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Rotation Summaries - Clinical Pathology

Transfusion Medicine - Multi-institutional Rotation
(Blood Bank / Transfusion Medicine / Cellular Therapy)

Residency training in Transfusion Medicine prepares a person to provide laboratory and clinical transfusion services at community basic and tertiary care hospitals and medical school based tertiary care centers. Further, it prepares a person for additional training for career specializing in clinical transfusion medicine, transfusion medicine research, blood center operations, histocompatibility, semen or organ banking.

After the training period, the resident will be knowledgeable and experienced with red cell antigens, compatibility testing, component therapy, adverse effects of transfusion, transfusion appropriateness review, blood donor evaluation and donation, therapeutic apheresis, peripheral blood stem cell collection, stem cell processing and infusion. The resident will gain experience with the operation of the HLA/histocompability testing laboratory. The resident will also receive a basic introduction to operations of a disputed parentage testing laboratory and organ and semen donation programs.

Transfusion medicine clinical training and experience is provided at three major teaching hospitals.

  1. University of Minnesota Medical Center, Fairview (UMMC) is an academic medical center with major programs in organ and stem cell transplantation, oncology, cardiovascular surgery, obstetrics and a neonatal ICU.
  2. Hennepin County Medical Center (HCMC) is a major tertiary medical center and county hospital with the region's primary trauma center, a large obstetric service and provides a wide variety of surgical, medical and pediatric care to a diverse population.
  3. Veterans Administrative Medical Center (VAMC) is a large general hospital. Blood Bank physicians from each of these hospitals and the regional blood center coordinate the teaching program and meet with the resident at a weekly meeting to discuss transfusion and apheresis cases.

Training Sites And Locations

The Transfusion Medicine Training Program involves four consecutive months at various sites in the Minneapolis-St. Paul metropolitan area.

The primary training sites in Transfusion Medicine are:

  1. Veteran's Administration Medical Center (Minneapolis) - 2 weeks (Appendix A)
  2. Hennepin County Medical Center (Minneapolis) - 2 weeks (Appendix B)
  3. University of Minnesota Medical Center, Fairview (Minneapolis) - 12 weeks (Appendix C)

The secondary training sites are:

  1. American Red Cross North Central Blood Services (St. Paul)-1.5 days (Appendix D)
  2. American Red Cross National Testing Laboratory (Eagan) - 2 days (Appendix E)
  3. Memorial Blood Centers of Minnesota (Minneapolis) - 2 day (Appendix F)
  4. Life Source/Organ Procurement Organization (St. Paul) - 2 day (Appendix G)
  5. Cryogenic Laboratory Inc./Semen Bank (Roseville) - 2 day (Appendix H)

Post-Graduate Level Of Residents In Rotation

PGY Levels 1-4.

Duration Of Rotation

4 months with the following distribution topics covered by site.

During the first month the resident first spends two weeks at the VAMC and two weeks of time period at UMMC learning the operations of the HLA laboratory and the Cell Therapy laboratory (Stem Cell Processing). The resident then spends two weeks at the Hennepin County Medical Center. The subsequent 10 weeks at UMMC will be spent primarily in the UMMC Transfusion service, blood bank and apheresis/blood donor center (with brief off-site training periods at the Red Cross Regional Blood Center, Memorial Blood Centers of Minnesota, LifeSource Organ Procurement Organization, Cryogenic Laboratory Semen Bank and American Red Cross National Testing Laboratory).

Week 1 & 2: VAMC - Basic laboratory aspects (perform ABO/Rh, crossmatch, workup antibodies, etc) and clinical transfusion service.

Week 3: UMMC Cell Therapy Clinical Laboratory orientation.

  1. Didactic Sessions (Burger)
    1. Intro Cell Engineering and Transplantation, Regulatory Issue.
    2. Microbiology Contamination, Graft Infusion.
    3. Umbilical Cord Blood Transplant.
    4. Pos and Neg Cell Selection (Including GVH, GVL discussion).
    5. Cell Expansion, Transduction, Activation.
  2. Become familiar with cell therapy laboratory operational procedures (St. Paul campus).
  3. Attend Stem Cell Infusions.

