other etiologies may have contributed to the incidence of ABO incompatibility. The authors called for additional research related to reported complications.

Irradiation of cellular blood components prevents transfusion-associated graft-versus-host disease (GVHD), and, in patients with increased risk such as immunocompromised individuals, the known benefits of irradiation would outweigh the potential, yet unproven, increased risks of TRALI or ABO incompatibility suggested by the large CMS database study [22]. Irradiation of cellular products has not otherwise been reported to be associated with an increased risk of TRALI or ABO incompatibility.

Minimizing morbidity and mortality due to a transfusion reaction primarily resides with the transfusionist's ability to quickly recognize, diagnose, and treat transfusion reactions. The absence of on-site physician staff, equipment, and resources normally available in a hospital potentially pose significant safety hazards. For this reason, only transfusionists who have been trained and are experienced in transfusion therapy should transfuse in non-hospital settings. Further, the responsible physician must be immediately available. (See 'Management of reactions' below.)

MANAGEMENT OF REACTIONS

Assessing the reaction — Transfusion reactions are usually identified by the reporting of symptoms by the patient, observations by the on-site health care professional of a change in the patient’s physical condition, or changes in the patient's vital signs. The patient's temperature, pulse, blood pressure, and respiratory rate should be taken at the following times:

●Prior to the transfusion

●At least every 15 minutes during the first 45 minutes of the transfusion

●If the patient is stable, every 30 minutes thereafter (or more frequently)

●At the conclusion of the transfusion

●At least 15 or 30 minutes after the transfusion has ended.

Technology may facilitate remote monitoring of patients undergoing home transfusion and can capture peri-transfusion data as well as alert the responsible physician or other clinical team members of an impending or actual transfusion complication.

In a pilot study using pulse oximeters or electrocardiogram (ECG) instruments linked to the internet, researchers in Japan monitored the heart rate, ECG, respiratory rate, and Sp02 of three patients receiving 10 transfusions [32]. Although the number of participants was small and technical problems sometimes interfered with data transmission, the researchers were able to establish that real-time monitoring of these specific parameters was feasible. For use in the United States, such systems and devices would require approval by the US Food and Drug Administration (FDA) and following of applicable regulations. However, this exciting approach shows promise for increasing safety and monitoring in the home transfusion setting [2,32].

Minor transfusion complications — Febrile nonhemolytic transfusion reactions (FNHTRs) are not life-threatening. However, they must be distinguished from hemolytic reactions because chills and/or an increase in temperature occur in both.

When these symptoms appear, the transfusion should be discontinued and the responsible physician and blood bank notified. Blood specimens should be collected in the specimen tube specified by the facility that will be performing assays for evidence of hemolysis and/or incompatibility. (See "Approach to the patient with a suspected acute transfusion reaction".)

The transfusionist should arrange delivery of the specimens to the blood center but should not leave the patient until it is considered safe to do so. Blood bank staff should be able to contact the responsible physician immediately if there is evidence of hemolysis or incompatibility, and the patient should be transported to a care facility.

When pre-storage leukoreduction of cellular units is routinely performed, FNHTRs are less likely to be recurring phenomena. Hospital-based transfusion should be considered for patients with recurring reactions. (See "Immunologic transfusion reactions", section on 'Prevention of FNHTR'.)

Allergic reactions, characterized by urticaria and hives, are managed by discontinuing the infusion and notifying the responsible physician. (See "Immunologic transfusion reactions", section on 'Allergic reactions'.)

●If there is no evidence that the patient is having an anaphylactic reaction (also sometimes initially characterized by urticaria and pruritus), the physician may decide to resume the transfusion cautiously if the symptoms have responded to antihistamines.

●If a patient has a history of repeated allergic reactions or severe allergic reactions, consideration should be given to transfusing at a hospital setting.

