Clinical Pathology Program

Blood Bank/Transfusion Medicine

 

Rotation Director:
Melissa R. George, DO
 

Goals and Objectives:

The general goal of the Blood Bank/Transfusion Medicine rotation is to develop competence and expertise that will allow the resident to function as a blood bank/transfusion medicine medical director. By the end of the rotation the resident should be capable of assuming the position of Medical Director of the Blood Bank/Transfusion Medicine service in a moderate-sized community hospital. This requires that the resident become proficient in:

  • Immunohematology in the context of standard blood bank testing
  • Apheresis, including peripheral blood hematopoietic progenitor cell collection
  • Blood collection and the care of blood donors
  • Laboratory and apheresis instrumentation
  • Regulations pertaining to blood products, blood collection and processing
  • Blood bank inventory management

Additionally the resident must gain knowledge of blood bank laboratory testing, apheresis, basic hematology and coagulation, sufficient for satisfactory performance on the Clinical and Anatomic Pathology Board examinations.

The resident learning experience consists of a combination of service responsibilities, self-instruction, technical instruction, formal conferences and informal teaching during rounds with faculty.

The objectives of the rotation are encompassed by the six core competencies as defined by the ACGME and residents will be evaluated during their training in each of these areas.

Patient Care:

Residents must provide appropriate and effective consultation about transfusion medicine applications, including apheresis, component transfusions, and donor acceptability. Residents are expected to:

  • Be involved in patient care through direct patient contact and oversight of apheresis procedures, as well as acting as the principal liaison between the blood bank and clinical services.
  • Learn the scope and limitations of immunohematology tests and discuss them with requesting and interpreting physician staff.
  • Learn to interpret relevant lab results and integrate patient history into the diagnosis and make appropriate recommendations regarding the administration and selection of blood components and appropriateness of apheresis therapy.
  • Initiate consultations with, but are not limited to:
    • Medical or house staff inquiries or problems
    • Requests for apheresis therapy
    • Transfusion reactions
    • Donor reactions
    • Test interpretation issues
    • Requests for tests performed at a reference laboratory

Medical Knowledge:

Residents must demonstrate knowledge about established and evolving best practices in transfusion medicine and apply them to the practice of transfusion medicine services. Residents are expected to:

  • Observe blood bank procedures at the bench and understand the immunohematologic principles behind the testing. The recommended procedures to observe are outlined in the Bench Rotation Checklist.
  • Read recommended scientific literature and protocols provided in the blood bank rotation guide and discuss their content during regular, informal meetings with the medical director or attending of the day.
  • Work through CAP checklist for the blood banking section and FACT checklist for apheresis, to supplement the resident's knowledge of laboratory methodologies providing them with exposure to regulatory and lab management issues necessary to help prepare the resident for being a future laboratory director.

Practice-based Learning and Improvement:

Residents must demonstrate the ability to evaluate and improve clinical practices based on new and evolving scientific evidence. Residents are expected to:

  • Use the current scientific literature and apply consensus recommendations to patients undergoing apheresis and blood component therapy
  • Utilize library, web-based, and other education sources for self-study, trouble-shooting and to help answer clinical/technical questions
  • Participate in clinical conferences, be aware of new testing being introduced into the laboratory
  • Serve as consultants to requesting physicians regarding applications of transfusion medicine to optimize patient outcomes
  • Arrange for effective clinical care efficiently according to established protocols
  • Utilize performance evaluations to improve practice
  • Engage in "lifelong" learning through critical review and assimilation of scientific studies related to specific transfusion medicine challenges
  • Facilitate learning of medical students, residents and fellows (within and outside the Pathology department), and other health care professionals with regard to blood banking and transfusion medicine services

Systems-based Learning:

Residents must be aware of the importance of transfusion medicine in the larger context of the health care system and be able to call on system resources to help respond to needs as they emerge ensuring appropriate transfusion medicine services to provide optimal patient care. The resident is expected to:

  • Approach blood banking/transfusion medicine in the greater context of the particular patient's medical care and hematologic needs
  • Understand the optimization of workflow in the laboratory and computer information systems and EMR as a means to efficiently and accurately obtain clinical information
  • Participate in quality control, quality assurance, and proficiency testing to gain an understanding of the regulatory environment in medical laboratories
  • Participate in meetings pertaining to the business aspects of the laboratory, such as weighing options to obtain laboratory instrumentation (i.e., purchasing, reagent rental or leasing)
  • Demonstrate understanding of the role of the clinical laboratory in the health care system
  • Demonstrate the ability to design resource-effective diagnostic plans based on knowledge of best practices in collaboration with other clinicians to provide cost-effective services without compromising patient care
  • Demonstrate knowledge of basic health care reimbursement methods and transfusion service management as it related to other health care professionals, organizations, and society
  • Demonstrate knowledge of the laboratory regulatory environment
  • Understand policies and systems to continually improve patient safety as they relate to clinical laboratory testing at all levels acting as an advocate for quality patient care

Interpersonal and Communication Skills:

