Section: Transfusion Medicine

Duration: 2 months

Goals & Objectives

1. Problem-solving and clinical rounds combined with a comprehensive, intensive reading schedule, selected technical experiences at the bench, and discussions with fellow/attending or director comprise major learning opportunities in Transfusion Medicine (BB/TM). Progressive assumption of responsibility with appropriate supervision allows the resident to respond to hemotherapy clinical consultations, transfusion reactions and patients with irregular antibodies, while adhering to ethical principles and sensitivity to diverse populations.
2. Clinical problem-solving, bedside/OR/ED rounds and consultations, e.g. hemotherapy (components), transfusion reactions and antibody identification are pursued aggressively as a first priority over the course of the rotation supplemented by Clinical Pathology on call experience throughout the entire Clinical Pathology GME experience. Resident works with fellow and attending/director and after initial month, assumes progressive response/ responsibility for consults while supervised initially by Fellow and then Director or Attending daily. Demonstrate knowledge and its applications, with understanding of health care system.
3. In Hemapheresis, he/she evaluates requests for peripheral blood stem cell collection and performs informed consent, patient assessment, plan with progress notes and management of adverse reactions. Resident responds and evaluates clinical consultations for therapeutic apheresis procedures including patient assessment, informed consent, venous access, treatment plan with availability during apheresis procedure(s) and completion of progress notes and follow through for additional procedures expected. Records of hemapheresis patients' diagnoses and outcomes are incorporated into a database by staff. Hemapheresis patients (stem cell collection and therapeutic) are visited daily when scheduled and problems discussed with attending/director while assuming progressive responsibility for patient management. Demonstrate the ability to investigate and evaluate diagnostic and consultation procedures with importance in patient care practice.
4. Selected technical bench experiences (about six hours per week) facilitate understanding in basics of blood typing, compatibility testing, antibody identification, transfusion reactions, blood product dispensing, inventory management, HLA, parentage testing, stem cell processing, storage/ infusion, solid organ and stem cell transplantation. Resident observes blood donor processing, collection, component preparation, product release and inventory management/distribution over three days at regional Red Cross Center.
5. Self-directed learning through text, monograph, journal and other assigned reading followed by discussion and review with attending/director daily is crucial for life-long learning and second only to clinical problem-solving in priority of activities. Transfusion Committee meets quarterly and resident and fellow assigned that period attend and participate in the presentation of patient transfusion reactions and perceived excess or inappropriate blood product utilization. Demonstrate communication and interpersonal skills with the entire team, as well as individual team members.
6. Conferences, seminars and presentations bi-weekly provide an additional structured learning experience with each resident expected to contribute two presentations selected/assigned to enhance his/her teaching skills and learn even more through preparation and delivery. Computer skills focus on generation and "mining" of databases, graphic presentations of hemotherapy with selected laboratory measurements and clinical information. Residents daily retrieve through Sunquest (LIS) patient specific blood product utilization and outcome reflected by appropriate laboratory measurements, e.g. platelet increment, hematocrit change. Access to AABB and FDA Web sites is available as a tool of learning, teaching, and transfusion medicine practice from a national perspective.
7. A scholarly and/or research effort is encouraged in a manner to culminate in a presentation (local/national) and/or publication. Research opportunities are provided either in areas of expressed resident interest, stem cell transplantation/banking, or medical informatics/database management to generate and manage a clinical pathology database (FileMaker Pro V3.01 - flat file and relational).
8. At the completion of the rotation, resident should be capable of solving technical and clinical problems that arise day-to-day and be able to offer consultation in hemotherapy (components), stem cell processing, respond to transfusion reactions, alloantibody identification, hemapheresis consultations, contribute to parentage analysis, interface with solid organ transplant surgery team, appreciate selection of organ donors (living-related/cadaver) through assessment of waiting list, crossmatch and status of PRAs (percent reactive antibodies) and investigate platelet refractoriness of patients. Matching of related/unrelated donors with Class I and Class II HLA typing should provide a learning opportunity, as well as selection of the most appropriate donor.

