Cross-training

[RR1]

Are majority of qualified technical staff around the Globe multidisciplinary trained in Haem, Biochem and Transfusion ?

In the U.K most Biomedical Scientists (BMS) specialised early on in Haem/Transfusion and Biochemistry. As changes are now being discussed, we will probably need to develop a more multidisciplinary approach with lots of cross-training in the future. I'd be really interested to know how you handle cross-training and any specific problems/ useful tips.

Many thanks

[Malcolm Needs ☆]

I mis-read the heading to your thread.

I was thinking, I never got cross training; I always enjoyed it!!!!!!!!!

:haha::haha:

[RR1]

I mis-read the heading to your thread.

I was thinking, I never got cross training; I always enjoyed it!!!!!!!!!

:haha::haha:

Ah, but if you worked in a hospital blood sciences lab, you would probably start to get cross, training staff, especially as comments made by certain folk is that there is nothing to transfusion, just adding some plasma to gel cards and centrifuging...even a trained monkey could do this!

What specific training needs are there for a monkey?!!

[Fluffy agglutinates]

Hi Rashmi,

Part of my job is teaching on the NBS courses so I can give you an idea of the people we get & why...

Last week we ran our Practical Intro to Transfusion Science (5 days theory & prac). Quite a few were multi-disciplinary. It seems that some managers are happy to send staff on this course & then expect them to be competent (& ready for solo-working!). One person had been told to do the advanced course but he insisted himself that he needed to start with the basics.

In my opinion, based on recent attendees, is that transfusion training in the workplace is random, intermittent, lacking in underpinning knowledge, not followed up, not given enough time, & leaves the BMS feeling either (as you mention) that there's 'nothing' to it or completely terrified of transfusion. Everytime I talk about BCSH guidelines it's quite clear that they are not being used in the lab as source material for training - not one of the 9 attendees had heard of them! And yet they carry out pre-transfusion testing...

We always encourage the attendees to go back to work 'armed' with questions about why their policies are set the why they are.

A couple of new 'policies' I heard about this week at one hospital:

If anti-Kpa cannot be excluded they are told to select K- units as these 'won't be Kp(a+)' - their blood bank manager has decided this!

If anti-Cw cannot be excluded they are told to give C- units (regardless of patient Rh phenotype).

My real worry is that transfusion knowledge is disappearing at an alarming rate & no one appears to be too bothered. Is time & money so tight that we can no longer teach our staff the basics?

The one thing that does give me hope is the majority of attendees at the end of the week realise how much they don't know & go away wanting to learn more. Also, this goes for all BMSs not just the multi type.

What do you think can be done to help improve this situation?

Robina

[Malcolm Needs ☆]

If anti-Cw cannot be excluded they are told to give C- units (regardless of patient Rh phenotype).

Robina

I came across (almost) this exact situation not long ago with a Biomedical Scientist (BMS) on-call for Blood Transfusion in a very large London Teaching Hospital (no name, no pack drill).

In this case, the patient did have an anti-Cw, but also had an anti-c (with a probable Rh genotype of R1R1). The BMS on-call was asking our Issues Department for D+, E-, e+, C-, c-, Cw- blood, and took me ages to convince her that 1) she didn't need it ("but it's our policy"), 2) that she wasn't going to get it, 3) that cross-match compatible R1R1 blood would be perfectly safe, and 4) that such blood does not exist anyway (I didn't go into the details of the genetics behind this).

I was quite proud of myself; I didn't loose my temper and I didn't swear at her!!!!!!!!!!!!!!

:ohmygod::ohmygod:

[tbostock]

We have a couple "dedicated" Blood Bankers; just about everyone else in the Lab is crosstrained in at least one other department. Having crosstrained techs around is great for staffing shortages, it gives you some more flexibility. The key to crosstraining is finding the right balance...having enough techs crosstrained to have that flexibility, and having enough Blood Bank "experts" to provide that experience needed.

[Fluffy agglutinates]

Hi Malcolm,

We often get disgruntled people asking why they need to learn Rh nomenclature, haplotypes, genotype & phenotype etc. They think they should just be able to ask for 'antigen negative' & have it delivered. They take ages to connect 'what I want' with 'what actually exists'!

It also makes me very sad indeed that some transfusion staff don't want to learn.

It is very difficult not to swear sometimes!