Week 4: UMMC HLA laboratory orientation

  1. Basic Laboratory operation, learn tests.
  2. Type own cells.
  3. LifeSource visit: Organ Procurement Organization (donor selection process including HLA selection, matching with waiting list, etc).

Week 5 & 6: HCMC - clinical transfusion experience, RBC antibody rounds, hemolytic disease of the newborn testing, massive transfusions, obstetrics.

Week 7-16: UMMC

  1. Provide Clinical Transfusion Services:
    1. Approve HLA/XM platelets.
    2. Difficult XM, Aby problem, etc.
    3. Review Aby identification.
    4. Manage blood shortage.
    5. Provide PBSC collection.
    6. Provide Therapeutic phlebotomy.
    7. Management of Transfusion Reactions.
    8. Manage Donor Reactions.
    9. Provide TM consultation.
    10. Attend Transfusion Committee Meeting.
    11. Evaluate requests for components that do not meet guidelines established by Transfusion Committee.
  2. Stem Cell infusions
  3. Provide Therapeutic Apheresis Service
  4. Transfusion Appropriateness Audits
  5. Didactic Sessions (Eastlund):
    1. Managing Platelet Refractoriness.
    2. Platelet Antibody and Antigen Testing and Clinical Disease.
    3. Hemolytic Disease of Newborn.
    4. Transfusion Reactions.
  6. Ongoing experience with Cell Therapy Clinical Laboratory (managing SOP deviations, positive cultures, etc) and with HLA Laboratory (including HLA data reviews with Director, periodic clinical relevance studies, etc.).
  7. Red Cross Visit 1.5 Days: Neutrophil and Platelet Serology Laboratory, RBC Ref Laboratory, Blood Collection and Processing.
  8. Visit to Memorial Blood Center of Minnesota for training in Disputed Parentage Testing.
  9. Visit to Cryogenic Laboratory Semen Bank.
  10. Visit to Red Cross National Testing Laboratory.

Supervisory Guidelines For Patient Care

UMMC Transfusion Service: Most residents will work with a Transfusion Medicine Fellow and Blood Bank Attending Physician and receive direct supervision from both. There are 1-2 months per year when a fellow may not be present, and in this case the resident is directly supervised by the Attending physician. The attending physician spends one to three hours each week day with the resident. The resident, with or without the fellow, carries out the provision of clinical blood bank services but with close overview. The daily assignments essentially all go to the resident who consults the fellow for assistance. The attending physician also sees therapeutic apheresis patients and inpatient consults and contersigns notes made by the resident in the patient's medical record (consults, stem cell infusions, therapeutic procedures). Individual decisions to approve components not meeting guidelines and deviations from blood bank procedures (e.g. release incompatible blood,) are reviewed by the attending physician, not only for supervision and teaching purposes but also for attending physician billing documentation. In addition to daily mentoring by the attending physician, the resident receives scheduled didactic learning sessions (one-on-one) from the physician in charge of the apheresis/donor center, the blood bank laboratory and the cell therapy laboratory.

UMMC HLA Laboratory: After one week of training in HLA laboratory procedures, the resident meets periodically with the HLA laboratory director to review analysis of laboratory results and to report and analyze cases. These periodic meetings are arranged during the subsequent 10 weeks of clinical transfusion service training at UMMC. While the resident does not sign off on reports, he/she meets with the HLA laboratory director during report generation.

UMMC Cell Therapy Laboratory: After one week of training in the cell therapy laboratory, the resident carries out clinical services (regularly scheduled stem cell infusions, decisions regarding deviation from normal procedures, problem solving, etc) under supervision of the blood bank attending physician but also with guidance by the medical director of the cell therapy laboratory. The resident receives several didactic sessions (one-on-one) from the cell therapy laboratory medical director.

HCMC: The resident carries out the activities of the transfusion service for 2 weeks with no fellow but with close supervision by the blood bank medical director. The resident routinely is involved with direct decision making and consults. Each morning the resident and blood bank medical director make blood bank rounds, reviewing activities of the previous 24 hours and any antibody findings. For 2 months the resident is the primary on call physician nights and weekends with supervision by the HCMC blood bank medical director.

