Specialist Haematology Copy —
Training activity: 20

Details

Interpret morphological and FBC features associated with infectious aetiology and identify further investigations to confirm the underlying cause to include:

• Malaria
• Infectious mononucleosis
• Bacterial infections/sepsis

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
• Clinical presentations and other investigations
• National and international 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 interpreting morphological and FBC features associated with infectious aetiology and identifying further investigations.
• Consider how the learning outcomes apply, specifically what specific morphological or FBC features are indicative of infections like malaria, infectious mononucleosis, or bacterial sepsis.
• What does successful interpretation look like, including identifying expected FBC changes and morphological findings in the specified infectious conditions, and determining appropriate further investigations?
• Discuss with your training officer to gain clarity on expectations regarding the range of infectious aetiologies to cover and the expected link between initial findings and further testing.

What is your prior experience of this activity?

• Think about what you already know about the typical haematological response to different types of infection (bacterial, viral, parasitic).
• What are the key morphological features to look for on a blood film that might suggest infection, for example:
  • Toxic granulation
  • Dohle bodies
  • Reactive lymphocytes
  • Malarial parasites
• Consider possible challenges you might face in interpreting findings, and think about how you might handle them, for example:
  • Overlapping features between infections
  • Identifying rare parasites
  • Interpreting sepsis-related changes
• Recognise the scope of your own practice for this activity, i.e., know when you would need to seek advice regarding suspicious morphological findings or the selection of further investigations.
• Acknowledge how you feel about interpreting morphology in potentially urgent cases like sepsis or malaria.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop in correlating FBC data and morphology with clinical suspicion of infection.
• Identify specific insights you hope to gain into the role of the haematology laboratory in the initial investigation and diagnosis of infectious diseases.

What additional considerations do you need to make?

• Consult actions identified following previous experience with FBC analysis or blood film morphology interpretation.
• Identify important information you need to consider before embarking on the activity, such as:
  • The clinical context provided with the sample
  • The urgency of suspected cases like sepsis or malaria
  • The availability of specific confirmatory tests e.g., malaria microscopy, serology, PCR

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst interpreting morphological and FBC features associated with infectious aetiology?
• Are you encountering situations such as:
  • Identifying atypical lymphocytes suggestive of Infectious Mononucleosis, but the FBC concurrently shows a severe neutropenia atypical for that diagnosis, suggesting an alternative viral process or drug effect.
  • Observing suspicious bodies within red cells that could be Malaria but requiring immediate differentiation from artefacts, Howell-Jolly bodies, or other inclusions.
  • The morphological changes being subtle or non-specific e.g., mild toxic granulation, making the differentiation between mild bacterial infection and sepsis challenging without clinical correlation.

How are you reacting to the unexpected development?

• How is this impacting your actions? Did you adapt or change your interpretive approach or urgency level in the moment?
• Consider the steps you are taking in the moment, such as:
  • Immediately consulting a senior morphologist or consultant haematologist to confirm the presence of parasitic forms (e.g., Malaria) or severe toxic changes indicative of sepsis.
  • Rapidly preparing a thick film or contacting the microbiology department to initiate confirmatory testing e.g., Malaria PCR or blood culture based on high suspicion of a critical infectious agent.
  • Reviewing the patient’s full clinical data e.g., temperature, white cell count trend, CRP to correlate non-specific morphological findings with clinical suspicion of sepsis.
• How are you feeling in that moment? For instance, are you finding it difficult to adapt your knowledge to distinguish between parasitic forms and artifacts? Is the urgency of potential diagnoses like sepsis or malaria affecting your ability to focus on detail?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice e.g., successfully identifying the need for immediate clinical notification and confirmatory testing, or needing support because the morphological finding is novel or requires specialist microbiological input?
• What are you learning as a result of the unexpected development? For example, are you gaining crucial insight into the laboratory features that mandate urgent clinical notification in infectious disease, or mastering the differentiation of reactive lymphocytosis patterns?

On action

What happened?

• Begin by summarising the key points of the experience of examining blood film morphology and FBC data for a patient with suspected infection. What specific features did you look for e.g., reactive lymphocytes, toxic granulation, parasites, and what further investigations did you identify?
• Consider specific events, actions, or interactions which felt important, such as morphological features you observed that were challenging to interpret or identify. How did you feel when trying to link the lab findings to a potential infectious cause?
• Include any ‘reflect-in-action’ moments where your observation of a key morphological feature e.g., a potential malarial parasite immediately led you to change your focus or recommend specific urgent tests.

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding the haematological manifestations of different types of infections e.g. malaria, Infectious mononucleosis, bacterial infections/sepsis. What skills in identifying and interpreting morphological features did you develop? Were there knowledge gaps regarding the typical FBC patterns or specific morphological clues for certain infections?
• Compare this experience against previous blood film reviews. Has your ability to recognise infectious aetiologies improved?
• Identify any challenges you experienced (e.g., differentiating reactive changes from malignancy, identifying rare organisms) and how you reacted to these. How did you attempt to address these?
• Identify anything significant about the activity, such as whether you needed to seek advice or discuss the findings with a more experienced colleague or microbiologist. Did you ensure your interpretation and recommendations for further tests were within your scope of practice?
• Acknowledge any changes in your own feelings now you are looking back on the experience regarding your ability to interpret features suggestive of infection.

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 infectious conditions or morphological features you need to study further.
• What will you do differently next time in your approach to reviewing FBC and blood films in patients with suspected infection?
• Do you need to practise any aspect of the activity further, such as blood film examination for infections or identifying appropriate confirmatory investigations based on morphological clues?

Beyond action

Have you revisited the experiences?

• Looking back at your past experiences interpreting morphology and FBC features for suspected infectious causes like malaria, infectious mononucleosis, bacterial infections/sepsis, have you reviewed your previous reflections? What specific areas did you focus on for improvement e.g., recognising specific red or white cell morphology, linking findings to clinical suspicion, suggesting appropriate confirmatory tests? Have you actively worked on these skills, and are you now more proficient?
• Have you shared interesting or challenging cases involving infectious aetiologies with colleagues or discussed morphological features with senior haematologists? Did these interactions broaden your understanding of the spectrum of haematological changes seen in infection or improve your ability to identify subtle signs?

How have these experiences impacted upon current practice?

• How does the cumulative learning from interpreting morphological and FBC features in the context of infection, combined with your ongoing reflection, support your preparation for assessments such as a DOPS involving morphology interpretation or an OCE presenting a case?
• How has your ability to interpret morphological and FBC features and effectively suggest further investigations for infectious causes developed over time? Are you more confident in distinguishing features of infection from other haematological conditions? How clearly can you now identify when the morphological findings or clinical picture require urgent attention or are outside your current expertise, ensuring you work within your scope?

Relevant learning outcomes

#	Outcome
# 5	Outcome Perform a range of laboratory-based techniques to investigate anaemia, red cell disorders and white cell disorders.
# 7	Outcome Perform quality assurance and control tasks across the range of investigations.