Texas Tech University Health Sciences Center
Department of Pathology
Resident Guidelines
VIII
Page 46
RE: Resident Responsibilities
Reviewed June 21, 2010
NAME OF ROTATION: Transfusion Medicine
YEAR(S) RESIDENCY ROTATION IS TAKEN AND DURATION: PGY I-IV. Five
months total.
SITES: University Medical Center (UMC), Covenant Health Systems, United Blood Services,
TTUHSC BMT and HLA laboratories
GOALS: The goal of this program is designed to teach residents how to provide care to the
patient and be able to consult with the attending physicians related to transfusion medicine.
Resident training should give the resident an understanding of Transfusion Medicine and a broad
based working knowledge regarding its practice in an academic setting. Upon completion, the
resident should have acquired the knowledge and skills to direct a hospital blood
bank/transfusion service or donation center.
OBJECTIVES:
I.
SKILL LEVEL IA: RECOMMEND 1 MONTH
Goal: Develop everyday experience in basic clinical laboratory medicine as it applies to
transfusion medicine.
A.
B.
Medical Knowledge: A schedule of didactic and practical laboratory experience
will be covered in order for the resident to:
1.
Learn the basics of immunohematology including the blood group systems
ABO, Rh, Le, P1, MNSs, Ii, Kell, Duffy, Kidd. This will include antigens
and immunology of the antibodies and their clinical significance.
2.
Understand basic test procedures involved in antigen typing, antibody
detection and antibody identification.
3.
Learn the official names of blood components, how they are prepared and
stored; their shelf life; preservation and anticoagulant solutions; labeling;
transport; their composition; indications for use; dosage; administration of
components.
4.
Be familiar with ordering practices for blood components, to include
MSBO, C: T ratio, monitoring activities required by JCAHO.
Patient Care: During the first rotation, the resident trainee will work in the
Transfusion Service department to broaden his/her knowledge of:
1.
Operations:
a.
Workflow
b.
Requisitions/logs
c.
Data entry and retrieval
d.
Procedure and Policy manuals
e.
Specimens
Texas Tech University Health Sciences Center
Department of Pathology
Resident Guidelines
VIII
Page 47
RE: Resident Responsibilities
Transfusion Medicine
Reviewed June 21, 2010
2.
C.
D.
E.
Procedures:
a.
ABO - Rh blood typing, cord and adult
b.
Direct antiglobulin testing, including IgG and C' differentiation
c.
Elution
d.
Antibody Screen (Indirect antiglobulin test)
e.
Antibody identification
f.
Use of ficin, PeG, LISS potentiators
g.
Cold agglutinins
h.
Typing for other antigens
i.
Compatibility testing (crossmatch)
3.
Blood Components:
a.
Storage/dating of all components
b.
Blood selection
c.
Anticoagulants/preservatives
d.
Indications for transfusion of each blood component
e.
MSBO, ordering practices, dosage of blood components
f.
Massive protocol
g.
Neonatal protocol
h.
Exchange transfusions/Intrauterine transfusions
i.
Uncrossmatched blood
j.
BMT protocol
Professionalism: Residents are expected to present themselves as medical
professionals and develop an effective laboratory management style. These
expectations should continue throughout the remainder of the residents’ rotations.
Interpersonal/communication skills: Interpersonal communication is of prime
importance in clinical pathology and residents must show proficiency in
interpersonal communication with the following members of the health care team:
1.
Medical technologists and medical laboratory technicians
2.
Laboratory supervisors
3.
Attending pathologists
4.
Clinical residents and/or attendings from whom consultations are
requested
Systems based practice: Interface with other services within the hospital and
understand federal regulations as they apply to the transfusion service. These
expectations should continue throughout the remainder of the residents’ rotations.
1.
Use of the laboratory computer system for order entry, data retrieval
2.
Review of proper safety requirements (OSHA)
3.
Understanding of basic concepts of laboratory medicine and federal
regulations as they apply to transfusion (CLIA, JCAHO, CAP, CMS,
HIPAA, FDA, AABB): proficiency testing, QC, quality management,
personnel qualifications, coding, procedures & policies, confidentiality, etc.
4.
Regular attendance of hospital transfusion committee meetings.
