Transfusion Medicine Rotation

Goals and Objectives

By completion of the rotation, the resident will have demonstrated competency in the following skills and demonstrate the ability to:

Patient Care

  • Understand and perform the role of the consultant in blood banking/transfusion medicine (BB/TM), including therapeutic apheresis and:
    • Perform timely, clinically useful consultation for requests for blood components, apheresis, transfusion reactions, and other immunohematology work-ups and evaluations
      • Observe and assists in apheresis consultation, including obtaining informed consent.
    • Effectively communicate consultative recommendations and action plans with the TM attending, clinical team, blood bank and/or apheresis staff
    • Prepare a consultative written report with comprehensive review of medical records on common and uncommon diseases
    • Evaluate, as requested in consultation with the clinical team, patients with refractory thrombocytopenia including HLA-alloimmunization, isoimmune neonatal thrombocytopenia and post-transfusion purpura. Coordinate special testing required to diagnose the etiology of the thrombocytopenia and the procurement as needed of specialized blood components,
  • Demonstrate knowledge of:
    • blood and blood component testing, preparation, storage, handling, and administration
    • indications for transfusion of different blood components and their dosing
    • transfusion requirements of special patient populations
    • potential side effects of neonatal whole-blood exchanges and massive transfusions in neonates associated with extracorporeal circuits
    • pathophysiology and treatment of neonatal alloimmune thrombocytopenia
    • general principles and risks of apheresis, including appropriate laboratory testing, replacement fluid, American Society for Apheresis (ASFA) category indications and relative and absolute contraindications
    • potential confounding factors that may contribute to erroneous results
  • Able to use the electronic medical record (EMR) and other electronic resources to obtain clinical information.
  • Describe, understand, and apply principles of transfusion therapy including:
    • proper transfusion administration and the critical importance of proper
    • patient identification according to written blood administration protocols
    • specimen identification, labeling, and recipient identification in transfusion
    • risks/benefits and how to optimize therapy based on recipient’s clinical status
    • monitoring patients undergoing transfusion therapy and recognizing adverse    reactions to blood and blood component transfusion, and understand how such reactions are reported, evaluated by Transfusion Medicine service and then participate as appropriate in developing recommendations for therapeutic interventions in management of adverse reactions
  • Evaluate autologous/allogeneic stem cell donors and apheresis patients prior to/during /after procedure, and generate written clinical notes of procedures for electronic record.
  • Assist in the management of emergency situations that may arise in the Donor Apheresis Center
  • Interface with clinical team to recommend tests, based upon current literature
  • Serve as a liaison between the Transfusion Medicine service and clinical teams.

Medical Knowledge

  • Describe and apply principles of immunohematology involved in the performance of compatibility testing and associated applications including:
    • the importance of clerical checks to insure proper patient identification
    • knowledge of major erythrocyte blood group antigen systems
    • understanding of testing procedures/methods including fundamentals of ABO and Rh blood grouping techniques
    • choice of cross match technique (major, minor, serologic, electronic (computer))
    • unexpected antibody detection screening and identification erythrocyte panels
    • various unexpected antibodies identification techniques (Gel, LISS, PEG, homozygous testing cells, enzyme treated cells)
    • positive Direct Antiglobulin Test evaluation using mono and polyspecific anti-human globulin reagents
    • techniques for antibody elutions when clinically indicated
    • indications for and procedures utilized in the performance of antibody titrations
    • methods to detect and quantitate fetal-maternal hemorrhage
    • laboratory and technical procedures employed in the identification and evaluation of a suspected transfusion reaction
  • Be involved in inventory management and triaging of component requests that may occur.
  • Be involved in inventory management and its interface with clinical transfusion therapy needs for individual patient
  • Know differential diagnosis of immunohematologic test result and primary clinical and laboratory factors that affect test results
  • Perform blood component indication review audit for platelets and cryoprecipitate dosing and red cell dosing as applicable
  • Demonstrate knowledge of:
    • blood component handling, storage, processing and administration fundamentals:
    • indications and dosage calculations for use of blood components in adults and children including, RBCs, plasma, platelets and cryoprecipitate
    • indications and techniques for washing red blood cells and platelets
    • steps employed in proper thawing and storage of  plasma and cryoprecipitate
    • steps employed in the handling, pooling and appropriate storage of platelets
    • principles, techniques and applications of blood irradiation to prevent transfusion-associated graft versus host disease
    • utility of pre-storage leukocyte-reduced blood for removal of CMV and HLA alloimmunization reduction
    • impact of the HLA system on transfusion medicine practices
    • pathophysiology and treatment of hemolytic disease of newborn and neonatal alloimmune thrombocytopenia
    • steps involved in blood and blood component administration including the identification procedure, type of IV access, compatible fluids, appropriate filtration, application of a blood warming device as indicated, duration of transfusion and proper documentation
    • current eligibility criteria for blood donors
    • various methods of blood conservation
    • and proficiency in evaluating patients refractory to platelet transfusion transfusion and with hemolytic anemia
    • indications for therapeutic phlebotomy and techniques of safe, sterile venipuncture
  • Evaluate all clinical service requests for therapeutic apheresis procedures (plasma exchange, red blood cell exchange, platelet depletion and white blood cell depletion) in consultation with the clinical team and transfusion medicine attending; obtain informed consent from the patient or appropriate family member, write orders, prepare a clinical consultation note for the chart, coordinate with the Blood Bank and Donor Apheresis Center amount/type of replacement fluid(s) and follow daily each patient's clinical and laboratory indicators.
  • Identify complications and risk of blood transfusion, apheresis therapy and hematopoeitic progenitor cell product donation and how they can be prevented
  • Demonstrate ability to interpret, synthesize, and summarize knowledge and teach across departments and at all levels, including to clinicians, patients, and families

