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Educational Goals of the Clinical Pathology Rotation in Transfusion Medicine (Blood Bank)

The Transfusion Medicine (Blood Bank) Program is a component of the Clinical Pathology (CP) portion of the residency training program and is highly clinically oriented. The objective is to produce a specialist who possesses the competencies and skills to cope with the problems presented by everyday in-hospital and outpatient Transfusion Medicine practice. It is imperative that the resident develop familiarity with clinical problems and insight into the needs of the clinicians as these relate to Transfusion Medicine.

Consisting of three parts, the training occurs at the New York Blood Center, its affiliate Long Island Blood Services and in the Blood Banks of State University of New York at Downstate (SUNY) and Kings County Hospital Center (KCHC). It includes:

Part One—seminars in which different topics in Transfusion Medicine are discussed. The
resident is expected to present some of the seminars as requested. These serve as a means of making the individual read and give him/her the opportunity to present his/her views to peers. Group interaction is encouraged. As an alternative to resident presentations, AABB, ASCP or other programs may be presented. The resident is expected to attend all of these as well, unless excused.

Part Two—emphasis on the development of technical skills. The resident will be taught the techniques in Transfusion Medicine: serological methods, donor selection, phlebotomy, pheresis techniques, etc. At the completion of the rotation, he/she is expected to be familiar with the performance of these procedures.

Part Three—applications of theoretical and technical skills to solving the problems encountered in the everyday operation of a Blood Bank. The residents are expected to take night and weekend calls. They are to perform as consultants and serve as a bridge between the blood bank staff and clinical services. Additional expectations include reporting all encountered problems to the Blood Bank Director or designate; documenting all their calls in the LOGBOOK (and/or additional applicable sites); and following-up with donors, patients and clinicians.

The residents also are encouraged to initiate special reading, laboratory service and/or research projects and to document and/or publish their findings, when appropriate.

It must be emphasized that the Transfusion Medicine (Blood Bank) Program is flexible, with opportunity for modifications to suit the special aptitudes, background, and interests of the individual residents, as well as the needs of the Blood Bank.

TRANSFUSION MEDICINE (BLOOD BANK) RESIDENCY PROGRAM
SKILLS AND COMPETENCIES

The skill levels for the residency program in Transfusion Medicine are listed below. They represent the increasing responsibilities and capabilities which should be acquired in Transfusion Medicine during two years of Clinical Pathology residency training. Skill Levels I and II correspond roughly to cumulative rotations of three to five months and one to two months respectively. Each skill also is coded for the following corresponding ACGME-endorsed general competencies

A Patient care
B Medical knowledge
C Practice-based learning and improvement
D Interpersonal and communication skills
E Professionalism
F Systems based practice

I. Transfusion Service

Skill Level I:

• Demonstrate knowledge of the principles of patient/unit identification and pre-transfusion testing, including ABO/Rh testing, RBC antibody screening, and antibody identification……………………….............................................................................................................................................A, B
• Demonstrate knowledge of optimal transfusion techniques including patient/unit identification and observe and assess these……………...………………..........................................................................................................................................................................A, B, C, D, E
• Recognize the symptoms and signs of hemolytic and non-hemolytic transfusion reactions, and demonstrate knowledge of the pathophysiology, treatment, outcomes and prevention of these complications………………………………..……………................................................................A, B, C
• Demonstrate proficiency in following-up on transfusion reactions including discussion with the reporting physician, patient interview, presentation to the Transfusion Medicine attending physician documentation...................................................................................................A,B,C,D,E
• Identify the major infectious complications of blood transfusions, the risk of these infections, and explain how these infections can be prevented…………………………………………………………………………....................................................................................................................B
• Identify the major non-infectious complications of blood transfusions, the risk of these complications, and explain how to prevent or treat these complications…………………………………………………….............................................................................................................................................B
• Review prospectively requests for and choose appropriate blood components and products and coagulation factor concentrates based on a thorough knowledge of the indications for transfusion and discussion with the requesting physician, and document the review............A, B, C, D, E
• Demonstrate knowledge of the pathophysiology, prevention, and treatment of hemolytic disease of the newborn. Recognize those antibodies and titers in pregnant patients that are clinically significant, and make appropriate recommendations for follow-up and/or blood product.A, B, C, D
• Demonstrate knowledge of the pathophysiology and treatment of neonatal alloimmune thrombocytopenia and thrombocytopenias of pregnancy………………………………………………….................................................................................................................................................A, B
• Demonstrate proficiency in the evaluation and appropriate transfusion therapy of coagulopathic and thrombocytopenic patients (both adult and pediatric)...............................................................................................................................................................................................................A, B, C, D, E
• Apply the principles of a massive transfusion protocol and communicate these to clinicians…...................................................................A, B, C, D
• Demonstrate a working knowledge of the principles of hemostasis and coagulation and proficiency in the initial treatment of patients with bleeding disorder……….……………………………………….................................................................................................................................A, B, C
• Demonstrate knowledge of the transfusion requirements of special patient populations (e.g., hematology/oncology, including patients with sickle cell or autoimmune diseases, pediatrics, geriatrics, transplantation, burn/trauma)………………………..……………………………………A, B, C
• Demonstrate knowledge of important prior published studies in transfusion medicine…..................................................................A, B, C, D, E, F
• Demonstrate proficiency in evaluating and presenting findings from recent peer-reviewed journal articles related to transfusion medicine……………………...……..............................................................................................................................................................A, B, C, D, E, F
• Demonstrate the ability to prepare and present quality assurance and other types of reports at Transfusion Committee and other meetings, as requested……………………………………....................................................................................................................................................A, C, D, E, F