Texas Tech University Health Sciences Center
Department of Pathology
Resident Guidelines
VIII
Page 48
RE: Resident Responsibilities
Transfusion Medicine
Reviewed June 21, 2010
II.
SKILL LEVEL IB: RECOMMEND 1 MONTH
Goal: Expand on knowledge and experience in the transfusion service gained in the first
month.
A.
Medical Knowledge: The resident will broaden his/her knowledge base in
transfusion medicine to include the following areas:
1.
Review of Rh nomenclature (Weiner, Race)
2.
Typing discrepancies
3.
Understand the cause, prevention and treatment of hemolytic disease of
the newborn to include use of RhIG prophylaxis, antibody titers, bilirubin
scan, Liley curve, intrauterine transfusions, and exchange transfusions
HDN
4.
Implications of a positive direct antiglobulin test:
a.
Drug-induced
b.
Warm autoimmune hemolytic anemia
c.
Cold agglutinin disease, paroxysmal cold hemoglobinuria
5.
Indications for special attributes in blood components (irradiation,
leukoreduction, CMV negative, hemoglobin S negative)
6.
Blood component modifications and preparation for transfusion (low
volume platelets, thaw plasma, pool components, wash red cells, aliquots)
7.
Learn and understand the complications of hemotherapy, to include an
understanding of the etiology and pathogenesis of hemolytic reactions,
complement-mediated lytic and agglutinative reactions involving
leukocytes, including febrile reactions and non-cardiogenic pulmonary
edema, allergic, anaphylactoid, and anaphylactic reaction, endotoxic shock
due to blood contamination, hypervolemia and circulatory overload, air
embolism.
8.
Be familiar with the modes of acquisition of infectious diseases which
may be transmissible by infusion of blood products; the epidemiology,
etiology and pathogenesis, clinical and laboratory diagnosis, clinical
manifestations, to include: AIDS, hepatitis B and C, CMV, HTLV1 and 2,
syphilis, malaria, Leishmania, and Babesia.
9.
Become familiar with and understand the principals of technology used for
testing for infectious markers for transfusion transmissible agents, all
pertinent FDA and AABB regulations pertaining to the screening of
donors for such agents, criteria for exclusion of donors, criteria for
reinstatement of donors, notification and counseling of donors found
positive for such infectious markers; be familiar with the Look Back
program, and notification of patients who have received blood from
donors now found to be positive for HIV, HTLV1&2, and HCV.
Texas Tech University Health Sciences Center
Department of Pathology
Resident Guidelines
VIII
Page 49
RE: Resident Responsibilities
Transfusion Medicine
Reviewed June 21, 2010
10.
Understand the purpose, indications, and protocol for irradiation of blood
components for the prevention of GVHD.
11.
Be familiar with the purpose, methods/principals of leukoreduction to
include indications for leukoreduced blood products
Patient Care: Residents will continue to work in the transfusion service to learn
more advanced techniques in this area of clinical pathology, to include the
following:
1.
Fetal bleed screen (rosette test)
2.
Special techniques (neutralization, adsorption, titration)
3.
Resolution of compatibility testing problems
4.
Infusion of blood components
a.
Verification of recipient identification
b.
Consent for transfusion
c.
Infusion devices (blood warmers, filters, pumps)
d.
Infusion rate
e.
Vital signs/patient observation
f.
Outpatient transfusions
g.
Directed Donations
h.
Autologous Donations
i.
Predeposit
ii.
Perioperative
iii.
Normovolemic hemodilution
i.
Viral positive donations
B.
III.
SKILL LEVEL IIA: RECOMMEND 1 MONTH
Goal: During the third rotation, the resident trainee will work in the apheresis section
and at the donor center.
A.
Medical Knowledge:
1.
Be familiar with apheresis technique, equipment and applications to
include collection of products for transfusion, collection of peripheral
progenitor cells for transplant and therapeutic procedures.
2.
Criteria for selection of blood donors
3.
FDA required testing for blood components
4.
Indications and methods for therapeutic phlebotomy
Texas Tech University Health Sciences Center
Department of Pathology
Resident Guidelines
VIII
Page 50
RE: Resident Responsibilities
Transfusion Medicine
Reviewed June 21, 2010
B.
