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Revista

Brasileira

de

Hematologia

e

Hemoterapia

Brazilian

Journal

of

Hematology

and

Hemotherapy

w w w . r b h h . o r g

Special

article

Teaching

transfusion

medicine:

current

situation

and

proposals

for

proper

medical

training

Gustavo

de

Freitas

Flausino,

Flávio

Ferreira

Nunes,

Júnia

Guimarães

Mourão

Cioffi,

Anna

Bárbara

de

Freitas

Carneiro

Proietti

Fundac¸ãoHemominas,BeloHorizonte,MG,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received1July2014 Accepted15September2014 Availableonline21November2014

Keywords: Bloodtransfusion Advisorycommittees Bloodsafety

a

b

s

t

r

a

c

t

Thecurrentcurriculainmedicalschoolsandhospitalresidenceworldwidelackexposureto bloodtransfusionmedicine,andrequirethereformulationofacademicprograms.Inmany countries,traininginbloodtransfusionisnotcurrentlyofferedtomedicalstudentsorduring residency.Clinicalevidenceindicatesthatbloodtransfusionsoccurmorefrequentlythan recommended,contributingtoincreasedriskduetothisprocedure.Therefore,therational useofbloodanditscomponentsisessential,duetothefrequentundesirablereactions,to theincreasingdemandofbloodproductsandthecostoftheprocess.Significant improve-mentsinknowledgeofandskillsintransfusionmedicineareneededbybothstudentsand residents.Improvementsareneededinbothbackgroundknowledgeandthepractical appli-cationofthisknowledgetoimprovesafety.Studiesprovethathemovigilancehasanimpact ontransfusionsafetyandhelpstopreventtheoccurrenceoftransfusion-relatedadverse effects.Toensurethatalltheseaspectsofbloodtransfusionarebeingproperlyaddressed, manycountrieshaveinstitutedhospitaltransfusioncommittees.Fromthisperspective, theinterventionsperformedduringtheformationofmedicalstudentsandresidents,even thesimplest,haveproveneffectiveintheacquisitionofknowledgeandmedicaltraining, therebyleadingtoareductionininappropriateuseofblood.Therefore,wewouldliketo emphasizetheimportanceoftheexposureofmedicalstudentsandresidentstoblood ser-vicesandtransfusionmedicineinorderforthemtoacquireadequatemedicaltraining, aswellastodiscusssomechangesinthecurrentmedicalcurricularegardingtransfusion medicinethatwejudgecritical.

©2014Associac¸ãoBrasileiradeHematologia,HemoterapiaeTerapiaCelular.Published byElsevierEditoraLtda.Allrightsreserved.

Introduction

The inadequacy of the current medical curricula in blood transfusioninBrazilmakesitnecessarytorecasttheacademic

Correspondingauthorat:Fundac¸ãoHemominas,RuaGrãoPará,882,BeloHorizonte,MG,Brazil.

E-mailaddress:annaproietti@gmail.com(A.B.d.F.C.Proietti).

programsofmedicalgraduationandresidence.Inthe major-ityofcountries,traininginbloodtransfusionisnotcurrently offeredtomedicalstudents orresidents, and thus curricu-lum teachingispoorinthisarea.1 Theoptimalclinical use

of blood and blood products requires profound theoretical

http://dx.doi.org/10.1016/j.bjhh.2014.11.004

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andpracticalknowledgeoftransfusionmedicine.Whilethe importanceofacontinuousknowledgetransferintransfusion medicineiswellrecognized,lessisknownaboutthe charac-terandscopeofeducationprovidedtomedicalstudentsand residents.2Despitemajoradvancesindifferentmedical

disci-plinesandtheapplicationofmodernspecializedtherapeutic methods,transfusionmedicineisstilltraditionallypracticed bynon-specializedmedicalpractitioners,whoareunawareof thenumerousadvancesintransfusionmedicine.1

Thelack ofknowledge inblood transfusion can reduce transfusion safety and cause significant harm to the patient. Thus, competent performance becomesan essen-tialrequirementintransfusionmedicine,preventingpossible complicationsand transfusion reactions.3 Transfusionsare

becoming increasingly important in medical treatments nowadays. The awareness that these procedures have an inherentrisk,makesitnecessarytokeepawatchfuleyeon the quality of transfused blood. This is directly linked to thestandardsofqualityofthebloodprovider,whichstarts withtherecruitmentofblooddonorcandidates,afactthat many physicians are unaware. Of utmost importance is a fullunderstandingofthecorrectindicationsofblood com-ponents,which isthe initialstepinincreasingtransfusion safety.“Musebeforeyoutransfuse”isarulethatallpotential transfusersshouldutilize(J.P.Isbster,personal communica-tion).

