Training activity information
Details
Perform and interpret all of the following coagulation investigations:
- PT
- APTT
- TT
- Fibrinogen
- D dimer
- Anticoagulation monitoring
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
- Local SOPs
- Guidelines and standards, including EQA and IQC Maintenance and basic troubleshooting
- Reference intervals
- Limitations of the methods
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 performing and interpreting all the listed coagulation tests: PT, APTT, TT, Fibrinogen, D dimer, and Anticoagulation monitoring.
- Consider how the learning outcomes apply, specifically in relation to selecting, performing, and interpreting techniques, describing limitations, applying quality control principles, and communicating results.
- Discuss with your training officer to gain clarity of what is expected of you when following coagulation investigations for all the listed tests.
What is your prior experience of this activity?
- Think about what you already know about performing coagulation tests, including sample collection requirements, instrument use, and quality control. Consider your prior experience interpreting results for all the specific tests listed.
- Consider possible challenges you might face during the activity, such as haemolysed samples, lipaemic samples, unexpected results, or instrument calibration issues, and think about how you might handle them.
- Recognise the scope of your own practice for this activity, meaning knowing when you will need to seek advice or help (e.g., for abnormal results, technical issues) and from whom.
- Acknowledge how you feel about embarking on this training activity, especially if you are new to performing or interpreting the full range of these tests.
What do you anticipate you will learn from the experience?
- Consider the specific skills you want to develop, drawing upon previous experiences, which might include proficiency with a specific analyser, troubleshooting assay issues, or calculating INR.
- Identify specific insights you hope to gain from engaging with the activity, such as understanding how these tests relate to different clinical conditions e.g., haemostatic and platelet disorders, thrombotic disorders or how anticoagulation is monitored.
What additional considerations do you need to make?
- Consult actions identified following previous experience of the specific coagulation investigations.
- Identify important information you need to consider before embarking on the activity, such as:
- Reviewing the principles of these specific coagulation investigations (PT, APTT, TT, Fibrinogen, D dimer, Anticoagulation monitoring).
- Understanding the critical sample collection requirements (e.g., tube fill volumes) necessary to ensure the validity of coagulation testing.
- Reviewing how these tests relate to different clinical conditions such as haemostatic and platelet disorders or thrombotic disorders.
- Familiarising yourself with the protocols for anticoagulation monitoring, such as calculating the INR for warfarin patients.
In action
Is anything unexpected occurring?
- Are you noticing anything surprising or different from what you anticipate whilst running and interpreting the coagulation tests?
- Are you encountering situations such as:
- Critical issues with sample quality e.g., severe haemolysis, lipaemia, or an incorrect fill volume that immediately jeopardise the validity of the entire test panel (PT, APTT, TT, etc.)?
- Unusual or contradictory results across the panel, such as a prolonged APTT with a normal PT and D-dimer, suggesting an unexpected factor deficiency or inhibitor presence?
- An unexpected result in anticoagulation monitoring e.g., a therapeutic INR unexpectedly falling below the target range, requiring immediate investigation into possible pre-analytical or analytical issues?
- How did this specific sample or run compare with previous experiences performing coagulation testing?
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 the interpretation?
- Consider the steps you are taking in the moment, such as:
- Immediately checking sample collection details and pre-analytical notes e.g., phlebotomy time, tube type, fill volume to rule out pre-analytical error as the cause of the unexpected result?
- Seeking immediate advice from a senior colleague to determine if a specific reflex test e.g., mixing study, specific factor assay is required based on the unexpected pattern of results?
- Performing quality control checks and/or repeating the test using a modified approach if an analytical issue is suspected?
- How are you feeling in that moment? For instance, are you finding it difficult to adapt your interpretation skills to a complex pattern of results? Is it affecting your confidence in making a preliminary interpretation, especially concerning critical anticoagulation monitoring?
What is the conclusion or outcome?
- Identify how you are working within your scope of practice. For example, are you successfully identifying the likely cause of a sample quality issue and recommending recollection? Or are you needing support because the coagulation profile is highly complex or suggests a novel inhibitor?
- What are you learning as a result of the unexpected development? For example, are you mastering an efficient workflow for troubleshooting sample issues in coagulation testing, or gaining crucial insight into how abnormal results guide the selection of appropriate downstream/reflex tests?
On action
What happened?