IV.
Patient Care:
1.
Apheresis
a.
Instrument
b.
Stem cell collection
c.
Therapeutic apheresis
2.
Donor Center
a.
Criteria for selection of donors
b.
Preparation of components
c.
Component labeling
d.
Donor apheresis
3.
Therapeutic phlebotomy
SKILL LEVEL IIB: RECOMMEND 2 MONTHS
Goal: The resident trainee will work in Transfusion Service, the BMT laboratory, and
the HLA laboratory to broaden exposure to handling of transfusion incidents, regulations,
bone marrow and peripheral stem cell transplantation and histocompatibility testing.
A.
Medical Knowledge:
1.
FDA reportable errors/events
2.
Sentinel events (JCAHO)
3.
CAP/AABB/FDA requirements, inspections and accreditation, including
cGMP
4.
Monitoring activities QI
5.
Understand the general principals of marrow and peripheral progenitor
cell transplantation to include the processing, handling,
cryopreservation/thaw and infusion of such products; be aware of FAHCT
regulations and accreditation; differentiate between related and unrelated
allogeneic and autologous transplants and cord blood transplants.
6.
B.
Be familiar with the principles of HLA antigen/antibody detection and
crossmatch; HLA involvement with renal and BMT transplantation.
Patient Care:
1.
Blood and Marrow Transplant laboratory
a.
Autologous program
b.
Processing/storage of peripheral progenitor cells
c.
Thawing and infusion of peripheral progenitor cells
d.
Allogeneic program
e.
Handling/infusion of progenitor cells
f.
Accreditation
Texas Tech University Health Sciences Center
Department of Pathology
Resident Guidelines
VIII
Page 51
RE: Resident Responsibilities
Transfusion Medicine
Reviewed June 21, 2010
2.
Histocompatibility laboratory:
a.
T and B Cell Isolation
b.
Typing techniques
c.
Crossmatching Serology
d.
MLC
e.
Renal Transplant Program
f.
Genotyping for BMT selection
DUTIES AND RESPONSIBILITIES OF RESIDENTS:
Initially the rotation will involve the resident becoming familiarized with the blood transfusion
laboratory including workflow, data entry and retrieval, procedure manuals, and the over-all
operation. Subsequently the resident will spend time at the bench with the technologists learning
aspects of crossmatching, antibody identification, and blood product preparation. The resident
will review all transfusion workups including antibodies, transfusion reactions or special product
requests. The resident will also act as a liaison between the clinicians and the laboratory after
having discussed the problem with the medical director. The resident will also be involved with
both inpatient and outpatient therapeutic phlebotomies. During the rotations, the resident will be
expected to completely review the AABB Technical Manual on a regular basis, each chapter in
the book will be discussed with the medical director. Over the course of the curriculum the
resident will be responsible for the presentation of any interesting case or problem to the medical
director which will involve a description of the case or pertinent medical problems as well as a
review of the literature on a weekly basis. Through United Blood Services, the resident will be
exposed to donor collections, selection, handling and processing of the donor units and become
involved with donor apheresis. Exposure to the apheresis service will involve understanding the
operation of the apheresis instrumentation, familiarity with the indications for therapeutic
apheresis and providing an information resource to the requesting physician. Time spent in the
TTUHSC HLA laboratory will involve the resident with all aspects of histocompatibility testing,
including its importance in organ and bone marrow/stem cell transplantation.
TEACHING STAFF RESPONSIBLE FOR SUPERVISION:
Dale M. Dunn, M.D.
Medical Director of Transfusion Service
Medical Director of HLA Laboratory
Texas Tech University Health Sciences Center
Department of Pathology
Resident Guidelines
VIII
Page 52
RE: Resident Responsibilities
Transfusion Medicine
Reviewed June 21, 2010
SUPERVISION AND EVALUATION:
Periodically during the rotation the resident will be given an assessment of his/her progress and
whether or not he/she is meeting expectations. The evaluation will be based on skill and
knowledge, timeliness and thoroughness of work, attendance, attitude, interaction with
professional and ancillary staff and conference presentation.
SUGGESTED TEXT:
Technical Manual by AABB, most recent edition.