Considering that a large number of medical students and residents willbeinvolved inthe course oftheir prac-tice,whetherbeit medicalorsurgical,withhealthservices wheretheprescriptionofbloodcomponentsandderivatives isnecessary,it ismandatorytohaveappropriateandsolid knowledgethrough theoretical and practical training. This trainingmust aimtoenableacorrectprescriptionand use ofbloodproducts.However,atpresentaconsiderable num-berofyoung physiciansare unaware oftheimportance of blood use, and lack the knowledgeon the indicationsand hazardsoftheuseofbloodproducts,despitemedical educa-tionprogramsthatareincreasinglylookingtotraingeneral professionals, who should be ableto aptlyprescribe blood components.

Theprescription ofbloodcomponents mobilizesa com-plexstructurethroughacyclicalprocessthatstartswiththe awarenessofthepopulationregardingblooddonation,which comprisestheselectionofadequatecandidatestodonateand endswiththeprocessingandadequatestorageoftheblood component.

Thispreciousandexpensiveproductwillideallylaterbe made available to the patient in need ofa blood transfu-sionthroughapreciseindicationandwithadequatesupport during the procedure. For this to be accomplished, it is necessarytoinvestinthemedicaltrainingofboththe gen-eralpractitioner andthe specialistwho,inBrazil today,do notreceive training intheir graduationand residence pro-grams.

Wewould like to discuss somechanges in the current medicalcurriculumregardingtransfusionmedicinethatwe judgecritical and analyzesomeinformationonthe educa-tionalpracticeintransfusionmedicinethroughouttheworld, withparticularemphasison the education and training of medicalstudentsandresidents.

Educational

practice

in

transfusion

medicine

in

the

world

In Australia, medical student education is primarily the responsibility of universitiesand their associatedteaching hospitals. Differentstructures exist atvarious universities, withsomeofferingundergraduateandothers postgraduate medicalschoolprograms. Thecontent,amount andtiming oftransfusionteachingvarygreatlybetweenmedicalschools. Some programs include transfusion content from the first yearoftraining,whileothersonlyincludeitatlaterstages. Theeducationmainlyconsistsoflecturesandtutorialswith greatdiversitybetweeninstitutionswithregardtopractical vs. didacticteaching methods.Medicalresident teachingis providedlargely bytheacademic teaching hospitals.There isagainconsiderablevariationbetweeninstitutionsastothe timing,contentandemphasisplacedonteachingtransfusion medicine.Mostwillincludetransfusionaspartoftheintern educationprogram;however,theextentandcontentof teach-inginthisareavariesgreatly.Thereiscurrentlynonational, standardizedcurriculum intransfusionforall medical stu-dentsorresidents.Universityteachinghospitalssettheirown curricula,andtherelevantstaffatindividualtraininghospitals determinesthecontentoflocaltransfusionteachingtojunior residentstaff.SomeAustralianstatesrequirecompletionofa transfusionmodulebeforeorduringinternshiporresidency intheirpublichospitals.Completionofthesecourses, how-ever,isnotrequiredformedicalschoolgraduationormedical registration.2

