REVIEW Simulation-based education for transfusion medicine Shanna Morgan,1 Benjamin Rioux-Masse,2 Cristina Oancea,3 Claudia Cohn,1 James Harmon, Jr,4 and Mojca Konia5
BACKGROUND: The administration of blood products is frequently determined by physicians without subspecialty training in transfusion medicine (TM). Education in TM is necessary for appropriate utilization of resources and maintaining patient safety. Our institution developed an efficient simulation-based TM course with the goal of identifying key topics that could be individualized to learners of all levels in various environments while also allowing for practice in an environment where the patient is not placed at risk. STUDY DESIGN AND METHODS: A 2.5-hour simulation-based educational activity was designed and taught to undergraduate medical students rotating through anesthesiology and TM elective rotations and to all Clinical Anesthesia Year 1 (CA-1) residents. Content and process evaluation of the activity consisted of multiple-choice tests and course evaluations. RESULTS: Seventy medical students and seven CA-1 residents were enrolled in the course. There was no significant difference on pretest results between medical students and CA-1 residents. The posttest results for both medical students and CA-1 residents were significantly higher than pretest results. The results of the posttest between medical students and CA-1 residents were not significantly different. CONCLUSION: The TM knowledge gap is not a trivial problem as transfusion of blood products is associated with significant risks. Innovative educational techniques are needed to address the ongoing challenges with knowledge acquisition and retention in already full curricula. Our institution developed a feasible and effective way to integrate TM into the curriculum. Educational activities, such as this, might be a way to improve the safety of transfusions.
T
he majority of blood product transfusions in American hospitals are administered by physicians without subspecialty training in transfusion medicine (TM).1 This may lead to inappropriate utilization of resources, additional medical costs, and regional variability in practice.2-4 To standardize TM education, significant efforts have been invested into universal and consistent education of all physicians on the topic. In 1989 and 1995 the National Heart, Lung, and Blood Institute (NHLBI), of the National Institutes of Health (NIH), sponsored the Transfusion Medicine Academic Awards Group (TMAA), which published the TM curriculum goals for undergraduate medical education and provided grants for the development of these goals.5,6 However, the knowledge gap in TM still exists.7-9 For example, a study by Karp and colleagues1 indicated poor familiarity with TMAA transfusion curricula by undergraduate medical school administrators responsible for the curricula. Furthermore, there is evidence that junior residents have limited knowledge of TM in the areas of complications of blood product transfusion, management of complications, transmission rates of infectious agents,
ABBREVIATIONS: CA-1 = Clinical Anesthesia Year 1; TM = transfusion medicine; TMAA = Transfusion Medicine Academic Awards Group. From the 1Department of Laboratory Medicine and Pathology, the 4Department of Surgery, and the 5Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota; the 2Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada; and the 3Department of Family and Community Medicine, University of North Dakota, Grand Forks, North Dakota. Address reprint requests to: Shanna M. Morgan, Department of Laboratory Medicine and Pathology, Division of Transfusion Medicine, University of Minnesota, D242 Mayo Building, MMC 609, 420 Delaware Street SE, Minneapolis, MN 55455; e-mail: [email protected]. Received for publication May 30, 2014; revision received August 20, 2014, and accepted September 10, 2014. doi: 10.1111/trf.12920 © 2014 AABB TRANSFUSION **;**:**-**. Volume **, ** **
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and indications for irradiation of blood products.10 Studies also indicate that practicing clinicians’ knowledge base requires an ongoing education of TM, especially as it relates to coagulation topics.2,11-18 The knowledge gap in TM at different levels of medical practice is of concern for several reasons: 1) residents are frequently actively involved in managing transfused patients on the wards and therefore contribute to patient safety, 2) transfusion of blood products carries significant risks, and 3) transfusion of blood products has a continuously increasing cost.19-21 It is therefore important that all physicians, irrespective of their specialty, have knowledge of TM. This can be challenging with the already full medical school curricula. Recognizing the importance of TM education, an intense 2.5-hour simulation-based course was developed at our institution. The course was designed with the following goals: 1) cover broad TM topics along with an in-depth coverage of risks and appropriateness, 2) have the ability to be individualized for learners at different levels and in different environments of the hospital (e.g., ward, operating room, or intensive care unit), 3) utilize several educational techniques to enhance knowledge acquisition, 4) be time efficient and therefore easy to integrate into curricula, and 5) allow for repetition and practice in an environment where the patient is not at risk. This article presents the framework used by our institution to develop this course and summarizes the results of the implementation of this course.
MATERIALS AND METHODS Due to the research being conducted in an educational setting as a part of normal educational practice, this study has been granted an exempt status by the institutional review board at the University of Minnesota (Minneapolis, MN).
Learners The session was taught to all undergraduate medical students rotating through anesthesiology and TM elective rotations between May 2011 and March 2012 and to all Clinical Anesthesia Year 1 (CA-1) residents. The majority of undergraduate medical students came from the University of Minnesota Medical School. Approximately one-half of CA-1 residents finished their internship at one institution, the other half finished their internship at a different institution within the United States.
Study design A 2.5-hour simulation-based educational activity of TM was designed. The TM, anesthesiology, and surgery departments collaborated in the development of all educational activities. The same faculty members taught all sessions. 2
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Pretest
Posttest
Lecture
Survey
Simulation with debriefing
6 weeks Posttest
Session evaluation
Fig. 1. Timing of specific sections of the educational activity. The session begins with a survey about the previous exposure to TM education, followed by a pretest, lecture, simulation session with debriefing, posttest, and session evaluation. A small group of learners repeated the test 6 weeks after the session.
Before the educational activity, learners were given a survey regarding the number of TM training hours they have received in the past. The University of Minnesota Medical School, from which a majority of the learners came, was contacted to verify the actual hours of TM training at our institution. Learners then participated in a 2.5-hour educational activity, which consisted of a pretest with 10 multiplechoice questions, a 45- to 60-minute simulation session of an acute hemolytic transfusion reaction with recording of the session and debriefing, a 30- to 45-minute lecture, and a posttest consisting of the same 10 multiple-choice questions as the pretest. After the educational experience the learners were asked to evaluate the educational activity. A limited number of learners were able to return after 6 weeks and were given the same multiple-choice test again to assess for retention of knowledge (Fig. 1).
