EDITORIAL Transfusion medicine education: an integral foundation of effective blood management
M
edical education and continuing medical education (CME) for transfusion medicine are integral and necessary elements for quality patient care. The misuse and overuse of blood components, and the sequelae resulting from this inappropriate use, increases the risk for patient morbidity. Unwarranted blood transfusions also add avoidable costs for hospitals at a time of diminishing financial resources. Prudent and conservative blood product use further helps to control inventory and prevent blood shortages. As education and direct intervention are required to ensure the appropriate use of pharmaceutical agents, we are also driven in a similar manner to inform our colleagues about the appropriate use and adverse effects of blood products. The current economic and regulatory climate demands that we act to facilitate and lead transfusion education for our clinical colleagues, and if we do not, hospital administrations soon will demand that we do so. In fact, the growing enthusiasm for patient blood management has created a long sought opportunity to enhance transfusion education for a more receptive audience. Decades have been spent discussing the necessary incorporation of transfusion medicine into medical education programs. The Transfusion Medicine Academic Awards (TMAA) program was started in 1983 by the National Heart, Lung, and Blood Institute to provide financial support to medical schools who wanted to strengthen transfusion education for their students.1 The participating medical centers published proposed transfusion medicine curricula twice: once in 1989 and again in 1995.1,2 Additional transfusion medicine–focused educational programs have been suggested for pediatrics (PedsTMAA) in 2006 and for laboratory medicine in 2010.3,4 These publications, however, only provided recommendations and did not dictate standards for medical trainee knowledge. Not surprisingly, these efforts have resulted in minimal changes to transfusion education or medical education requirements. As defined by the United States Medical Licensing Exams (USMLE), knowledge of blood components or transfusion practices is not identified as a fundamental topic for minimum competency standards for medical practice (Table 1).5-7 The USMLE does not
© 2014 AABB TRANSFUSION 2014;54:1208-1211. 1208
TRANSFUSION Volume 54, May 2014
require that students know the appropriate use of blood products during medical school at any level, and the only exam that specifically mentions blood products is the exam that occurs after the second year of medical education, before any direct clinical experience in many programs (Step 1).5-7 Perhaps as a consequence of these limited requirements, medical schools do not emphasize transfusion medicine education, making room for the more heavily tested topics. Karp and coworkers8 determined that 17% of medical schools provided no didactic lectures on transfusion medicine topics, and of those that do, only about 50% of them provided more than 1 or 2 hours of content. Also, more than 41% of students do not recall ever having a transfusion lecture, regardless of whether the student actually received one.9 Despite the limited number of formal training hours in transfusion medicine, medical school curricula do provide enough material for successful completion of USMLE exams. According to the USMLE Web site, in 2012, greater than 96% of MD degree first-time test takers pass all three of the Step exams on their first attempt.10 Knowledge of blood products and transfusion indications are simply not tested by the USMLE as an indicator of a new physician’s ability to assume independent responsibility without supervision. The deficiency in medical education for transfusion medicine starts early and is continued into professional life for housestaff and attendings. With little or no training in medical school with evidence-based practices to guide decisions, the use of transfusions are often based on individual clinical experience. Defining the extent of this deficiency has been the focus of multiple publications. Bryant and coworkers11 prospectively identified that 85.3% of referrals to the blood bank physician on-call required some form of physician education regarding the appropriateness of blood component orders. O’Brien and colleagues9 found that nonpathology PGY-1’s at one institution scored 24.0% to 67.1% correct on a standardized test that evaluated knowledge of the red blood cell (RBC) consent process and transfusion medicine general knowledge. Of particular concern, they found that none of the tested physicians could define the use of blood irradiation, and less than 10% knew the transfusion transmission risk for HIV and HCV.9 Salem-Schatz and coworkers12,13 found that less than 31% could answer questions regarding transfusion indications and, perhaps more revealing, found that attending physicians performed worse than residents, but revealed greater
EDITORIAL
TABLE 1. The knowledge of transfusion medicine–related principles required of medical trainees as defined by national USMLE Step exam content* USMLE step 15
2 (CK)6
• • • • • • • • •
•
37
• • • • • •
