University of Cincinnati

Blood Bank and Transfusion Medicine

Duration: Two Months

Rotation Director(s): Patricia Carey, MD

Faculty/ Instructor(s):
Pam Inglish, MT(ASCP)SBB, Margaret Simon

Description of Rotation
During the rotation the resident completes program objectives by rotating through the various areas of the blood center. After the first six weeks, the resident is placed on the on-call schedule for one week with a staff physician available at all times for backup. The pathology resident rotation at Hoxworth Blood Center is subdivided into the various areas that constitute the blood center.

These include: Donor Services, Transfusion Service and Immunohematology Reference Laboratories, Transfusion Service, Donor Testing Laboratory, Components Laboratory, Transplant Immunology Division, Cellular Therapies Division, Donor Recruitment and Community Relations and Blood Center Administration. Goals and objectives for each of these specific areas are provided.

In addition to the rotations, the resident is expected to attend Apheresis Rounds, Tuesday Rounds at MSB, Journal Club and Clinical Update meetings, the Leadership Team Meeting and other meetings including Medical-Technical Advisory Committee and Transfusion Committee as these meetings are scheduled. The resident is encouraged to attend lectures in the graduate program and other learning opportunities, including teleconferences and special lectures. 

Finally, the resident is expected to make a presentation to the staff at the end of the rotation. The resident will select his/her own topic that relates to blood transfusion medicine. Additionally, the resident will take a written examination during the last week of the rotation.

Rotation Objectives

Donor Services

Goal: To become familiar with the overall procurement of human blood for transfusion.

Objectives:

• The resident will become familiar with the health history form and all regulations and standards from the FDA, aaBB and Hoxworth SOP for acceptance or rejection of allogeneic, designated and autologous blood donors.
• The resident will become familiar with the health history screening procedures, aseptic arm preparation technique, phlebotomy procedures and procurement of samples for donor testing.
• Demonstrate proficiency in evaluating and treating adverse reactions associated with blood donation and/or phlebotomy (both whole blood and automated collections).
• Demonstrate knowledge of the indications for therapeutic phlebotomy.
• The resident will become familiar with the FDA variance process and management of donors with hemochromatosis.
• Demonstrate professionalism in interactions with prospective donors.

Components Laboratory

Goal: To become familiar with the preparations, use, dosage requirements and expiration date of human blood and its components.

Objectives:

• The resident will understand the differences between CPD, CPDA-1 and optional additive solutions for the preservation of red blood cells and the expiration dates associated with these preservative solutions and any newer modifications thereof.
• The resident will become familiar with the preparation, storage requirements, expiration dates, and clinically important contents and indications.
• Discuss the “storage lesion” present in components, as applicable.
• The resident will understand the principle of blood component irradiation and the clinical situations where such components are used.
• The resident will become familiar with the distribution of components to the hospitals in the blood center service area.
• The resident will be familiar with the procedures for labeling blood.
• The resident will become familiar with the sterile connecting device and accepted standards of performance.
• The resident will explain the process and indication for washed components.
• Explain the process for leukoreduction of blood components and the indication for the transfusion of such components.
• Discuss the basic principles of plasma derivative preparation and their composition.
• Demonstrate knowledge of recombinant versions of clotting and hematopoietic growth factors, their clinical indications for use, testing assessment and dosing.

Introduction to Red Cell Testing 

Goal: To understand the basic serological tests used in red cell testing laboratories.

Objectives:

• The resident will be able to perform forward and reverse ABO typing and interpret the results.
• The resident will be able to perform Rh typing and interpret the results.
• The resident will be able to discuss the reasons for including an Rh Control test while performing Rh typing.
•  The resident will be able to discuss the purpose and applications of the indirect antiglobulin test and be able to perform this test in its various applications.
• The resident will be able to perform weak D testing and understand the reasons for this test.
• The resident will be able to discuss the principle of antibody screening and be able to perform this test.
• The resident will be able to perform basic antibody identification studies and interpret the results.
• The resident will understand the principle of compatibility testing, perform the test and interpret results.
• The resident will become familiar with the necessary tests to issue Rh Immune Globulin (RhIG).
• The resident will become familiar with the methodology to calculate fetal-maternal hemorrhage and number of vials of RhIG to be administered.
• The resident will be able to discuss the principle of direct antiglobulin testing and how to perform the test and interpret results.
• The resident will be able to state the clinical situations where direct antiglobulin testing is applied.
• The resident will be able to describe laboratory safety procedures used in the blood bank.
• Describe the biochemical structure of the major blood group antigens. 

