Transfusion Medicine Rotations for Pathology Residents: Structure, Resources, and Milestones

The Pathology and Laboratory Medicine Institute in Cleveland, Ohio, accepts 7 AP/CP residents a year, for a total of 28 across all 4 years. The residents spend their postgraduate years (PGYs) 1 and 3 rotating through AP and their PGYs 2 and 4 rotating through CP. The blood bank rotation consists of 3 blocks of 4 weeks each: 2 blocks during PGY2 and 1 block during PGY4. In the fall semester, a PGY2 and a PGY4 rotate together, with the PGY4 resident mentoring the PGY2. In the spring semester, the PGY2 resident returns for the second block and is the only resident on the service. The hospital has both adult and pediatric patients. The residents get routine exposure to both patient types.

Apheresis is run by the hematology/oncology service; therefore, it is not integrated fully into the blood bank rotation. The residents spend the final week of their PGY4 rotation in apheresis with the hematology/oncology team. This rotation functions more as an observership than true hands-on experience. The residents attend the morning meetings with the apheresis team, observe how the instrumentation and machines work with the nurses, go on any consults throughout the hospital, and discuss cases with the apheresis director. Apheresis topics are also covered during didactic lectures. For any resident who is interested in going into blood bank for fellowship, an elective rotation, which would be 2 to 4 weeks in length, can be done. During the elective the resident would spend time putting in orders, writing notes, and seeing consults independently.

There is no blood donor center experience in this program. Donor center topics are covered during didactic lectures and one-on-one discussions, but no time is spent in a donor center. The transfusion medicine department does run the progenitor cell processing laboratory, but the residents do not have any responsibilities within this laboratory. If they are interested, tours and extra teaching about the progenitor cell processing laboratory can be arranged.

The residents on the blood bank rotation maintain a daily list of patients. This list contains patients with complex antibody profiles who may need multiple units of blood because of surgery or bleeding, patients receiving human leukocyte antigen (HLA)–selected platelets, patients who have had a minor incompatible solid organ transplant, and any other patient who has a complicated or uncommon blood need (eg, granulocytes, washed red blood cell requests) (Figure 1). This list is housed on Microsoft 365’s online word-processing application. The document is digitally secured within the hospital’s Microsoft account, where only invited individuals can view and edit it. The online nature of this list allows any resident or attending physician to access, review, and edit the most recent version. It can also be accessed from home on secured devices, giving easy access to vital information. This online system ties into the ACGME milestone of Systems-Based Practice (SBP) 4: Informatics.^8,9  The intent of this milestone is “to acquire the knowledge, skills, and tools that will enable collection, management, use, and sharing of data and information to support the delivery of accurate, high-quality health care and promote optimal patient outcomes.”⁹  Using every resource, even something as straightforward as a network-accessed online shared Microsoft Word document, supports this goal of residency education.

In the morning, the residents receive handoffs from the resident who was on call the previous evening and attend a required pathology departmental didactic lecture, after which they update the daily list.

For complex antibody patients, the residents confer with the clinical teams to determine the patients’ needs, including number of units and when needed, and relay the information to the technologists, who work on identifying compatible blood through the hospital inventory or ordering it from the blood supplier. Both of these tasks relate to the ACGME milestones of Interpersonal and Communication Skills (ICS) 2: Interprofessional and Team Communication and ICS3: Communication With Health Care Systems.^8,9  The goal of these milestones is effective communication within the health care team. The residents must communicate with the blood bank technologists, the apheresis team, the clinical floors, and occasionally the blood center to help coordinate care.

For HLA-selected platelet patients, on average 2 to 4 active patients at a time, the residents update an internally created tracking spreadsheet that is made for each patient within Microsoft Excel (Figure 2). Antibody avoidance and/or direct HLA matching is used to provide HLA-selected platelets. The residents review the blood center’s online portal and the electronic medical record to obtain the donor identification number, the HLA type of the unit, the expiration date, the ABO type, and the platelet type (pathogen-reduced versus large-volume delayed sampling). This is all recorded on the spreadsheet. The residents monitor the electronic medical record to see when the unit is transfused. Once transfused, the pretransfusion and posttransfusion platelet counts are recorded, and the corrected count increment (CCI) is automatically calculated. If the clinical team transfuses non-HLA platelets, this is also recorded on the same spreadsheet with the CCI calculated. If the unit is not transfused to the intended patient and is released into the general inventory, this is also recorded. These spreadsheets provide the opportunity to easily track how each patient is responding to HLA-selected platelets and to provide real-time, effective feedback to the clinical teams. If the clinical team consistently releases units (ie, does not transfuse the patient), the residents discuss stopping HLA-selected products with them. If the CCIs remain poor after HLA-selected platelets, the clinical team is reminded to look for nonimmune causes of platelet refractoriness. Human platelet antigen antibody workups are rarely pursued because of the difficulty in obtaining human platelet antigen–negative units. This format for following the HLA-selected platelet patients gives the residents a lot of autonomy to manage these patients and recommend appropriate follow-up. It also meets the milestones of ICS2 and ICS3, plus it helps the residents meet SBP2: Systems Navigation for Patient-Centered Care.^8,9  The patients receiving these platelets all have very individualized needs, and the need to adapt to each patient situation is a vital skill the residents learn from these responsibilities.