Test and lecture The 30- to 45-minute didactic session and multiplechoice question test was created to address the following areas of TM: blood groups, blood donation (including apheresis) and testing (including processing times for tests and volume of products), blood component indications (including emergent and massive needs), and transfusion complications (including reactions and infectious risks) and management.22,23 The lecture was reinforced during the debriefing period and during the posttest discussion.
Simulation sessions A high-fidelity advanced patient simulator (SimMan 3G, Laerdal, Wappingers Falls, NY) was used as a model. Each simulation scenario took approximately 20 minutes and was recorded for review during the 30- to 45-minute debriefing period. The session begins with an introduction to the simulator mannequin and explanation of simulation environment technology. The patient history,
SIMULATION-BASED EDUCATION FOR TM
physical examination, and current status are then introduced to the learners and the simulation session begins. Two learners actively lead the session, with additional learners available to help if called upon. Two simulation specialists serve as facilitators to provide guidance for the learners, as needed. After the simulation, there is a debriefing period in which the learners and facilitators review the recording and examine actions and thought processes and discuss both what went well and also opportunities for improvement. The facilitators’ role is to guide the learners to critically analyze their own performance and also incorporate TM principles into the discussion through formative feedback. Five different versions of simulation scenarios were created with options available to practice an acute hemolytic transfusion reaction occurring both in the operating room and in the ward and a massive transfusion protocol occurring in the operating room, intensive care unit, and the ward. Each simulation scenario is designed to allow participants to apply medical knowledge to a realistic clinical situation.22,23
Evaluation of the educational activity The educational session was evaluated on content and process. Content evaluation consisted of a multiplechoice question test, which was administered to learners before educational activity, immediately after the session, and to five available learners 6 weeks after the simulation session to assess knowledge retention. Process evaluation consisted of a course evaluation form using the Likert scale from 0 (nonsatisfactory) to 5 (excellent) and asked learners to evaluate the educational experience in terms of their subjective satisfaction with the session.
Statistical analysis Data on learner TM education received were collected. Pretest and posttest results were compared. Pretest results for undergraduate medical students and CA-1 residents were compared. Data were analyzed for a normal distribution. A nonparametric test Wilcoxon signed-rank sum test was used with a p value of 0.05 to be considered as significant. Data are presented as median and range. Additionally, percentage correct was obtained on five learners given a test 6 weeks after the educational experience. The Likert scale evaluated mean and percentage satisfaction.
RESULTS Seventy medical students and seven CA-1 residents were enrolled in the course. Data are presented as median and range. All participants reported between 1 and 2 hours of TM education during undergraduate medical school. In con-
trast, the medical school administrators reported 18 activities in which TM topics were addressed although often these topics were imbedded into another education topic such as clinical medicine, human disease, orthopedics, pathology, and science of medical practice. CA-1 residents reported the same 1 to 2 hours of TM education during undergraduate medical school and commented that they gained additional TM education while administering blood products during their internship and the majority of that education occurred in a nonstructured, nonfocused manner while addressing other patientrelated problems. All participants took a pretest, which consisted of 10 multiple-choice questions. The median pretest score for medical students was 40 (range, 0-80). Overall, there was no general pattern seen with regard to TM knowledge of a particular category as questions in certain categories fell into both the highest and the lowest scoring responses. The highest scores were on one question in the blood donation and testing category (mean, 65%) and one question in the transfusion complications category (mean, 63%). The lowest scores were on two questions in the transfusion complications category (mean, 10 and 22%) and one question in the blood donation and testing category (mean, 22%). The median pretest score for CA-1 residents was 30 (range, 20-60). The highest scores were on two questions in the transfusion complications category (mean, 71 and 57%) and two questions in the blood donation and testing category (mean, 57% on both questions). The lowest scores were on one question in the blood groups category (mean, 0%), one question in the transfusion complications category (mean, 0%), one question in the blood component indications category (mean, 14%), and one question in the transfusion complications category (mean, 14%). There was no significant difference on pretest scores between medical students and CA-1 anesthesiology residents (p = 0.82) as summarized in Fig. 2A. The maximum score (80 vs. 60) and median score (40 vs. 30) was higher for medical students, compared to CA-1 anesthesiology residents; however, the minimum score was lower for medical students compared to CA-1 anesthesiology residents (0 vs. 20). All participants took a posttest. Posttest scores for medical students had a median of 80 (range, 30-100). There was a significant difference between the pre- and posttest scores for medical students (p < 0.001; Fig. 3A). The highest scores were in the blood donation and testing category (mean, 88% on both questions). The lowest scores were in the blood component indications category (mean, 65%) and on one question in the transfusion complications category (mean, 65%). Posttest scores for CA-1 residents had a median of 70 (range, 60-80). For CA-1 residents, there was a significant difference between pre- and posttest scores (p = 0.03; Fig. 3B). The highest scores were in the blood donation and testing category (mean, 100% Volume **, ** **
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A
B B
Fig. 3. Median, minimum (Min), and maximum (Max) score on pretest ( ) and posttest ( ) for medical students (A) and CA-1 residents (B) are presented. Significant increase in between Fig. 2. Median, minimum (Min), and maximum (Max) scores on pretest (A) for medical students (MS, ) and CA-1 residents ( ) and posttest (B) for both groups are presented. No statistical difference between medical students and CA-1 residents was demonstrated for pretest (p = 0.82) and posttest (p = 0.08). p < 0.05 was considered significant.
on both questions), as seen in the pretest, as well. The lowest scores were in the blood groups category (mean, 58%), blood component indications category (mean, 58%), and on two questions in the transfusion complications category (mean, 58 and 42%). There was no significant difference between the posttest scores obtained by medical students and residents (p = 0.08; Fig. 2B). Five learners took an additional test 6 weeks after the educational activity. The number of learners was small due to medical student availability and logistic difficulties in getting medical students now at different institutions to come back and take the posttest. As such, these learners’ results were not statistically analyzed; however, the results indicate that knowledge was retained as they responded correctly to 80, 80, 90, 90, and 70% of questions. 4
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pre- and posttest was demonstrated for medical student scores (p < 0.001) and CA-1 resident scores (p = 0.03). p < 0.05 was considered significant.
