Specialist Haematology Copy —
Training activity: 6

Details

Select, perform and interpret the appropriate tests for screening for a micro angiopathic haemolytic anaemia for example DIC and TTP

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 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 screening for a microangiopathic haemolytic anaemia (MAHA), for example DIC and TTP.
• Consider how the learning outcomes apply, specifically what constitutes an appropriate panel of tests for screening for conditions like DIC and TTP.
• What does accurate performance and interpretation look like in this context, including recognition of key laboratory features expected in MAHA, DIC, or TTP?
• Discuss with your training officer to gain clarity on expectations regarding which specific conditions to focus on and the expected depth of your investigation.

What is your prior experience of this activity?

• Think about what you already know about the pathophysiology of MAHA, DIC, and TTP.
• What do you already know about laboratory tests typically included in a MAHA screening panel, such as:
  • FBC
  • Film morphology
  • Coagulation tests
  • Haptoglobin
  • LDH
• Consider possible challenges you might face in selecting, performing, or interpreting these tests, and think about how you might handle them, for example:
  • Distinguishing between conditions.
  • Interpreting equivocal results.
  • Urgent turnaround times.
• Recognise the scope of your own practice for this activity, i.e., know when you would need to seek advice regarding potentially positive or complex MAHA screening results.
• Acknowledge how you feel about investigating these critical conditions.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop in selecting and interpreting a panel of tests for a specific clinical presentation.
• Identify specific insights you hope to gain into the diagnostic process for MAHA and related conditions, including the importance of urgent and accurate results.

What additional considerations do you need to make?

• Consult actions identified following previous experience with FBC, morphology, or coagulation testing that are relevant here.
• Identify important information you need to consider before embarking on the activity, such as:
  • Local protocols for MAHA screening
  • The availability of specific tests
  • The clinical urgency associated with suspected MAHA

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate during the MAHA screening process?
• Are you encountering situations such as:
  • Identifying subtle schistocytes or atypical morphological features on a blood film that make the differentiation between TTP and DIC ambiguous.
  • Obtaining simultaneous FBC and coagulation results that suggest a complex picture, such as mild thrombocytopenia but highly elevated D-dimer, requiring immediate assessment of fibrinolysis.
  • An urgent clinical request requiring interpretation and recommendation within a very short turnaround time, increasing pressure on troubleshooting and interpretation.

How are you reacting to the unexpected development?

• How is this impacting your actions? Did you adapt or change your approach to morphological interpretation or test prioritisation in the moment?
• Consider the steps you are taking in the moment, such as:
  • Immediately performing a targeted assay (e.g., haptoglobin or LDH) to quantify the severity of haemolysis.
  • Seeking immediate expert opinion from a senior morphologist or clinical scientist to confirm subtle morphological findings and their clinical relevance to MAHA.
  • Prioritising the completion of the full MAHA screen despite other ongoing urgent tasks, adhering to protocols for critical results.
• How are you feeling in that moment? For instance, are you finding it difficult to adapt your knowledge to distinguish overlapping features of DIC versus TTP? Is it affecting your ability to recommend the next diagnostic steps e.g., ADAMTS13 testing?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice e.g., successfully classifying the findings as suggestive of MAHA and recommending appropriate reflex testing, or needing support because the interpretation is equivocal and requires specialist discussion?
• What are you learning as a result of the unexpected development? For example, are you gaining key learning regarding the time-critical nature of MAHA diagnosis, or mastering the distinction between subtle morphological changes and artifacts?

On action

What happened?

• Begin by summarising the key points of the experience of selecting, performing, and interpreting tests for a suspected case of MAHA, DIC, or TTP. Which tests did you focus on e.g., FBC, blood film, coagulation screens, LDH, haptoglobin?
• Consider specific events, actions, or interactions which felt important, such as any significant observations on the blood film or unexpected laboratory results that stood out to you. How did you feel when interpreting these complex findings?
• Include any ‘reflect-in-action’ moments where your initial interpretation of morphology or a test result led you to immediately adapt your plan for further investigation or interpretation.

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding the specific laboratory features that suggest MAHA, DIC, or TTP. What skills in interpreting blood films or linking results from different assays did you develop? Were there knowledge gaps about the pathophysiology or specific diagnostic criteria?
• Compare this experience against previous engagement with similar activities. Has your ability to recognise and investigate MAHA improved?
• Identify any challenges you experienced e.g., subtle findings, urgency of the case and how you reacted to these. Were you able to overcome them effectively?
• Identify anything significant about the activity, such as whether you needed to seek advice from a pathologist or senior scientist for help with blood film interpretation or case management. Did you ensure your interpretation and suggested further investigations were within your scope of practice?
• Acknowledge any changes in your own feelings now you are looking back on the experience regarding your confidence in screening for MAHA.

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, determining specific areas related to MAHA, DIC, or TTP investigation that you need to study further e.g., specific morphological features or complex coagulation results.
• What will you do differently next time in your approach to reviewing blood films or interpreting laboratory panels in patients with suspected haemolytic anaemia or clotting activation?
• Do you need to practise any aspect of the activity further, such as blood film morphology review or integrating findings from multiple tests?

Beyond action

Have you revisited the experiences?

• Reflecting on your prior experiences screening for microangiopathic haemolytic anaemia (MAHA) like DIC and TTP, what specific areas did you aim to improve, based on past reflections e.g., test selection rationale, interpretation nuances, turnaround time?
• Have you successfully integrated these improvements into your practice? Are you now more confident and proficient in performing these screening investigations?
• Have you shared experiences of investigating suspected MAHA cases with peers or discussed the diagnostic pathways for DIC or TTP with senior staff? Did these discussions offer new perspectives on the key screening tests or the interpretation of challenging results?

How have these experiences impacted upon current practice?

• How does the knowledge and skill gained from repeatedly selecting, performing, and interpreting tests for MAHA screening, supported by reflection, help you prepare for assessments like a DOPS investigating unexplained bleeding or an OCE presenting a complex case?
• How has your ability to recognise the indicators for MAHA screening and effectively manage these investigations evolved over time?
• Are you more adept at interpreting the often subtle or rapidly changing results associated with conditions like DIC and TTP?
• How clear are you now on the boundaries of your scope of practice when interpreting these complex findings and suggesting further steps?

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.