Suggested fundamental knowledge related to transfusion medicine as defined by USMLE content outlines Blood and blood products Drugs affecting blood coagulation, thrombolytic agents, and anti-PLT agents Non–immunologically mediated transfusion complications Production and function of RBCs, Hb, O2, and CO2 transport and transport proteins Production and function of PLTs Production and function of coagulation and fibrinolytic factors Rh and ABO antigens, including genetics Anaphylaxis and other allergic reactions Anemia, disorders of RBCs, Hb, and iron metabolism (e.g., blood loss; iron deficiency anemia, nutritional deficiencies; pernicious anemia, other megaloblastic anemias; hemolytic anemia; anemia associated with chronic disease; aplastic anemia, pancytopenia; thalassemia; sickle cell disease; polycythemia vera; hemochromatosis) Bleeding disorders, coagulopathies, thrombocytopenia (e.g., hemophilia, von Willebrand disease; qualitative and quantitative PLT deficiencies; disseminated intravascular coagulation; hypofibrinogenemia; immune thrombocytopenic purpura; hemolytic-uremic syndrome) Anemias and cytopenias (e.g., iron deficiency anemia, hereditary spherocytosis, hemoglobinopathies, thrombocytopenic purpura and immune thrombocytopenic purpura) Bleeding disorders (e.g., coagulation defects, congenital factor VIII disorder/hemophilia, von Willebrand disease, disseminated intravascular coagulation) Heparin-induced thrombocytopenia Immediate postpartum hemorrhage Reactions to blood components (e.g., transfusion reaction, ABO incompatibility reaction, Rh incompatibility reaction) Trauma
* Adapted from References 5, 6, and 7.
confidence in their inaccurate opinions. Arinsburg and coworkers14 similarly used a 14-question electronic survey evaluating transfusion knowledge where they found that the mean score was 31.4%, with participating attending physicians scoring slightly worse than their fellows, residents, and interns. Finally, Rock and colleagues15 and Gharehbaghian and colleagues16 found that these educational deficits extend outside the borders of the United States. Unlike the USMLE exams, however, the exams and surveys used in these studies were neither standardized nor validated to be used as educational or competency tools. While the physicians clearly performed poorly on these surveys of transfusion medicine knowledge, the study methods used were varied, and one could question the reproducibility of the individual study methods.17 More importantly, perhaps, it is not clear that the surveys and exams used tested transfusion knowledge that nonpathologist clinicians truly need to know. To this aim, Haspel and colleagues,18 in this issue of TRANSFUSION, report the first validated transfusion medicine knowledge exam. They describe the development and validation of a 23-question exam for nonpathologists. Unlike previous studies, test topics were rigorously scrutinized using the opinions of international transfusion medicine experts (Biomedical Excellence for Safer Transfusion Collaborative, a.k.a. the BEST Collaborative). Moreover, the exam was validated using pilot data from three different hospitals and analyzed using modern test development theories (Rasch psychometric analysis). This new transfusion knowledge tool represents a significant advancement for the field of transfusion medicine
education as each question evaluates a topic considered important by a panel of experts, and each question has a predictive quality not previously obtained. Despite this clear advance, the test remains imperfect. First, less than half of BEST Collaborative physician experts participated in the initial test design surveys (36%-48%), which may have introduced selection bias to the topic selection process. Second, only transfusion medicine experts determined the critical topics and not expert clinical physicians who order transfusions, which may ultimately alter the validity of the test (what transfusion experts think is important may not be what senior surgeons, oncologists, or internists consider critical transfusion knowledge). Third, the exam was validated, in part, using 19 pathology residents. The use of pathology residents in their test validation process is problematic given that their training offers specific instruction in transfusion medicine that non–pathology residents and attendings do not receive. It would seem preferable to ensure that all subjects used to validate a test for nonpathologists should be nonpathologists. Fourth, the test is brief and does not clearly establish a minimum competency score. Finally, the test does not appear designed for repeat testing so that the efficacy of educational interventions could be evaluated. Regardless of these limitations, the needs assessment exam, as designed by Haspel and colleagues, is an important component for the future advancement of transfusion education. Transfusion education will require aggressive improvement in multiple areas. First, transfusion medicine, as a medical discipline, needs to be granted greater weight on the USMLE exams, especially Volume 54, May 2014
TRANSFUSION
1209
EDITORIAL