All participants evaluated the simulation session. Their overall rating of the education experience on the Likert scale from 0 (nonsatisfactory) to 5 (excellent) had a median of 5 (range, 3-5). Forty-eight percent of participants thought that the experience was excellent, 48% thought that it was very good, and 4% of participants thought that it was good. No participant thought that it was satisfactory or nonsatisfactory (Fig. 4).
DISCUSSION The need for improved education of TM has been recognized for many years.6 The TMAA, sponsored by the National Heart, Lung, and Blood Institute of the NIH, has developed and published comprehensive curricula over the past 25 years.6 In spite of significant efforts and investments, studies published in the past few years still demonstrate deficiencies in TM knowledge
SIMULATION-BASED EDUCATION FOR TM
Participant Satisfaction
5-excellent
4
3-good
2
% of participants
1-nonsatisfactory
60 50 40 30 20 10 0
Fig. 4. Percentages of participants choosing the overall satisfaction rate on the Likert scale from 0 to 5 are presented. 0 = not able to assess, 1 = nonsatisfactory, 2 = satisfactory, 3 = good, 4 = very good, 5 = excellent. Forty-eight percent of participants chose 5, 48% chose 4, and 4% chose 3. No participants chose 2, 1, or 0.
among medical students, residents, and practicing physicians.1,2,7,8,10,11,15-17 Bryant and coworkers11 found that 85.3% of the calls received by the TM physician at a large academic health center were related to physician education and blood component appropriateness. O’Brien and colleagues10 demonstrated deficiencies in TM knowledge and the consent process across 10 medical specialties. Salem-Schatz and coworkers3,4 revealed that less than half of the routinely prescribing subspecialty physicians surveyed could correctly assess transfusion risk. A few studies suggest that the knowledge gap is wider at the attending level.3,8,9 Finally, the TM knowledge deficiencies are not confined to within the United States undergraduate medical system as Rock and colleagues7 and Gharehbaghian and colleagues9 have found similar issues in Canada and Iran. This is not a trivial problem as the suboptimal transfusion of blood products is associated with morbidity, mortality, and significant cost.19-21 Educational intervention is a common and effective method for improving the quality of health professional performance.24 There are four studies that focus on educational intervention to reduce suboptimal transfusion of blood products.2,15-17 These studies examine red blood cell and fresh-frozen plasma usage and target education among internists, surgeons, anesthetists, and perioperative physicians, with one study targeting all prescribing physicians.2,15-17 All studies suggest that inappropriate use of blood products can be altered.2,15-17 Despite these findings, it is hoped that TM education will be increased at an earlier point in a new physician’s career, preferably before the ability to order blood independently. Our institution developed an innovative TM educational session for medical students and residents. This study demonstrated significant improvement in participants’ knowledge of TM. It further demonstrated that a comprehensive curriculum, which uses multiple teaching
techniques including testing, simulation with debriefing and didactic session, reinforces retention of knowledge over 6 weeks in learners and increases learner satisfaction. Furthermore, we demonstrated that the current practice of exposure of junior residents to the clinical environment with a nonstructured education of TM does not lead to the desired acquisition of knowledge. Our study demonstrated that knowledge of CA-1 residents is not greater than medical student knowledge. This is supported by the results of studies demonstrating lack of knowledge among PGY-1 residents and attending physicians.7,9-11 As we think about the education of TM, or any other topic in medical education, recommendations by Cooke and colleagues,25,26 in their book entitled Educating Physicians: A Call for Reform of Medical School and Residency, should be taken into account. The authors propose that medical education of the future should be standardized and individualized; it should integrate knowledge and skills, promote habits of inquiry and innovation, and help develop professional identity. Based on the suggestions of Cooke and colleagues, we developed a curriculum that incorporates several of the recommendations. We designed an educational activity that 1) provides a standardized curriculum with carefully defined goals and objectives; 2) has goals and objectives that can be adjusted to the individual learner’s knowledge and skill level; 3) provides immediate opportunity to apply knowledge into practice, uncovers any remaining deficiencies in understanding, and allows for immediate feedback and correction; 4) provides an educational experience that promotes the appropriate attitudes, communication skills, and teamwork building; and 5) allows instructors to promote the habits of inquiry by challenging the learners to explain their actions and possibly look for basic science research supportive of their proposed solutions. The development of our TM educational session was systematically approached by starting with a needs assessment. The needs assessment determined the following: 1.
2. 3.
4.
Faculty member anesthesiologists observed that the majority of trainees reporting to the department lack a comprehensive understanding of TM. When asked which educational experiences learners would like to have, TM topics were listed. Our suspicion of deficiencies in TM knowledge was confirmed by a low average percentage of correctly answered multiple-choice questions on a test of TM designed by TM specialists. The systematic follow-up of massive transfusion protocol activations in the hospital by the TM department indicated a need for education for all members of the operating room team including interns, residents, attendings of different specialties, and operating room personnel. Volume **, ** **
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Faculty members from the department of surgery were also in favor of increasing TM educational opportunities.