Practice-Based Learning and Improvement

  • Analyze and appraise pertinent literature, identifies, interprets, and applies evidence-based medicine clinically
  • Perform literature searches, incorporate medical literature into presentations and lectures, correlating pertinent scientific information from current literature, publications and textbooks with clinical problems, case consultations and specific clinical presentations.
  • Recognize errors and discrepancies that may occur in Transfusion Medicine practices and displays attitudes, knowledge and practices that permit improvement
  • Present patient cases as appropriate at daily teaching rounds.
  • Perform concurrent and retrospective blood administration audits for University Hospitals Cleveland Medical Center and Rainbow, Babies, and Children’s Hospitals
  • Participate in daily Morning Report to review critical and clinically significant events occurring during the prior 24 hours
  • Participate in and present transfusion medicine resident Quality Assurance activities at Transfusion Medicine Monthly Quality Assurance meeting
  • Present case summaries and participate in discussions, as appropriate, at clinical conferences
  • Use clinical cases as a starting point to initiate focused, self-learning, scholarly investigations for presentation at Departmental Conferences and selectively, at local and regional and national meetings if Transfusion Medicine research is undertaken.
  • Recognize symptoms and signs and transfusion reactions and demonstrate knowledge of pathophysiology, treatment and prevention of such complications
  • Identify risks/complications from transfusion and blood donation and explain how they can be prevented

Interpersonal and Communication Skills 

  • Understands own role on Transfusion Medicine team, and flexibly contributes to team success through a willingness to assume appropriate roles as needed
  • Participates in Transfusion Medicine morning report to accomplish patient care
  • Helps to organize the Transfusion Medicine Team to facilitate optimal communication and co-education among its members
  • Demonstrates ability to lead Morning Report meeting to reach goals in management of Transfusion Medicine Service activities
  • Recognizes and understands pathologist’s role in the clinical team and the utility of communication with other members of the clinical team and Transfusion Medicine team
  • Participate where appropriate in multidisciplinary conferences related to the practice of Transfusion Medicine
  • Participate through observation and active interaction/interfacing with clinicians to obtain relevant clinical and/or radiologic data for consultative and interpretative reports and to narrow differential diagnosis and arrive at final diagnosis in Transfusion Reaction interpretation
  • Participate in or leads communication with the clinical team to contribute to patient care
  • Mentors other residents at the initiation of the Transfusion Medicine Rotation.
  • Obtain informed consent for therapeutic apheresis procedures
  • Meets patient and his/her family as appropriate and obtain informed consent for therapeutic procedures
  • Be aware of limitations of own knowledge, communicates such limitations, and seeks further knowledge and/or guidance as appropriate for such limitations
  • Generate initial consult for therapeutic apheresis
  • Generate interpretive reports and recognize the importance of timely production of a final diagnosis and the role it plays in patient care
  • Interact and interface routinely with clinical colleagues to formulate differential diagnosis and arrive at final diagnosis and/or treatment plan
  • Respond in timely manner to inquiries from clinical team to contribute to patient care
  • Effectively communicates clinically significant or unexpected values including critical values
  • Assess, analyze and interpret laboratory results and pathology reports in Transfusion Medicine and is able to discuss findings in consultation with clinical colleagues
  • Evaluate patient and write notes for patients undergoing therapeutic apheresis procedures
  • Evaluate patient and write notes for stem cell donor undergoing autologous or allogeneic collection
  • Serve as the interface and liaison between the Blood Bank and Donor Apheresis Center staffs, the clinical nursing staff and clinical house staff
  • Present briefly two journal articles –at morning report
  • Write consultative reports, procedure notes, immunohematologic diagnostic reports, and transfusion reaction investigation reports that provide clear, accurate, concise synthesis of clinicopathologic patient findings into comprehensive diagnosis
  • Interface and interact with outside blood supply vendors and reference laboratories
  • Interface and interact with other Pathology residents for weekend and evening call coverage