later in a physician’s training, such as Step 3. At a minimum, transfusion indications and blood component selection should be tested. These changes will likely drive medical training programs to incorporate more time for transfusion education in their curriculum either through required medical school rotations in blood banking or through transfusion medicine expert-driven educational sessions during their clinical years. Second, post–medical school needs assessment exams for nonpathologists, such as the one developed by Haspel and colleagues, will need to be regularly and universally used by non–pathology residency training programs to define and remedy gaps in transfusion medicine knowledge before a new physician’s ability to order blood. Minimum competency standards need to be established, and subsequent in-service training will need to be developed. Third, attending physicians will need continuing education through a combination of strategies including audits with specific feedback, one-toone discussions, grand rounds lectures, dissemination of hospital transfusion guidelines or algorithms, and transfusion medicine physician participation in clinical rounds; these tools have already been shown to be effective when carefully implemented, continuously monitored, and strongly supported by hospital administration.19-22 Electronic ordering safeguards supported by hospital blood management committees have also recently been established as an effective tool to monitor and limit inappropriate transfusion practice.23,24 Transfusion represents the most common medical procedure in the United States,25 and the American Medical Association has recently identified transfusion as one of the five most overused medical treatments.26 The increasing concern over adverse events associated with transfusion and its overuse has given rise to the field of blood management, and in 2010, blood management was determined to be one of the 10 key advances in transfusion medicine over the past 50 years.27 Major organizations have taken note. The Joint Commission, as of October 2013, is offering a Patient Blood Management Certification program (in field review),28 and AABB has recently announced its intention to create standards for patient blood management programs.29 The goal of blood management programs is to improve blood safety and patient outcomes, preserve the blood inventory, and limit escalating blood costs.30 Changing clinical practice will be one of the main objectives of hospital blood management programs, and if a blood management committee is not already being established or efforts incorporated into existing transfusion practice committees, these changes will be arriving soon. Transfusion medicine education at all stages of medical training will be required. The tools necessary for these educational initiatives, such as that developed by Haspel and colleagues, are ready for use. Transfusion medicine professionals take note! Education activities for 1210
TRANSFUSION Volume 54, May 2014
physicians and other nonphysician clinical staff need to grow to make patient blood management programs effective, and our long lamented lack of recognition of the need for education is finally becoming acknowledged. CONFLICT OF INTEREST The authors have disclosed no conflicts of interest.
Matthew S. Karafin, MD1,2 e-mail: [email protected] Barbara J. Bryant, MD1,2 1 Medical Sciences Institute BloodCenter of Wisconsin 2 Department of Pathology Medical College of Wisconsin Milwaukee, WI
REFERENCES 1. Simon TL. Comprehensive curricular goals for teaching transfusion medicine. Curriculum Committee of the Transfusion Medicine Academic Award Group. Transfusion 1989; 29:438-46. 2. Cable RG, Thal SE, Fink A, et al. A comprehensive transfusion medicine curriculum for medical students. The Transfusion Medicine Academic Award Group. Transfusion 1995; 35:465-9. 3. Department of Health and Human Services. Pediatric Transfusion Medicine Academic Career Awards (K07). 2006. [cited 2014 March 26]. Available from: http://grants.nih .gov/grants/guide/rfa-files/RFA-HL-07-001.html#PartI 4. Smith BR, Aguero-Rosenfeld M, Anastasi J; for The Academy of Clinical Laboratory Physicians and Scientists, et al. Educating medical students in laboratory medicine: a proposed curriculum. Am J Clin Pathol 2010;133:533-42. 5. USMLE. United States Medical Licensing Examination: Step 1 content outlines. 2013. [cited 2014 March 26]. Available from: http://www.usmle.org/step-1/#content-outlines 6. USMLE. United States Medical Licensing Examination: Step 2CK content outlines. 2013. [cited 2014 March 26]. Available from: http://www.usmle.org/step-2-ck/#content -outlines 7. USMLE. United States Medical Licensing Examination: Step 3 content outlines. 2013. [cited 2014 March 26]. Available from: http://www.usmle.org/step-3/#content-outlines 8. Karp JK, Weston CM, King KE. Transfusion medicine in American undergraduate medical education. Transfusion 2011;51:2470-9. 9. O’Brien KL, Champeaux AL, Sundell ZE, et al. Transfusion medicine knowledge in postgraduate year 1 residents. Transfusion 2010;50:1649-53. 10. USMLE. United States Medical Licensing Examination: 2012 performance data. 2013. [cited 2014 March 26]. Available from: http://www.usmle.org/performance-data/ default.aspx#2012_overview
EDITORIAL
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. Salem-Schatz SR, Avon J, Soumerai SB. Influence of clinical
inappropriate transfusion: what can be learned from a system review of the literature. Transfusion 2002;42: 1224-9. 23. Collins RA, Triulzi DJ, Waters JH, et al. Evaluation of real-
knowledge, organizational context, and practice style on
time clinical decision support systems for platelet and
transfusion decision making. J Am Med Assoc 1990;264: 476-83.