We then developed a list of possible solutions, which included didactics, problem-based learning sessions, workshops, and simulation. The following questions were taken into consideration: 1) How much time should be dedicated to TM education? 2) At which time point in medical education should the TM education happen? and 3) How should it be done and by whom? We decided that our educational activity must be time-efficient, multimodal, and easily modifiable for different learners in different environments and must allow for repetition. We further considered the educational theory that proposes that the mastery of an area requires a learner to go through acquisition of key component skills, practice and integrate skills, and learn how to appropriately apply new skills in new environments.27 The majority of undergraduate medical education in the United States offers 1 to 4 hours of TM training, primarily in the first and second years.1 The learners of our study reported the same, although medical school administrators specified 18 exposures of TM topics. It appears that students do not recall the majority of TM training opportunities. It may be that a more innovative approach to TM education might be more successful. Our intense, face-to-face, focused curriculum, which combines theoretical discussions of TM topics with practical use of learned principles during simulation scenarios, allows learners to practice clinical skills and uncover deficiencies in knowledge and skills and allows for immediate feedback on areas that need improvement. This was achievable in 2.5 hours. This was considered an important attribute in view of overpacked medical school curricula. Our study demonstrated that there is no difference in TM knowledge between the medical students and the CA-1 residents. This may indicate that the current mode of education does not add to the understanding of TM. A potential solution might be to embed an educational activity like the one we developed into the last year of medical school or initial months of internship. The educational activity, which can be modified for different learner levels, can also be repeated and utilized in later years of residency and for refresher courses for faculty members for knowledge retention. We further believe that medical educators of today should utilize a mix of educational methods, which allows learners to examine their own understanding of TM principles and forces learners to apply knowledge into practice in a safe environment of a simulation laboratory, without exposing patients to the risk of transfusion. Two reports support the use of simulation-based education for skill and knowledge acquisition and propose the success to be due to intense, repetitive-performance, rigorous-skill6
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assessment, immediate-feedback, and controlled setting where patients’ well-being is not at stake.28,29 Because it combines didactic session with simulation, checklist, testing, and debriefing, during which the understanding of the principles of TM is examined, the objective measures of learner understanding can be gained. Furthermore learners’ feedback suggests that the experience provided learners with an insight into the practical application of acquired knowledge. This summary of our innovative educational activity suggests a feasible and effective way to integrate TM into the curriculum. Our activity allows learners of all levels to adjust to different environments within the hospital (ward, operating room, intensive care unit) and practice in an environment where the patient is not at risk. Utilization of several educational techniques promotes learner satisfaction, knowledge acquisition, and potentially better retention. It is hoped that more educational activities, such as this one, will be further developed to address the knowledge gap in TM. ACKNOWLEDGMENT The authors thank the SimPORTAL for providing the space, equipment, technical, and logistic support for the educational activities. CONFLICT OF INTEREST The authors have disclosed no conflicts of interest.
REFERENCES 1. Karp JK, Weston CM, King KE. Transfusion medicine in American undergraduate medical education. Transfusion 2011;51:2470-9. 2. Soumerai SB, Salem-Schatz S, Avorn J, et al. A controlled
3.
4.
5.
6.
7.
trial of educational outreach to improve blood transfusion practice. JAMA 1993;270:961-6. Salem-Schatz SR, Avorn J, Soumerai SB. Influence of clinical knowledge, organizational context, and practice style on transfusion decision making. Implications for practice change strategies. JAMA 1990;264:476-83. Salem-Schatz SR, Avorn J, Soumerai SB. Influence of knowledge and attitudes on the quality of physicians’ transfusion practice. Med Care 1993;31:868-78. Simon TL. Comprehensive curricular goals for teaching transfusion medicine. Curriculum Committee of the Transfusion Medicine Academic Award Group. Transfusion 1989; 29:438-46. Cable RG, Thal SE, Fink A, et al. A comprehensive transfusion medicine curriculum for medical students. Transfusion Medicine Academic Award Group. Transfusion 1995; 35:465-9. Rock G, Berger R, Pinkerton P, et al. A pilot study to assess physician knowledge in transfusion medicine. Transfus Med 2002;12:125-8.
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8. Arinsburg SA, Skerrett DL, Friedman MT, et al. A survey to assess transfusion medicine education needs for clinicians. Transfus Med 2012;22:44-9; quiz 49-51. 9. Gharehbaghian A, Javadzadeh Shahshahani H, Attar M, et al. Assessment of physicians knowledge in transfusion
20. Rohde JM, Dimcheff DE, Blumberg N, et al. Health careassociated infection after red blood cell transfusion: a systematic review and meta-analysis. JAMA 2014;311: 1317-26. 21. Shander A, Hofmann A, Gombotz H, et al. Estimating the
medicine, Iran, 2007. Transfus Med 2009;19:132-8. 10. O’Brien KL, Champeaux AL, Sundell ZE, et al. Transfusion
cost of blood: past, present, and future directions. Best Pract Res Clin Anaesthesiol 2007;21:271-89.
medicine knowledge in Postgraduate Year 1 residents.
22. Konia M, Rioux-Masse B, Forde-Thielen K. Acute hemolytic
Transfusion 2010;50:1649-53. 11. Bryant BJ, Alperin JB, Indrikovs AJ. Blood bank on-call physician’s experiences at a large university medical center. Transfusion 2005;45:35-40. 12. Strauss RG. Transfusion medicine education in medical school: only the first of successive steps to improving patient care. Transfusion 2010;50:1632-5. 13. Toy P. Guiding the decision to transfuse. Arch Pathol Lab Med 1999;123:592-4. 14. Toy PT. Audit and education in transfusion medicine. Vox
transfusion reaction. MedEdPORTAL Publications; 2011. 23. Konia M, Rioux-Masse B. Comprehensive simulation curriculum of transfusion medicine. MedEdPORTAL Publications; 2012. 24. Oxman AD, Thomson MA, Davis DA, et al. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ 1995;153:1423-31. 25. Irby DM, Cooke M, O’Brien BC. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Acad Med 2010;85:
Sang 1996;70:1-5. 15. Barnette RE, Fish DJ, Eisenstaedt RS. Modification of freshfrozen plasma transfusion practices through educational
220-7. 26. Cooke M, Irby D, O’Brien B, et al. Educating physicians: a call for reform of medical school and residency. San
intervention. Transfusion 1990;30:253-7. 16. Vos J, Gumodoka B, van Asten HA, et al. Changes in blood
Francisco: Jossey-Bass; 2010. 27. Ambrose S, Bridges M, DiPietro M, et al. How learning
transfusion practices after the introduction of consensus guidelines in Mwanza region, Tanzania. AIDS 1994;8:113540. 17. Hameedullah, Khan FA, Kamal RS. Improvement in intraoperative fresh frozen plasma transfusion practice— impact of medical audits and provider education. J Pak Med Assoc 2000;50:253-6.
works: seven research-based principles for smart teaching. San Francisco: Jossey-Bass; 2010. 28. Wayne DB, Butter J, Siddall VJ, et al. Simulation-based training of internal medicine residents in advanced cardiac life support protocols: a randomized trial. Teach Learn Med 2005;17:210-6. 29. Wayne DB, Butter J, Siddall VJ, et al. Mastery learning of
18. Panzer S, Engelbrecht S, Cole-Sinclair MF, et al. Education in transfusion medicine for medical students and doctors.
advanced cardiac life support skills by internal medicine residents using simulation technology and deliberate prac-
Vox Sang 2013;104:250-72. 19. MacLennan S, Williamson LM. Risks of fresh frozen plasma and platelets. J Trauma 2006;60:S46-50.
tice. J Gen Intern Med 2006;21:251-6.