- Begin by summarising the key points of the experience of performing and interpreting the panel of coagulation tests, including for anticoagulation monitoring. What were the main steps from sample check-in to result interpretation and validation?
- Consider specific events, actions, or results which felt important, such as identifying a problematic sample (e.g., clotted or underfilled) or encountering unexpected results e.g., a significantly prolonged PT/APTT not correlating with clinical history. Include your own feelings during the experience.
- Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately re-checking sample integrity based on flags or deciding to run a reflex test (e.g., mixing study) based on the pattern of results.
How has this experience contributed to your developing practice?
- Identify what learning you can take from the experience regarding assay principles, QC application, or result correlation, e.g., improving your ability to interpret complex haemostatic profiles. What strengths did you demonstrate e.g., accuracy in manual INR calculation or troubleshooting instrument performance? What skills and/or knowledge gaps were evident e.g., unfamiliarity with specific result interpretation nuances (e.g., complex inhibitor detection) or anticoagulation monitoring guidelines?
- Compare this experience against previous coagulation activities – were any previous identified actions for development achieved? Has your practice improved?
- Identify any challenges you experienced e.g., dealing with a problematic sample or interpreting complex or unexpected results and how you reacted to these. Did dealing with a problematic sample or interpreting complex results affect your ability to deal with the situation? Were you able to overcome the challenges?
- Identify anything significant about the activity. Did you need to seek advice or clarification regarding test results, QC, or clinical interpretation e.g., for an unexpected INR result or TT result? Did you need to escalate to ensure that you were working within your scope of practice?
- Acknowledge any changes in your own feelings now you are looking back on the experience.
What will you take from the experience moving forward?
- Identify the actions / ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received e.g., routinely reviewing BSH guidelines for coagulation defects or sample handling.
- What will you do differently next time you perform or interpret coagulation tests? Has anything changed in terms of what you would do if you were faced with a similar situation again e.g., a clotted sample, a challenging INR?
- Do you need to practise any aspect of the activity further e.g., sample handling procedures, interpreting specific result patterns?
Beyond action
Have you revisited the experiences?
- Have you reviewed your previous reflections for this activity? Has your understanding of the principles and interpretation of PT, APTT, TT, Fibrinogen, D dimer, and anticoagulation monitoring deepened, perhaps through reviewing external quality assurance (EQA) results?
- Have you had further opportunities to perform and interpret coagulation investigations since completing this activity? Have you encountered different clinical presentations e.g., specific haemostatic or thrombotic disorders or patient samples that challenged your initial understanding?
- Can you recall specific instances in routine work where interpreting these coagulation results was critical for patient diagnosis or management e.g., monitoring anticoagulant therapy like Warfarin or investigating acute thrombosis? How did your experience in this TA inform your approach?
- Have you engaged in professional storytelling or case discussions with peers, colleagues, or clinicians? Did these discussions change your perspective on the clinical relevance of these tests in emergency settings?
How have these experiences impacted upon current practice?
- Has this activity improved your technical skills in performing coagulation assays and your confidence in interpreting the results in the context of different clinical indications?
- Do you now have a better understanding of the coagulation cascade, the principles of these tests, and their limitations?
- Has this experience influenced how you assess sample quality or potential pre-analytical issues for coagulation testing e.g., recognising the impact of underfilled tubes?
- How will your experience with core coagulation testing prepare you for investigating more complex haemostatic or thrombotic disorders or implementing new coagulation assays (e.g., specific factor assays) in the future?
Relevant learning outcomes
| # | Outcome |
|---|---|
| # 1 |
Outcome
Select techniques for the investigation of clinical presentations in haematology, haemostasis and transfusion science and medicine. |
| # 2 |
Outcome
Perform the laboratory techniques required for the investigation of clinical presentations in haematology, haemostasis and transfusion science and medicine. |
| # 3 |
Outcome
Interpret the results of the laboratory investigations for cases including red and white cell disorders and haemostatic and platelet disorders, haematological malignancy and transfusion serology. |
| # 4 |
Outcome
Describe the limitations of techniques applied in the investigation of clinical presentations in haematology, haemostasis and transfusion science. |
| # 5 |
Outcome
Apply the principles of internal quality control and external quality assessment and draw conclusions about assay performance. |
| # 6 |
Outcome
Demonstrate appropriate communication skills to present the results of investigations and cases clearly to healthcare professional colleagues. |