Duties & Responsiblities

1. Review blood and component request forms with utilization. Interact with attending/resident physicians when Rh positive blood must be given to Rh negative recipient.
2. Follow protocol when switching blood types.
3. Contact ordering physician if the blood component order form is not completed properly. Consult with attending if necessary on unusual circumstances. Verify and record changes in orders and rationale for such orders on blood component order form. If an order is not changed and appears inappropriate, bring information to attending's attention for subsequent review by Blood Utilization Review Committee (meets quarterly). Follow-up cases for whom orders were canceled. Note any deviations or outcomes that may have resulted from use.
4. Review surgical OR schedule for adherence to recommended blood ordering/type and screen policies in "Guidelines for Ordering Blood for Elective Surgery". Contact clinician or review chart to discuss exceptions. Approve exceptions or bring problems to the attention of attending. Notify Transfusion Medicine staff of changes in orders.
5. Use clinical flow sheets or computer reports to monitor hematologic component use patterns in patients receiving components/derivatives.
6. Review platelet utilization.
7. Approve in advance the use of greater than 5 units of platelets per day per patient.
8. Monitor hematologic-oncologic use patterns. Anticipate the development of refractory state in patients being chronically transfused. Be aware of patients who are refractory to random donor units.
9. Approve orders for HLA-matched platelets and PRA (percent reactive antibody). Review order with patient's attending/resident.
10. Remind clinicians of the importance of post-transfusion platelet counts within 60 minutes.
11. Monitor daily outdating
12. Approve leuko-reduced packed cell, washed or frozen red cell orders for initial use by a patient. Review all use as needed and discuss problems with attending.
13. Approve initial requests for irradiated blood products after consulting with clinicians and/or reviewing patient and record. Patients who may need irradiated products are immunodeficient/immunocompromised patients and potential bone marrow/stem cell transplant recipients.
14. Review fresh frozen plasma utilization in excess of 4 units per patient per transfusion episode. Ensure that appropriate pre-and post-testing (especially coags) are performed. Communicate with clinicians regarding requests for products for which there has been no pre-testing performed.
15. Approve initial requests for cryoprecipitate after obtaining appropriate information and evaluating coags.
16. Assist with review of patient's medical records as part of quality assurance studies. Gather data for quality assurance studies.
17. Review immunohematology antibody work-ups and sign out with attending.
18. Complete patient history form, visit patient and review medical record. Obtain relevant clinical information for inclusion in report of all irregular antibodies and transfusion reactions.
19. Communicate results of crossmatch problems to clinicians of pre-surgery or in bleeding patients. Place note in chart including anticipated time for blood to be available, or if incompatible blood must be transfused.
20. Meet with the Transfusion Medicine Fellow and/or attending to review work-ups for irregular antibodies, positive DAT and transfusion reactions at one of the daily meetings (AM and PM).
21. Transfusion reactions.
22. Evaluate all acute transfusion reactions with patient/medical record review. See inpatients with all reported transfusion reactions. Review Transfusion Medicine work-up and request special studies if indicated. Call clinician with a preliminary interpretation. Write transfusion reaction report within 12-24 hours (including weekends) for attending's review and sign out. When appropriate, enter note in chart of preliminary evaluation noting that a formal report is to follow. Make recommendations for use of special components (i.e. Ieukoreduced) if indicated.
23. Complete a delayed hemolytic transfusion reaction (acute/remote) form on patients who develop an alloantibody or positive direct antiglobulin test within initial 10 days or three months after transfusion(s). Return form to supervisor or assistant supervisor and review/sign out with attending.
24. Review blood and component inventory on a daily basis with special attention to potential shortage situations and available O negative units, including those in ER and OR.
25. Review emergency release forms.
26. Follow-up as necessary with clinician(s) when emergency release of non-crossmatched blood occurs and Transfusion Medicine staff is unable to obtain signatures on emergency release form.
27. Discuss problems promptly with Transfusion Medicine attending.
28. Be alert for and follow up post-transfusion hepatitis or transfusion associated HIV with fellow. Prepare letter and complete Red Cross form notifying Red Cross of details, blood unit numbers involved, etc., for attending's signature.
29. Follow up with fellow FDA/Red Cross for recalled blood products, i.e. patient identification and date product administered with name of attending physician and service.
30. Obtain data for look-back studies if appropriate.
31. Hemapheresis Service:
32. Evaluate all requests for peripheral blood stem cell collection procedures (consultation form completion) and patient assessment, plan, progress and management of adverse reactions. Complete appropriate request forms, orders and progress notes.
33. Obtain consultation forms and evaluate clinical consultations for therapeutic apheresis procedures. Consultation will involve patient assessment, informed consent, venous access, treatment plans, with availability during apheresis procedure(s). Progress notes as necessary and follow through for additional procedures expected. Monitor patient records of hemapheresis patients, diagnoses and outcomes in hemapheresis database.
34. Visit hemapheresis patients (stem cell collection and therapeutic) daily when scheduled and discuss problems with attending. Assume progressive responsibility for patient management.
35. Review and analyze hemapheresis database
36. Obtain data for reportable incidents for New York State Department of Health and FDA and sign out with supervisor and attending.
37. Make daily rounds with Transfusion Medicine fellow and Transfusion Medicine attending to clarify and follow-up on problem cases, component use, antibody problems, transfusion reactions, etc. and review of reference reading in AM and PM at mutually agreed upon times.
38. Attend weekly supervisors' meetings and Blood Utilization Review Committee meetings as appropriate.

