Transfusion - Pre-compatibility Testing —
Training activity: 10

Details

Perform and report a transfusion reaction investigation and advise on clinical management where appropriate

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

• Criteria for acute/delayed haemolytic transfusion reactions
• BSH guidelines and laboratory protocols
• SHOT reporting categories and reporting mechanisms
• Testing and referral algorithms
• Antibody elution

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 and reporting a transfusion reaction.
• Consider how the learning outcomes apply, specifically learning outcomes which relate to selecting techniques, identifying algorithms, describing limitations, practicing according to guidelines/procedures, performing acceptance testing, performing phenotyping/genotyping (if needed), and devising investigative strategies.
• What constitutes an appropriate initial and subsequent panel of tests for a suspected transfusion reaction?
• What are the key laboratory tests typically performed in a transfusion reaction investigation e.g., clerical check, visual inspection, DAT, repeat ABO? What results would indicate a potential haemolytic reaction?
• Discuss with your training officer to understand the expected investigation algorithms and the process for communicating findings and advising clinicians.

What is your prior experience of this activity?

• Think about what you already know about the different types of transfusion reactions and their clinical presentations and laboratory findings. What do you know about the importance of a prompt and thorough investigation?
• Consider possible challenges you might face e.g., incomplete information from the clinic, sample issues, interpreting equivocal results, dealing with distressed clinicians. And think about how you might handle these.
• Recognise the scope of your own practice for this activity. When would you need to seek advice regarding a complex investigation, unexpected findings, or providing clinical advice?
• Acknowledge how you feel about investigating transfusion reactions, recognising the potential severity and the need for urgent action.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop in performing emergency investigations, integrating laboratory findings with clinical information, and communicating effectively with clinical staff.
• Identify specific insights you hope to gain into the causes, investigation, and management of transfusion reactions, including the haemovigilance process.

What additional considerations do you need to make?

• Have you consulted any actions identified from previous experiences with DAT, antibody identification, or urgent testing that are relevant here?
• Identify important information you need to consider before embarking on the activity, such as the local protocol for transfusion reaction investigation, reporting requirements (including haemovigilance), and accessing the patient’s full transfusion and clinical history.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate during the transfusion reaction investigation?
• Are you encountering situations such as:
  • Initial serological results e.g., DAT, repeat ABO contradicting the clinical findings or suspected reaction type
  • Incomplete clinical details provided by the requesting team, hindering the interpretation of non-specific symptoms
  • Difficulty differentiating between two types of non-haemolytic reactions e.g., differentiating between FNHTR and an allergic reaction

How are you reacting to the unexpected development?

• How is this impacting your actions? Did you adapt or change your investigative approach or communication strategy in the moment?
• Consider the steps you are taking in the moment, such as:
  • Immediately planning further investigations based on the initial laboratory findings.
  • Adapting communication to gather necessary clinical details from staff despite the urgency of the situation.
  • Seeking expert advice from a senior colleague or Transfusion Practitioner regarding the interpretation of ambiguous results or formulation of appropriate clinical advice.
• How are you feeling in that moment? For instance, are you finding it difficult to integrate laboratory findings with clinical information? Is it affecting your confidence in advising on appropriate clinical management?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully devising and performing investigative strategies, or needing support because the result requires senior consultation regarding haemovigilance reporting?
• What are you learning as a result of the unexpected development? For example, are you gaining crucial insight into the importance of a prompt and thorough investigation or the need to consider alternative explanations for findings?

On action

What happened?

• Begin by summarising the process you followed to investigate a suspected transfusion reaction. What initial checks and appropriate tests did you perform e.g., clerical check, visual inspection, DAT, repeat ABO? What were the findings?
• Consider specific aspects of the investigation that were challenging, such as conflicting clinical information, equivocal lab results, or communicating with clinical staff. How did you feel managing this urgent investigation?
• Include any ‘reflect-in-action’ moments where an unexpected laboratory result or new clinical information prompted you to immediately adjust the investigative plan or your interpretation.

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding the types and investigation of transfusion reactions. What strengths did you demonstrate, such as skills in devising and performing investigative strategies and advising on clinical management? Were there knowledge gaps regarding specific types of reactions, reporting requirements e.g., haemovigilance, or management advice?
• Compare this to previous cases. Has your ability to investigate and interpret transfusion reactions improved? Are you more confident in liaising with clinicians?
• Identify any challenges you faced e.g., urgency of the case, communication barriers and how you handled them. Were you able to overcome the challenges?
• Did you need to seek advice or discuss the case findings, interpretation, or management recommendations with a senior colleague, pathologist, or transfusion practitioner? Did you ensure your advice on clinical management was within your scope of practice?
• Acknowledge any changes in your own feelings now you are looking back on the experience regarding your confidence in performing and reporting transfusion reaction investigations.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take, such as specific types of transfusion reactions, investigative tests, or reporting procedures e.g., haemovigilance reporting requirements you need to study further. Do you need to review national guidelines on transfusion reactions?
• How will your approach to investigating and reporting transfusion reactions change based on this experience?
• Do you need more practice in interpreting the laboratory findings in the context of the clinical presentation or in communicating findings and advice to clinical staff?

Beyond action

Have you revisited the experiences?

• Reviewing your past experiences performing and reporting transfusion reaction investigations, have you reflected on your previous learning points?
• What specific aspects did you aim to improve, such as following investigation protocols, identifying the potential cause, communicating findings, or understanding haemovigilance reporting?
• Have you successfully applied these improvements in subsequent investigations? Are you now more proficient in managing the laboratory investigation of suspected transfusion reactions?
• Have you engaged in professional storytelling or discussed suspected or confirmed transfusion reaction cases with peers, supervisors, transfusion practitioners, or clinicians?
• Did these discussions provide new insights into the clinical presentation, differential diagnoses, required laboratory testing, or appropriate communication and reporting procedures?

How have these experiences impacted upon current practice?

• How does the cumulative learning from investigating transfusion reactions and your reflections, contribute to your overall preparation for assessments that may involve discussing a transfusion reaction case with a transfusion practitioner and explaining haemovigilance reporting (OCE)?
• How has your ability to perform, interpret, and report transfusion reaction investigations evolved over time? Are you more skilled at initiating the correct laboratory work-up, interpreting the results in the clinical context, and communicating findings effectively?
• How confident are you now in recognising the severity of a potential reaction and knowing when to escalate, seek advice on clinical management, or determine the scope of the laboratory’s role, ensuring you work within your scope?

Relevant learning outcomes

#	Outcome
# 1	Outcome Select suitable and valid techniques for transfusion pre-compatibility testing.
# 2	Outcome Identify sequential testing algorithms appropriate to the samples under investigation for pre-compatibility testing.
# 3	Outcome Describe the limitations of methods used in pre-compatibility testing including sources of error and sample issues.
# 4	Outcome Practice in accordance with guidelines and procedures relevant to pre-transfusion testing.
# 5	Outcome Perform acceptance testing of samples requiring pre-transfusion testing and ensure samples follow appropriate testing streams relating to clinical condition.
# 6	Outcome Perform phenotyping and/or referral of genotyping to complete investigation for pre-transfusion testing.
# 8	Outcome Devise and perform investigative strategies for complex antibody identifications and transfusion reaction investigations.