Coagulation Rotation

Goals and Objectives

During this rotation, the resident will demonstrate the following competencies: 

Patient Care

Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to:

• Work with healthcare professionals, including those from other disciplines, to provide patient-focused care
• Observe patient counseling/clinic sessions/ history and physical examinations at the pediatric hematology clinic.
• Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families in pediatric hematology clinic
• Gather essential and accurate information about patients
• Synthesize and present cases seen in clinic to pathology attending with a focus on relevant coagulation clinicopathologic findings
• Provide prompt consultative support for patients with bleeding and thrombotic disorders.
• Use information technology to support patient care
• Preview cases, synthesize clinical and laboratory findings, obtain histories and review results to render a diagnostic interpretation
• Demonstrate an investigatory and analytic thinking approach to clinical situations
• Answer questions from clinicians about coagulation testing with attending approval and review prior to answering questions (graded responsibility)
• Review data on implementation of new hemostasis assays
• Be involved in interpretive pathologist reviews of cases
• Know and apply the basic and clinically supportive sciences which are appropriate to their discipline including molecular biochemistry of the hemostatic system, relevant findings in the patient history, congenital and acquired coagulation disorders, diagnostic test strategies
• Demonstrate knowledge of:
  • algorithmic strategies to coagulation testing
  • manual and automated methods used to perform routine and specialty coagulation laboratory testing the limitations and interferences for such tests
  • application and interpretation of platelet function testing and mixing studies
  • differential diagnosis, evaluation, and management of bleeding disorders and for thrombophilia
  • pathophysiology of normal hemostasis and for hemostatic disorders
  • diagnosis and management of disseminated intravascular coagulation
  • impact of phlebotomy and sample collection on coagulation testing
• Assess technical performance of routine and specialty coagulation assays
• Participate in routine and specialty coagulation testing assay sign-out and generate written interpretations of test results with communication to ordering physicians as applicable
• Prepare a 10-15 minute presentation to coagulation technologists on a coagulation testing topic
• Pass 3 quizzes and 1 final examination
• Complete reading of routine and specialty coagulation test procedures

Practice-Based Learning and Improvement

• Analyze practice experience and perform practice-based improvement activities using a systematic methodology
• Participate in current coagulation laboratory operations and assist with projects such as: method validation, new assays implementation, normal range studies, laboratory assay trouble-shooting, quality assurance, procedure review
• Review daily quality control results for specialty assays and specialty coagulation laboratory pending list for specialty assays at the start and end of each day
• Obtain previous laboratory test results from LIS and clinical data from HIS
• Interface and interact with ordering physicians to determine the reason for the test order and the information sought by the clinicians
• Review specialty testing for inappropriate test order entry patterns and communicate findings to attending pathologist and/or ordering physician as appropriate
• Use information technology to manage information, access on-line medical information; and support his/her education
• Interpret coagulation and special coagulation test results
• Perform clinical correlation and assess appropriateness of coagulation testing based on clinical correlations
• Correlation of abnormal coagulation results with hematology and chemistry assays
• Facilitate the learning of students and other healthcare professionals
• Demonstrate mastery of didactic case studies

Interpersonal and Communication Skills

• Use effective listening skills and elicit and provide information using effective verbal and nonverbal, explanatory, questioning, and writing skills
• Communicate with laboratory technologists about test methods, additional test requests, etc.
• Communicate with attending pathologists about patient results
• Work effectively with others as a member or leader of a healthcare team or other professional group
• Present clinical cases at laboratory sessions or clinical conferences as appropriate
• Interact appropriately with technical staff in coagulation laboratories
• Present lecture to technical staff at the end of the rotation
• Communication of test results to clinicians
• Communication with clinicians to obtain history for interpretation of test results and/or appropriateness of tests ordered.
• Presentation of journal articles about coagulation topics at Journal Club if scheduled

Professionalism

• Demonstrate respect, compassion, and integrity with patients and accountability to the profession by observation of patient evaluations in Pediatric Hematology Clinic and presenting findings to pathology attending
• Demonstrate a commitment to excellence and on-going professional development by attendance at all didactic sessions, conferences, and bench sessions with technologists
• Being punctual
• Being available and visible in coagulation laboratory area as required
• Answering pages promptly
• Conveying information to laboratory staff in a timely manner
• Reading independently on topics related to patient case material and search primary sources
• Demonstrating self-motivation and organization in pursuit of coagulation rotation requirements (reading and clinical service time)
• Demonstrating courteous and collegial behavior with laboratory staff (laboratory supervisor will evaluate resident based on input from laboratory personnel)
• Following up on all assigned coagulation cases until the case is completely signed-out with the Attending pathologist