VAMC: The resident carries out the activities of the clinical transfusion service without a fellow and under the supervision of the blood bank medical director. The resident is directly involved with decision making.

Goals And Objectives

The resident gradually assumes more responsibility. At the end of the transfusion medicine rotation the resident will routinely be able to competently provide the following daily clinical duties. At UMMC, VAMC and HCMC the objectives are similar so that at the end of the rotation the resident should have attained the following objective:

  1. General Transfusion Medicine Objectives:
    1. Interacts with physicians to ensure that blood components are used appropriately balancing risk, benefit and availability.
      1. Evaluate transfusions and transfusion requests that are out of established guidelines.
      2. Approve initial requests for HLA-matched donors or crossmatch-negative platelets.
      3. Advise about difficult crossmatches, antibody problems and selection of compatible red cells.
      4. When fully compatible red cells are unavailable, approves release of least-incompatible blood and assures that clinician is aware of risk for a risk-benefit analysis.
      5. Approves use of granulocyte transfusion and ensures availability of high-dose (G-CSF) granulocytes when needed.
    2. Provide medical direction to ensure an adequate supply of blood components
      1. Make decisions for the donor center regarding blood donors with medical suitability conditions out of established guidelines.
      2. Provides medical management of donors experiencing adverse reactions and complications due to blood donation.
      3. Provide peripheral blood stem cell collections.
      4. Evaluate requests, suitability of patient, write orders.
      5. Manage blood shortages (ABO, Rh switches).
      6. Interacts with clinicians using stem cell components particularly if there are positive bacterial culture results or if cell dose is out of desired range.
      7. Approves directed platelet donors.
    3. Provide transfusion-related services directly to patients.
      1. Provide therapeutic apheresis services (plasma exchange, cytapheresis, SPA column, photopheresis, red cell exchange).
      2. Evaluate request and determine suitability of patient.
      3. Write note on the patient's hospital medical record at the first treatment, complete consultation record
      4. Write orders.
      5. Obtain consent.
      6. Be present during beginning of first procedure.
      7. Follow therapeutic response and decide continuation of treatments.
      8. Evaluate patient suitability and approve therapeutic phlebotomy requests.
      9. Infuse cryopreserved bone marrow, peripheral blood and cord blood stem cells.
      10. Inform patient as to nature of procedure.
      11. Ensure patient's physician has written orders and premedication is given.
      12. Ensure medical management of adverse reactions by patient's physician.
      13. Provide supervision of thawing and thawing problems.
      14. Overview patient identification and infusion.
      15. Write note in patient's medical record.
    4. Ensure appropriate recognition and management of transfusion adverse outcomes.
      1. Evaluate, complete and sign reports of adverse reactions to transfusions. Follow-up subsequent test results to assure appropriate patient medical care and donor suitability.
      2. Ensure that suspected cases of disease transmission through blood transfusion are evaluated and reported to the blood supplier, when appropriate.
    5. Counsel blood donors with confirmed positive infectious disease blood tests.
    6. Provide transfusion education
      1. Provide transfusion consultations to clinicians.
      2. Provide educational experience to the students.
      3. Attend and participate in patient case discussions at Blood Bank breakfast meetings and other Blood Bank conferences.
  2. Immunohematology Objectives:

    The resident will be able to explain and perform basic tests, solve antibody problems and correlate laboratory findings with clinical significance in the following areas:

    1. Blood Groups:
      1. ABO and other carbohydrate antigens (Lewis, P)
      2. Rh and other protein antigens (Kell, Duffy, Kidd, MNSs)
      3. Inheritance
      4. Clinical significance for transfusion or pregnancy
      5. Resolution of typing problems
    2. Pre-transfusion Testing:
      1. Type and screen
      2. Compatibility tests including a complete crossmatch through the antiglobulin phase
      3. IgM and IgG antibodies
      4. Mechanisms of immune hemolysis
      5. Direct and indirect antiglobulin testing
      6. Alloantibody identification using panels
      7. Enhancement media including low ionic strength (LISS), enzyme, albumin and polyethylene glycol (PEG)
      8. Testing before non-red cell transfusion
      9. Role of the computer crossmatch
    3. Red Cell Serological Studies:
      1. Autoantibody evaluation, cold and warm
      2. Autoimmune hemolytic anemias - treatment and transfusion
      3. Drug-related antibodies - evaluation and mechanisms
      4. Elution - purpose, methods, and interpretation
      5. Complex antibody problems - i.e. multiple, high frequency antigens, selection of appropriate components
      6. Prenatal screening and intrapartum monitoring
      7. Evaluation of hemolytic diseases of the newborn
        1. Fetal maternal hemorrhage, Rh immune globulin dose
        2. Exchange transfusion and/or intrauterine transfusion
    4. Platelet Serology:
      1. Platelet antigen groups
      2. Drug-dependent platelet antibodies
      3. Autoimmune thrombocytopenia
      4. Neonatal alloimmune thrombocytopenia
      5. Post transfusion purpura
      6. Platelet antibody testing including platelet immunofluorescence and antigen capture assays (MAIPA)
    5. Neutrophil Serology:
      1. Neutrophil-specific antigens
      2. Autoimmune neutropenia
      3. Drug-dependent neutrophil antibodies
      4. Neutrophil serology including immunofluorescence and agglutination assays
  3. Whole Blood Collection Objectives:

    The resident will be able to provide medical assistance to a blood donation program. A basic understanding of the following topics will be obtained:

    1. Blood Donation:
      1. Performance of donor interview and physical examination
      2. Donor safety issues
      3. Recipient safety issues
      4. Phlebotomy process
      5. Evaluation and treatment of donor reactions and injuries
      6. Autologous donation - candidates, frequency, common problem
      7. Directed donation - pros and cons of a directed donor program
    2. Blood Component Preparation and Testing:
      1. Component preparation including labeling
      2. Donor testing
        1. Blood groups - ABO, Rh, antibody screen
        2. Infectious disease marker testing: syphilis, HBsAg, anti-HIV, ALT, anti-HBc, anti-HTLV, anti-HCV
        3. Confirmatory testing including anti-HIV western blots, anti-HCV RIBA, and anti-HTLV western blot
        4. CMV antibody testing
        5. Nucleic acid amplification testing (NAT)
    3. Blood Donor Counseling:
      1. Donor notification of positive results
      2. Confidentiality and requirements for reporting infectious disease markers to public health agencies
  4. Clinical Transfusion Service Objectives:

    The resident should be able to discuss standard laboratory and clinical practices, investigate problems and questions, and assess transfusion therapy in the following areas:

    1. Blood Component Therapy:
      1. Blood administration - specimen and patient identification, thawing, pooling, issuing, transport time and temperature, filtration
      2. Blood components - red blood cells, platelet concentrates, apheresis platelets, plasma, cryopoor plasma, cryoprecipitate, and granulocytes
      3. Blood appropriateness review - audit requirements, methods, transfusion committee activities.
      4. Modified components - washed, irradiated, leukocyte-reduced, frozen/thawed deglycerolized red cells, HLA-matched platelets, crossmatched platelets.
      5. Support for solid organ and bone marrow transplant patients
    2. Adverse Effects of Transfusion:

      The resident will:

      1. be able to recognize and discuss pathophysiology, treatment, and prevention of the following: febrile, allergic, acute hemolytic, delayed hemolytic, anaphylactic, septic, transfusion-associated graft-versus-host disease, transfusion-related acute lung injury, and circulatory overload
      2. be able to manage massive transfusion including the appropriate and timely ordering of laboratory tests for monitoring the patient and recognizing the metabolic and hemostatic consequences of massive transfusion
      3. have a working knowledge of the effects of stored blood on recipients, including pediatric patients
    3. Transfusion-Related Infections:
      1. HIV, hepatitis B and C, HTLV, CMV, protozoa, and bacterial contaminants
        1. current risks of transfusion
        2. procedures to minimize risk for recipients
  5. Apheresis for Collection of Blood Components, Patient Therapy and Blood Progenitor Cell Collections:

    The resident will have an understanding of the basic concepts of apheresis and stem cell collection. The resident will have a working knowledge of the variety of therapeutic apheresis instruments, procedures, and the appropriate indications.