Skill Level II:

• Identify clinically significant RBC antibodies from an antibody panel including multiple alloantibodies and mixtures of alloantibodies and autoantibodies; determine how difficult it will be to obtain blood for the patient, and effectively communicate these results to the Transfusion Medicine attending physician and to clinicians……………………………………………………………………………….......................................................................................A, B, C, D, E
• Demonstrate appropriate judgment regarding the necessity for reference lab consultations…………………………………………...A, B, C, E, F
• Demonstrate proficiency in evaluating and recommending treatment plans for complex transfusion reactions…………………………..A, B, C, F
• Demonstrate familiarity with the appropriate use of highly specialized blood products (e.g., granulocytes, donor lymphocyte infusions, HLA-matched platelets, coagulation factor concentrates, irradiated and leukoreduced cellular products, red cell preparations for neonates)…………............................................................................................................................................................................................A, B, C, D, F
• Demonstrate familiarity with the requirements of all applicable regulatory and accrediting agencies (e.g., JCAHO, CAP, AABB, FDA).B, C, F
• Compare and contrast the various means of performing blood utilization review……………….................................................................C, D, E, F
• Demonstrate competence in the management of blood inventory and ability to communicate effectively the hospital’s needs to the blood supplier…....………………………………………………...........................................................................................................................A, B, C, D, E, F
• Demonstrate knowledge of various methods of blood conservation, including pre- and peri-operative autologous blood collection, approaches to “bloodless” surgery and requirements of Jehovah’s Witnesses…...………………………………………………………………….........A, B, C, D
• Demonstrate proficiency in evaluating patients refractory to platelet transfusions. Outline the principles of histocompatibility testing and platelet crossmatching, and apply this knowledge in selecting appropriate platelet products when indicated……………..........................................A, B, C
• Demonstrate proficiency in the evaluation of patients with immune-mediated and non-immune-mediated hemolytic anemia and in the appropriate transfusion management of these patients…...…………...................................................................................................................A, B, C
• Demonstrate the ability to maintain collegial and professional relationships with staff at all levels…………………………………………......D, E

II. Blood Collection/ Blood Center/ Cell Processing

Skill Level I:

• Compare and contrast the eligibility requirements for allogeneic and autologous blood donations...................................................................B, C
• Demonstrate knowledge of the indications for therapeutic phlebotomy……………………………................................................................A, B, C
• Demonstrate knowledge of the evaluation and treatment of adverse reactions associated with blood donation/phlebotomy (whole blood and apheresis donations)……..............................................................................................................................................................................................A, B
• Outline the assay principles of required donor blood tests and the associated confirmatory testing and describe donor re-entry algorithmsB, E
• Understand how to interact professionally with prospective donors……………………………..................................................................B, C, D, E
• Summarize the steps in blood component and blood derivative preparation……...........................................................................................B, C, F
• Describe the factors that influence the motivation of volunteers to donate blood………………………..............................................................B, D
• Explain the operational logistics required in determining appropriate blood inventory for a geographic region, and the process of meeting daily, weekly, and monthly collection goals.…………………...........................................................................................................................................B, C, F