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BACKGROUND: The administration of blood products is frequently determined by physicians without subspecialty training in transfusion medicine (TM). Education in TM is necessary for appropriate utilization of resources and maintaining patient safety. Our institution developed an efficient simulation-based TM course with the goal of identifying key topics that could be individualized to learners of all levels in various environments while also allowing for practice in an environment where the patient is not placed at risk. STUDY DESIGN AND METHODS: A 2.5-hour simulation-based educational activity was designed and taught to undergraduate medical students rotating through anesthesiology and TM elective rotations and to all Clinical Anesthesia Year 1 (CA-1) residents. Content and process evaluation of the activity consisted of multiple-choice tests and course evaluations. RESULTS: Seventy medical students and seven CA-1 residents were enrolled in the course. There was no significant difference on pretest results between medical students and CA-1 residents. The posttest results for both medical students and CA-1 residents were significantly higher than pretest results. The results of the posttest between medical students and CA-1 residents were not significantly different. CONCLUSION: The TM knowledge gap is not a trivial problem as transfusion of blood products is associated with significant risks. Innovative educational techniques are needed to address the ongoing challenges with knowledge acquisition and retention in already full curricula. Our institution developed a feasible and effective way to integrate TM into the curriculum. Educational activities, such as this, might be a way to improve the safety of transfusions.
T
he majority of blood product transfusions in American hospitals are administered by physicians without subspecialty training in transfusion medicine (TM).1 This may lead to inappropriate utilization of resources, additional medical costs, and regional variability in practice.2-4 To standardize TM education, significant efforts have been invested into universal and consistent education of all physicians on the topic. In 1989 and 1995 the National Heart, Lung, and Blood Institute (NHLBI), of the National Institutes of Health (NIH), sponsored the Transfusion Medicine Academic Awards Group (TMAA), which published the TM curriculum goals for undergraduate medical education and provided grants for the development of these goals.5,6 However, the knowledge gap in TM still exists.7-9 For example, a study by Karp and colleagues1 indicated poor familiarity with TMAA transfusion curricula by undergraduate medical school administrators responsible for the curricula. Furthermore, there is evidence that junior residents have limited knowledge of TM in the areas of complications of blood product transfusion, management of complications, transmission rates of infectious agents,
ABBREVIATIONS: CA-1 = Clinical Anesthesia Year 1; TM = transfusion medicine; TMAA = Transfusion Medicine Academic Awards Group. From the 1Department of Laboratory Medicine and Pathology, the 4Department of Surgery, and the 5Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota; the 2Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada; and the 3Department of Family and Community Medicine, University of North Dakota, Grand Forks, North Dakota. Address reprint requests to: Shanna M. Morgan, Department of Laboratory Medicine and Pathology, Division of Transfusion Medicine, University of Minnesota, D242 Mayo Building, MMC 609, 420 Delaware Street SE, Minneapolis, MN 55455; e-mail: [email protected]. Received for publication May 30, 2014; revision received August 20, 2014, and accepted September 10, 2014. doi: 10.1111/trf.12920 © 2014 AABB TRANSFUSION **;**:**-**. Volume **, ** **
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and indications for irradiation of blood products.10 Studies also indicate that practicing clinicians’ knowledge base requires an ongoing education of TM, especially as it relates to coagulation topics.2,11-18 The knowledge gap in TM at different levels of medical practice is of concern for several reasons: 1) residents are frequently actively involved in managing transfused patients on the wards and therefore contribute to patient safety, 2) transfusion of blood products carries significant risks, and 3) transfusion of blood products has a continuously increasing cost.19-21 It is therefore important that all physicians, irrespective of their specialty, have knowledge of TM. This can be challenging with the already full medical school curricula. Recognizing the importance of TM education, an intense 2.5-hour simulation-based course was developed at our institution. The course was designed with the following goals: 1) cover broad TM topics along with an in-depth coverage of risks and appropriateness, 2) have the ability to be individualized for learners at different levels and in different environments of the hospital (e.g., ward, operating room, or intensive care unit), 3) utilize several educational techniques to enhance knowledge acquisition, 4) be time efficient and therefore easy to integrate into curricula, and 5) allow for repetition and practice in an environment where the patient is not at risk. This article presents the framework used by our institution to develop this course and summarizes the results of the implementation of this course.
MATERIALS AND METHODS Due to the research being conducted in an educational setting as a part of normal educational practice, this study has been granted an exempt status by the institutional review board at the University of Minnesota (Minneapolis, MN).
Learners The session was taught to all undergraduate medical students rotating through anesthesiology and TM elective rotations between May 2011 and March 2012 and to all Clinical Anesthesia Year 1 (CA-1) residents. The majority of undergraduate medical students came from the University of Minnesota Medical School. Approximately one-half of CA-1 residents finished their internship at one institution, the other half finished their internship at a different institution within the United States.
Study design A 2.5-hour simulation-based educational activity of TM was designed. The TM, anesthesiology, and surgery departments collaborated in the development of all educational activities. The same faculty members taught all sessions. 2
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Pretest
Posttest
Lecture
Survey
Simulation with debriefing
6 weeks Posttest
Session evaluation
Fig. 1. Timing of specific sections of the educational activity. The session begins with a survey about the previous exposure to TM education, followed by a pretest, lecture, simulation session with debriefing, posttest, and session evaluation. A small group of learners repeated the test 6 weeks after the session.
Before the educational activity, learners were given a survey regarding the number of TM training hours they have received in the past. The University of Minnesota Medical School, from which a majority of the learners came, was contacted to verify the actual hours of TM training at our institution. Learners then participated in a 2.5-hour educational activity, which consisted of a pretest with 10 multiplechoice questions, a 45- to 60-minute simulation session of an acute hemolytic transfusion reaction with recording of the session and debriefing, a 30- to 45-minute lecture, and a posttest consisting of the same 10 multiple-choice questions as the pretest. After the educational experience the learners were asked to evaluate the educational activity. A limited number of learners were able to return after 6 weeks and were given the same multiple-choice test again to assess for retention of knowledge (Fig. 1).
