Training activity information
Details
Select, perform and interpret the appropriate tests for easy bruising, bleeding or menorrhagia
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
- The sample type required and the preanalytical variables affecting results.
- Management of potential bleeding disorder
- Clinical presentations and other investigations
- National guidelines
- Local SOPs
- Quality assurance
- Prioritisation and communication of results
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 investigating easy bruising, bleeding, or menorrhagia.
- Consider how the learning outcomes apply, specifically what constitutes an appropriate initial and subsequent panel of tests for these broad clinical presentations.
- What does accurate performance and interpretation look like in this context, including identifying the key laboratory pathways to investigate when presented with bleeding symptoms?
- Discuss with your training officer to gain clarity on expectations regarding the scope of the investigation and the range of potential underlying causes to consider.
What is your prior experience of this activity?
- Think about what you already know about the different categories of bleeding disorders, such as:
- Platelet disorders
- Coagulation factor deficiencies
- What are the fundamental tests typically used to screen for bleeding disorders, including FBC, PT, APTT, and Fibrinogen?
- Consider possible challenges you might face in selecting or interpreting tests for these symptoms, and think about how you might handle them, for example:
- Mild deficiencies
- Acquired inhibitors
- Distinguishing between platelet function vs. number issues
- Recognise the scope of your own practice for this activity, i.e., know when you would need to seek advice regarding investigation strategies or interpretation for complex bleeding cases.
- Acknowledge how you feel about investigating patients presenting with bleeding symptoms, recognising the potential impact on their diagnosis and management.
What do you anticipate you will learn from the experience?
- Consider the specific skills you want to develop in applying a systematic approach to investigating bleeding symptoms.
- Identify specific insights you hope to gain into the correlation between specific test abnormalities and different types of bleeding disorders.
What additional considerations do you need to make?
- Consult actions identified following previous experience with PT, APTT, or platelet testing that are relevant here.
- Identify important information you need to consider before embarking on the activity, such as:
- The patient’s clinical history severity and site of bleeding, family history
- Relevant clinical guidelines for investigation
In action
Is anything unexpected occurring?
- Are you noticing anything surprising or different from what you anticipate whilst investigating easy bruising, bleeding, or menorrhagia?
- Are you encountering situations such as:
- Normal screening tests (PT/APTT) despite a significant clinical history of bleeding, immediately pointing towards a primary platelet function disorder or a mild factor deficiency not detected by screening.
- Inconsistent or borderline results between different factor assays e.g., Factor VIII, requiring immediate investigation for mild factor deficiency or the presence of a weak inhibitor.
- Complex or vague patient history provided on the referral e.g., ‘easy bruising’ without clear information regarding drug use or family history, complicating the choice of initial testing panel.
How are you reacting to the unexpected development?
- How is this impacting your actions? Did you adapt or change your approach to the investigation strategy in the moment?
- Consider the steps you are taking in the moment, such as:
- Immediately initiating further specific tests e.g., VWF antigen/activity or platelet function studies based on the normal screening results.
- Reviewing the patient’s full electronic record for unreported drug use e.g., aspirin, NSAIDs that could interfere with haemostasis but not standard coagulation tests.
- Seeking immediate advice from a specialist haemostasis scientist regarding the interpretation of borderline factor levels or the necessity of performing genetic screening for mild inherited disorders.
- How are you feeling in that moment? For instance, are you finding it difficult to adapt your approach from factor testing to platelet function testing? Is it affecting your confidence in justifying the need for second-line assays?
What is the conclusion or outcome?
- Identify how you are working within your scope of practice (e.g., successfully directing the investigation based on clinical rationale, or needing support because the interpretation of specific factor interactions or inhibitor characteristics is beyond your current scope)?
- What are you learning as a result of the unexpected development? For example, are you gaining crucial insight into the pitfalls of relying solely on screening tests in mild bleeding disorders, or mastering the systematic investigation of platelet function defects?
On action
What happened?
- Begin by summarising the key points of the experience of investigating a patient presenting with symptoms like easy bruising, bleeding, or menorrhagia. Which initial screening tests like FBC, coagulation screen and potentially more specific tests did you select, perform, and interpret?
- Consider specific events, actions, or interactions which felt important, such as moments where you had to weigh different potential diagnoses or interpret conflicting results. How did that make you feel?
- Include any ‘reflect-in-action’ moments where an unexpected result prompted you to immediately adjust the testing strategy or focus your interpretation in a different direction.
How has this experience contributed to your developing practice?
- Identify what learning you can take from this experience regarding the range of potential causes for bruising/bleeding and the tiered approach to laboratory investigation. What skills in test selection and interpretation for bleeding disorders did you develop or improve? Were there knowledge gaps regarding rare bleeding disorders or specific assay limitations?
- Compare this experience against previous engagement with similar activities. Has your understanding of investigating bleeding symptoms deepened?
- Identify any challenges you experienced e.g., vague symptoms, normal screening tests and how you reacted to these. How did you try to overcome these challenges?
- Identify anything significant about the activity, such as whether you needed to seek advice on interpreting a complex pattern of results. Did you ensure you were working within your scope of practice regarding diagnosis or management recommendations?
- Acknowledge any changes in your own feelings now you are looking back on the experience regarding your confidence in approaching the laboratory investigation of patients with bleeding symptoms.
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. For example, identifying specific types of bleeding disorders or diagnostic tests you need to learn more about, including reviewing relevant BSH guidelines.
- What will you do differently next time in how this experience influences your approach to selecting and interpreting tests for bleeding symptoms?
- Do you need to practise any aspect of the activity further, such as interpreting specific factor assays or platelet function tests?
Beyond action
Have you revisited the experiences?
- Considering your various experiences investigating patients with easy bruising, bleeding, or menorrhagia, have you looked back at your previous reflections on these cases?
- What specific actions did you identify to enhance your test selection, performance, or interpretation skills in this area e.g., understanding differential diagnoses, applying guidelines? Have you implemented these actions, and can you now demonstrate improvement?
- Have you discussed cases of unexplained bleeding or bruising with colleagues or presented findings in a team meeting? Did the collective knowledge or feedback provided change your understanding of specific bleeding disorders or diagnostic approaches?
How have these experiences impacted upon current practice?
- How does the cumulative learning from investigating bleeding/bruising/menorrhagia cases, coupled with your ongoing reflection, contribute to your preparation for assessments such as a DOPS investigating unexplained bleeding, an OCE presenting a case, or discussing bleeding risk with a surgical team?
- How has your expertise in selecting, performing, and interpreting tests for these diverse presentations developed over time?
- Are you more skilled at tailoring investigations based on clinical history and initial findings?
- How effectively can you now recognise when a case is particularly complex or rare and requires input from senior colleagues, ensuring you are working within your scope?
Relevant learning outcomes
| # | Outcome |
|---|---|
| # 1 |
Outcome
Identify appropriate clinical and laboratory investigations for the investigation of haemostasis. |
| # 2 |
Outcome
Interpret and report results of investigations of haemostasis in the correct clinical context. |
| # 7 |
Outcome
Perform quality assurance and control tasks across the range of investigations. |