cryoprecipitate orders. Am J Clin Pathol 2014;141: 78-84.
13. 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. 14. Arinsburg SA, Skerrett DL, Friedman MT, et al. A survey to assess transfusion medicine education needs for clinicians. Transfus Med 2012;22:44-51. 15. Rock G, Berger R, Pinkerton P, et al. A pilot study to assess physician knowledge in transfusion medicine. Transfus Med 2002;12:125-8. 16. Gharehbaghian A, Javadzadeh Shahshahani HJ, Attar M, et al. Assessment of physicians knowledge in transfusion medicine, Iran, 2007. Transfus Med 2009;19:132-8. 17. Strauss RG. Transfusion medicine education in medical school: only the first of successive steps to improving patient care. Transfusion 2010;50:1632-5. 18. Haspel RL, Lin Y, Fisher P, Ali A, Parks E; Biomedical Excellence for Safer Transfusion (BEST) Collaborative. Development of a validated exam to assess physician transfusion medicine knowledge. Transfusion 2014;54:1225-30. 19. Toy P. Guiding the decision to transfuse: interventions that do and do not work. Arch Pathol Lab Med 1999;123:592-4. 20. Toy P. Audit and education in transfusion medicine. Vox Sang 1996;70:1-5. 21. Tinmouth A, MacDougall L, Fergusson D, et al. Reducing the amount of blood transfused. Arch Intern Med 2005;165: 845-52. 22. Wilson K, MacDougall L, Fergusson D, et al. The effectiveness of interventions to reduce physician’s level of
24. Yazer MH, Triulzi DJ, Reddy V, et al. Effectiveness of a realtime clinical decision support system for computerized physician order entry of plasma orders. Transfusion 2013; 53:3120-7. 25. Pfunter A, Wier LM, Stocks C. Most frequent procedures performed in US hospitals, 2010. [cited 2014 March 26]. Available from: http://hcup-us.ahrq.gov/reports/statbriefs/ sb149.pdf 26. Kennedy W. Decline in need for blood leads to staff cuts at center. The Joplin Globe. April 10, 2013. [cited 2014 March 26]. Available from: http://www.joplinglobe.com/local/ x2015922821/Decline-in-need-for-blood-leads-to-staff -cuts-at-center 27. McCullough J. Innovation in transfusion medicine and blood banking: documenting the record in 50 years of TRANSFUSION. Transfusion 2010;50:2542-46. 28. Rhamy J. Lab accreditation: proposed standards for a multidisciplinary approach to patient blood management. 2013. [cited 2014 March 26]. Available from: http:// www.jointcommission.org/lab_accreditation/ proposed_standards_multidisciplinary_approach_patient_blood_management/. 29. American Association of Blood Banks. AABB introduces new standards for a patient blood management program. AABB News 2014;15:4-5. 30. Murphy WG. Of mad cows and bolted horses: the economics of blood safety. Transfusion 2012;52:2278-81.
