Specialised Transfusion

Module details

Title

Specialised Transfusion

Type

Specialist

Module code

SLS144

Credits

10

Requirement

Compulsory

Aim of this module

This module will provide the trainee with the knowledge and practical skills to resolve serological anomalies in pre-transfusion testing and to know when further referral is necessary. It will also enable them to undertake antenatal testing and procedures to prevent anti-D sensitisation of women with child-bearing potential. In the work-based module they will be expected to apply this knowledge as they learn to perform relevant laboratory methods and gain experience of the interpretation of patient results in a variety of clinical settings. The module will also provide the trainee with an understanding of the principles and practice of blood transfusion in a blood services setting, and the relevance of these procedures in reducing transfusion risk and providing optimum component therapy for patients.

Competencies

#	Learning outcome	Competency	Action
# 1	Learning outcome 1	Competency Recognise, investigate and resolve patient blood grouping anomalies, selecting appropriate reagents/techniques and making interpretations in clinical context, including: post haematopoietic stem cell transplant (HSCT) immunocompromised patients AIHA.	Action View
# 2	Learning outcome 1	Competency Recognise cases where referral for further investigation is required before a blood group can be assigned.	Action View
# 3	Learning outcome 1	Competency Identify the group/phenotype of red cells required for safe transfusion where blood grouping is not straightforward.	Action View
# 4	Learning outcome 1	Competency Identify and investigate. Interpret anomalous donor ABO/D typing results and assign appropriate groups, or quarantine donations following further investigation.	Action View
# 5	Learning outcome 2	Competency Select, perform and interpret specific antibody tests in non-routine or complex cases with red cell alloantibodies. Report results in the correct clinical context, including the implications for transfusion.	Action View
# 6	Learning outcome 2	Competency Perform more complex antibody identification, selecting techniques and additional panel cells required to elucidate antibodies present and exclude all other antibodies of clinical significance, recognising situations where specialist referral is required.	Action View
# 7	Learning outcome 2	Competency Perform red cell phenotyping, interpret results in the context of antibody identification and prediction of HDFN, and recognise situations where serological testing is not appropriate and molecular genotyping is required.	Action View
# 8	Learning outcome 2	Competency Select and perform tests for the differential diagnosis of AIHA including: monospecific direct antiglobulin test (DAT) specific antibody identification adsorption elution.	Action View
# 9	Learning outcome 3	Competency Interpret and report results in the correct clinical context.	Action View
# 10	Learning outcome 3	Competency Select and provide safe blood for transfusion for patients with AIHA.	Action View
# 11	Learning outcome 4	Competency Perform routine antenatal testing on pregnant women including: ABO and RhD type red cell antibody screen.	Action View
# 12	Learning outcome 4	Competency Interpret and report results in the correct clinical context.	Action View
# 13	Learning outcome 4	Competency Select and issue appropriate doses of prophylactic anti-D immunoglobulin; for antenatal cases following potentially sensitising events, as RAADP, and as a post-natal standard dose.	Action View
# 14	Learning outcome 4	Competency Perform FMH tests by acid elution, evaluate the need for referral for confirmation by flow cytometry, request follow-up samples and communicate with midwives/clinicians on the need for additional doses of anti-D.	Action View
# 15	Learning outcome 4	Competency Perform FMH testing by flow cytometry, interpret results, and determine follow-up actions and additional anti-D prophylaxis required.	Action View
# 16	Learning outcome 5	Competency Perform tests on cord and maternal blood to predict, diagnose and monitor potential HDFN including: direct antiglobulin test elution of red cell antibodies titration of ABO and IgG antibodies red cell alloantibody identification.	Action View
# 17	Learning outcome 5	Competency Undertake follow-up in antenatal cases with red cell antibodies, including additional serological testing, referral to specialist units, paternal typing (and fetal genotyping where appropriate). Report results in clinical context, recognising the need for referral, and communicating with clinicians and midwives.	Action View
# 18	Learning outcome 5	Competency Provide transfusion support for pregnant women with red cell antibodies.	Action View
# 19	Learning outcome 5	Competency Provide transfusion support for the fetus and neonate, undertaking appropriate compatibility testing and selecting blood components with the correct specifications for IUT, neonatal top-up and exchange transfusion.	Action View
# 20	Learning outcome 6	Competency Inform clinicians (and patients where applicable) on the specifications of components, blood safety, risk benefit of transfusion and blood supply issues.	Action View
# 21	Learning outcome 6	Competency Co-operate with blood services to co-ordinate testing and provision of blood components for patients with special requirements.	Action View
# 22	Learning outcome 2	Competency Select and perform non-routine serological tests to investigate cases with red cell antibodies: • IAT strictly at 37ºC • two-stage enzyme • direct agglutination • enzyme IAT.	Action View