[Deny Morlino]

As a small hospital lab everyone here is crosstrained. Most of us are cross trained for day shift competence in every department except micro as to be adept in micro requires frequent exposure to plate work. All of the techs on second and third shifts are generalists. Those on days that are supervisors tend to "stay" in their department of responsibility, but even then we do spend a fair amount of time in other departments. Terri covered some good points. The balance mentioned is a delicate and important situation to maintain.

[Dr. Pepper]

Our training/competency varies by shift. On 1st shift we have 1 or 2 "core" techs each for BB, Chem and Hem and several "generalists" who have been crosstained at multiple work stations depending on need, talent, experience etc. As Terry points out, this gives you a lot of flexibility in scheduling and helps with call-outs, vacations, LOAs etc. We are very lean; without crosstrained techs we would have a lot of trouble. On 2nd and 3rd shift we have generalists trained who cover all 3 depts (2-5 techs scheduled/shift). When initialling training, generalists stay in a dept usually 2-4 weeks until you and they are comfortable with their performance. We demonstrate competency, sign off and move them to the next dept. 2nd and 3rd shift techs train on 1st shift, then "shadow" on their shift until they're ready to solo.

[AMcCord]

We operate much like Dr. Pepper's lab. It's very common in the U.S.

[pbaker]

US techs are trained in all departments while in school. Depending on where and what shift they end up working, they may be working in one department, some departments or all departments. We have 3 BB only techs on days and several that are cross-trained in 1 other department. Evening shift techs are all cross trained in a minimum of 2 departments. Night shift techs are cross-trained in all departments. Microbiology off shifts only does set-ups and the day cross-trainers are only trained on set-ups and 1 micro bench.

Cross trainers do come in very handy when there is vacation, call-ins or mandatory hospital training and/or meetings.

[clmergen]

Being back in a small hospital has really opened my eyes to cross-trained staff inadequacies. They need to know so much information that they have lost the basics in so many areas. I saw a tech recently be confused on how to deal with a patient with a history of 2 antibodies but a current negative antibody screen. And antigen matched blood was already available. All he needed to do was crossmatch it..... He left it for me to do. And it isn't just in transfusion! The instruments in the other departments are sadly neglected.

[Malcolm Needs ☆]

Being back in a small hospital has really opened my eyes to cross-trained staff inadequacies. They need to know so much information that they have lost the basics in so many areas. I saw a tech recently be confused on how to deal with a patient with a history of 2 antibodies but a current negative antibody screen. And antigen matched blood was already available. All he needed to do was crossmatch it..... He left it for me to do. And it isn't just in transfusion! The instruments in the other departments are sadly neglected.

"Jack of all trades; master of none.", and in Blood Bank, you need to be something of a master.

:disbelief:disbelief:disbelief:shakefist:shakefist

[L106]

Our training/competency varies by shift. On 1st shift we have 1 or 2 "core" techs each for BB, Chem and Hem and several "generalists" who have been crosstained at multiple work stations depending on need, talent, experience etc. As Terry points out, this gives you a lot of flexibility in scheduling and helps with call-outs, vacations, LOAs etc. We are very lean; without crosstrained techs we would have a lot of trouble. On 2nd and 3rd shift we have generalists trained who cover all 3 depts (2-5 techs scheduled/shift). When initialling training, generalists stay in a dept usually 2-4 weeks until you and they are comfortable with their performance. We demonstrate competency, sign off and move them to the next dept. 2nd and 3rd shift techs train on 1st shift, then "shadow" on their shift until they're ready to solo.

We also operate this way. (Dr. Pepper did a good job of describing the situation.)

[RR1]

Hi Rashmi,

What do you think can be done to help improve this situation?

Robina

Hi Robina..nice not to have to call you fluffy anymore,

Completely agree with everything you have said- seeing these things all the time. There is significant apathy with many staff who think this is just a 9-5 job, and responsibility for their own education lies with their place of work. I see the coming years are going to be a massive shock for many staff with new and more responsibilities given, for same pay, and accountability assigned.This is not necessarily a bad thing and could lead to a first class pathology service.

With the formation of HUb/ Spoke models for Pathology services there is a need for high quality training departments to be formed, with dedicated staff (not just another role tacked onto someones JD) that could address these problems long term;

Lets hope the "significant folk" in the DoH/ Networks who make these plans remember that Transfusion specifically requires highly skilled and knowledgeable staff to maintain patient safety - and listen to the discussions taking place about the loss of expertise.