Transfusion Service Testing

Goal:  To understand the overall operation of a compatibility service beginning with the acceptance of patient samples, component ordering, serological tests, issuance of component and the investigation of any adverse effects of transfusion.

 Objectives:

• Demonstrate familiarity with the requirements of all applicable regulatory and accrediting agencies (e.g., JCAHO, CAP, aaBB, FDA, FACT).
• The resident should be able to evaluate patient blood samples and blood order forms and determine if both are properly labeled according to SOP and aaBB Standards.
• Choose appropriate cross matching methods for various patients (e.g., electronic, immediate-spin, antiglobulin)
• The resident will be familiar with the information management system used for assessing patient flags in the Cerner computer system.
• They will also understand the importance of assessing the patient's previous transfusion/pregnancy history.
• The resident will be able to perform ABO and Rh grouping tests, antibody screening and compatibility testing.
• The resident will become familiar with issuing blood components and updating patient information records.
• Demonstrate proficiency in evaluating patients with immune-mediated and non-immune-mediated hemolytic anemia and in the appropriate testing and transfusion management of these patients.
• Demonstrate a working knowledge of the principles of hemostasis and coagulation and proficiency in the initial treatment of patients with bleeding disorders.
• Describe the expected response to transfusion therapy in adult and pediatric patients.
• The resident will become familiar with quality control procedures on reagents and equipment.
• Demonstrate the ability to perform blood utilization reviews.
• The resident will be able to discuss the tests utilized to investigate hemolytic disease of the newborn and the methodologies and components used to treat this disease, including intrauterine and exchange transfusions.
• The resident will be able to state the various types of transfusion reactions and the investigations associated with suspected hemolytic and other transfusion reactions.
• Demonstrate the ability to clinically evaluate a reported transfusion reaction and order and interpret appropriate initial laboratory testing.
• Recognize the symptoms and signs of hemolytic and nonhemolytic transfusion reactions and demonstrate knowledge of the pathophysiology, treatment and prevention of these complications.
• The resident will become familiar with the report form for transfusion reactions.
• The resident will be able to calculate platelet concentrate dose and explain the expected increment from this component following transfusion.
• The resident will be able to calculate cryoprecipitated AHF and fibrinogen dosage for management of Factor VIII and fibrinogen problems.
• The resident will demonstrate knowledge of the indications for irradiated, washed, volume-reduced, leukoreduced and CMV-reduced risk blood components.
• The resident will be able to select the appropriate ABO alternates to issue for red cells and plasma components for patients, including bone marrow transplant patients.
• The resident will become familiar with SOPs relating to special procedures, i.e., liver transplant protocol, ECMO protocol, designated donations, autologous donations and emergency cross match and issue.
• The resident will become familiar with the physician trigger list.
• The resident will outline product selection for: neonatal alloimmune thrombocytopenia, pediatric and adult trauma, sickle cell disease, idiopathic thrombocytopenic purpura.
• Demonstrate knowledge of various methods of blood conservation, including pre- and perioperative autologous blood collection and approaches to “bloodless” surgery.
• Demonstrate knowledge of requirements for administration of blood components.
• Discuss transfusion alternatives.

Donor Testing Laboratory

Goal: To understand the testing required on blood and blood components before blood components are available for issue. To understand blood component quality control as applied to FDA and AABB regulations.