Skill Level II:

• Outline the necessary steps in donor notification and counseling associated with positive infectious disease testing results, and the donor look-back process……………………………………………...........................................................................................................................................B, C, F
• Demonstrate knowledge of the requirements of all applicable regulatory and accrediting agencies……………………………………….B, C, F
• Demonstrate knowledge of the principles of hematopoietic stem cell transplantation including collection, processing, and storage of these stem cell products, and the indications for use (e.g., bone marrow, peripheral blood, and cord blood)……………………………………….............B, C
• Demonstrate understanding of the elements of current good manufacturing practices (cGMP) and current good tissue practices (cGTP) as they apply to the collection, processing, ex vivo manipulation, and storage of all cellular therapeutic products (e.g., pancreatic islet cells, negative/positive selection/purging of hematopoietic stem cells, gene manipulations, donor lymphocyte infusions, dendritic cell vaccines, ex vivo expansion of progenitor cells)……………………………………........................................................................................................................A, B, C, F

III. Therapeutic Apheresis

Skill Level I:

• Summarize the principles of apheresis technology, including centrifugation, filtration, and immunoadsorption……………………………A, B, C
• Demonstrate knowledge of the indications for therapeutic apheresis and of the appropriate replacement fluids to be used in various situations…………………..........................................................................................................................................................................................A, B, C
• Demonstrate knowledge of the considerations in evaluating and preparing patients for therapeutic apheresis, including discussion with the patient of the risks and benefits associated with apheresis procedures…………………………………………………………………….....A, B, C
• Communicate effectively with nurses, clinicians and housestaff regarding emergent or scheduled therapeutic apheresis procedures through conversations and observation.......................................................................................................................................................................A, B, C, D, E

Skill Level II:

• Demonstrate knowledge of the evaluation and treatment of adverse reactions associated with therapeutic apheresis………………...A, B, D
• Demonstrate knowledge of the treatment of patients using specialized methods (e.g., photopheresis, immunoadsorption columns)…A, B, D

REFERENCE: Smith BR, Wells A, Alexander B, Bovill E, Campbell S, et al.
Curriculum Content and Evaluation of Resident Competency in Clinical Pathology (Laboratory Medicine): A Proposal. Clin Chem 2006; 52 (6): 917-949.

 

Transfusion Medicine Residency Program Reference Materials:

*1. AABB Standards for Blood Banks and Transfusion Services, 25th edition, AABB (2008)
*2. AABB Technical Manual, 15th edition, AABB (2005)
3. Practical Guide To Transfusion Medicine. Marian Petrides, Laura Cooling, Lanne Maes, Gary Stack. AABB Press (2007)
*4. Selected articles from current literature.
*5. Selected websites, e.g., that of the California Blood Bank Society, cbbs.org and bbguy.org of the Osler course.
*6. Schedules, e-mail and other communications and handouts related to the rotation.
7. Applied Blood Group Serology, 4th edition. Issitt and Anstee. Montgomery Scientific. (1998)
8. Blood Transfusion in Clinical Medicine, 11th edition. Mollison, Engelfriet, Contreras, Blackwell Science (2006)
9. Modern Blood Banking and Transfusion Practices, 5th edition. Harmening, F.A. Davis Co. (2005)
10. Transfusion Therapy: Clinical Principles and Practice, 2nd edition. Mintz. AABB Press (2005)
11. Immune Hemolytic Anemias. 2nd edition. Lawrence D. Petz and George Garratty. Churchill Livingstone (2003)
12. Consultative Hemostasis and Thrombosis. 2nd edition. Kitchens, Alving, Kessler, et al. W.B. Saunders (2002)
13. Blood Transfusion Therapy. A Physician’s Handbook, 8th edition. Gottschall, et al. American Association of Blood Banks (2005)
14. AABB monographs on selected topics.
15. Inspection checklists for Blood Bank, e.g., College of American Pathologists checklist.

*An asterisk denotes required reading/resources.