Edited March 22, 2011 by RR1

[RR1]

Thanks everyone else, do you folk see any particular, recurring errors with your cross-trained staff ? Also, is there any data being collected by the U.S Biovigilance program that shows the type of errors vs staff grade/transfusion experience ?

"Being back in a small hospital has really opened my eyes to cross-trained staff inadequacies. They need to know so much information that they have lost the basics in so many areas. I saw a tech recently be confused on how to deal with a patient with a history of 2 antibodies but a current negative antibody screen. And antigen matched blood was already available. All he needed to do was crossmatch it..... He left it for me to do. And it isn't just in transfusion! The instruments in the other departments are sadly neglected"

Regarding the above from Carrie, this is really scary but is happening in the UK too. Hopefully new developments will improve the UK situation and in 10yrs time we can be really proud of our training programs.

[Malcolm Needs ☆]

Lets hope the "significant folk" in the DoH/ Networks who make these plans remember that Transfusion specifically requires highly skilled and knowledgeable staff to maintain patient safety - and listen to the discussions taking place about the loss of expertise.

"Remember" Rashmi? I didn't know that they knew in the first place. For decades, the Blood Transfusion Laboratory in most hospitals had been led by the most senior Biomedical Scientist in Haematology (or worse), and by a Consultant Haematologist with a side interest in blood transfusion. It is really only since the advent of SHOT, SABRE and Better Blood Transfusion that we have become the bridesmaid - we still have a very long way before we become the blushing bride.

Remember that there is no Blood Transfusion Specialist on the CPA's Inner Council (can't remember what they are actully called) by right. They are only allowed to attend when and if the other members think that there is something to discuss about the subject that they think they do not understand (so you can imagine how foten that happens), and the Blood Transfusion Reperesentative does not always even receive the minutes of the meetings, and so they only find out about some of the crass decisions after the event.

:angered::angered:

[RR1]

"Remember" Rashmi? I didn't know that they knew in the first place.

That's very true!!!

Remember that there is no Blood Transfusion Specialist on the CPA's Inner Council (can't remember what they are actully called) by right. They are only allowed to attend when and if the other members think that there is something to discuss about the subject that they think they do not understand (so you can imagine how foten that happens), and the Blood Transfusion Reperesentative does not always even receive the minutes of the meetings, and so they only find out about some of the crass decisions after the event.

Actually this statement seems to applies to a lot of what is going on in the UK with mergers. Pathology management seems to think you just tack on transfusion to any plan without consequesnces- and forget there are patients ultimately involved and who could be harmed if the structures aren't formed correctly at the start of these changes.

Time for transfusion folk to stand up for what we really believe in and voice our concerns loudly...risk registers can be helpful tools.

[Steven Jeff]

"Jack of all trades; master of none.", and in Blood Bank, you need to be something of a master.

Hi Malcolm, I thought I would challenge you a little on this statement. As you know I have managed a multidisciplinary lab for nearly 24 years and have some UK experience in this area. I am primarily haematology trained with a fellowship in haematology. My laboratory skills include clinical chemistry and immunoassay as well blood transfusion. Although good at Chemistry and immunoassay analysis I would agree my theoretical knowledge would be lacking but I do know when the results are obscure. At the end of the day dare I suggest it the results are mainly numbers. However, I realised many years ago that I had to make an effort to keep up with blood transfusion, this combined with an ever increasing interest in blood transfusion. It would be fair to say I know less about haematology now than I did when I trained. What I do have is a lot of experience and I know when I am out of my depth and will quickly ask for advice if I need to.

I would suggest however, that multidisciplinary trained staff often see the bigger picture when reviewing pathology results from a patient.

Finally, I do agree that somebody in the lab has to take the lead in blood transfusion and have the necessary skills to move with the times and interpret the results. For this I thank all the friends I have made through transfusion fraternity that have inspired me.

See you tomorrow!!

Steve

:wave:

[Malcolm Needs ☆]

I do agree with a lot of what you are saying Steve, but I still maintain that the Blood Transfusion Laboratory does require a certain amount of specialist knowledge, simply because it is not a question of numbers, and the fact that we are giving out a product that (although this may sound overdramatic) has the potential to kill in a very short space of time.

I am not thinking just of patients with complex antibody mixtures, but also of when, for example, irradiated cellular products are, or are not required, when washed red cells are required, when CMV- components are required, etc, etc.

Sadly, I will not be able to make the meeting today. Have a good one.