Assessments

You must complete:

• 2 case-based discussion(s)
• 2 of the following DOPS/ OCEs:

Perform additional testing to resolve a range of ABO and RhD abnormalities	DOPS
Perform appropriate procedures following incorrect results of controls of ABO D grouping and antibody screening	DOPS
Perform antibody identification on a sample with at least 3 antibody specificities with appriate reflex testing	DOPS
Perform an IAT strictly at 37C and an enzyme IAT	DOPS
Select appropriate blood for a range of patients of different age and gender with an abnormal expression of the RhD antigen	DOPS
Perform alloadsorption and subsequent antibody panels to identify or exclude underlying alloantibodies in a patient with autoantibodies	DOPS
Perform autoabsorption and subsequent antibody panels to identify or exclude underlying alloantibodies in a patient with autoantibodies	DOPS
Perform a Donath Landsteiner test	DOPS
Perform antibody elution on a DAT positive sample and determine the antibody specificity	DOPS
Perform a monspecific DAT on 3 different DAT positive samples and correctly interpret the results	DOPS
Perform routine antenatal testing on an Rh D negative booking case and explain subsequent routine testing and anti D prophylaxis requirements	DOPS
Complete a full investigation on a sample from an antenatal patient with red cell antibodies ABO RhD antibody screen and panel	DOPS
Perform FMH testing by acid elution on a positive and calculate FMH explain followup testing actions required.	DOPS
Perform FMH testing by flow cytometry and calculate the appropriate amount of anti D Ig required	DOPS
Perform antibody titration on a repeat sample from an antenatal patient with two red cell antibodies	DOPS
Perform anti D quantification	DOPS
Perform a crossmatch to provide blood for a neonate where the mother has a clinically significant red cell antibody	DOPS
Select appropriate red cell units for patients with a mixture of allo and auto antibodies	DOPS
Advise a clinician in the selection of appropriate blood for patients with a range of nonroutine anomalous ABO grouping results in routine and emergency situations	OCE
Advise a clinician about the appropriate blood for a patient with sickle cell disease with multiple antibodies	OCE
Liaise with clinicians to explain why a transfusion has been delayed for a patient with red cell alloantibodies	OCE
Take a patient history and plan a family study on a patient with an antibody to a high incidence antigen or an unusual red cell phenotype	OCE
Visit a ward to collect a sample from a patient for investigation of CHAD	OCE
Liaise with specialist reference red cell immuno haematology services over testing and provision of blood for a patient with AIHA and underlying red cell antibodies.	OCE
Liaise with blood services to negotiate stocks where there is a national blood shortage	OCE
Liaise with reference services to obtain blood with a rare phenotype that is not readily available from the regional transfusion service	OCE
Visit component monitoring and TTI investigating department and determine the white cell count on two different components	OCE

Learning outcomes

1. Troubleshoot serological tests, investigate patient and donor blood grouping anomalies, and make interpretations in clinical context.
2. Select, perform and interpret the results of non-routine additional tests to elucidate alloantibodies in complex cases (mixtures, high frequency, etc.), and liaise with clinicians and blood services regarding transfusion support.
3. Select and perform serological tests for differential diagnosis of autoimmune haemolytic anaemia (AIHA) and for provision of suitable blood for transfusion.
4. Use algorithms for routine and non-routine antenatal testing and the use of anti-D prophylaxis and fetomaternal haemorrhage (FMH) testing.
5. Select and perform tests to predict and monitor haemolytic disease of the fetus and newborn (HDFN), and provide appropriate transfusion therapy for the fetus and neonate.
6. Work with specialist blood transfusion services to provide safe transfusion support for patients and be able to inform clinicians on blood safety issues.