    1. Therapeutic Apheresis - The resident will:
      1. have a clear understanding of the appropriate indications for either cytapheresis or plasmapheresis.
      2. act as a consultant and evaluate the patient before, during and after apheresis.
      3. be able to design a treatment plan including and write orders for use of replacement solutions.
      4. understand and recognize the side effects and reactions related to therapeutic apheresis.
      5. understand the processing of the instrumentation with regard to the separation and collection of various blood components.
  6. UMMC Cell Therapy Laboratory:
    1. Hematopoietic Stem Cell Processing - The resident will:
      1. understand the preparation and cryopreservation of bone marrow/stem cells.
      2. have an introductory knowledge of the quality control aspects of a marrow processing laboratory including cell culture, cell viability, and sterile technique.
      3. have a general understanding of purging malignant cells.
      4. have a conceptual understanding of the protocol to change blood types in patients undergoing allogeneic transplants.
      5. understand the concepts of engraftment and the use of cytokines to speed marrow engraftment.
      6. understand the overall theory and methods of T-cell depletion.
      7. understand methods to positively select CD34+ stem cells.
      8. be very familiar with techniques for thawing and transfusing frozen marrow or PBSCs including the side effects or reactions and will participate in these transfusions.
    2. Umbilical Cord Blood Banking and Processing - The resident will:
      1. understand the role of cord blood in hematopoietic cell transplantation.
      2. understand the structure and operation of a cord blood bank.
      3. understand the medical evaluation and other criteria used to determine the suitability of cord blood for banking.
      4. understand the ethical issues involved in cord blood banking including those relating to consent.
      5. be knowledgeable of the methods used to process and store cord blood.
      6. be familiar with techniques for thawing and transfusing cord blood.
  7. VAMC Transfusion Service:

    The resident will have a basic understanding of blood bank laboratory procedures, component production, blood collection, component therapy and evaluation of transfusion reactions.

  8. HCMC Transfusion Service:

    The resident will be able to manage component transfusion in patients with massive blood loss and transfusion. The resident will understand basic blood bank laboratory operations, component therapy and transfusion reaction evaluations. The resident will be able to diagnose hemolytic disease of the newborn by appropriate laboratory tests.

  9. UMMC HLA Laboratory:

    The HLA experience for residents is oriented to clinical decision-making regarding selection of organ and hematopoietic stem cell donors and donors for patients refractory to platelet transfusions. The resident will:

    1. Understand the procedures used for serologic and molecular HLA typing.
    2. Understand the procedures used to crossmatch patients with potential kidney donors.
    3. Participate in the selection of one or more unrelated marrow donors
    4. Be able to type your own cells.
  10. Memorial Blood Centers of Minnesota:

    Following training in the Disputed Parentage Laboratory the resident will have an understanding of the legal, technical, and laboratory test systems employed in paternity testing.

    1. Specimen Identification and chain of custody
    2. Test systems employed in paternity testing:
      1. ABO blood group
      2. Rh and other red cell antigens
      3. HLA typing
      4. DNA analysis
    3. Analysis and calculation of paternity index
    4. Legal implications of reporting system including testing protocol, affidavit, and deposition/testimony.

The transfusion medicine proficiency checklist should be used to document training in the various learning areas.

Opportunities To Function As Consultant To Other Physicians

In combination with the transfusion medicine fellow, the pager for the daily clinical service at UMMC will be carried by the resident who is the primary contact from 8:00 a.m. to 5:00 p.m. for all clinical transfusion problems and consultations. The most common calls from clinicians on a daily basis include several on the topic of requests for HLA or crossmatched platelets in patients refractory to transfusion and questions about management of therapeutic apheresis patients. Calls also are received via this pager several times a day from blood bank staff and usually result in the need for the resident to directly contact our clinical colleagues. During the 3 months at UMMC, specific time periods will be assigned to the resident for carrying this pager, depending on the resident's experience and capabilities. As part of the clinical service team, the resident will document consultations and other patient updates directly in the patient's record. The resident often interacts by phone and directly on the patient care unit with the clinicians taking care of the patient. Daily, the resident is on the patient care units usually re-evaluating the use of components that were issued outside of the guidelines set by the Transfusion Committee. The daily situations whereby the resident correlates laboratory results with clinical findings to determine whether special platelets are needed or should continue to be provided, including platelet counts, platelet antibody and platelet crossmatching results, the patient's clinical state (i.e. bleeding) or has non-immune causes of platelet refractoriness. Approximately twice a week the resident will correlate patient signs and symptoms with laboratory data in evaluating transfusion reactions. In plasma exchange patients, the resident will follow the clinical status daily, correlating with laboratory tests to determine effectiveness of therapy, and decide further treatments or manage adverse reactions (e.g. hypocalcemia). The resident will correlate results from several laboratories in the care of pheresis patients (e.g. TTP patients - following hematology laboratory results (platelet count) and chemistry laboratory results (creatinine, LDH) and special hematology laboratory results (peripheral smear for shistocytes).