Residents must be able demonstrate interpersonal and communication skills that result in effective information exchange and learning with other health care professionals, patients and patients' family or other representatives. Residents are expected to:

  • Exhibit effective listening skills, follow verbal instructions and written standard operating procedures
  • Interact with laboratory staff, departmental faculty, fellow residents and other health care providers and administrators in an effective and professional manner
  • Work effectively as a team member with other health care professionals and staff
  • Answer questions pertaining to blood components, blood testing, apheresis procedures and to utilize appropriate resources to make appropriate recommendations to clinicians, including
    • Writing comprehensive, concise consultation notes
    • Being proactive about keeping all providers involved in a patient's care informed
    • Using effective and appropriate means of communication
    • Helping others understand transfusion medicine concepts
    • Accurately communicate information by presenting laboratory data in an organized, coherent fashion, with well-constructed presentation materials

Professionalism:

Residents must conduct themselves in a professional manner when interacting with patients, donors, laboratory personnel, nurses, and medical staff. They must be committed to fulfilling their professional responsibilities abiding by ethical principles and sensitivity to diverse patient populations. Residents are expected to:

  • Demonstrate a commitment to excellence and ongoing professional development
  • Adhere to ethical principles pertaining to confidentiality of patient information, informed consent and business practices at all times
  • Adhere to guidelines and regulations set forth by regulatory and accrediting agencies
  • Demonstrate compassion and integrity in all interactions with patients, their families, faculty, other trainees, technologists, and other staff
  • Practice positive work habits; punctuality, dependability, and professional appearance
  • Attend all required conferences and actively participate in them to enhance individual and group learning
  • Be respectful of patients, and those involved in their care
  • Be an active listener
  • Be able to identify deficiencies in peer performance and address them in a constructive manner to ensure appropriate patient care and safety
  • Demonstrate sensitivity and responsiveness to ethnicity, diversity, age, gender, sexual orientation, and disabilities of patients, colleagues , and staff and interacting with them without discrimination
  • Demonstrate responsiveness to the needs of patients that supersedes self-interest

 

Requirements:

  • Level of training: PGY-1 through PGY-4
     

Duration and Timing of the Rotations:

  • Combined AP/CP residency training, core rotations include:
    • 5 Blood Bank 4-week rotations
      • 4 Blood Bank/Apheresis (BB/TM)
      • 1 combined Blood Banking Bench/Histocompatibility typing rotation (BBB/HLA) 4-week rotation
  • CP only resident training:
    • 5 Blood Bank 4-week rotations
      • 4 Blood Bank/Apheresis (BB/TM)
      • 1 combined Blood Banking Bench/Histocompatibility typing rotation (BBB/HLA) 4-week rotation
  • Ideally, the Blood Bank Bench/HLA rotation would be scheduled first to give the resident exposure to elements of immunohematology that he/she will build upon in subsequent rotations. If this is not possible, coordination with the blood bank fellow, discussions with the medical director or clinical pathology attending of the day and recommended readings will allow the resident to get the necessary exposure to immunohematology.


Teaching Faculty and Staff:

Clinical Pathology Faculty:

  • William Castellani, MD
  • Michael Creer, MD
  • Ronald E. Domen, MD
  • Keri Donaldson, MD, PhD
  • Melissa R. George, DO
  • Hiroko Shike, MD

Blood Bank Technical Supervisor:

  • Jerry Davis, MT(ASCP)SBB

Apheresis Charge Nurse:

  • Linda Bears, RN,HP(ASCP)

Quality Coordinator:

  • Christine Kerr, MLT(ASCP)


Components:

On the first day of the rotation the resident should meet with the Medical Director to review his/her prior progress and the responsibilities and expectations for the resident on the current rotation. The resident is expected to have reviewed this description prior to beginning the rotation.

The blood bank rotation is structured as a "full-immersion" experience, exposing the resident to apheresis, immunohematology, blood collection, donor care, regulations and laboratory management as pertinent issues arise. The resident will have protected time to spend time observing in the laboratory. Graduated responsibility in the blood bank rotation is mainly a matter of working with the blood bank fellow and attendings to develop a greater level of independence in thought and daily actions. The resident is expected to act independently according to the resident's level of experience and expertise. A Clinical Pathology attending will be available for consultation and guidance. The resident is expected to make decisions as a learning experience; resident decisions will be reviewed during daily sign-out sessions and informally throughout the day.

Advanced rotations/projects can be arranged with the Medical Director's approval in advance. The goals, expectations and responsibilities for advanced elective rotations will be defined on an individual basis before approval is granted.


Logistics:

The resident will coordinate with Blood Bank chief technologist (Jerry Davis, MT(ASCP)SBB) and with the blood bank technologists of the day to set up times to observe technical procedures within the Blood Bank. The resident will work with the apheresis nurses to gain exposure to the technical aspects of apheresis including apheresis instrument set-up and basic operation. Observing the set-up and developing a basic understanding of apheresis instrument operation is required. The resident will coordinate with the rotation director/ attending of the day to arrange time to discuss transfusion medicine topics. A junior resident starting the blood bank rotation will have instruction/oversight in writing orders from the blood bank fellow or a senior resident.