Platelet-associated allergic reactions and FNHTRs can be reduced by transfusion of apheresis platelets with additive solution (PAS platelets), in which approximately two-thirds of the plasma is replaced with a propriety additive solution [33,34]. (See "Platelet transfusion: Indications, ordering, and associated risks", section on 'Collection methods'.)

Major transfusion complications — Reactions that are most likely to result in significant morbidity or even mortality include hemolytic reactions, fluid overload (referred to in this context as transfusion-associated circulatory overload [TACO]), sepsis, transfusion-related acute lung injury (TRALI), and anaphylaxis [35,36]. These complications warrant immediate cessation of the transfusion; appropriate bedside interventions; and transfer of the patient to a hospital. (See "Approach to the patient with a suspected acute transfusion reaction".)

Hemolysis — A hemolytic transfusion reaction should be suspected if there is a rise in temperature, chills, back pain, nausea and/or vomiting, dark-colored or red urine, or any of the other symptoms that can characterize hemolysis. (See "Diagnosis of hemolytic anemia in adults", section on 'Overview of the evaluation'.)

If the bedside clerical check demonstrates that the wrong unit is being transfused, suspicion of a hemolytic transfusion reaction should be high. If the patient is stable, has no other findings or symptoms beyond fever and/or chills, and it has been confirmed that a mistransfusion has not occurred, the physician may decide to await the results of serologic tests for hemolysis before sending the patient to a hospital; otherwise the transfusionist should expeditiously make transport arrangements.

The work up for a suspected hemolytic transfusion reaction is presented separately. (See "Hemolytic transfusion reactions", section on 'Evaluation and immediate management of AHTR'.)

Fluid overload (TACO) — Fluid overload, usually referred to in the transfusion setting as transfusion-associated circulatory overload (TACO), requires immediate intervention. The transfusionist should stop the transfusion, put the patient in an upright position to facilitate breathing, and start oxygen if available. (See "Transfusion-associated circulatory overload (TACO)", section on 'Supportive care and diuresis'.)

Administration of diuretics under the direction of the responsible physician should be considered if there is clear evidence that TRALI is not the cause of the patient’s respiratory symptoms. The physician should be contacted and arrangements made to transport the patient to an appropriate health care facility.

Additional issues in the management of transfusion-associated fluid overload are discussed separately. (See "Transfusion-associated circulatory overload (TACO)", section on 'Management'.)

Bacterial contamination — Based on one of the few prospective studies on bacterial contamination, an estimated per-unit risk of red cells was approximately 1 per 32,000 units transfused [37]. As a result of the implementation of bacterial culturing of platelets, largely in response to a 2004 AABB standard requiring such testing, the risk of transfusing bacterially contaminated platelets has been meaningfully reduced. Risk estimates depend on the methods of data collection and are discussed separately. (See "Transfusion-transmitted bacterial infection", section on 'Epidemiology'.)

Transfusion of platelets that have undergone pathogen inactivation further reduces risk of exposure to bacteria, viruses, and parasites. (See "Pathogen inactivation of blood products".)

A pathogen inactivation process for platelets and plasma has been licensed by the FDA, and it is estimated that approximately 60 to 65 percent of apheresis platelets in the United States undergo pathogen inactivation. Because of the unique circumstances associated with home transfusion, pathogen-inactivated platelets would be associated with a lower risk of transfusion-associated sepsis than bacterially cultured apheresis platelets.

Bacterial sepsis can be catastrophic in a hospital setting, but even more so in a non-hospital environment, where successful intervention is based on rapid and accurate diagnosis. The sudden onset of fever, rigors, severe changes in systolic blood pressure, flushing, or other symptoms, call for immediate supportive measures and emergency transport to a hospital. (See "Transfusion-transmitted bacterial infection", section on 'Evaluation and management'.)

TRALI — Transfusion-related acute lung injury (TRALI) is characterized by acute dyspnea and oxygen desaturation that may occur shortly after transfusion is initiated but can occur up to six hours or more after transfusion. Other symptoms may include cough, fever, chills, and hypotension. TRALI presents radiographically with bilateral pulmonary infiltrates. (See "Transfusion-related acute lung injury (TRALI)".)