In Brazil we have a common hematology and transfu-sionmedicine(calledhemotherapy)residenceprograminthe country;thelatteraccountsforapproximately30%ofa min-imum 2-year program. Some private hospitals maintain a residenceprogramandthenthebloodtransfusionserviceis responsible toprovide adequate training and education on the clinical aspects concerning patientblood management forallresidents duringtheir training.Theeducational pro-grammayincludelecturesandpracticalactivitiescoveringthe basicbloodcycle(recruitment,collection,processingofblood components,storage,pre-transfusionaltests,prescriptionof bloodcomponentsandtransfusionalreactionmanagement), therapeuticaphaeresis;plateletrefractoriness management (clinicalandlaboratory),bloodtransfusioninintensivecare unit; maximum blood surgery ordering schedule (MBSOS); autologousbloodtransfusion(mainlyintra-operativesalvage); infectiousmarkerdonorcounseling,etc.Inaddition,residents followthepermanentbloodtransfusionservicemedicalstaff intheirdailyactivities,whichallowsthemtoseethemedical problemsthatoccurinhospitals.2

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of the teaching of transfusion depends on each Hospital-UniversityCenter(theyworkindependentlyfromeachother). The same is also true for the distribution of lecturetime vs.practicaltraining.Thetimedevotedtopracticaltraining isvariable,sometimesveryreduced,ifexistent.Coursesare obligatoryformedicalstudents,and optionalforresidents. Mostoftenthesubjectoftheblood transfusionisincluded inhematologyformedicalstudents.Successfulpassingofthe hematologytransfusionexaminationisnecessarytogointo thefollowingyear.Fortheresidents,transfusionmedicineis fullyoptionalanddependsonthespecialtychosen.2

Invirtuallyall thesecountries, medicalstudentsreceive some education in transfusion medicine. The extent and formofthiseducationdoesnotonlyvaryconsiderablyfrom country to country, but also between universities/medical schoolswithinmostofthecountries. Educationin transfu-sionmedicine forresidentsalsovariesanddependsonthe specializationinvolved.2

Evidence-based

blood

transfusion

Whenagoodbloodproductisavailable,preparedinablood center that hasgood manufacturing processesand quality assurance,thenoneneedstouseitproperly,i.e.,toprescribe itaccordingtoacceptedandupdatedprotocolsofblood uti-lization.

Todevisetheseprotocols,bloodtransfusionphysiciansand researchersutilizestudiesthathighlightwhichbloodproduct isthebestforthepatient,whichwillgivelessmorbidityand bettersurvival.

Clinicalevidenceindicatesthattransfusionsoccur world-wide more often than recommended,4 contributing to the

increasedriskoftheprocedurewhichisalsodirectly propor-tionaltotheamountofbloodtransfused.Amongtheknown risks,oneisthetriggeringofaninflammatoryresponseinthe recipient.5

Inthisway,itisnecessarytobetterassesstherealbenefits ofbloodtransfusion,sincerecentstudieshavedemonstrated forexamplethatareductioninthereferencethresholdsfor transfusionincriticallyillpatientsmaybeofbenefit.5,6Thus,

the individualizedassessmentofeach case,the evaluation ofthe risksand benefitsassociatedwithblood transfusion, aswellasalwaysrevisingexistingprotocols,areactionsthat mustbeconsideredmandatorybeforeprescribingtransfusion. Thus,thebestwaytoreducetheadverseeffectsofblood transfusionistoreducethenumberofunnecessaryand inap-propriatetransfusions.Moreover,therationaluseofbloodand itscomponentsisnecessary,duetotheincreasingdemandof bloodproductsandthecostofproduction.7

Giventhisreality,manynationalandinternational guide-lineshavebeencreated,aimingtooptimizeandstandardize transfusionpractices.Forthis,severalstudieswereconducted toevaluatetheeffectivenessoftheprotocols,individuallyor combinedwithotherinterventions,suchasthedistributionof educationalmaterialsandpracticaltrainingofclinicalstaff.6

Despitetheinterventionsperformed,thefactorsthat influ-enceprescribingatransfusionintheclinicalpracticearenot yetfully known.4,8 Currentstudiesstillfailtoclearlydefine

therationalityoftransfusionpracticeandtheeffectivenessof

performedinterventions.Therefore,itisstillnecessarytoseek abetterunderstandingofthesefactorsinordertoreducethe unnecessaryuseofbloodproducts.8

Asastartingpoint,inthedevelopmentofsuch interven-tions, it is suggested that investmentbe made inmedical training byexposingboth the generalpractitioner and the specialisttobloodservicesandtransfusionmedicineteaching.