Daily Service Activities and Responsibilities:

Apheresis Service

Initial evaluation of patients who are candidates for therapeutic apheresis is a primary activity for the Blood Bank resident. This includes: review of patient problem; preparation of initial draft of consultation report and review with the fellow and attending; determining apheresis protocol to be used and methods to evaluate patient response to therapy.

The resident will:

  • Obtain informed consent for therapeutic apheresis from patients.
  • Schedule therapeutic apheresis procedures with apheresis personnel.
  • Complete therapeutic apheresis worksheets and write the detailed orders for the apheresis procedure.
  • Evaluate patient pre-procedure and document procedure/"SOAP" note.
  • Evaluate and manage patient reactions during therapeutic apheresis.
  • Monitor and evaluate patient response to therapeutic apheresis

Immunohematology (consists of Blood Bank testing on patient specimens, including: blood typing; pretransfusion testing (compatibility testing); serum antibody screening; prenatal testing; and cord blood evaluations)

  • Provide consultation and support to technical and clerical staff concerning specimen and requisition acceptability.
  • Review and interpret: blood typing discrepancies; positive antibody screens; antibody panels; prenatal titers; positive direct antiglobulin tests. Consult with the attending physician and resident staffs as necessary.
  • Provide consultation to technical staff concerning additional evaluation of patients with complex serologic problems. Review clinical significance of serologic findings and decide on additional testing required prior to transfusion.
  • Determine risks of transfusion in: patients with complex serologic problems; and, patients who require transfusion before routine serologic testing can be completed. Provide consultation to attending physician and resident staffs as indicated.

Blood Component Preparation and Transfusion

  • Evaluate and approve requests for selected and specialized blood components, including washed red cells, deglycerolized red cells, and HLA-matched platelet concentrate.
  • Evaluate and approve requests for components from specific donors, including directed whole blood donations and family-donor apheresis platelets.
  • Provide consultation to supervisory and technical personnel on maintaining adequate inventory of all blood components. In times of limited inventory, provide interface to attending physician and resident staffs on requests for those components in short supply.


Transfusion Reaction Evaluation

  • Review initial workup of all transfusion reactions reported to the Blood Bank. Determine additional evaluation required and prepare a written interpretation for review and discussion with the attending. Provide consultation to attending physician and resident staffs as indicated.


Daily Work and Teaching Rounds

  • Under supervision of the fellow, the resident has responsibility for drafting interpretative reports for transfusion reaction evaluations, antibody identifications and requests for specialized components or services.
     

Reading Lists

  • Required
    • Petrides M, Stack G et al.: Practical Guide to Transfusion Medicine, 2nd Ed, Bethesda, MD: AABB Press, 2007.
    • Harmening DM:  Modern Blood Banking & Transfusion Practices, 5th Ed, F.A. Davis Company, Philadelphia, 2005.
    • Journal of Clinical Apheresis 2010 Guidelines – electronic copy.
    • McLeod BC. Et al:  Apheresis: Principles and Practice, AABB Press, Bethesda, MD, 1997.
    • Popovsky, MA:  Transfusion Reactions, 3rd Ed, AABB Press, Bethesda, MD, 2007.
    • Mais, D:  Quick Compendium of Clinical Pathology, ASCP Press (most recent edition).
    • Cbbsweb.org (California Blood Banking Society website - information on policies, procedures and practical blood bank advice.
  • Supplemental
    • Hillyer CD, Shaz BH et al.: Transfusion Medicine and Hemostasis: Clinical and Laboratory Aspects. Elsevier, 2009.
    • Klein HG, Anstee, DJ (Ed): Mollison's Blood Transfusion in Clinical Medicine (11th Ed.), Blackwell, 2005.
    • Bloodbankguy.com (Osler notes and transfusion reaction guides).
  • References
    • Standards for Blood Banks and Transfusion Services. Bethesda, MD: American Association of Blood Banks (The "Standards" are the regulations under which the Blood Bank and Transfusion Service operates. The resident should be familiar with the major regulations by the end of the basic rotation. A new edition is published every 1-2 years. Current edition is available electronically).
    • Technical Manual. Bethesda, MD: American Association of Blood Banks. (The Technical Manual is a compendium of technical suggestions and guidelines compiled by the American Association of Blood Banks. This reference contains explicit instructions for most procedures and practical discussions of approaches to resolving serologic problems. The resident should consult this reference frequently during technical instruction. Current edition is available electronically).
    • Code of Federal Regulations, Title 21 Part 600. (Contains FDA regulations that pertain to blood banking. Current edition is available online).
  • Journals (All available electronically through library)
    • Transfusion
    • Journal of Clinical Apheresis
    • American Journal of Clinical Pathology
    • Blood
    • Vox Sanguinis
  • Method(s) of Evaluation:
  • Residents will be evaluated based on direct observation by faculty
  • After each rotation, residents will be evaluated by faculty in New Innovations

Updated:  6/2011 MRG