Transfusion Medicine

Goals and Objectives

By the end of the rotation in transfusion medicine, Residents will demonstrate the ability to:

Patient Care

• Understand the principles of proper transfusion administration, and the critical importance of proper patient identification according to written blood administration protocols
• Understand all aspects of specimen accessioning in the Blood Bank
• Appreciate the risks and benefits of transfusion therapy and understand the concept of optimizing transfusion therapy to maximize clinical utility
• Monitor patients undergoing transfusion therapy and recognize the occurrence of adverse reactions and understand how these are reported and evaluated in the Blood Bank.
• Participate as appropriate in recommendations for therapeutic interventions for adverse reactions to transfusion of blood and blood components
• Review atypical serologic investigations and appreciate the clinical implications.
• Evaluate and monitor patients undergoing therapeutic apheresis and stem cell donation prior to and during the procedure.
• Evaluate and monitor donors undergoing autologous red cell and allogeneic platelet and stem cell donation prior to and during collection.
• Be able to participate in the management of emergency situations that may arise in the Donor Room.

Medical Knowledge

• Understand the principles of immunohematology in order to learn the principles involved in the performance of compatibility testing and associated applications including: the importance of the clerical check to insure proper patient identification; knowledge of the major erythrocyte blood group antigen systems; understanding of testing procedures including fundamentals of ABO and Rh blood grouping techniques; principles of the major and minor crossmatch, serologic and electronic (computer) crossmatch, and, antibody screening procedure for the identification of irregular antibodies; the application of erythrocyte panels in the identification of irregular antibodies; helping to direct the application of various techniques in the identification of irregular antibodies including use of Gel, LISS, PEG, homozygous testing cells and enzyme treated cells; understanding the procedures employed in evaluating a specimen exhibiting a positive direct antiglobulin test including the use of mono and polyspecific anti-human globulin reagents and techniques for antibody elutions when clinically indicated; understanding the indications for and procedures utilized in the performance of antibody titrations and methods to detect and quantitate fetal-maternal hemorrhage; the principles of the in vivo crossmatch procedure in situations where compatible blood is difficult to obtain; the laboratory and technical procedures employed in the identification and evaluation of a suspected transfusion reaction.

• Understand the fundamentals of blood component handling and processing including: indications and dosage calculations for use of blood components in adults and children including, RBCs, plasma, platelets and cryoprecipitate; indications and the techniques for washing red blood cells and platelets; the steps employed in proper thawing and storage of fresh frozen plasma; and in the proper thawing, pooling and storage of cryoprecipitate; the steps employed in the handling, pooling and appropriate storage of platelets; the principles, techniques and applications of blood irradiation in the prevention of transfusion-associated graft versus host disease; the utility of pre-storage leukocyte-reduced blood for the removal of the CMV virus and reduction in the occurrence ofHLA alloimmunization; the overall impact of the HLA system on transfusion medicine practices; the steps involved in blood and blood component administration including the identification procedure, the nature of IV access, compatible fluids, appropriate filtration, application of a blood warming device as indicated, duration of the transfusion and proper documentation.

Practice-Based Learning and Improvement

• Perform literature searches correlating pertinent scientific information from publications and textbooks with clinical problems and case consultations.
• Complete written assessment forms, which are reviewed by the Blood Bank-Transfusion Medicine Attending, for all 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.
• Learn from presenting cases to the Blood Bank-Transfusion Medicine Attending and Fellow or Senior Resident, as appropriate at daily teaching rounds.
• Participate in daily Morning Report to review critical and clinically significant events occurring during the prior 24 hours
• Present case summaries and participate in discussions, as appropriate, at clinical conferences.
• Use clinical cases as a starting point to initiate focused, scholarly investigations for presentation at Departmental Conferences and selectively, at local and regional and national meetings. 

Interpersonal and Communication Skills 

• Serve as mentor for other residents at the initiation of the Blood Bank-Transfusion Medicine Rotation.
• Obtain informed consent for therapeutic apheresis procedures
• Meet daily with patients and family members during patient's course of therapeutic apheresis therapy
• Interact with autologous phlebotomy and platelet apheresis donors
• Serve as the interface and liaison between the Blood Bank and Donor Apheresis Center staffs, the clinical nursing staff and c!inical housestaff
• Interface with outside blood supply vendors and reference laboratories
• 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-Blood Bank attending
• Attend indicated meetings, arriving punctually

Systems-Based Practice 

• Understand the principles of inventory management as it relates to the operation of a Blood Bank.
• Understand the utility of a computer data management system for the retrieval of patient information.
• Participating in monthly Blood Bank Administrative and Process Improvement meetings.
• Participating in quarterly Transfusion Committee meetings as possible.
• Participating in monthly Blood Bank-Transfusion Medicine Breakfast meetings held at the Northern Ohio American Red Cross.
• Helping to deal with issues of blood inventory management such as times when there is insufficient blood and/or blood products to meet clinical needs.
• Addressing ethical issues in transfusion management such as the futile use of large
• amounts of blood and blood products in patients, especially those of blood group O, who are clinically beyond recovery.
• Understanding, and addressing as indicated, the risks and benefits of transfusion therapy.
• Helping to participate, as indicated, in the FDA-mandated lookback and BPDR programs.
• Know the fundamentals of accreditation requirements for blood banks, as put forth by the American Association of Blood Banks.