Transfusion

medicine

in

medical

training

Significantimprovementsinknowledgeofandskillsin trans-fusionmedicineareneededforbothstudentsandresidents. However, the minimal lecturing schedules needed at both undergraduateandpostgraduatelevelsaredifficultto deter-mine.Ongoingmonitoringofclinicalpracticeoutcomes,such asthroughhemovigilance programsand in-hospitalaudits, isneededtocontinuallyevaluatetheeffectivenessof educa-tionandtrainingprograms,withfurtherefforttailoredtothe resultsoftheseassessments.2

Improvement is needed in both background knowledge and practical application (general and institution-specific) of this knowledge to further the safe practice of transfu-sionmedicine.Anyadditionalteachinginthisareacouldbe adaptedandimplementedatdifferentstagesoftraining,with possiblymoreemphasisonknowledgeofthetheoretical back-groundduringmedicalschoolandhighlightingthepractical aspectsatthestartofresidency.2,6,7

Formal assessments, whether by examination or other means,orrequirementofcompletionofatrainingprogram should ideally be incorporated into the various teaching structurestoenhancealignmentofstudents’andresidents’ knowledge and skills with the relevant educational activi-ties. Anationalapproachtothetraining ofresidents could ensure that all medical practitioners have atleast a basic exposuretothefundamentalsoftransfusionmedicine. Addi-tionaltrainingofmedicalstudentsandresidentscouldbeof substantial benefit. Medicaleducation in transfusion could be further enhanced at the start of residency, reinforcing importantconceptsandpromotingcompliancewithbasicsafe transfusionpractices.Attentionshouldbepaidtocritical prac-ticalapplicationssuchaspatientidentification,appropriate clinicaldecision-making,prescriptionofblood,monitoringof patientsandinvestigationofadversereactionscoveringboth generalprinciplesandinstitution-specificrequirements.2,7

The knowledge of interns and residents could also be improved through a multidisciplinary team approach, incorporating input from seniortransfusion scientists and specialist transfusion nursesinto the deliveryofeducation andtraining.Ifeveryresidentcouldbeexposedtothisrotation atsomepointduringtheirresidency,thegreaterawarenessof transfusionissueswouldbeanticipatedandtranslatedinto improvedpractice.2,6

Blood

safety

and

hemovigilance

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throughResolutionRDC153oftheBraziliansanitaryagency ANVISA,startedin1999.9

Hemovigilanceisdefinedasanevaluationandalert sys-tem,organizedwiththeobjectiveofcollectingandevaluating informationaboutadverseand/orunexpectedeffectsofthe useofbloodproductstopreventtheoccurrenceorrecurrence oftheseeffects.10,11 Hemovigilancedealswiththe safetyof

thebloodtransfusionchainandcanbesummarizedinone phrase:“thesecurityofveintovein.”12Thisinformationis

usedtoidentifyrisk, improve qualityofproductsand pro-cessesandincreasethesafetyofthedonorandthepatient, preventing the occurrenceor recurrence of suchevents. It isimportant,forexample,insituationsofseroconversionof donorstoHumanImmunodeficiencyVirus(HIV),HepatitisB Virus(HBV)andHepatitisCVirus(HCV)thatareassociated withinfection in the recipient. Proper monitoringofthese casesareonlyaccomplishedthroughtheexistenceofanactive systemofhemovigilanceinthehospitalandbloodcenter,a factthatdemonstratestheuniqueimportanceofthistoolin transfusionsafety.10

Moreover,despite advances in serological methods, the risk attached to the immunological window period isstill presentandthereforethedevelopmentofdiagnostic meth-odswithgreater sensitivity,suchasNAT,andwithalower negativepredictivevalue,but withoutthelossofspecificity arerequiredtoreducetheriskoftransmissionofinfectious diseasesthroughbloodtransfusions.Thesedatademonstrate theneedtoeducatethemedicalandlaycommunityand pub-licizethatdonationisanactofcitizenshipthataimstosave livesandnottotransmitdiseases.9

Perhapsduetoitsrecentimplementation,hemovigilance hasnotyetbeenincludedinmedicalgraduationorresidency programs,aswouldbedesirable.