Volume 54, May 2014 TRANSFUSION
1211
M
edical education and continuing medical education (CME) for transfusion medicine are integral and necessary elements for quality patient care. The misuse and overuse of blood components, and the sequelae resulting from this inappropriate use, increases the risk for patient morbidity. Unwarranted blood transfusions also add avoidable costs for hospitals at a time of diminishing financial resources. Prudent and conservative blood product use further helps to control inventory and prevent blood shortages. As education and direct intervention are required to ensure the appropriate use of pharmaceutical agents, we are also driven in a similar manner to inform our colleagues about the appropriate use and adverse effects of blood products. The current economic and regulatory climate demands that we act to facilitate and lead transfusion education for our clinical colleagues, and if we do not, hospital administrations soon will demand that we do so. In fact, the growing enthusiasm for patient blood management has created a long sought opportunity to enhance transfusion education for a more receptive audience. Decades have been spent discussing the necessary incorporation of transfusion medicine into medical education programs. The Transfusion Medicine Academic Awards (TMAA) program was started in 1983 by the National Heart, Lung, and Blood Institute to provide financial support to medical schools who wanted to strengthen transfusion education for their students.1 The participating medical centers published proposed transfusion medicine curricula twice: once in 1989 and again in 1995.1,2 Additional transfusion medicine–focused educational programs have been suggested for pediatrics (PedsTMAA) in 2006 and for laboratory medicine in 2010.3,4 These publications, however, only provided recommendations and did not dictate standards for medical trainee knowledge. Not surprisingly, these efforts have resulted in minimal changes to transfusion education or medical education requirements. As defined by the United States Medical Licensing Exams (USMLE), knowledge of blood components or transfusion practices is not identified as a fundamental topic for minimum competency standards for medical practice (Table 1).5-7 The USMLE does not
© 2014 AABB TRANSFUSION 2014;54:1208-1211. 1208
TRANSFUSION Volume 54, May 2014
require that students know the appropriate use of blood products during medical school at any level, and the only exam that specifically mentions blood products is the exam that occurs after the second year of medical education, before any direct clinical experience in many programs (Step 1).5-7 Perhaps as a consequence of these limited requirements, medical schools do not emphasize transfusion medicine education, making room for the more heavily tested topics. Karp and coworkers8 determined that 17% of medical schools provided no didactic lectures on transfusion medicine topics, and of those that do, only about 50% of them provided more than 1 or 2 hours of content. Also, more than 41% of students do not recall ever having a transfusion lecture, regardless of whether the student actually received one.9 Despite the limited number of formal training hours in transfusion medicine, medical school curricula do provide enough material for successful completion of USMLE exams. According to the USMLE Web site, in 2012, greater than 96% of MD degree first-time test takers pass all three of the Step exams on their first attempt.10 Knowledge of blood products and transfusion indications are simply not tested by the USMLE as an indicator of a new physician’s ability to assume independent responsibility without supervision. The deficiency in medical education for transfusion medicine starts early and is continued into professional life for housestaff and attendings. With little or no training in medical school with evidence-based practices to guide decisions, the use of transfusions are often based on individual clinical experience. Defining the extent of this deficiency has been the focus of multiple publications. Bryant and coworkers11 prospectively identified that 85.3% of referrals to the blood bank physician on-call required some form of physician education regarding the appropriateness of blood component orders. O’Brien and colleagues9 found that nonpathology PGY-1’s at one institution scored 24.0% to 67.1% correct on a standardized test that evaluated knowledge of the red blood cell (RBC) consent process and transfusion medicine general knowledge. Of particular concern, they found that none of the tested physicians could define the use of blood irradiation, and less than 10% knew the transfusion transmission risk for HIV and HCV.9 Salem-Schatz and coworkers12,13 found that less than 31% could answer questions regarding transfusion indications and, perhaps more revealing, found that attending physicians performed worse than residents, but revealed greater
EDITORIAL
TABLE 1. The knowledge of transfusion medicine–related principles required of medical trainees as defined by national USMLE Step exam content* USMLE step 15
2 (CK)6
• • • • • • • • •
•
37
• • • • • •