Objectives:

• The resident will become familiar with FDA and AABB regulations for processing donor blood.
• The resident should become familiar with the automated typing, syphilis and antibody-screening procedures used at the blood center.
• The resident will be able to discuss the principle of enzyme immunoassay and how this is applied to the detection of Hepatitis B Surface Antigen (HBsAg) and detection of antibodies to HIV-1/2, Human T-Cell Lymphotropic Virus-I/II (HTLV-I/II), Hepatitis C Virus (HCV), Hepatitis B Core (HBc) and Trypanosoma cruzi.
• The resident will become familiar with discard criteria of components with positive test results and the application of confirmatory test results in the donor testing algorithm.
• The resident will observe quality control testing performed on blood components and become familiar with applicable FDA and AABB requirements for quality assurance on all components.
• The resident will observe and become familiar with bacterial detection system testing.
• The resident will explain nucleic acid testing and its use in processing donor blood.

Immunohematology Reference Laboratory

Goal: To understand the overall operation of an AABB accredited Reference Laboratory, the kinds of complex serological problems referred to a Reference Laboratory and how this service may impact on patient care.

 Objectives:

• The resident will be able to identify simple antibody specificities and understand the identification of complex multiple antibodies and antibodies directed to high-frequency antigens.
• The resident will be able to discuss the principles and uses of elution and adsorption.
• The resident will become familiar with the serological work-up for warm, cold and drug-induced immune hemolytic anemia and how these serological results may relate to the patient.
• The resident will understand the use of antibody-enhancement solutions, enzymes, and monospecific antiglobulin reagents and the applications of these reagents.
• The resident will be able to discuss the causes of ABO discrepancies and the resolution of these discrepancies.
• The resident will be able to select donor units for compatibility testing for the serologically difficult patient.
• Demonstrate ability to write an appropriate consult note for a patient who has an alloantibody, explaining the clinical significance of the finding to the treating physicians and the additional logistical requirements for obtaining compatible blood.

Automated Collections and Therapeutic Apheresis

Goal: To understand the overall operation of an automated technology as it relates to blood component procurement and therapeutic procedures.

Objectives:

• The resident will know applicable FDA, aaBB and FACT requirements for apheresis donors.
• The resident will understand the operation and principles of cell separators currently in use and will become familiar with all quality control procedures applicable to apheresis and the resulting components.
• The resident will become familiar with the various clinical situations that may require therapeutic apheresis.
• Demonstrate proficiency in evaluating and preparing patients for therapeutic apheresis, including obtaining consent for the procedure and for transfusion of blood products during the procedure.
• Demonstrate knowledge of the appropriate replacement fluids to be used in an apheresis procedure.
• Demonstrate knowledge of vascular access requirements and options for therapeutic apheresis.
• The resident will become familiar with the care of donors, including adverse events, when automated collections are performed.
• The resident will become familiar with donor plasmapheresis procedures and be aware of criteria for selection and care of such donors.
• The resident will become familiar with clinical situations requiring components collected by apheresis and understand the need for HLA-typed platelet apheresis donors and the process involved in their recruitment.
• The resident will understand how to order therapeutic apheresis procedures and/or components.
• Demonstrate proficiency in evaluating and treating adverse reactions associated with therapeutic apheresis and peripheral blood progenitor cell (PBPC) collection.
• The resident will be familiar with apheresis technology in the collection of peripheral blood progenitor cells, autologous and allogeneic.
• The resident will explain adsorption column apheresis.

Transplantation Immunology Division

Goal: To understand the overall operations of a Histocompatibility Laboratory and the tests performed in regard to transplantation, donor typing and disease association studies.

Objectives:

• The resident will understand the genetics of the HLA system and be familiar with the terminology associated with histocompatibility.
• The resident will be able to separate lymphocytes from whole blood and remove contaminating red cells, platelets and polymorphonuclear leukocytes.
• The resident will be able to separate T and B-lymphocytes and know the differences between these two types of lymphocytes.
• The resident will be able to identify viable and non-viable lymphocytes on a histocompatibility tray and determine the percentage of non-viable cells.
• The resident will understand the need for HLA typed apheresis donors, be familiar with the ongoing search for these donors, and selection of appropriately matched donors for specific patients.
• The resident will become familiar with the ongoing investigations for association of HLA antigens and certain disease states.
• The resident will become familiar with the procedures of matching kidney, heart and liver recipients with potential cadaver donors.
• The resident may observe and understand the cross match procedures for selection of recipients for cadaver organs, including flow cytometry, special cross matches and additional technology.
• The resident will understand the criteria for final cross matches against T, B cells and monocytes.
• The resident will be familiar with PCR and DNA testing performed in this laboratory.
• The resident will become familiar with and understand the requirements of HLA matching for related and unrelated stem cell transplantation.