Hospital

blood

transfusion

committees

Inordertoensuretheappropriatenessofbloodtransfusion, “HospitalTransfusionCommittees”(HTCs)havebeencreated indifferentcountriestooverseeallaspectsofthetransfusion ofbloodproducts.HTCsarelocalcommitteeswitha multi-disciplinaryapproachforthepromotion and monitoringof correctnessofbloodproductusage.13

The approaches used to achieve this goal have varied bothhistoricallyandbetweennations.Theprinciplesofthese methodsarecommon,andtheuseofaHTCorBlood Utiliza-tionCommitteehasbeenpromotedworldwideatonetimeor another.TheroleoftheHTCcanbedescribedasthe promo-tionofbesttransfusionpracticethroughtheenhancementof awarenessandeducation,facilitationofpolicydevelopment, andmonitoringandreviewingtheuseofbloodandblood prod-uctsandadverseincidentsinvolvingtheseproducts.13

ThemainfunctionsofaHTCinclude:(a)developing sys-temsfortheimplementationofthenationalguidelineswithin the hospital; (b)liaison withthe blood transfusion service toensuretheavailabilityofrequiredbloodandblood prod-uctsatalltimes;(c)liaisonwiththerelevantdepartmentto ensure areliable supply ofintravenous replacement fluids andotheralternativestotransfusionatalltimes;(d) develop-ingahospitalbloodorderingschedule;(e)developinghospital

standardoperatingproceduresforallstepsinthetransfusion process;(f)trainingallhospitalstaffinvolvedintransfusion; (g)monitoringtheusageofbloodandbloodproductswithin the hospital;(h)theinvestigation andmonitoringofsevere adverseeffectsorerrorsassociatedwithtransfusion,taking anycorrectiveandpreventiveactionsrequiredandreporting throughthehemovigilancesystemtonationalcommitteeson theclinicaluseofblood.13

Generallyspeaking, cliniciansreceive little orno formal trainingontheclinicalindicationsforbloodtransfusion thera-piesduringtheirtimeatmedicalschool.2,5HTCscanpromote

bestpracticebyprovidingcontinuingprofessionaleducation andmonitoringperformancebyclinicalauditandpeer review-ing.Regularlynotifyingcliniciansontheirperformanceisan additionalstrategythatmayimprovetransfusionpractice.13

Final

considerations

Over the past decades, the fields of activity and knowl-edgeintransfusionmedicinehaveevolvedintoanarrayof diverseareasandsub-specialtiesincluding immunohematol-ogy,blood component production,hemapheresis,pathogen detection,methodsofcellandtissuecollectionand manipu-lation,cellconservationandbanking,transplantimmunology andhemostaseology.Inthemajorityoftheclinicaldisciplines, cliniciansarerequiredabasicormoreadvancedknowledgein thesefields tomeettherequirements ofmodernmedicine. Specialist physicians in transfusion medicine are valuable andcompetentpartnersfortheserelateddisciplineswhenit comestosafe,effectiveandtailoredbloodtransfusion. Trans-fusion medicine is thus an important qualification at the interfacesofanalyticallaboratorymedicine,pharmaceutical productionandclinicaldisciplinessuchasinternalmedicine, anesthesiologyandsurgery.Althoughtransfusionspecialists havefocusedconsiderableeffortsonidentifyingmechanisms toreducetransfusions,therehasbeenlittleanalysisto iden-tify the best means tochange transfusion practiceamong physicians.14

Behavioralinterventions tomodifytransfusionpractices haveproveneffective,anditisimportanttobeabletochange transfusionpracticesamongphysicians,giventhepotential risksassociatedwithtransfusionsandthechallengesfacing thebloodtransfusionsystem.1Oneofthemethodstoreduce

blood useistodoonsiteinterventionsand monitoring,as well as providingtraining tophysicians.14 Previousstudies

haveshownthattheknowledgeofmedicaldoctorsneedsto beimproved,asithasanimportantroleintheoptimaluse ofbloodproducts.Moreover,thisawarenessinfluencestheir approachtowardbloodtransfusionofpatientsinneedofblood andbloodcomponents.Asphysiciansaretheonesordering blood,theyplayamajorroleindeterminingtheamountof bloodandbloodcomponentstobeused.