Suggested fundamental knowledge related to transfusion medicine as defined by USMLE content outlines Blood and blood products Drugs affecting blood coagulation, thrombolytic agents, and anti-PLT agents Non–immunologically mediated transfusion complications Production and function of RBCs, Hb, O2, and CO2 transport and transport proteins Production and function of PLTs Production and function of coagulation and fibrinolytic factors Rh and ABO antigens, including genetics Anaphylaxis and other allergic reactions Anemia, disorders of RBCs, Hb, and iron metabolism (e.g., blood loss; iron deficiency anemia, nutritional deficiencies; pernicious anemia, other megaloblastic anemias; hemolytic anemia; anemia associated with chronic disease; aplastic anemia, pancytopenia; thalassemia; sickle cell disease; polycythemia vera; hemochromatosis) Bleeding disorders, coagulopathies, thrombocytopenia (e.g., hemophilia, von Willebrand disease; qualitative and quantitative PLT deficiencies; disseminated intravascular coagulation; hypofibrinogenemia; immune thrombocytopenic purpura; hemolytic-uremic syndrome) Anemias and cytopenias (e.g., iron deficiency anemia, hereditary spherocytosis, hemoglobinopathies, thrombocytopenic purpura and immune thrombocytopenic purpura) Bleeding disorders (e.g., coagulation defects, congenital factor VIII disorder/hemophilia, von Willebrand disease, disseminated intravascular coagulation) Heparin-induced thrombocytopenia Immediate postpartum hemorrhage Reactions to blood components (e.g., transfusion reaction, ABO incompatibility reaction, Rh incompatibility reaction) Trauma
* Adapted from References 5, 6, and 7.
confidence in their inaccurate opinions. Arinsburg and coworkers14 similarly used a 14-question electronic survey evaluating transfusion knowledge where they found that the mean score was 31.4%, with participating attending physicians scoring slightly worse than their fellows, residents, and interns. Finally, Rock and colleagues15 and Gharehbaghian and colleagues16 found that these educational deficits extend outside the borders of the United States. Unlike the USMLE exams, however, the exams and surveys used in these studies were neither standardized nor validated to be used as educational or competency tools. While the physicians clearly performed poorly on these surveys of transfusion medicine knowledge, the study methods used were varied, and one could question the reproducibility of the individual study methods.17 More importantly, perhaps, it is not clear that the surveys and exams used tested transfusion knowledge that nonpathologist clinicians truly need to know. To this aim, Haspel and colleagues,18 in this issue of TRANSFUSION, report the first validated transfusion medicine knowledge exam. They describe the development and validation of a 23-question exam for nonpathologists. Unlike previous studies, test topics were rigorously scrutinized using the opinions of international transfusion medicine experts (Biomedical Excellence for Safer Transfusion Collaborative, a.k.a. the BEST Collaborative). Moreover, the exam was validated using pilot data from three different hospitals and analyzed using modern test development theories (Rasch psychometric analysis). This new transfusion knowledge tool represents a significant advancement for the field of transfusion medicine
education as each question evaluates a topic considered important by a panel of experts, and each question has a predictive quality not previously obtained. Despite this clear advance, the test remains imperfect. First, less than half of BEST Collaborative physician experts participated in the initial test design surveys (36%-48%), which may have introduced selection bias to the topic selection process. Second, only transfusion medicine experts determined the critical topics and not expert clinical physicians who order transfusions, which may ultimately alter the validity of the test (what transfusion experts think is important may not be what senior surgeons, oncologists, or internists consider critical transfusion knowledge). Third, the exam was validated, in part, using 19 pathology residents. The use of pathology residents in their test validation process is problematic given that their training offers specific instruction in transfusion medicine that non–pathology residents and attendings do not receive. It would seem preferable to ensure that all subjects used to validate a test for nonpathologists should be nonpathologists. Fourth, the test is brief and does not clearly establish a minimum competency score. Finally, the test does not appear designed for repeat testing so that the efficacy of educational interventions could be evaluated. Regardless of these limitations, the needs assessment exam, as designed by Haspel and colleagues, is an important component for the future advancement of transfusion education. Transfusion education will require aggressive improvement in multiple areas. First, transfusion medicine, as a medical discipline, needs to be granted greater weight on the USMLE exams, especially Volume 54, May 2014
TRANSFUSION
1209
EDITORIAL