Test and lecture The 30- to 45-minute didactic session and multiplechoice question test was created to address the following areas of TM: blood groups, blood donation (including apheresis) and testing (including processing times for tests and volume of products), blood component indications (including emergent and massive needs), and transfusion complications (including reactions and infectious risks) and management.22,23 The lecture was reinforced during the debriefing period and during the posttest discussion.
Simulation sessions A high-fidelity advanced patient simulator (SimMan 3G, Laerdal, Wappingers Falls, NY) was used as a model. Each simulation scenario took approximately 20 minutes and was recorded for review during the 30- to 45-minute debriefing period. The session begins with an introduction to the simulator mannequin and explanation of simulation environment technology. The patient history,
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physical examination, and current status are then introduced to the learners and the simulation session begins. Two learners actively lead the session, with additional learners available to help if called upon. Two simulation specialists serve as facilitators to provide guidance for the learners, as needed. After the simulation, there is a debriefing period in which the learners and facilitators review the recording and examine actions and thought processes and discuss both what went well and also opportunities for improvement. The facilitators’ role is to guide the learners to critically analyze their own performance and also incorporate TM principles into the discussion through formative feedback. Five different versions of simulation scenarios were created with options available to practice an acute hemolytic transfusion reaction occurring both in the operating room and in the ward and a massive transfusion protocol occurring in the operating room, intensive care unit, and the ward. Each simulation scenario is designed to allow participants to apply medical knowledge to a realistic clinical situation.22,23
Evaluation of the educational activity The educational session was evaluated on content and process. Content evaluation consisted of a multiplechoice question test, which was administered to learners before educational activity, immediately after the session, and to five available learners 6 weeks after the simulation session to assess knowledge retention. Process evaluation consisted of a course evaluation form using the Likert scale from 0 (nonsatisfactory) to 5 (excellent) and asked learners to evaluate the educational experience in terms of their subjective satisfaction with the session.
Statistical analysis Data on learner TM education received were collected. Pretest and posttest results were compared. Pretest results for undergraduate medical students and CA-1 residents were compared. Data were analyzed for a normal distribution. A nonparametric test Wilcoxon signed-rank sum test was used with a p value of 0.05 to be considered as significant. Data are presented as median and range. Additionally, percentage correct was obtained on five learners given a test 6 weeks after the educational experience. The Likert scale evaluated mean and percentage satisfaction.
RESULTS Seventy medical students and seven CA-1 residents were enrolled in the course. Data are presented as median and range. All participants reported between 1 and 2 hours of TM education during undergraduate medical school. In con-
trast, the medical school administrators reported 18 activities in which TM topics were addressed although often these topics were imbedded into another education topic such as clinical medicine, human disease, orthopedics, pathology, and science of medical practice. CA-1 residents reported the same 1 to 2 hours of TM education during undergraduate medical school and commented that they gained additional TM education while administering blood products during their internship and the majority of that education occurred in a nonstructured, nonfocused manner while addressing other patientrelated problems. All participants took a pretest, which consisted of 10 multiple-choice questions. The median pretest score for medical students was 40 (range, 0-80). Overall, there was no general pattern seen with regard to TM knowledge of a particular category as questions in certain categories fell into both the highest and the lowest scoring responses. The highest scores were on one question in the blood donation and testing category (mean, 65%) and one question in the transfusion complications category (mean, 63%). The lowest scores were on two questions in the transfusion complications category (mean, 10 and 22%) and one question in the blood donation and testing category (mean, 22%). The median pretest score for CA-1 residents was 30 (range, 20-60). The highest scores were on two questions in the transfusion complications category (mean, 71 and 57%) and two questions in the blood donation and testing category (mean, 57% on both questions). The lowest scores were on one question in the blood groups category (mean, 0%), one question in the transfusion complications category (mean, 0%), one question in the blood component indications category (mean, 14%), and one question in the transfusion complications category (mean, 14%). There was no significant difference on pretest scores between medical students and CA-1 anesthesiology residents (p = 0.82) as summarized in Fig. 2A. The maximum score (80 vs. 60) and median score (40 vs. 30) was higher for medical students, compared to CA-1 anesthesiology residents; however, the minimum score was lower for medical students compared to CA-1 anesthesiology residents (0 vs. 20). All participants took a posttest. Posttest scores for medical students had a median of 80 (range, 30-100). There was a significant difference between the pre- and posttest scores for medical students (p < 0.001; Fig. 3A). The highest scores were in the blood donation and testing category (mean, 88% on both questions). The lowest scores were in the blood component indications category (mean, 65%) and on one question in the transfusion complications category (mean, 65%). Posttest scores for CA-1 residents had a median of 70 (range, 60-80). For CA-1 residents, there was a significant difference between pre- and posttest scores (p = 0.03; Fig. 3B). The highest scores were in the blood donation and testing category (mean, 100% Volume **, ** **
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Fig. 3. Median, minimum (Min), and maximum (Max) score on pretest ( ) and posttest ( ) for medical students (A) and CA-1 residents (B) are presented. Significant increase in between Fig. 2. Median, minimum (Min), and maximum (Max) scores on pretest (A) for medical students (MS, ) and CA-1 residents ( ) and posttest (B) for both groups are presented. No statistical difference between medical students and CA-1 residents was demonstrated for pretest (p = 0.82) and posttest (p = 0.08). p < 0.05 was considered significant.
on both questions), as seen in the pretest, as well. The lowest scores were in the blood groups category (mean, 58%), blood component indications category (mean, 58%), and on two questions in the transfusion complications category (mean, 58 and 42%). There was no significant difference between the posttest scores obtained by medical students and residents (p = 0.08; Fig. 2B). Five learners took an additional test 6 weeks after the educational activity. The number of learners was small due to medical student availability and logistic difficulties in getting medical students now at different institutions to come back and take the posttest. As such, these learners’ results were not statistically analyzed; however, the results indicate that knowledge was retained as they responded correctly to 80, 80, 90, 90, and 70% of questions. 4
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pre- and posttest was demonstrated for medical student scores (p < 0.001) and CA-1 resident scores (p = 0.03). p < 0.05 was considered significant.