In keeping with blood bank procedure, the residents monitor patients with minor incompatible solid organ transplants. Each patient who has undergone a minor incompatible transplant has a fillable PDF where their hemoglobin level and the results of a type and screen are monitored for 21 days posttransplant for passenger lymphocyte syndrome (PLS). For any type and screen that is ordered, the residents follow up on DAT as appropriate to evaluate for PLS. As above, this task relates to the milestones of ICS2 and 3 and SBP2. This also relates to the milestone of Patient Care (PC) 3: Clinical Consultation.^8,9  The monitoring of these patients by the residents gives them an opportunity to be a member of the patient care team and provide a service that the clinical team may not be able to accomplish on their own. The resident also provides vital clinical consultation to the clinical team when evidence of PLS is noted, in the form of either anti-A and/or anti-B in the eluate or a DAT positive for C3, a surrogate marker for IgM. The resident follows up with a written report explaining the risks of PLS, which also ties into the milestones PC1: Reporting and PC4: Interpretation and Diagnosis.^8,9 

Later in the morning, daily teaching rounds are conducted. Any calls from overnight are reviewed and any changes to the daily patient list are discussed. Transfusion reactions from overnight are presented and reports are written up by the rotating resident (milestones PC1 and PC4).

Once the call log and the list are reviewed (this can take anywhere from 10 minutes to more than an hour, depending on the complexity of cases), the remainder of the morning is used for teaching. The topic for teaching frequently comes out of a discussion or question that arose from the call log or the daily patients. Otherwise, the resident or attending physician will suggest a topic to review. This teaching can take the form of impromptu chalk talks on the whiteboard, more formal presentations through slide decks, worksheets that are given out and reviewed in the afternoon, or any other method that works best for that attending physician and residents. These are examples of how to tie into the milestones of Medical Knowledge (MK) 1 and 2: Diagnostic Knowledge and Clinical Reasoning.^8,9 

There are dedicated workstations for the residents in the blood bank. The residents are expected to be present save for required educational activities and lunch. After rounds, the residents complete any patient follow-up that was discussed during rounds. They also respond to any pages from the blood bank technologists or the clinical teams. The residents respond to the questions they are comfortable with and come to the attending physician for direction when they need to. This is an additional way to assess the MK1 and MK2 milestones.^8,9  How much they have reasoned out the question and come up with independent solutions of their own before coming to discuss with the attending physician gives a sense of their progress and what may need to be focused on with them the next day. The afternoon is also meant to be used for independent study. Because the blood bank has a steep learning curve and covers topics that are different from AP, the transfusion medicine attending physicians have strived to make as many resources as possible available to the residents.

The residents also cover overnight and weekend transfusion medicine call. As during the daytime, the residents are encouraged to handle as many of the calls independently as they feel comfortable. They are also assured that if they have any questions, no matter how simple they may feel the question is, they can call the on-call attending physician for assistance. Milestones MK1 and MK2 can be assessed in this way as well.^8,9 

A survival guide was put together by residents and refined by the attending physicians. This is a 16-page document detailing how to handle many common pages, information technology problems, blood product triaging recommendations, etc. This guide is meant to help them with the day-to-day responsibilities. Within the survival guide are 10 appendices that cover other topics in more detail (Table 1). One of the appendices is a “passport” that includes 49 one-sentence high-yield board-relevant prompts for the resident to review. Examples include “State the circumstances under which a transfusion reaction must be reported to external agencies,” “State the risk of infectious diseases from blood transfusion,” and “Be able to direct the investigation of patients who are refractory to platelet transfusion and the selection of appropriate platelet products.” Residents are encouraged to keep a printout of this passport with them during their rotations to check off each prompt once they feel comfortable with it. At the moment there is not a formal assessment of residents to assess their competencies in these topics, but through the use of informal discussions and questioning during teaching, the attending physicians can get a sense of the resident’s level. The full version of the passport is available in the supplemental digital content, at https://meridian.allenpress.com/aplm in the October 2024 table of contents.