Donor Center Experiences

UMMC: The resident will evaluate requests, review donor suitability and write procedure orders on allogeneic family donors of peripheral blood stem cells collected by pheresis. The resident will be responsible for immediate care and management of the donor in case of adverse reactions. The resident will evaluate requests for therapeutic phlebotomy and manage adverse outcomes during blood collection.

VAMC: The resident will be given an overview of whole blood collection and provide medical director services under faculty supervision to the center (donor eligibility decisions, adverse reaction management).

RED CROSS: The resident will be given an orientation and overview of blood donor recruitment, donor screening, and blood collection. At the National Testing laboratory, the resident will become familiar with the various donor test procedures.

Transfusion Reaction Workups

All suspected transfusion reactions (from 8:00 a.m. - 5:00 p.m. weekdays) are immediately referred to the resident (when carrying pager) for immediate evaluation regarding need for intervention or special testing. Within 24 hr of a suspected reaction, the laboratory will have preliminary data (DAT, serum color, gram stain if performed, etc) and refer the case to the resident with the evaluation report form. The resident obtains a clinical history for the patient, reviews the laboratory data and subsequently shares the data and the resident's preliminary assessment with the blood bank attending physician. Together, the assessment and recommendations are documented on the report.

All reactions are handled in this manner either by the fellow and attending MD or the resident and attending M.D. or all three.

Training In The Unique Computer Needs Of A Transfusion Service

During the blood bank laboratory orientation and training, the resident learns how laboratory staff use computers to acquire components from the blood supplier, enter test results, track the unit, and release the unit to the patient care unit. The resident also learns the principles behind the electronic crossmatch using a computer. The resident frequently uses the blood bank computer for retrieving patient and blood bank data. The resident has computer continuous access in the resident/fellow office for patient care and for Medline literature searches.

Training In Immunologic/Serologic Aspects Of Blood Product Screening

The resident is trained regarding blood donor testing at the Red Cross, including red blood cell serology and infectious disease serologic testing. In addition they spend time learning neutrophil serology and platelet serology & crossmatches.

On Call Duties

For a two month period during the rotation, the resident carries the HCMC on call pager (nights and weekends), provides first call consultation and blood bank problem solving for HCMC. During this period, the residents will on average have one out of every seven days free of hospital duties. The resident is directly supervised by the HCMC blood bank medical director and has access to additional help from blood bank medical faculty at UMMC and the American Red Cross. While on-call, residents are supervised by a Faculty Member, who is available at all times, either via their office phone, pager, or home phone. During the HCMC site rotation, all calls are reviewed at the weekday morning blood bank rounds, with the HCMC blood bank medical director.

At all sites except for HCMC, the resident is expected to be available to laboratory personnel, either in person or by pager, throughout the working day. No on call duties outside of regular laboratory working hours are assigned to the resident involving coverage at these sites.

Due to the at-home nature of call, the call duties are constructed in the following fashion. The residents are on at-home/pager call every other week. The on-call periods last from 7:00 a.m. on Monday morning through the following weekend, ending at 7:00 a.m. on the subsequent Monday.

Reliable Communication With On Duty Faculty

Blood Bank Medical Directors and Teaching Faculty Members on service are physically present during standard operating hours (8:00 AM - 5:00PM) and immediately available in person or by pager; specific faculty members when not physically present in the laboratory are available by phone or pager. At all times, a supervising faculty member is on call for evening and weekend questions.

