TRANSFUSION MEDICINE & HEMOSTASIS & THROMBOSIS

Supervisors:

Richard (Mick) Scanlan, M.D, Associate Professor, Director of Transfusion Medicine;
Lynn Boshkov, M.D., Professor, Director of Hemostasis and Thrombosis;
Tom DeLoughery, MD, Professor, Hematology Oncology

Location:

Formal Transfusion Medicine and Hemostasis & Thrombosis clinical training and experience is provided at:

Primary Training Site:
Oregon Health & Science University
3181 SW Sam Jackson Park Rd.
Portland, OR 97239-3098

Field Sites:
American Red Cross Pacific Northwest Blood Services
3131 N Vancouver Blvd.
Portland, OR 97217

American Red Cross National Testing Laboratory
12124 NE Ainsworth Cir
Portland, OR 97220

Duration:

The rotation in Transfusion Medicine and Hemostasis & Thrombosis is three months.

Goals and Objectives:

Transfusion Medicine and Hemostasis & Thrombosis Medicine Rotation Goal

The overall goal of the Transfusion Medicine and Hemostasis rotation is to provide the resident with a set of tools that will enable him or her to develop and maintain expertise in transfusion medicine and clinical coagulation appropriate to the professional responsibilities required of a practicing pathologist. These range from an understanding the biochemistry behind the immunohematologic and hemostatic systems to full direction of clinical coagulation and transfusion laboratories. These tools will include basic background information in transfusion and hemostasis, major disorders encountered in clinical practice, an understanding of the most common assays used in assessing patients, clinical interpretation of assays, quality assurance, laboratory management, development of effective personal reference tools (textbooks, journals, files, databases, search strategies, etc.). Opportunities will be provided to become proficient through employing these tools in the clinical laboratory setting. The goals and objectives are presented below, organized by the general competencies defined by the Accreditation Council for Graduate Medical Education (ACGME) and the Pathology Residency Review Committee (RRC).

Patient Care
The resident will demonstrate ability to:

• Gather relevant clinical information relating to transfusion history, bleeding and thrombosis
• Interpret laboratory test results within the clinical context
• Advise clinicians on clinically appropriate and cost-effective use and monitoring of blood components for transfusion therapy
• Advise clinicians on the diagnosis and management of various immunohematologic disorders, including those related to pregnancy, solid organ, and hematopoietic stem cell transplantation
• Advise clinicians on the use of alternatives to conventional transfusion therapy
• Advise clinicians on appropriate follow-up for unexpected coagulation test results
• Explain the current infectious and non-infectious risks and potential adverse events related to transfusion therapy, and advise clinicians on their appropriate management
• Help the clinical team manage patients experiencing massive hemorrhage
• Understand the appropriate indications for therapeutic apheresis and phlebotomy
• Understand the risks and management of adverse reactions that may occur during blood donation
• Interpret clinical coagulation laboratory test results within the clinical context
  
  

Medical Knowledge
The resident will demonstrate:

• Knowledge of basic principles of immunology, hematology, biochemistry, and genetics required for an understanding of transfusion medicine and hemostasis and coagulation
• Knowledge of blood component preparation, storage, processing, and modification
• Knowledge of the metabolic and hemostatic complications of massive blood transfusion
• An understanding of the basic principles of apheresis technology
• A basic understanding of clinically significant blood cell antigens and antibodies
• Ability to understand the basic principles and evaluate medical evidence regarding the utility of various blood bank assays related to compatibility testing, immunohematologic diagnosis, and infectious disease testing
• Knowledge of common clinical coagulation tests and their medical application and correlation
• Knowledge of the effects of disease, drugs, matrix and pre-analytical variables on coagulation test results
• Ability to collect and evaluate medical evidence regarding the utility of laboratory tests
• Ability to use a variety of resources to investigate clinical questions
  
  

Practice-Based Learning and Improvement
The resident will demonstrate:

• Development of a personal strategy to regularly maintain and update medical knowledge·
• Understanding and ability to apply the principles of quality control and quality assurance
• Ability to evaluate current and proposed testing methods for analytical performance, clinical utility and cost-effectiveness
• Use of proficiency-testing results to improve laboratory practice
• Ability to use laboratory problems and clinical inquiries to identify process improvements that may minimize opportunities for medical errors

Interpersonal and Communication Skills
The resident will demonstrate:

• Ability to communicate clearly and effectively with the primary patient care team, medical technologists and other medical personnel
• Ability to use appropriate modes of communication (direct, telephone, e-mail, written)
• Ability to prepare and deliver effective presentations
  
  

Professionalism
The resident will demonstrate:

• Knowledge and understanding of ethical and privacy issues affecting the clinical laboratory
• Maintenance of confidentiality of patient information
• Respectful behavior towards all patients and medical personnel
• Prompt and courteous response to all pager and telephone calls
• Regular, punctual attendance and participation in rounds, conferences, meetings and rotation responsibilities
  
  

Systems-based Practice
The resident will demonstrate:

• Understanding of the role of the transfusion and coagulation services in the health care system, and the importance of reliable, cost-effective and timely provision of blood components and laboratory test results in patient care and clinical decision-making
• Ability to work with clinicians, administrators and others to determine the role of the transfusion service laboratory in specific situations to optimize patient outcomes
• Understanding of CLIA, CAP and JCAHO requirements for transfusion service laboratories
• Understanding of basic laboratory reimbursement mechanisms and regulatory requirements
• Ability to do cost analysis of blood services, transportation, and laboratory tests
  

