Advanced H&I – Solid Organ Transplantation and Transfusion —
Training activity: 4

Details

Perform a virtual crossmatch assessment and prepare a report for a potential transplant recipient according to local policy

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• National guidelines for risk assessment of solid organ recipients
• Accreditation standards
• Local criteria for cross-match suitability
• Local policy for virtual cross-match suitability
• Clinical interpretation of cross-match results in relation to HLA antibody testing

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to accurately performing a virtual crossmatch assessment according to local policy for a potential transplant recipient.
• Consider how the learning outcomes apply, specifically in relation to interpreting and reporting tests, assessing suitability, practicing according to standards, and practicing effectively in partnership.
• Discuss with your training officer to gain clarity of what is expected of you in relation to how a clear, concise, and clinically relevant report is prepared based on the virtual crossmatch assessment.

What is your prior experience of this activity?

• Think about what you already know about performing virtual crossmatches before, or if you are familiar with the concept and methodology.
• Consider possible challenges you might face during the activity, such as interpreting complex antibody profiles against donor HLA, applying risk stratification criteria, or ensuring report clarity.
• Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example if the interpretation results in a high-risk virtual crossmatch that deviates from antibody screening data.
• Acknowledge how you feel about performing assessments that guide decisions about potential transplantation.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as applying virtual crossmatch principles and using relevant software/tools.
• Identify the specific insights you hope to gain into the clinical risk assessment process that incorporates virtual crossmatch findings.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of interpreting antibody data or drafting clinical reports.
• Identify important information you need to consider before embarking on the activity, such as what specific criteria are used to determine the risk level (e.g., standard, intermediate, high risk) based on the virtual crossmatch.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst performing a virtual crossmatch assessment and preparing a report?
• Are you encountering situations such as:
  • The virtual crossmatch assessment predicts a high risk, but the patient’s recent antibody screening results show low-level reactivity, leading to conflicting data?
  • Difficulty phrasing the report’s conclusion clearly due to a borderline risk assessment that requires nuanced terminology?
  • Specific local policy guidelines regarding virtual crossmatch reporting contradict or complicate the application of national guidelines for this particular donor-recipient pairing?

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to data synthesis or report drafting methodology?
• Consider the steps you are taking in the moment, such as:
  • Reviewing historical antibody data and MFI trends immediately to understand the context of the conflicting results
  • Consulting the standardised local report template for specific terminology required for high-risk or borderline virtual crossmatch outcomes
• How are you feeling in that moment? For instance, are you finding it difficult to translate conflicting technical data into a definitive clinical risk statement? Is it affecting your confidence in providing clear clinical advice based on the virtual crossmatch?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully synthesising the conflicting data and preparing a justified risk assessment report? Or are you needing support because the data conflict is severe, requiring pathological sign-off to justify the final risk assessment?
• What are you learning as a result of the unexpected development? For example, are you gaining insight into the critical nature of integrating technical results with clinical policies during complex risk reporting?

On action

What happened?

• Begin by summarising the key steps you took when performing the virtual crossmatch assessment and preparing the report for the potential recipient.
• Consider specific events, actions, or interactions which felt important, such as the specific recipient and potential donor data you used and how you applied local policy to the assessment, or the content you included in the report.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, double-checking policy or re-running the assessment.
• How did you feel during this experience, e.g., did you feel confident in assessing suitability or stressed if the case involved complex antibody data?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding virtual crossmatching and reporting according to local policy. What strengths did you demonstrate, e.g., adherence to quality standards?
• What skills and/or knowledge gaps were evident, e.g., gaps in your assessment technique or understanding of policy?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in your proficiency in virtual crossmatching?
• Identify any challenges you experienced, such as interpreting complex data or ensuring the report met all requirements, and how you reacted to these. Were you able to overcome them?

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to improving your interpreting and reporting tests.
• What will you do differently next time you approach performing a virtual crossmatch assessment and prepare a report, for instance, by proactively interpreting specific types of data or ensuring adherence to policy nuances?
• Do you need to practise any aspect of the activity further, such as interpreting specific types of data or ensuring adherence to policy nuances or key learning outcomes related to assessing the suitability of patients?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of performing virtual crossmatch assessments and preparing reports since completing this specific training activity led you to revisit your initial approach or decisions during that activity? The subsequent actual crossmatch results or clinical outcomes may lead you to evaluate the accuracy and utility of your initial assessment.
• Considering what you understand about applying policy or refining the clarity of your reports now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? You should review any actions for improvement you identified in previous reflections for this activity.
• How have you since implemented or adapted improvements in your consistency in applying policy or refining the clarity of your reports based on further learning and experiences? For example, improving consistency in applying policy or refining the clarity of your reports forced you to re-evaluate the clarity and conciseness of your reported assessment during your first attempt at this training activity.
• Has discussing virtual crossmatching and reporting with peers or the assumptions underlying virtual crossmatching or the impact of different antibody assays on virtual crossmatch results with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity?

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent virtual crossmatch assessment and report preparation experiences, contributed to your overall confidence and ability in applying laboratory data (HLA typing, antibody screening) and local policy to predict the outcome of a physical crossmatch, particularly in preparing for assessments like DOPS or OCEs? For example, how your accumulated ability in understanding the correlation between antibody profiles and virtual crossmatch results now enables you to confidently perform a virtual crossmatch for deceased or living donation during an OCE assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to performing a virtual crossmatch assessment and report preparation?
• How does this evolved understanding help you identify when a virtual crossmatch assessment is borderline, potentially misleading, or requires correlation with additional data (e.g., historical samples, titre), and when this is beyond your scope of practice requiring expert input?
• Looking holistically at your training journey, how has this initial virtual crossmatch assessment and report preparation experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to integrating multiple data sources, applying complex policies, predictive analysis, and clinical reporting? For example, how this foundational experience has supported your development in transferable skills such as integrating multiple data sources, applying complex policies, predictive analysis, and clinical reporting.

Relevant learning outcomes

#	Outcome
# 2	Outcome Interpret and report tests across the range of techniques applied and provide appropriate clinical advice for solid organ transplant.
# 3	Outcome Assess the suitability of patients for crossmatch and transplantation in deceased and live donor settings.
# 7	Outcome Practice in accordance with quality management and accreditation standards.
# 8	Outcome Practice effectively in partnership with service users, other clinical specialisms and the wider multidisciplinary team in the investigation of solid organ transplantation and platelet transfusion.