Duties and Responsibilities of Transfusion Medicine (Blood Bank) Residents

Resident Assignment During Transfusion Medicine (Blood Bank) Rotation(s)*

Attend New York Blood Center Transfusion Medicine/Immunohematology Course and corresponding hands-on laboratory sessions at the hospitals. This course should be taken during an introductory month-long Blood Bank rotation at the beginning of the academic year (usually in July).
After an introductory month (usually in July) including attendance at the New York Blood Transfusion Medicine/Immunohematology Course, residents are responsible for night (5 pm - 9 am), and round the clock holiday and weekend Blood Bank call. Residents rotating through Blood Bank (after the introductory month) are responsible for daytime (9 am – 5 pm) call on standard workdays during their rotation. On-call residents must be available by beeper and other appropriate modalities.
Review the KCHC LOGBOOK each morning and follow-up all Kings County Hospital Center (KCHC) problem patients.
Attend and report on problem patients from both hospitals at morning Blood Bank rounds, SUNY, weekdays, 10 AM.
Review selected SUNY problem patients, upon request by Blood Bank Attending or Supervisor.
Prepare presentations and seminars and attend lectures, rounds, in-services, and laboratory sessions as scheduled.
Handle all problem cases, irregular antibodies, positive direct Coombs tests, patients requiring blood warmer, etc.
Consult on patients with incompatible crossmatches, release of Rh positive blood to Rh negative individuals in case of emergency, Rh immune globulin dosage, etc.
Carry on first line communication with physician clinical staff and technical staff regarding SUNY/KCHC problem patients.
Prospectively review, assess and document disposition of all requests for elective transfusion of platelets, fresh frozen plasma, cryoprecipitate and coagulation factor concentrates, KCHC and SUNY. This should include a discussion with the requesting physician and consultation with the Blood Bank Attending, if necessary.
Expedite delivery of emergency specimens to the Blood Bank for send out to a reference laboratory.
Review antibody panels, KCHC and SUNY, in conjunction with problem patients review.
Review all transfusion reactions by consulting all pertinent written and electronic records and interviewing the patient, SUNY and KCHC; document these and present to the Blood Bank Attending.
Advise clinicians of the results of Blood Bank workups and of recommendations.
Observe actual transfusions at KCHC and SUNY, as part of the Quality Assurance Program. Each resident will review 10 each a month at KCHC and 1 each a month at SUNY, and document adherence to or breaches of standards for administration of transfusions. The resident will distribute and present the KCHC audit at Transfusion Committee.
Prepare and present at Transfusion Committee meetings, Quality Assurance and other reports requested by the Blood Bank Director.
Research selected administrative, technical, quality assurance or medical questions, depending upon resident interest and the current needs of the Blood Bank.
Mentor other residents as to appropriate areas of concentration in preparation for residency and board examinations questions in blood banking.
Coordinate Blood Bank-related activities, e.g., communication with pheresis staff and residents, to maximize resident pheresis experience.
Review interesting clinical cases with other residents and attendings.
Attend clinical specialty and blood bank meetings, conferences, as a physician representative from SUNY and KCHC Blood Banks.
Attend Transfusion Medicine conferences sponsored by the New York Blood Center, and other outside organizations if/when time permits.
Maintain amicable, professional relationships with clinical house staff, blood bank technology staff, and other colleagues.

*Residents should consult initially with the Clinical Pathology Chief Resident on any issues impacting on them as a group, and secondarily with attending physicians as needed.

 

Transfusion Medicine (Blood Bank) Resident Hands-On Laboratory Sessions

Techniques
ABO Grouping (cell and reverse)
ABO Discrepancies

Rh and Weak D Procedure
Direct Antiglobulin Test (DAT) Procedure

Indirect Antiglobulin Test (IAT) Procedure
Lewis Blood Group Substance

Antibody Identification Procedure
Dry Panel Readings

Dry Panel Readings
Enzyme Procedure

Elution Procedure
Absorption Procedure (explain)

Titration Procedure

Crossmatch Procedure (adult)
Crossmatch Procedure (neonate)

Transfusion Reaction Workup

Hemolytic Disease of the Newborn (HDN)

Warm Autoimmune Hemolytic Anemia (WAIHA)
Cold Autoimmune Hemolytic Disease (CAIHD)
Paroxysmal Cold Hemoglobinuria (PCH)