Graduated Responsibility, Supervision and Evaluation:

First Month:

• Learn practical methods in Immunohematology by spending time in the Transfusion Service under the supervision of the Transfusion Service Technical Staff.
• Learn practical methods in Hemostasis & Thrombosis by spending time in the Hemostasis & Thrombosis lab under the supervision of the Hemostasis & Thrombosis Technical Staff.
• Develop facility with the use of the Transfusion Service (Hemocare), Clinical Laboratory (Ultra), Hospital Clinical Information Systems (SMS-A2K), and Tamtron.
• Be familiar with clinical circumstances of problem patients being treated by the Transfusion Service and Hemostasis & Thrombosis Service and be able to present their cases at morning rounds.
• Learn practical methods for diagnosing and supporting patients undergoing massive transfusion.

Second Month:

• The Residents will familiarize themselves with the CAP checklist under the coordination of the Staff and Medical Director.
• Residents will directly observe patient transfusions in order to learn proper technique for patient identification and administration of blood products and will conduct at least 3 direct observations of transfusions.
• Residents will begin to consult with other house staff and attending staff in a variety of clinical situations, evaluate patients in both in-patient and out-patient areas, write progress notes and formal consultations in the medical record, and speak directly with patients and donors concerning transfusion medicine and hemostasis & thrombosis issues.
• Residents will visit briefly the American Red Cross Pacific Northwest Regional Blood Service, and American Red Cross National Testing Laboratories and become familiar with issues regarding donor eligibility, donor aphaeresis, component preparation, and donor infectious disease testing.
  
  

Third Month:

• Residents will increasingly consult on transfusion medicine and hemostasis & thrombosis issues.
• Residents are expected to undertake an educational project related to transfusion medicine, under the supervision of the Director of the Transfusion Service.
• Residents will present their project to the Director at the end of their rotation.
  
  

All Months:

• Residents are expected to attend patient rounds with the Transfusion Service and Hemostasis & Thrombosis staff, and to have reviewed each case beforehand, including transfusion reactions, coagulation issues, reference workups and component usage problems.
• With the cooperation of the Transfusion Medicine and Hemostasis & Thrombosis Service Staff, residents are expected to be able to take night or weekend call for the Transfusion Service and Hemostasis & Thrombosis after completing the Clinical Pathology Core Curriculum and documenting the interaction on Transfusion Medicine Evaluation Forms.
  
  

Call Responsibility:

• During routine working hours, this resident on service has primary responsibility for Transfusion Service and Hemostasis & Thrombosis coverage.
• One resident is on each weekday night and provides basic support to the Clinical Pathology laboratories.
• One resident takes weekend call and covers Friday evening to Monday morning.
• Evening call is similar to weekday night call. Staff backup is readily available and weekend call is taken from home and long-range beepers are provided.

Evaluations

• Residents are evaluated formally at the end of each monthly rotation. These evaluations are communicated both verbally and in writing
• Residents must also complete the formative competencies listed below by the end of their third month on the service.

Formative Competencies requiring Staff Signature

Transfusion Medicine/Hemostasis and Thrombosis 3 months
Skill level I (First 1-2 months)	Competency Fulfilled
Serologic Testing (MK) Demonstrates a working understanding of tests used in the transfusion service by successfully completing a course on serologic testing under the supervision of technical staff and passing quiz.
Component Therapy (MK, SBP) Demonstrates a working understanding of the uses and indications for various blood components and demonstrates ability to properly conduct Blood Utilization Review.
Blood Administration (PC, MK, ICS, SBP) Demonstrates a working understanding of the policies and procedures used in the administration of blood and completes three Direct Observations of Transfusions.
Adverse Consequences of Transfusion (PC, MK, IPC) Has a working knowledge of infectious and non-infectious complications of transfusion and is able to independently direct routine transfusion reaction workups, complete the evaluation, and communicate the findings to the clinical team.
Hemostasis Monitoring (PC) Demonstrates a working knowledge of the use and interpretation of common coagulation tests used in the diagnosis and management of hemostatic and thrombotic disorders.
Skill level II (3^rd month)	Competency Fulfilled
Complex Reporting (PC, MK, ICS) Demonstrates ability to workup and report out complex transfusion and coagulation problems (e.g., certain difficult transfusion reactions, platelet refractory workups, complex serologic problems, Heparin induced Thrombocytopenia, etc)
Complex Clinical Consultations (PC, MK, ICS) Working with the transfusion service attending, resident demonstrates ability to consult and helps manage patients with complex medical problems (e.g., organ and bone marrow transplants, platelet refractory patients, ECMO, obstetric hemorrhage, inherited disorders of coagulation, heparin induced thrombocytopenia, etc.)
Massive Transfusion Protocol (PC, MK, ICS, PBL, SBP) Functions independently, managing patients with massive hemorrhage using appropriate laboratory monitoring and selection of blood components appropriate to the situation.
Management of Donor Reactions (PC, MK, ICS) Demonstrates ability to correctly diagnose and understands management of adverse reactions to blood donation.