HNELHD_Guideline_and_Procedure

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Guideline and Procedure Title and Document No.
Guideline and
Procedure
Renal: Monthly tissue typing collection
Sites where Guideline and Procedure
applies
Target audience:
Description
This Guideline and Procedure applies to:
1. Adults
2. Children up to 16 years
3. Neonates – less than 29 days
HNE health facilities where a renal patient currently on
transplant waiting list receives care.
Nephrology clinical staff, who provide care to renal patients
who are on transplant waiting list.
Yes
No
No
Keywords
Tissue typing, transplant, waiting list, blood collection, HLA,
acute rejection
Replaces Existing Guideline and Procedure Yes
Registration Number(s) and/or name and of JHH Nephrology SWP N.4.2
Superseded Documents
Related Legislation, Australian Standards, NSW Health Policy or Circular, EQuIP Criterion, other HNE
Health Documents, Professional Guidelines, Codes of Practice or Ethics:
 EQuIP Criterion:
 NSW Health Policy Directive 2007_079 Correct patient, Correct procedure, correct site
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_079.pdf
 NSW Health Policy PD 2005_406 Consent to Medical Treatment
http://www.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_406.pdf
 NSW Health Policy Directive PD 2007_036 Infection Control Policy
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_036.pdf
 Hunter new England Local Health Net work Guidelines and Procedures:
Renal: Blood Collection via Haemodialysis Access HNELHD GandP 12_05
Prerequisites (if required)
Nil
Guideline and Procedure Note This document reflects what is currently regarded as safe and appropriate
practice. The guideline section does not replace the need for the
application of clinical judgment in respect to each individual patient but the
procedure/s require mandatory compliance. If staff believe that the
procedure/s should not apply in a particular clinical situation they must
seek advice from their unit manager/delegate and document the variance
in the patients health record.
If this document needs to be utilised in a Non-Nephrology Area please
liaise with the Nephrology Service to ensure the appropriateness of the
information contained within the Guideline and Procedure.
Position responsible for the
Tier 2 Executive or Network or Stream Clinical Leader (or applicable
Guideline and Procedure and committee) with authority to authorise
authorised by
Contact Person
Kelly Adams, Tina Straker
Contact Details
Date authorised
This Guideline and
No
Procedure contains advice
on therapeutics
Date of Issue
Review due date
TRIM Number
Version Number
Month and Year
Guideline and Procedure Title and Document No.
RISK STATEMENT
Staff may potentially be exposed to body substance and needle injury when carry out this
procedure. Therefore strict Infection Control and Occupational Health and Safety rules should be
followed when attend this procedure, including wearing recommended Personal Protective
equipment and following the procedure steps.
Any unplanned event resulting in, or with the potential for, injury, damage or other loss to
patients/HCN/visitors as a result of this procedure must be reported through the Incident
Information Management System and managed in accordance with the Ministry of Health Policy
Directive: Incident Management PD2007_061.
OUTCOMES
1
Correct tissue typing is collected, labeled and sent to the Red Cross at the correct time each
month
2
Enabling the patient’s details to be updated on the current transplant waiting list
ABBREVIATIONS & GLOSSARY
Abbreviation/Word
Definition
Acute rejection
An early and rapid antibody-mediated rejection that is not easily controlled
with immunosuppression medication
HLA
Hyperacute rejection
HAPS
GP
Human Leukocyte antigens
The immediate and usually irreversible destruction of the transplanted
kidney
Hunter Area Pathology Service
General Practitioner
GUIDELINE
A tissue type test is a blood test that measures substances called anti- human leukocyte antigens
on the surface of body cells and tissues. Checking the antigens permits assessment of donor and
potential recipients for degree of histocompatibility, and prevent the risk of hyperacute rejection.
This procedure is typically used prior to transplantation of tissues or organs.
The monthly tissue typing blood samples need to be sent to Red Cross in Sydney by the 20th day
of the month to enable cross-match when a kidney becomes available.
PROCEDURE
This procedure requires mandatory compliance.
Patient Preparation
It is mandatory to ensure that the patient has received appropriate information to provide informed
consent and, that patient identification, correct procedure and correct site process is completed
prior to any procedure. Patients are to inform staff when a sample of blood for tissue typing is due.
Staff Preparation
It is mandatory for staff to follow relevant: “Five moments of hand hygiene”, infection control,
Version Number
Month and Year
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Guideline and Procedure Title and Document No.
moving safely/safe manual handling, and documentation practices.
Equipment Requirements

Alcohol based hand rub

Personal Protective Equipment including protective eye wear & non-sterile gloves

8 ml Z serum Sep. clot activator tube x1

Vacutainer Sheath x1

Vacutainer Leur Adaptor
Procedure Steps
1. Collect blood as per Renal guideline and procedure- Renal: Blood Collection via
Haemodialysis Access HNELHD GandP 12_05
2. All samples are to labeled correctly with the patient’s full name, date of birth and date of
collection
3. Patient samples in the Greater Newcastle are couriered to the Nephrology department
CSU by HAPS and dispatched to Sydney together.
Note: For peritoneal dialysis, home patients and patients in the area have no HAPS
eg. Moree, and Narrabri, patients are to attend GP service or pathology of their
choice for blood collection.
REFERENCES
Hand Hygiene Australia
Danovitch, G.M. (2005) Handbook of Kidney Transplantation, Philadelphia: Lippincott Williams &
Wilkins
FEEDBACK
Any feedback on this document should be sent to the Contact Officer listed on the front page.
Version Number
Month and Year
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