Cellular Therapies Division

Goal: To understand the processing and storage of bone marrow and peripheral stem cells.

Objectives:

• Demonstrate understanding of, and the ability to interpret, the major regulations and guidelines applicable to cellular therapy products including FDA, aaBB and FACT.
• Demonstrate knowledge of the principles of hematopoietic stem cell transplantation including the indications for use (e.g., marrow, peripheral blood, and placental and/or umbilical cord blood).
• The resident will understand principles involved with the processing of bone marrow from autologous and/or allogeneic marrow donors.
• The resident will observe and understand principles involved with processing of peripheral blood progenitor cells.
• The resident will observe and understand principles involved with thawing and infusion of a stem cell product.
• The resident will become familiar with stem cell selection and purging techniques currently available.
• The resident will understand the cryopreservation procedure for freezing bone marrow and peripheral stem cells.
• The resident will become familiar with cell marker evaluation using flow cytometry and monoclonal antibodies.
• The resident will become familiar with pancreatic islet cell processing for autologous transplant.

Donor Quality Assurance

Goal: To be aware of some special issues in blood banking that have assumed increasing importance because of diseases transmissible by blood transfusion.

Objectives:

• The resident will be familiar with the operation of a designated donor program.
• The resident will understand the consequences and the deferment of donors with test results consistent with diseases transmissible by blood.
• The resident will become familiar with the FDA and aaBB requirements for autologous donation and how such a program operates.
• The resident will know the procedures used to notify or recall donors with positive HBsAg, STS, anti-HCV, anti-HIV-1/2, anti- HTLV-I/II, anti-HBc, West Nile Virus, nucleic acid test (NAT) HIV and NAT HCV tests and procedures for additional testing for counseling of these donors.
• The resident will become familiar with the recall of components based on donor history and current tests.
• The resident will understand the principles and applications of individual and universal
  look back.
• The resident will become familiar with the policy on look back for HIV, HTLV and HCV.
• The resident will become familiar with the policy on re-entry for HBV, HCV and HIV.

Donor Recruitment and Community Relations

Goal: To be exposed to the overall operation of donor recruitment.

Objectives:

• The resident will understand the difference between community responsibility and individual responsibility for blood donation.
• The resident will become familiar with the various segments of the donor population and how the two divisions of DR/CR recruit from these segments.
• The resident will understand how the daily donor requirements for the community are planned.
• Describe the factors that influence the motivation of blood donors.

Administration

Goal: To be exposed to the overall administration of a community blood center.

Objectives:

• The resident will be familiar with the table of organization at Hoxworth Blood Center.
• The resident will be familiar with how Hoxworth Blood Center functions as a part of the University of Cincinnati and the region.
• The resident will become familiar with the budgeting process at Hoxworth Blood Center.
• Demonstrate knowledge of how to host an inspection by a regulatory or accrediting agency.

Level of Training

Through faculty and staff evaluations the resident is assessed regarding interest and motivation, initiative, problem solving abilities, teaching skills and interaction/communication with faculty and staff. Through evaluation of the seminar presentation we assess the resident’s ability to organize the material for his/her topic, use current references, use visual aids to present the topic, field questions on their topic and to appropriately present the material (speak clearly, concisely, appropriate body posture, eye contact etc). The final assessment of competency is the written examination taken at the completion of the department rotations.

Evaluation

• The rotation director will review the objectives with the resident on a continuing basis.
• Staff and faculty, in each area that the resident rotates through, complete an evaluation of the resident. 
• The resident presents a seminar on a transfusion medicine topic. The rotation director and education coordinator evaluate this presentation.
• The resident takes an examination at the conclusion of department rotations.
• A formal evaluation will be completed at the conclusion of the rotation.
• The resident will also provide feedback through department evaluations on an ongoing basis to Dr. Carey, Pam Inglish and Margaret Simon.