Professionalism

  • Maintain a clean and appropriate appearance
  • Act respectfully to all members of the laboratory, clinical healthcare teams, patients and family members
  • Answer pages promptly when on service and on-call
  • Attend to clinical duties as indicated and when instructed to do so by the Transfusion Medicine attending(s)
  • Follow-up on all Blood Bank and Donor Apheresis patient cases until case is signed out or treatment course completed, respectively
  • Attend indicated meetings, arriving punctually
  • Assist and be available to deal with any day-to-day operational activities requiring medical consultative input
  • Manages health and issues related to fatigue/sleep deprivation, especially in stressful conditions
  • Recognizes signs of impairment in self and others, and facilitates seeking appropriate help when needed
  • Gives, receives and accepts feedback constructively and modifies practice in response to feedback and exemplifies giving and receiving constructive feedback
  • Identifies, communicates and corrects errors
  • Demonstrates respect, compassion, and empathy even in difficult situations and promotes those in others
  • Puts the needs of each patient above his or her own interests
  • Demonstrates responsibility and follow-through on tasks by dependably completing assigned tasks in a timely manner, assisting team members when requested, and anticipates team needs and assist as needed and implement solutions
  • Encourages and actively seeks feedback to improve performance
  • Demonstrates responsiveness to each patient’s unique characteristics with cultural competency by identifying and avoiding biases and recognizing cultural differences that may affect clinical care

Systems-Based Practice 

  • Understand the principles of inventory management as it relates to the operation of a blood bank/ hospital transfusing service and assist in managing issues of blood component inventory at times when there are blood supplier shortage notifications or difficulty filling blood or blood component orders or insufficient blood and/or blood components to meet clinical needs.
  • Understand and apply policies and procedures in PHI as defined by HIPAA in management of patient cases and practice of Transfusion Medicine
  • Understand the utility of a computer data management system for the entry/retrieval of patient information.
  • Troubleshoot patient safety issues including pre-analytic, analytic, and post analytic as needed
  • Able to perform and interpret;
    • a cost-benefit analysis and to understand and describe the process of implementing new technology
    • charts and graphs that demonstrate blood component utilization patterns and intervene effectively in inappropriate utilization situations
  • Review and analyze proficiency testing results and demonstrates knowledge of proficiency testing and its consequences
  • Participate in meetings/conferences including:
  • Transfusion Medicine Monthly Quality Assurance meeting(s) and present resident associated Quality Assurance activities
  • Transfusion Committee meetings (quarterly), administrative, and process improvement meetings as possible.
  • Understand complexity of and how to address ethical issues in transfusion management such as the futile use of large amount of blood and blood components in patients, especially those of blood group O, who are clinically beyond recovery.
  • Understand and address, as indicated, the risks and benefits of transfusion therapy.
  • Help to participate, if indicated, in FDA-mandated lookback and BPDR programs.
  • Know the fundamentals of accreditation and regulatory requirements for blood banks, as put forth by the AABB/CAP and FDA, respectively.
  • Follow-up on critical Hemoglobin and Hematocrit calls to insure timely transfusion
  • Coordinate evaluate for and completion of send-out testing requests for Transfusion Medicine (platelet antibody work ups).

Duration

The Transfusion Medicine rotation is three months in duration (12 weeks), and is completed in four week blocks.