Because access to a chest radiograph or other imaging studies is unlikely in a home environment, TRALI may be difficult to distinguish clinically from fluid overload. Clues that could favor the diagnosis of TRALI and guide the decision to withhold diuretics include rapidly occurring acute dyspnea shortly after starting the transfusion or after only a small volume has been transfused [38-42]. The patient should be placed on oxygen and emergency services should be summoned to transport the patient to a hospital.

TRALI can be caused by all blood components and is attributed mainly to donor human leukocyte antigen (HLA) or human neutrophil antigen (HNA) antibodies against cognate recipient HLA or HNA antigens, predominantly from plasma-containing products donated by females who have been pregnant. TRALI can also be caused by recipient antibodies directed against donor white blood cells (WBCs) or biologically active breakdown products that may accumulate in cellular components.

The risk of TRALI has been reduced, but not totally eliminated, by providing plasma and platelets from male donors or female donors who either have no history of pregnancy or no evidence of WBC alloimmunization [43,44]. (See "Transfusion-related acute lung injury (TRALI)", section on 'Prevention'.)

Risk estimates vary by component [45,46]:

●RBCs – 1 per 480,000 units

●Plasma from male donors – 1 per 240,000 units

●Platelets – 1 per 138,000 units

Anaphylaxis — Traditional thinking is that anaphylaxis can occur in patients with IgA deficiency who have developed anti-IgA antibodies. Prompt recognition and administration of epinephrine by the transfusionist could prevent a catastrophic outcome. The occurrence of anaphylaxis represents a scenario in which the transfusionist could be authorized in advance to administer medication without awaiting a physician's order. (See "Immunologic transfusion reactions", section on 'Anaphylactic transfusion reactions'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Transfusion and patient blood management".)

SUMMARY AND RECOMMENDATIONS

●Indications and exclusions – In an effort to increase accessibility and convenience of care and to possibly decrease the risk of hospital-acquired infections to chronically ill and other patients, transfusions are occasionally given in patients' homes. The decreased availability of emergency medical care for serious complications is a significant potential limitation. (See 'Indications and general approach' above.)

Safety can be enhanced by:

•Assessing the location of the home for proximity to a hospital or urgent care facility.

•Affirmation by the transfusionist that:

-The patient's physical and mental status are appropriate for home transfusion.

-A cell phone, land line, or reliable electronic communication device and another responsible adult are available in the home.

Examples of exclusion criteria are listed above. (See 'Exclusion criteria' above.)

●Procedures and personnel – After blood is ordered, the transfusionist assesses the patient's residence, collects and labels blood specimens for pre-transfusion testing, and applies appropriate identification such as an identification band that meets regulatory criteria. Only transfusionists who have been trained and are experienced in transfusion therapy should be permitted to transfuse in non-hospital settings. The nurse remains with the patient during the entire transfusion and for at least 30 minutes afterwards to monitor for symptoms of peri-transfusion complications. The physician must be familiar with each agency's procedures for recognizing and managing acute reactions, and they may participate in developing such procedures. They should also decide which medications should be available on-site, such as antipyretics, antihistamines, and epinephrine. (See 'Service models and personnel' above and 'Physician role' above.)

●Patient – The prospective recipient must be medically stable; those with compromised cardiac or pulmonary function or who have other serious conditions should be transfused in a hospital or outpatient facility. (See 'Patient profile' above.)

●Transfusion reactions – The chance of minimizing a patient's morbidity and mortality due to a transfusion reaction primarily resides in the transfusionist's ability to expeditiously recognize, diagnose, and treat reactions. The responsible physician must be immediately available during the transfusion. Technologies that can enable remote monitoring should be explored and developed for potential use in "hospital in the home" transfusions. (See 'Management of reactions' above.)