All participants evaluated the simulation session. Their overall rating of the education experience on the Likert scale from 0 (nonsatisfactory) to 5 (excellent) had a median of 5 (range, 3-5). Forty-eight percent of participants thought that the experience was excellent, 48% thought that it was very good, and 4% of participants thought that it was good. No participant thought that it was satisfactory or nonsatisfactory (Fig. 4).
DISCUSSION The need for improved education of TM has been recognized for many years.6 The TMAA, sponsored by the National Heart, Lung, and Blood Institute of the NIH, has developed and published comprehensive curricula over the past 25 years.6 In spite of significant efforts and investments, studies published in the past few years still demonstrate deficiencies in TM knowledge
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Participant Satisfaction
5-excellent
4
3-good
2
% of participants
1-nonsatisfactory
60 50 40 30 20 10 0
Fig. 4. Percentages of participants choosing the overall satisfaction rate on the Likert scale from 0 to 5 are presented. 0 = not able to assess, 1 = nonsatisfactory, 2 = satisfactory, 3 = good, 4 = very good, 5 = excellent. Forty-eight percent of participants chose 5, 48% chose 4, and 4% chose 3. No participants chose 2, 1, or 0.
among medical students, residents, and practicing physicians.1,2,7,8,10,11,15-17 Bryant and coworkers11 found that 85.3% of the calls received by the TM physician at a large academic health center were related to physician education and blood component appropriateness. O’Brien and colleagues10 demonstrated deficiencies in TM knowledge and the consent process across 10 medical specialties. Salem-Schatz and coworkers3,4 revealed that less than half of the routinely prescribing subspecialty physicians surveyed could correctly assess transfusion risk. A few studies suggest that the knowledge gap is wider at the attending level.3,8,9 Finally, the TM knowledge deficiencies are not confined to within the United States undergraduate medical system as Rock and colleagues7 and Gharehbaghian and colleagues9 have found similar issues in Canada and Iran. This is not a trivial problem as the suboptimal transfusion of blood products is associated with morbidity, mortality, and significant cost.19-21 Educational intervention is a common and effective method for improving the quality of health professional performance.24 There are four studies that focus on educational intervention to reduce suboptimal transfusion of blood products.2,15-17 These studies examine red blood cell and fresh-frozen plasma usage and target education among internists, surgeons, anesthetists, and perioperative physicians, with one study targeting all prescribing physicians.2,15-17 All studies suggest that inappropriate use of blood products can be altered.2,15-17 Despite these findings, it is hoped that TM education will be increased at an earlier point in a new physician’s career, preferably before the ability to order blood independently. Our institution developed an innovative TM educational session for medical students and residents. This study demonstrated significant improvement in participants’ knowledge of TM. It further demonstrated that a comprehensive curriculum, which uses multiple teaching
techniques including testing, simulation with debriefing and didactic session, reinforces retention of knowledge over 6 weeks in learners and increases learner satisfaction. Furthermore, we demonstrated that the current practice of exposure of junior residents to the clinical environment with a nonstructured education of TM does not lead to the desired acquisition of knowledge. Our study demonstrated that knowledge of CA-1 residents is not greater than medical student knowledge. This is supported by the results of studies demonstrating lack of knowledge among PGY-1 residents and attending physicians.7,9-11 As we think about the education of TM, or any other topic in medical education, recommendations by Cooke and colleagues,25,26 in their book entitled Educating Physicians: A Call for Reform of Medical School and Residency, should be taken into account. The authors propose that medical education of the future should be standardized and individualized; it should integrate knowledge and skills, promote habits of inquiry and innovation, and help develop professional identity. Based on the suggestions of Cooke and colleagues, we developed a curriculum that incorporates several of the recommendations. We designed an educational activity that 1) provides a standardized curriculum with carefully defined goals and objectives; 2) has goals and objectives that can be adjusted to the individual learner’s knowledge and skill level; 3) provides immediate opportunity to apply knowledge into practice, uncovers any remaining deficiencies in understanding, and allows for immediate feedback and correction; 4) provides an educational experience that promotes the appropriate attitudes, communication skills, and teamwork building; and 5) allows instructors to promote the habits of inquiry by challenging the learners to explain their actions and possibly look for basic science research supportive of their proposed solutions. The development of our TM educational session was systematically approached by starting with a needs assessment. The needs assessment determined the following: 1.
2. 3.
4.
Faculty member anesthesiologists observed that the majority of trainees reporting to the department lack a comprehensive understanding of TM. When asked which educational experiences learners would like to have, TM topics were listed. Our suspicion of deficiencies in TM knowledge was confirmed by a low average percentage of correctly answered multiple-choice questions on a test of TM designed by TM specialists. The systematic follow-up of massive transfusion protocol activations in the hospital by the TM department indicated a need for education for all members of the operating room team including interns, residents, attendings of different specialties, and operating room personnel. Volume **, ** **
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Faculty members from the department of surgery were also in favor of increasing TM educational opportunities.
We then developed a list of possible solutions, which included didactics, problem-based learning sessions, workshops, and simulation. The following questions were taken into consideration: 1) How much time should be dedicated to TM education? 2) At which time point in medical education should the TM education happen? and 3) How should it be done and by whom? We decided that our educational activity must be time-efficient, multimodal, and easily modifiable for different learners in different environments and must allow for repetition. We further considered the educational theory that proposes that the mastery of an area requires a learner to go through acquisition of key component skills, practice and integrate skills, and learn how to appropriately apply new skills in new environments.27 The majority of undergraduate medical education in the United States offers 1 to 4 hours of TM training, primarily in the first and second years.1 The learners of our study reported the same, although medical school administrators specified 18 exposures of TM topics. It appears that students do not recall the majority of TM training opportunities. It may be that a more innovative approach to TM education might be more successful. Our intense, face-to-face, focused curriculum, which combines theoretical discussions of TM topics with practical use of learned principles during simulation scenarios, allows learners to practice clinical skills and uncover deficiencies in knowledge and skills and allows for immediate feedback on areas that need improvement. This was achievable in 2.5 hours. This was considered an important attribute in view of overpacked medical school curricula. Our study demonstrated that there is no difference in TM knowledge between the medical students and the CA-1 residents. This may indicate that the current mode of education does not add to the understanding of TM. A potential solution might be to embed an educational activity like the one we developed into the last year of medical school or initial months of internship. The educational activity, which can be modified for different learner levels, can also be repeated and utilized in later years of residency and for refresher courses for faculty members for knowledge retention. We further believe that medical educators of today should utilize a mix of educational methods, which allows learners to examine their own understanding of TM principles and forces learners to apply knowledge into practice in a safe environment of a simulation laboratory, without exposing patients to the risk of transfusion. Two reports support the use of simulation-based education for skill and knowledge acquisition and propose the success to be due to intense, repetitive-performance, rigorous-skill6
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assessment, immediate-feedback, and controlled setting where patients’ well-being is not at stake.28,29 Because it combines didactic session with simulation, checklist, testing, and debriefing, during which the understanding of the principles of TM is examined, the objective measures of learner understanding can be gained. Furthermore learners’ feedback suggests that the experience provided learners with an insight into the practical application of acquired knowledge. This summary of our innovative educational activity suggests a feasible and effective way to integrate TM into the curriculum. Our activity allows learners of all levels to adjust to different environments within the hospital (ward, operating room, intensive care unit) and practice in an environment where the patient is not at risk. Utilization of several educational techniques promotes learner satisfaction, knowledge acquisition, and potentially better retention. It is hoped that more educational activities, such as this one, will be further developed to address the knowledge gap in TM. ACKNOWLEDGMENT The authors thank the SimPORTAL for providing the space, equipment, technical, and logistic support for the educational activities. CONFLICT OF INTEREST The authors have disclosed no conflicts of interest.