Drug Induced Hemolytic Anemia

Components (adult and neonatal)

Transfusion Medicine (Blood Bank) Resident Assessment

Examination (written)

Evaluations (written)

ORIENTATION TO CLINICAL PATHOLOGY RESIDENT DUTIES IN THE BLOOD BANKS AT KINGS COUNTY HOSPITAL CENTER (KCHC) AND STATE UNIVERSITY OF NEW YORK AT DOWNSTATE (SUNY)

Daily Responsibilities:

1. Take all calls for the Blood Banks.
2. Check anything that is important in logbook of KCHC for 10:00 AM meeting at Supervisor’s office of SUNY Blood Bank. Discuss issues with KCHC Supervisor before meeting.
3. Follow-up all transfusion reactions by review of all pertinent paper/electronic records, patient interview, documentation of data and presentation to Blood Bank Attending.
4. Sickle cell patient follow-up (contact sickle cell fellow and check patient information).
5. Hemophilia patient follow-up (review clinical condition and treatment plan). Contact Hematology fellow. Report to Blood Bank Supervisor and Attending.
6. Follow-up patients who have received rFVIIa. Check charts for completed consent forms and complete Review of Blood Product Forms. Document on Component/Derivative approval forms.
7. Check anti-D status and possible need for RhIG in Rh negative and weak D pregnant females and perform high-risk pregnancy follow-up for significant alloantibodies.
8. Check that positive direct Coombs tests and screens are reported to clinicians as needed.
9. Call clinicians to obtain samples for sendout to reference laboratories.
10. Follow-up on requests from the Blood Bank staff or attending physicians and check the patients related to those requests.
11. Check if any products are approved by Hematology physicians (review clinical diagnosis, reason for Blood Bank products, current clinical condition and future needs for products).
12. Make wastage and outdate inquiries for both hospitals.
13. QA: Review and document non-reported transfusion reactions and discuss with Dr. Gloster.
14. Recall and Lookback: Check patient’s records for information, both hospitals.
15. Attend at least one plasmapheresis session per patient undergoing such treatment in both hospitals and document observations on the Pheresis Documentation Sheet. Submit completed sheet to Dr. Gloster.
16. Wear white coat in the laboratory and for apheresis sessions and patient visits.
17. Except for inservice exams, arrange for your own coverage by other CP residents, when you are not available. Inform the Blood Bank Attendings and Supervisors of such arrangements.

Monthly/Other Responsibilities

1. Teach technologists at KCHC and SUNY, in 20 minute sessions, morning and evening shifts, on a topic requested by them, or related to a patient problem.
2. QA: Check transfusion procedures at SUNY using the “Monthly Assessment of Transfusion” form.
3. QA: Check 10 transfusions at KCHC regarding patient ID procedure using the “Targeted Assessment of Patient ID Prior to Transfusion” form. Summarize these observations in the “Assessment of Patient ID Prior to Transfusion Summary for Month/Year” at the end of the month. Check one transfusion a month at UHB using the appropriate form.
4. Attend Transfusion Committee meetings at both hospitals.
5. Update, backup and maintain electronic and paper files related to the rotation and its duties, in the residents’ office at KCHC Blood Bank.
6. Orient the resident who follows you in the rotation, as to the above expectations.

Originally written by: Y. Wang, MD, CP Resident
Revised by: A. Salarieh, MD; V. Cornea, MD, CP Residents
Approved by: E.S. Gloster, MD, Director of Blood Banks
Original Date: 3/3/03; Revised: 6/30/03; 6/18/04; 7/05; 1/06; 6/07; 6/08

Transfusion Medicine (Blood Bank) Faculty

E.S. Gloster, M.D... ……………..…………Blood Bank Director, University and Kings County Hospitals Professor, Clinical Pathology

C. Vinciguerra, M.D. ………….................................................Director of Laboratory Quality Assurance, Kings County Hospital Center

Blood Bank Managerial, Supervisory and Technical Staffs……………………………….SUNY Downstate and Kings County Hospitals

Written By: T. DiMaio, M.D.; E.S. Gloster, M.D.
Revised By: E.S. Gloster, M.D.
Original Date: 8/94; Revised 7/96; 7/97; 11/99; 4/01; 5/02; 6/04
Date: 7/05; 1/19/06; 6/07; 6/08