Teaching Responsibilities:

1. Participate and contribute to staff development by:
2. Presenting one inservice for Transfusion Medicine staff and one resident conference per 2-3 months rotation.
3. Hospital nursing staff - present inservices as requested and/or observe attending.
4. Other presentations as requested
5. Assist in medical technology student teaching, including lectures/seminars for MT-404 Immunohematology.
6. Participate in medical student/resident instruction including preparation for and participation in laboratory sessions.
7. Lecture in Oncology/Nurse Specialist Course as needed.
8. Attend and contribute to bi-weekly resident Transfusion Medicine conference. At the completion of rotation, resident/trainee should be capable of solving technical and clinical problems that arise day-to-day and be able to offer consultation in hemotherapy (components), respond to transfusion reactions, alloantibody identification, hemapheresis consultations, contribute to parentage identification procedure (SOP) and analysis, interface with solid organ transplant surgery team, appreciate selection of organ donors (living and cadaver), assessment of waiting list, crossmatch and status of PRAs.

Evaluation

Six Competencies

1. Medical Knowledge: evaluated in two ways: Chart Stimulated Recall Oral Examination and Portfolios (case logs). Chart Stimulated Recall Oral Examination: Patient cases of the examinee (resident) are assessed in a standardized oral examination. The attending physician questions the resident about the case provided, probing for reasons behind the work-up, diagnoses, interpretation of clinical findings, and treatment plans. Portfolio: A portfolio will include a log of clinical procedures performed; a summary of the research literature reviewed when selecting a treatment option and statements about what has been learned, its application, remaining learning needs, and how they can be met.
2. Practice-Based Learning & Improvement: evaluated in four ways: Portfolios, Global Rating, Surveys and 360 degree evaluations. Portfolio: Please see explanation under Medical Knowledge. Global Rating: A rater judges general categories of ability (patient care skills, medical knowledge, interpersonal and communication skills) and the ratings are completed retrospectively based on general impressions collected over a period of time (end of rotation) derived from multiple sources of information (direct observations or interactions); input from other faculty, lab technicians and residents and review of work products or written materials. Surveys: Surveys will be distributed to those individuals the resident lectures to (students, nurses, etc). They will address the quality of the lecture, preparation of the lecture, etc. 360 degree evaluation: An evaluation for the resident on service is completed by superiors, peers, subordinates, technical staff, etc. The ratings are summarized for all evaluators by topic and overall to provide feedback.
3. Interpersonal & Communication Skills: evaluated in two ways: Checklist and 360 degree evaluation. Checklist: consists of essential specific behaviors, activities and/or steps that make up a competency component. A check mark indicates that the behavior occurred or options to indicate the completeness or correctness of the action. The forms provide information about behaviors but for the purpose of making a judment about the adequacy of the overall performance. 360 degree evaluation: Please see explanation under Practice-based Learning & Improvement.
4. Professionalism: evaluated in one way: 360 degree evaluation. 360 degree evaluation: Please see explanation under Practice-based Learning & Improvement.
5. Systems-Based Practice: evaluated in two ways: Chart Stimulated Recall Oral Examination and 360 degree evaluation. Chart Stimulated Recall Oral Examination: Please see explanation under Medical Knowledge. 360 degree evaluation: Please see explanation under Practice-based Learning & Improvement.
6. Patient Care: evaluated in two ways: 360 degree evaluation and Portfolios. 360 degree evaluation: Please see explanation under Practice-based Learning & Improvement. Portfolios: Please see explanation under Medical Knowledge.

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