To help with the residents’ independent study, a reading curriculum was developed. This is a week-by-week breakdown of topics for them to study and read about during their 12 total weeks of blood bank. The topics in the 12 weeks are shown in Table 2. Under each topic, assignments include reading in textbooks, links to videos, links to standard operating procedures (SOPs) that need to be reviewed, and references to Microsoft PowerPoint presentations. The video links are to the Blood Bank Guy website of Joe Chaffin, MD,¹⁰  and the SOPs are linked to the internal document control system. The residents are expected to be familiar with the SOPs that cover common blood bank procedures. The Microsoft PowerPoint presentations have been developed over the years by one of the attending physicians and are frequently used by the residents as quick reviews. All of this is not required reading, in that the transfusion medicine attending physicians do not verify it was done, but it is highly recommended and encouraged. The residents have responded well to this curriculum and are pleased with the structure.

The residents are not directly involved with antibody identification. To mitigate this lack of experience, a standardized set of practice panels was curated from Antibody Identification: Art or Science? A Case Study Approach¹¹  and Investigating Positive DAT Results: A Case Study Approach.¹²  The PGY4s are given this packet on their first day of the rotation and at the end of their second week one of the transfusion medicine attending physicians reviews the panels with them. This ensures that all the residents, at a minimum, get the same standardized baseline teaching in antibody identification. Additionally, cases from actual patients or other practice panels are frequently shared with residents by the attending physicians.

Many of the resources described in this article were implemented between 2020 and 2022: specifically, the survival guide, the HLA platelet tracking spreadsheets, the reading curriculum, and the antibody identification review panels. Although resident evaluations of a rotation are an inexact measure of a rotation’s quality, they can give a good sense of the overall impression of a rotation. Before these new resources and tools were implemented, from the 2017–2018 academic year to the 2019–2020 academic year the residents gave the blood bank rotation an average score across the 3 years of 3.41 of 5.00 using a scale of 1 = poor, 2 = marginal, 3 = satisfactory, 4 = good, and 5 = outstanding. From the 2020–2021 academic year to the 2022–2023 academic year, the residents gave the rotation an average score across the 3 years of 4.00 of 5.00. Additionally, using a scale of 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree, average scores increased before and after implementation, from 2.97 to 3.94 of 5.00 and 3.31 to 4.05 of 5.00, respectively, for the following 2 statements: “There was an appropriate balance between service and education” and “The specimen volume/workload was appropriate for this rotation” (Figure 3). Although there are still fluctuations in the year-to-year scores, the overall trend of the evaluation scores has increased. The institutional review board advised that this curriculum assessment was exempt from review, as it was part of the evaluation of an educational program.

The resident in-service examination scores for the transfusion medicine section have always been in the upper tier.

Much of how the rotation is structured focuses on the tenets of adult learning. Principles of adult learning have been written about and focused on for years.^13–16  The main aspects of adult learning that this curriculum focuses on are self-directed learning, experiential learning, mentorship, and motivation.^17–20  The reading curriculum is predominantly self-directed learning. The residents are given topics to learn about and diverse means of learning that subject. It is up to them to direct how they obtain that information effectively. This also connects to mentorship in that the residents can take what they learned on their own and discuss with the attending physicians to gain a fuller knowledge of that subject. The residents self-report that they have greatly appreciated having this reading curriculum. They have reported finding it very useful that there are multiple avenues presented for their learning (textbooks, slide decks, online videos). Some residents have strictly followed the curriculum and made sure to read all the recommended chapters, whereas others have used a looser method of looking at the topics and searching out other resources to learn them.

Much of the residents’ day-to-day work falls into the category of experiential learning. They have hands-on experiences of how to deal with any number of calls and pages they receive. Although they are given lectures and “boot camps” to get them ready, it is never possible to teach everything in didactic sessions. These boot-camp lectures are given in July and August to the PGY 2 and 4 residents who will be rotating through the CP (concurrent sessions covering AP occur for PGY 1 and 3 residents on those rotations). The lectures cover a wide variety of CP topics, with the transfusion medicine topics focusing on the logistics of how to handle overnight calls and how to work up transfusion reactions. These lectures are not meant to cover subject matter content, but more the logistics of the rotation. The residents must learn on the job, and the structure of this rotation gives them ample opportunity to do that. Finally, motivation plays a keen role in adult education. The simple fact that blood bank topics are part of their board examination motivates the residents to learn the subject. But more than that, because the residents know that they will have to manage overnight and weekend calls and may have to manage a blood bank at some point in their career, the more comfortable they are with the subject matter, the more confident they will be in those early jobs.⁶ 

I hope that this discussion provides a window into how a busy hospital system approaches training in transfusion medicine and can provide a blueprint for how to structure a rotation and resource development/curation for a residency program. It is important to provide diverse styles of resources and learning opportunities for the residents. The more approachable and educational the blood bank is, the more likely that residents will be attracted to the specialty. Of note, the described program does not include apheresis, so any institution that does have apheresis as part of its rotation would have to modify this approach to factor that in as well. This system has been serving the rotation well during the past few years as the process continues to be refined. The residents are constantly reminded to provide feedback to help improve the rotation, and many recommendations, from both residents and attending physicians, have been implemented over the years.