Duration

The rotation in Transfusion Medicine is three months in duration, which may be completed in a single block or more often in a 2-month block followed by a one month-block

Duties and Responsibilities of Residents by Year

During the rotation in Transfusion Medicine, the Resident is expected to perform the following duties:

First and Second Months:

• Incoming Residents are expected to learn practical methods in Immunohematology by spending time in the Blood Bank under the supervision of the Blood Bank Technical Staff.
• Residents are expected to develop facility with the use of the Blood Bank Patient Information System.
• Residents are expected to attend the daily activities of the Donor Room-Apheresis Center, in order to learn proper technique for the administration of blood products, specimen accessioning and component preparation.

Third Month:

• The Residents will perform a mock accreditation inspection according to the AABB protocol under the coordination of the Staff of the Blood Bank and Donor-Apheresis Center.
• Residents are expected to undertake an educational project related to transfusion medicine, under the supervision of the Director of the Blood Bank

All Months:

• With the cooperation of the Blood Bank Staff, Residents are expected to be able to take night or weekend call for the Blood Bank after completing the Clinical Pathology Core Curriculum, documenting the interaction on Transfusion Medicine Evaluation Forms.
• Evaluate all requests for therapeutic plasma exchange in consultation with the clinical team, obtains informed consent from the patient or appropriate family members, writes orders, prepares a clinical consultation note for the chart according to the department therapeutic plasma exchange checklist, coordinates with the Blood Bank and Donor Center the amount and type of replacement fluid and follows daily each patient's clinical and laboratory response.
• Evaluate requests for leukapheresis plateletcytapheresis, or Prosorba column immunoadsorption in the same manner as therapeutic plasma exchange.
• Evaluate and approve as needed, in consultation with the ordering physician, autologous phlebotomy procedures from donor-patients with questionable medical histories and/or physical exams.
• Evaluate and approve as needed, allogeneic apheresis collections (platelets and granulocytes) from donors with questionable medical histories and/or physical exams.
• Evaluate, makes recommendations and approves as needed, in consultation with the clinical team and appropriate blood supplier, the use of granulocyte transfusion therapy; HLA and/or crossmatched compatible platelets; frozen, deglycerolized and/or washed blood; solvent-detergent treated plasma; and other specialized blood components.
• Provide on-call telephone coverage for review and evaluation of all suspected transfusion reactions reported to the blood bank. Responsible for preparing a written report after the completion of the work-up.
• Review and compile a written report in all instances of serologic investigations in which irregular antibodies are identified, positive direct Coombs test, antibody titration or other specialized immunohematological investigations are performed.
• Provide expertise to the clinical team in interpreting the clinical significance of these immunohematologic findings.
• 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 Blood Bank and clinical team patients exhibiting hemolysis in the setting
• of an ABO incompatible hematopoietic stem cell transplant.
• 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 thrombocytopcnia purpura, autoimmune hemolytic anemia, hemolytic disease of the newborn, liver failure and coagulopathies.
• Provide assistance in the decision to use least-incompatible or crossmatch incompatible blood in appropriate clinical settings such as a patient with life threatening autoimmune hemolytic anemia or alloimmunization with no compatible blood available.
• Provide assistance in the clinical application of erythrocyte and platelet-leukocyte reduction techniques to prevent febrile transfusion reactions, reduce HLA alloimmunization and reduce or prevent CMV transmission.
• Provides assistance in the decision, as needed, to utilize pooled random donor versus single donor apheresis platelets.
• Provide assistance in the interpretation oftests to detect fetal-maternal hemorrhage and assist in the determination of the appropriate dose of RH immune globulin.
• Provide assistance and guidance in the clinical decision to use RH+ RBCs or platelets in an RH- recipient.
• Residents are expected to attend patient rounds daily with the Blood Bank Attending, and to have reviewed each case beforehand, including transfusion reactions, reference workups and component usage problems.
• With the Attending Pathologist, Residents are expected to preview and address service issues in the Donor Room and Apheresis Center, including as indicated, donor cards, donor reactions, and issues related to therapeutic apheresis.

Teaching Staff

Katharine Downes, M.D. - Rotation Director

Robert Maitta, M.D., Ph.D.

Hollie Reeves, DO

Lan Zhou, M.D., Ph.D.

Marcella Pokorny, MT (ASCP)

Supervision and Evaluation

Residents meet on a regular basis with the Attending Pathologist and with the lead technologists for supervision.

The Staff will prepare a written evaluation of each Resident on the basis of the written examinations, and the performance of the Resident in each component of the rotation.

Residents are evaluated on a monthly basis with regard to attainment of core competencies in the rotation.

Evaluations are forwarded to the Residency Program Director, where they are available for review.