REFERENCES 1. Karp JK, Weston CM, King KE. Transfusion medicine in American undergraduate medical education. Transfusion 2011;51:2470-9. 2. Soumerai SB, Salem-Schatz S, Avorn J, et al. A controlled
3.
4.
5.
6.
7.
trial of educational outreach to improve blood transfusion practice. JAMA 1993;270:961-6. Salem-Schatz SR, Avorn J, Soumerai SB. Influence of clinical knowledge, organizational context, and practice style on transfusion decision making. Implications for practice change strategies. JAMA 1990;264:476-83. Salem-Schatz SR, Avorn J, Soumerai SB. Influence of knowledge and attitudes on the quality of physicians’ transfusion practice. Med Care 1993;31:868-78. Simon TL. Comprehensive curricular goals for teaching transfusion medicine. Curriculum Committee of the Transfusion Medicine Academic Award Group. Transfusion 1989; 29:438-46. Cable RG, Thal SE, Fink A, et al. A comprehensive transfusion medicine curriculum for medical students. Transfusion Medicine Academic Award Group. Transfusion 1995; 35:465-9. Rock G, Berger R, Pinkerton P, et al. A pilot study to assess physician knowledge in transfusion medicine. Transfus Med 2002;12:125-8.
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8. Arinsburg SA, Skerrett DL, Friedman MT, et al. A survey to assess transfusion medicine education needs for clinicians. Transfus Med 2012;22:44-9; quiz 49-51. 9. Gharehbaghian A, Javadzadeh Shahshahani H, Attar M, et al. Assessment of physicians knowledge in transfusion
20. Rohde JM, Dimcheff DE, Blumberg N, et al. Health careassociated infection after red blood cell transfusion: a systematic review and meta-analysis. JAMA 2014;311: 1317-26. 21. Shander A, Hofmann A, Gombotz H, et al. Estimating the
medicine, Iran, 2007. Transfus Med 2009;19:132-8. 10. O’Brien KL, Champeaux AL, Sundell ZE, et al. Transfusion
cost of blood: past, present, and future directions. Best Pract Res Clin Anaesthesiol 2007;21:271-89.
medicine knowledge in Postgraduate Year 1 residents.
22. Konia M, Rioux-Masse B, Forde-Thielen K. Acute hemolytic
Transfusion 2010;50:1649-53. 11. Bryant BJ, Alperin JB, Indrikovs AJ. Blood bank on-call physician’s experiences at a large university medical center. Transfusion 2005;45:35-40. 12. Strauss RG. Transfusion medicine education in medical school: only the first of successive steps to improving patient care. Transfusion 2010;50:1632-5. 13. Toy P. Guiding the decision to transfuse. Arch Pathol Lab Med 1999;123:592-4. 14. Toy PT. Audit and education in transfusion medicine. Vox
transfusion reaction. MedEdPORTAL Publications; 2011. 23. Konia M, Rioux-Masse B. Comprehensive simulation curriculum of transfusion medicine. MedEdPORTAL Publications; 2012. 24. Oxman AD, Thomson MA, Davis DA, et al. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ 1995;153:1423-31. 25. Irby DM, Cooke M, O’Brien BC. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Acad Med 2010;85:
Sang 1996;70:1-5. 15. Barnette RE, Fish DJ, Eisenstaedt RS. Modification of freshfrozen plasma transfusion practices through educational
220-7. 26. Cooke M, Irby D, O’Brien B, et al. Educating physicians: a call for reform of medical school and residency. San
intervention. Transfusion 1990;30:253-7. 16. Vos J, Gumodoka B, van Asten HA, et al. Changes in blood
Francisco: Jossey-Bass; 2010. 27. Ambrose S, Bridges M, DiPietro M, et al. How learning
transfusion practices after the introduction of consensus guidelines in Mwanza region, Tanzania. AIDS 1994;8:113540. 17. Hameedullah, Khan FA, Kamal RS. Improvement in intraoperative fresh frozen plasma transfusion practice— impact of medical audits and provider education. J Pak Med Assoc 2000;50:253-6.
works: seven research-based principles for smart teaching. San Francisco: Jossey-Bass; 2010. 28. Wayne DB, Butter J, Siddall VJ, et al. Simulation-based training of internal medicine residents in advanced cardiac life support protocols: a randomized trial. Teach Learn Med 2005;17:210-6. 29. Wayne DB, Butter J, Siddall VJ, et al. Mastery learning of
18. Panzer S, Engelbrecht S, Cole-Sinclair MF, et al. Education in transfusion medicine for medical students and doctors.
advanced cardiac life support skills by internal medicine residents using simulation technology and deliberate prac-
Vox Sang 2013;104:250-72. 19. MacLennan S, Williamson LM. Risks of fresh frozen plasma and platelets. J Trauma 2006;60:S46-50.
tice. J Gen Intern Med 2006;21:251-6.
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