At UMMC, the attending MD meets daily (weekdays) with the resident to discuss direct patient care activities. In addition, the resident and usually the fellow usually have an informed lunch meeting with the blood bank medical director at least once a week and often three times a week (case discussions, mentoring).

Education In Blood Bank Management

Specific blood bank management related to planning, organizing, staffing, and economic issues are discussed regularly at the weekly city wide blood bank conference that is attended by the resident. Blood supply inventory management is discussed both at regular blood bank staff meetings and the Transfusion Committee meetings. The resident is required to attend both of these meetings regularly.

Required Conferences

Optional Conferences

Scholarly Activities/Research

The resident is expected to regularly review the current medicine literature about difficult transfusion cases and is asked to present a topic for review at least once to the City wide weekly Blood Bank conference. Because of this the resident evaluates and discusses research findings in the literature and receives feedback from faculty. The resident is urged to write up and publish interesting or unique transfusion problems encountered during the rotation. Blood Bank faculty eagerly offers to mentor the resident through the process leading to a publication.

If a resident is interested in a research project and has sufficient time, the blood bank faculty will arrange this in one of the Transfusion Medicine research labs.

Resident Evaluation

If problems with not meeting expected knowledge and skills are observed during the rotation, the lead faculty member meets with the resident to evaluate the problem and develop a corrective action plan.

Residents will be evaluated on performance of daily activities (described previously), participation in required meetings and conferences, and presentations to the staff on assigned cases. The residents are provided with continuous feedback on their performance during the rotation. In general, only deficiencies are noted in writing. Residents are evaluated on their demonstrated ability to provide informative consultation to the clinical service teams, their medical knowledge, their application of this knowledge to efficient/quality patient care, and their diagnostic, technical and observational skills. Residents are also evaluated on their interpersonal skills, professional attitudes, reliability, and ethics with members of the teaching faculty, peers, laboratory staff, and clinicians. They are further evaluated on their initiative in fostering quality patient care and use of the medical literature, as it relates to their assigned cases. Their timely completion of assigned interpretive reports is another component of the evaluation. Residents on probation receive a written mid-rotation evaluation.

Educational Resources Available

UMMC: The Biomedical Library of the University of Minnesota is located on the UMMC campus. The resident has full access to borrowing, copying and literature searching at this library. The Blood Bank maintains a small library of it own, containing pertinent text books and selected journals (Transfusion, Vox Sanguinis). The blood bank fellow/resident office is maintained with key blood bank related textbooks and in addition to those available in faculty offices. Computer literature searches can be performed in the resident's office. Faculty members also have extensive reprint files readily available to residents.

VAMC: An on site full service library is available with over 500 journals, and 4000 book titles. Access to medical literature searches is readily available.

HCMC: A well supplied on site full service medical library is available to the residents 24 hours a day. Residents also have access to projection slide production and to existing slides on blood bank topics.

Computer Information Systems For Resident Education And Service Duties

In addition to the blood bank specific computers described above, residents have continuous access to the laboratory and hospital clinical information systems, which relate to patient care at each of the hospitals to which they are assigned. The residents also have access to on-line literature searching.

Appendix A

Site: Veteran's Administration Medical Center, Minneapolis, Minnesota.
Goal/Objective: The resident will understand the basic operations of a hospital blood bank, the clinical transfusion service and the on-site blood collection program.
Length of Rotation: 2 weeks.
Topics Covered: During the first week the resident will personally perform lab procedures: ABO/Rh typing, compatibility testing, antibody screening, antibody identification with panels. The resident, with supervision by the blood bank medical director will be the primary provider of clinical blood bank consultations or therapeutic apheresis and of medical decisions for blood collections.

Appendix B

Site: Hennepin County Medical Center, Minneapolis, Minnesota.
Goal/Objective: The resident will understand the basic operations of a hospital blood bank and the clinical transfusion service. Special experience will be acquired determining RBC incompatibilities and transfusion patients with massive blood loss.
Length of Rotation: 2 weeks on-site plus primary on-call duty nights and weekends for 2 months.
Topics Covered: The resident works closely with the blood bank medical director, John Crosson, M.D., provides clinical transfusion service duties (consults, component use appropriateness review, etc) under supervision by Dr. Crosson. Each morning the resident and blood bank medical director review with blood bank staff the events of the previous day, compatibility problems and antibody workups. The facility is the largest trauma center in Minnesota and the resident is responsible for managing blood transfusions in patients with massive transfusions.