System-Based Practice

• Understand the fundamentals of laboratory accreditation and regulatory requirements and how the College of American Pathologists Laboratory Accreditation Program affects the healthcare organization, and their own practice by:
• Review recent CAP proficiency testing programs results for coagulation for UHC
• Performing a "mock" CAP inspection of the coagulation laboratories
• Preparation of a report of the "mock" inspection findings
• Presentation of the "mock" inspection findings and report to the coagulation supervisor and pathology attending
• Practice cost-effective healthcare and resource allocation that does not compromise quality of care by
• Having a working knowledge of and familiarity with the Laboratory Information System (LIS) and entry/retrieval of laboratory results and familiarity with Hospital Information System (HIS) for retrieval of clinical information on patients
• Generating via the LIS on daily basis a list of special coagulation tests ordered ("Queue") and then reviewing each case for appropriateness of specialty coagulation tests ordered. After discussion with the pathology attending, with approval of the pathology attending the pathology resident may contact the ordering physician to discuss the tests ordered and if tests are recommended
• Understanding the steps in specimen handling and processing through the triage department and the criteria for sample rejection (observation and procedure review)
• Designing a change control packet for a mock new test including elements required for bringing up a new test
• Understanding cost-effective laboratory evaluation of coagulation disorders.

Duration

The Coagulation rotation is a one-month (4 week) rotation taught in one 4 week block.

Duties and Responsibilities

• Review all procedures in coagulation and special coagulation laboratories
• Arrange and attend bench instruction with the coagulation technical coordinator for bench time & observation of each of the routine and special coagulation tests performed
• Daily review of Quality Control results for special coagulation assays
• Attendance at monthly Quality Control review meeting
• Daily preparation, review and sign out of "Review queue" special coagulation cases with the Attending Pathologist.
• Coordinating a mutually convenient sign-out time with pathology attending on coagulation
• Answering questions/following up cases for Specialty Coagulation Assays
• Reviewing pending coagulation folder and review queue in morning and afternoon daily
• Calling clinicians and or chart review to obtain additional information when necessary with attending approval
• Complete special coagulation form for each patient case with written preliminary diagnosis on each form prior to attending review
• Preview cases and complete path interpretation in LIS prior to attending sign-out
• Entering review queue diagnosis/billing codes into LIS after sign-out
• Evaluation of "ST AT" requests for specialty coagulation testing.
• Attendance at clinical pathology conferences, hematology conference, laboratory rounds
• Discuss with Hematology fellow before weekly Hematology conference re: cases that will be presented and review results prior to conference with attending
• Participation in current coagulation laboratory operations and assistance with projects such as: method validation, implementation of new assays, normal range studies, laboratory assay trouble-shooting, quality assurance, procedure review
• Coordinate with pediatric hematology clinical service observation of patient evaluations in hematology clinic
• Preparation of 30 minute presentation to laboratory technologists on coagulation topic- for all three shifts

Teaching Staff

• Katharine A. Downes, M.D., Rotation Director
• Robert Maitta, MD, PhD
• Hollie Reeves, DO
• Lan Zhou, MD, PhD
• Xiangrong (Eric) He, MD
• Sanjay Ahuja, MD
• Molly Klima, MT (ASCP) Technical Coordinator

Supervision and Evaluation

Faculty attendings supervise all aspects of the Coagulation rotation. The pathologist with significant resident contact during the rotation evaluates the rotating residents addressing the above six competency areas. Evaluations are based on daily interaction with residents and "sign-out" activities. In this way, residents receive daily feedback on their interpretations of case material. Residents are assisted by attending staff in preparation of coagulation presentations for laboratory rounds and for the technical staff and receive feedback on their presentations. Residents are evaluated on a monthly basis with regard to competency areas. Evaluations are reviewed with the resident and then forwarded to the Residency Program Director, where they are available for review.