later in a physician’s training, such as Step 3. At a minimum, transfusion indications and blood component selection should be tested. These changes will likely drive medical training programs to incorporate more time for transfusion education in their curriculum either through required medical school rotations in blood banking or through transfusion medicine expert-driven educational sessions during their clinical years. Second, post–medical school needs assessment exams for nonpathologists, such as the one developed by Haspel and colleagues, will need to be regularly and universally used by non–pathology residency training programs to define and remedy gaps in transfusion medicine knowledge before a new physician’s ability to order blood. Minimum competency standards need to be established, and subsequent in-service training will need to be developed. Third, attending physicians will need continuing education through a combination of strategies including audits with specific feedback, one-toone discussions, grand rounds lectures, dissemination of hospital transfusion guidelines or algorithms, and transfusion medicine physician participation in clinical rounds; these tools have already been shown to be effective when carefully implemented, continuously monitored, and strongly supported by hospital administration.19-22 Electronic ordering safeguards supported by hospital blood management committees have also recently been established as an effective tool to monitor and limit inappropriate transfusion practice.23,24 Transfusion represents the most common medical procedure in the United States,25 and the American Medical Association has recently identified transfusion as one of the five most overused medical treatments.26 The increasing concern over adverse events associated with transfusion and its overuse has given rise to the field of blood management, and in 2010, blood management was determined to be one of the 10 key advances in transfusion medicine over the past 50 years.27 Major organizations have taken note. The Joint Commission, as of October 2013, is offering a Patient Blood Management Certification program (in field review),28 and AABB has recently announced its intention to create standards for patient blood management programs.29 The goal of blood management programs is to improve blood safety and patient outcomes, preserve the blood inventory, and limit escalating blood costs.30 Changing clinical practice will be one of the main objectives of hospital blood management programs, and if a blood management committee is not already being established or efforts incorporated into existing transfusion practice committees, these changes will be arriving soon. Transfusion medicine education at all stages of medical training will be required. The tools necessary for these educational initiatives, such as that developed by Haspel and colleagues, are ready for use. Transfusion medicine professionals take note! Education activities for 1210
TRANSFUSION Volume 54, May 2014
physicians and other nonphysician clinical staff need to grow to make patient blood management programs effective, and our long lamented lack of recognition of the need for education is finally becoming acknowledged. CONFLICT OF INTEREST The authors have disclosed no conflicts of interest.
Matthew S. Karafin, MD1,2 e-mail: [email protected] Barbara J. Bryant, MD1,2 1 Medical Sciences Institute BloodCenter of Wisconsin 2 Department of Pathology Medical College of Wisconsin Milwaukee, WI
REFERENCES 1. Simon TL. Comprehensive curricular goals for teaching transfusion medicine. Curriculum Committee of the Transfusion Medicine Academic Award Group. Transfusion 1989; 29:438-46. 2. Cable RG, Thal SE, Fink A, et al. A comprehensive transfusion medicine curriculum for medical students. The Transfusion Medicine Academic Award Group. Transfusion 1995; 35:465-9. 3. Department of Health and Human Services. Pediatric Transfusion Medicine Academic Career Awards (K07). 2006. [cited 2014 March 26]. Available from: http://grants.nih .gov/grants/guide/rfa-files/RFA-HL-07-001.html#PartI 4. Smith BR, Aguero-Rosenfeld M, Anastasi J; for The Academy of Clinical Laboratory Physicians and Scientists, et al. Educating medical students in laboratory medicine: a proposed curriculum. Am J Clin Pathol 2010;133:533-42. 5. USMLE. United States Medical Licensing Examination: Step 1 content outlines. 2013. [cited 2014 March 26]. Available from: http://www.usmle.org/step-1/#content-outlines 6. USMLE. United States Medical Licensing Examination: Step 2CK content outlines. 2013. [cited 2014 March 26]. Available from: http://www.usmle.org/step-2-ck/#content -outlines 7. USMLE. United States Medical Licensing Examination: Step 3 content outlines. 2013. [cited 2014 March 26]. Available from: http://www.usmle.org/step-3/#content-outlines 8. Karp JK, Weston CM, King KE. Transfusion medicine in American undergraduate medical education. Transfusion 2011;51:2470-9. 9. O’Brien KL, Champeaux AL, Sundell ZE, et al. Transfusion medicine knowledge in postgraduate year 1 residents. Transfusion 2010;50:1649-53. 10. USMLE. United States Medical Licensing Examination: 2012 performance data. 2013. [cited 2014 March 26]. Available from: http://www.usmle.org/performance-data/ default.aspx#2012_overview
EDITORIAL
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. Salem-Schatz SR, Avon J, Soumerai SB. Influence of clinical
inappropriate transfusion: what can be learned from a system review of the literature. Transfusion 2002;42: 1224-9. 23. Collins RA, Triulzi DJ, Waters JH, et al. Evaluation of real-
knowledge, organizational context, and practice style on
time clinical decision support systems for platelet and
transfusion decision making. J Am Med Assoc 1990;264: 476-83.