Appendix C

Site: University of Minnesota Medical Center (primary teaching hospital of the University of Minnesota Medical School), Minneapolis, Minnesota.
Goal/Objective: Comprehensive Clinical Transfusion Service Training in a busy tertiary care center and large transplant faculty (organs, marrow, etc.).
Length of Rotation: 3 months.
Topics Covered: 1. Clinical transfusion service. 2. Therapeutic apheresis. 3. Peripheral blood stem cell collection. 4. Therapeutic phlebotomy. 5. Stem cell processing, cryopreservation and infusion.

Appendix D

Site: American Red Cross North Central Blood Services, 100 South Robert Street, St. Paul, MN 55107, Phone: 651-291-6789.
Goal/Objective: The resident will obtain a basic understanding of a regional blood center operations to collect and provide blood to hospitals and the regional reference lab for red cell, granulocyte and platelet antibody testing and incompatibility evaluations.
Length of Rotation: One and one half days.
Topics Covered: 1. Donor recruitment. 2. Blood collection donor suitability determination. 3. Blood component preparation and processing, storage. 4. Neutrophil Serology Lab. 5. Platelet Serology Lab and platelet crossmatches. 6. Red Cell Reference Lab. 7. Role of Medical Director.

Appendix E

Site: American Red Cross National Testing Laboratory, 1919 Eagandale Blvd, Eagan, Minnesota 55121.
Goal/Objective: To understand the basic principles of blood donor infectious disease testing, ABO and Rh testing and red cell antibody testing.
Length of Rotation: One half day.
Topics Covered: By means of lecture and tour of facility: 1. Large scale, rapid throughput testing of blood donor samples for: A. ABO, Rh. B. red cell antibodies. C. ALT. D. Infectious disease (anti-HIV, anti-HCV, HBsAg, anti-HBc, anti-HTLV, HIV antigen, nucleic acid testing for HIV and HCV, syphilis). 2. The various enzyme immunoassays will be reviewed.

Appendix F

Site: Memorial Blood Centers of Minnesota, 2304 Park Ave. S., Minneapolis, MN 55404.
Goal/Objective: To understand the basic principles of disputed parentage testing.
Length of Rotation: One half day.
Topics Covered: 1. Sample chain of custody. 2. Disputed parentage testing, calculation of paternity index, and reporting.

Appendix G

Site: Lifesource - upper midwest organ procurement organization, St. Paul, Minnesota 55114.
Goal/Objective: The resident will understand the process of community provision of organs and tissues to patients in need and see the similarity to blood banking (donor recruitment, donor suitability determination, donation/collection, distribution and use).
Length of Rotation: One half day.
Topics Covered: 1. Recognition and referral of recently deceased prospective cadaveric organ and tissue donors. 2. Cadaveric organ and tissue donor suitability determination: Medical and social history requirement. 3. Transplant associated testing. 4. Maintenance of a heart-beating, brain-dead organ donor in the ICU. 5. Organ procurement, use of biopsy. 6. Prospective organ recipient waiting list, selection criteria and organ allocation. 7. Relationship between organ procurement organization, tissue bank and eye bank.

Appendix H

Site: Cryogenic Laboratory Inc., 1944 Lexington Ave., Roseville, MN 55113
Goal/Objective: The resident will understand the process of community provision of semen to infertile patients and storage of semen by cancer patients for their later use. The resident will see the similarity to blood banking (donor recruitment, donor suitability determination, processing and storage, distribution and use).
Length of Rotation: One half day
Topics Covered: 1. Donor recruitment. 2. Donor suitability determination: medical, social and genetic history, infectious disease and genetic testing, and physical examination. 3. Semen laboratory analysis: count, morphology, and motility. 4. Semen cryopreservation and storage. 5. Semen Donor Selection: Matching characteristics of donor with recipient. 6. Distribution and use. 7. Role of Medical Director.