Learning outcomes

1. Explain the clinical and technical basis of blood grouping anomalies and how to resolve these to make safe blood group interpretations for patients and donors.
2. Discuss and evaluate the process involved in resolving complex red cell antibody cases using non-routine serological and molecular testing.
3. Describe the aetiology and classification of autoimmune haemolytic anaemias, and the testing required to provide effective transfusion support.
4. Describe algorithms for routine and non-routine antenatal testing, and the use of anti-D prophylaxis and fetal maternal hemorrhage (FMH) testing to prevent sensitisation to the D antigen.
5. Discuss and evaluate the role of the transfusion specialist in diagnosis, management and treatment of haemolytic disease of the fetus and newborn (HDFN).
6. Explain and justify the rationale behind the selection of immunohaematological tests for new and established donors and how the requirements for donor testing differ from those for patient testing.
7. Discuss methods for preparation of blood components and products, and the requirement to work in conformance with quality systems and legislation such as Good Manufacturing Practice (GMP).
8. Describe the design, operation and performance of assays for markers of transfusion-transmitted infections (TTI). Understand which additional tests are required for specific groups of donors, and the algorithms for confirming positive results and for deferral/reinstatement of donors, and the impact on blood safety.
9. Discuss donor issues, including donor selection, recruitment, motivation and care.
10. Explain the principles of bone marrow and stem cell transplant, histocompatibility and immunogenetics (H&I) testing and cord banking.

Indicative content

• Strategies for resolution of complex antibody identification cases
• Causes and investigation of ABO and D typing anomalies
• Aetiology, classification, investigation and management of AIHA
• Aetiology and management of haemolytic disease of the fetus and newborn (HDFN)
• Routine antenatal testing and follow-up of cases with red cell antibodies
• FMH testing
• Molecular techniques for genotyping and antibody identification
• UK guidelines for blood transfusion services, GMP [Orange] Guide, EU directives, BSQR, Consumer Protection Act and Product Liability
• Principles of donor selection, recruitment, motivation, and care
• Blood collection, methods to prevent infection, and storage prior to processing
• Apheresis and use/management of specialist panels
• Mandatory and discretionary testing for transfusion-transmitted infections, and criteria for donor exclusion/reinstatement
• Principles of TTI assay methods, selection and validation
• Variant Creutzfeldt-Jacob disease (vCJD), emerging pathogens and pathogen reduction strategies
• Blood component production and quality control, and changes to blood and components on storage
• The national frozen blood bank and provision of rare red cells
• Fractionated products – types, storage and use
• Principles of bone marrow and stem cell transplantation
• Principles of testing for human leucocyte antigens (HLA), human platelet antigens (HPA) and neutrophil antigens/antibodies
• Principles of cord banking

Activities

• Attend antenatal clinics and observe the collection of specimens for routine antenatal testing and assess the potential for problems with sample identity.
• Observe routine antenatal anti-D prophylaxis and report on the logistics and documentation of anti-D prophylaxis.
• Participate in multidisciplinary review meetings at which clinical cases involving complex transfusion related issues are presented. Prepare a portfolio of relevant cases, including learning points and clinical outcomes.
• Attend a unit where blood is collected from donors. Reflect and discuss on the engagement and experience of donors and the role and responsibilities of staff within this unit.
• Attend a unit where blood is collected from donors, and report on how compliance with procedures ensures safety of the donor and the product.
• Attend an establishment where blood is tested and processed prior to transport and storage.
• Shadow other staff involved throughout the whole transfusion pathway and report on how they all contribute.
• Present a case study/audit report/training session to an invited audience (>10 people).