cryoprecipitate orders. Am J Clin Pathol 2014;141: 78-84.
13. 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. 14. Arinsburg SA, Skerrett DL, Friedman MT, et al. A survey to assess transfusion medicine education needs for clinicians. Transfus Med 2012;22:44-51. 15. Rock G, Berger R, Pinkerton P, et al. A pilot study to assess physician knowledge in transfusion medicine. Transfus Med 2002;12:125-8. 16. Gharehbaghian A, Javadzadeh Shahshahani HJ, Attar M, et al. Assessment of physicians knowledge in transfusion medicine, Iran, 2007. Transfus Med 2009;19:132-8. 17. Strauss RG. Transfusion medicine education in medical school: only the first of successive steps to improving patient care. Transfusion 2010;50:1632-5. 18. Haspel RL, Lin Y, Fisher P, Ali A, Parks E; Biomedical Excellence for Safer Transfusion (BEST) Collaborative. Development of a validated exam to assess physician transfusion medicine knowledge. Transfusion 2014;54:1225-30. 19. Toy P. Guiding the decision to transfuse: interventions that do and do not work. Arch Pathol Lab Med 1999;123:592-4. 20. Toy P. Audit and education in transfusion medicine. Vox Sang 1996;70:1-5. 21. Tinmouth A, MacDougall L, Fergusson D, et al. Reducing the amount of blood transfused. Arch Intern Med 2005;165: 845-52. 22. Wilson K, MacDougall L, Fergusson D, et al. The effectiveness of interventions to reduce physician’s level of
24. Yazer MH, Triulzi DJ, Reddy V, et al. Effectiveness of a realtime clinical decision support system for computerized physician order entry of plasma orders. Transfusion 2013; 53:3120-7. 25. Pfunter A, Wier LM, Stocks C. Most frequent procedures performed in US hospitals, 2010. [cited 2014 March 26]. Available from: http://hcup-us.ahrq.gov/reports/statbriefs/ sb149.pdf 26. Kennedy W. Decline in need for blood leads to staff cuts at center. The Joplin Globe. April 10, 2013. [cited 2014 March 26]. Available from: http://www.joplinglobe.com/local/ x2015922821/Decline-in-need-for-blood-leads-to-staff -cuts-at-center 27. McCullough J. Innovation in transfusion medicine and blood banking: documenting the record in 50 years of TRANSFUSION. Transfusion 2010;50:2542-46. 28. Rhamy J. Lab accreditation: proposed standards for a multidisciplinary approach to patient blood management. 2013. [cited 2014 March 26]. Available from: http:// www.jointcommission.org/lab_accreditation/ proposed_standards_multidisciplinary_approach_patient_blood_management/. 29. American Association of Blood Banks. AABB introduces new standards for a patient blood management program. AABB News 2014;15:4-5. 30. Murphy WG. Of mad cows and bolted horses: the economics of blood safety. Transfusion 2012;52:2278-81.
Volume 54, May 2014 TRANSFUSION
1211