Appropriateprescriptionofbloodcomponentsandblood transfusionisnegativelycorrelatedwiththenumberofyears inpractice,callingforchangeanddevelopmentofcontinuous in-servicetrainingprograms.1

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specializedmedicaldisciplinesrelatedtoblood transfusion andapplicationofmodernspecializedmethods,transfusion medicineisstillpracticedtraditionallybypractitionersand theyarelargelyunawareofthesenewdevelopmentsin trans-fusionmedicine.

Finally,whilemanychoicesofbloodproductshave compli-catedthephysician’sdecision-makingprocess,theyhavealso made hemotherapy morespecific and effective. Therefore, educational programsand preparationof curricula accord-ingtothemostrecentadvancesintransfusionmedicineare neededinordertoenhancethe knowledgeofmedical stu-dents,residentsandphysicians.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgments

TheauthorsthankFundac¸ãoHemominas,FAPEMIGandDr. AlcioneMariadePinhofortheirsupport.

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s

1. GharehbaghianA,JavadzadehShahshahaniH,AttarM, RahbariBonabM,MehranM,TabriziNaminiM.Assessment ofphysiciansknowledgeintransfusionmedicine,Iran,2007. Transfusion(Paris).2009;19(3):132–8.

2. PanzerS,EngelbrechtS,Cole-SinclairMF,WoodEM,Wendel S,BiaginiS,etal.Educationintransfusionmedicinefor medicalstudentsanddoctors.VoxSang.2013;104(3): 250–72.

3. FerreiraO,MartinezEZ,MotaCA,SilvaAM.Avaliac¸ãodo conhecimentosobrehemoterapiaeseguranc¸atransfusional deprofissionaisdeenfermagem.RevBrasHematolHemoter. 2007;29(2):160–7.

4.FrancisJJ,StocktonC,EcclesMP,JohnstonM,CuthbertsonBH, GrimshawJM,etal.Evidence-basedselectionoftheoriesfor designingbehaviorchangeinterventions:Usingmethods basedontheoreticalconstructdomainstounderstand clinicians’bloodtransfusionbehavior.BrJHealthPsychol. 2009;14Pt4:625–46.

5.SalpeterSR,BuckleyJS,ChatterjeeS.Impactofmore restrictivebloodtransfusionstrategiesonclinicaloutcomes: ameta-analysisandsystematicreview.AmJMed.

2014;127(2):124–31.

6.TinmouthAT,HareGM,MazerCD.The“sticky”businessof “adherence”totransfusionguidelines.IntensiveCareMed. 2010;36(7):1107–9.

7.TinmouthA.Reducingtheamountofbloodtransfusedby changingclinicians’transfusionpractices.Transfusion(Paris). 2007;472Suppl.:132S–6S.

8.IslamR,TinmouthAT,FrancisJJ,BrehautJC,BornJ,Stockton C,etal.Across-countrycomparisonofintensivecare physicians’beliefsabouttheirtransfusionbehaviour:A qualitativestudyusingthetheoreticaldomainsframework. ImplementSci.2012;7:93.

9.MartinsPR,MartinsRA,BarbosaVF,PereiraGA,Moraes-Souza H,SilvaSS.Theimportanceofhemovigilanceinthe

transmissionofinfectiousdiseases.RevBrasHematol Hemoter.2013;35(3):180–4.

10.Carneiro-ProiettiAB.Hemovigilance:asystemtoimprovethe wholetransfusionchain.RevBrasHematolHemoter. 2013;35(3):158–9.

11.MinistériodaSaúde(BR),AgênciaNacionaldeVigilância Sanitária.Manualtécnicodehemovigilância.Brasília: MinistériodaSaúde;2004.p.40.

12.deAlmeidaNetoC.Toolstoimplementandimproveblood donorhemovigilanceinBrazil.RevBrasHematolHemoter. 2014;36(2):106–7.

13.LiumbrunoGM,RafanelliD.Appropriatenessofblood transfusionandphysicians’education:acontinuous challengeforHospitalTransfusionCommittees?Blood Transfus.2012;10(1):1–3.

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