Duties and Responsibilities of Residents

During the Transfusion Medicine rotation, the resident is expected to perform the following duties and to:

  • Learn practical methods in immunohematology by spending time in the Blood Bank under the supervision of the Blood Bank Technical Staff.
  • Become familiar with the use of the hospital information systems (Lab/EMR)
  • Attend the daily activities of the Donor Apheresis Center
  • Attend daily morning report with the Transfusion Medicine Attending(s) and team, and to have reviewed each case beforehand, including transfusion reactions, reference workups, component usage problems and inventory management.
  • Attend immunohematology and transfusion reaction sign-out.
  • Speak with the attending immediately when notified of a new apheresis patient and must speak with the attending for each transfusion reaction immediately following notification, at the time of the reaction and for preparing a written report to be included in the patient’s electronic medical record once investigation is complete.
  • With the cooperation of Blood Bank Staff, residents are expected to be able to take night or weekend call for the Blood Bank after completing the Harry L Taylor IV MD Memorial Lecture Series, documenting the interaction(s) and calls on Transfusion Medicine Evaluation Forms.
  • Evaluate all requests from the clinical services for therapeutic apheresis procedures (plasma exchange, red blood cell exchange, platelet depletion and white blood cell depletion) in consultation with the clinical team and transfusion medicine attending ---obtain informed consent from the patient or appropriate family member, write orders, prepare a clinical consultation note for the chart, coordinate with the Blood Bank and Donor Apheresis Center amount/type of replacement fluid(s) and follow daily each patient's clinical and laboratory indicators.
  • Evaluate, make recommendations and approve as needed, in consultation with the clinical team, Transfusion Medicine attending and appropriate blood supplier, the use of granulocyte transfusion therapy; HLA and/or cross matched compatible platelets; frozen, deglycerolized and/or washed blood; and other specialized blood components.
  • Assist as need with Massive Transfusion Protocol
  • Review and compile a written report for serologic investigations in which unexpected antibodies are identified, positive direct antiglobulin test, antibody titration or when other specialized immunohematological investigations are performed.
  • Evaluate, as requested in consultation with the clinical team, patients with refractory thrombocytopenia including HLA-alloimmunization, isoimmune neonatal thrombocytopenia and post-transfusion purpura. Coordinate special testing required to diagnose the etiology of the thrombocytopenia and the procurement as needed of specialized blood components,
  • Evaluate, in consultation with the Blood Bank and clinical team, patients receiving unusually large quantities of blood and blood components over short time periods.
  • Evaluate, in consultation with the clinical team patients exhibiting signs of hemolysis post transfusion
  • Evaluate, in consultation with the Blood Bank and clinical team, the transfusion of patients with select clinical problems such as uremia, massive transfusion, shock, open-heart surgery, thrombotic thrombocytopenia purpura, hemolytic uremic syndrome, idiopathic thrombocytopenia purpura, autoimmune hemolytic anemia, hemolytic disease of the newborn, liver failure and coagulopathies.
  • Provide assistance in the:
    • Attending decision to use cross match incompatible blood in appropriate clinical settings such as a patient with life threatening autoimmune hemolytic anemia or alloimmunization with no compatible blood available.
    • Make decision, as needed, to utilize pooled random donor versus single donor apheresis platelets.
    • Interpretation of tests to detect fetal-maternal hemorrhage clinical decision to use RH+ RBCs or platelets in an RH- recipient.
  • Address in conjunction with the Transfusion Medicine attending service issues in the Donor Apheresis Center, as well as HPC donor collections, outpatient therapeutic apheresis consults and procedures and management of any adverse reactions.
  • Interpret tests to detect fetal-maternal hemorrhage and assist in determination of RH immune globulin appropriate dose.
  • Coordinate special testing required to diagnose the etiology of the thrombocytopenia and the procurement as needed of specialized blood components,
  • Perform blood administration audits (follow 5 different units of blood from issue to administration-at least 2 in RB&C and 3 from different UH locations; 10 retrospective chart copy audits)
  • Complete written assessment forms, which are reviewed by the Blood Bank-Transfusion Medicine Attending, for instances in which the Blood Bank or Donor Apheresis Center has contacted the resident to assist in problem solving and serving as an interface with a clinical service.

Teaching Staff

  • Katharine Downes, MD, Rotation Director
  • Robert Maitta, MD, PhD
  • Hollie Reeves, DO
  • Lan Zhou, MD, PhD
  • Xiangrong (Eric) He, MD
  • Marcella Pokorny, MT(ASCP), MBA, Manager
  • Anne Capetillo, MT (ASCP), Quality Assurance Coordinator
  • Victoria Cary, MT (ASCP), Technical Coordinator
  • Jamal Nofal, MT (ASCP), Technical Coordinator
  • Zamira Santiago, RN, Apheresis Coordinator

Supervision and Evaluation

Residents meet and interact daily with the Transfusion Medicine attending(s), apheresis staff, and with the lead technologists for supervision. Residents are evaluated on a monthly basis with regard to attainment of core competencies in the rotation using the MyEvaluations system which are then forwarded to the Residency Program Director, where they are available for review.

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