Saturday, October 12, 2013

Both sides now (Musings on transfusion medicine illusions)

Updated: 17 Nov. 2013
This month I couldn't resist a blog on abstracts from the 2013 AABB Annual Meeting in Denver, Oct. 12-15, published in Transfusion, Vol. 53, No. 2S, September 2013 Supplement.

Some people use People as bathroom reading. For ~38 years (since becoming an AABB member in 1975), mine has been Transfusion, with the meeting abstract issue offering many enjoyable hours 'on the throne'. Ok, cue the chorus of, 'Get a life!' 

What follows are random observations, covering a few of the many goodies that struck me in this year's abstract supplement. 

Because the AABB meeting is on when this blog is published, I realize that few North Americans will read it. Maybe after they return home and equilibrate? 

The blog's title derives from an iconic song by Canada's Joni Mitchell.

TRANSFUSION PROFESSIONALS
First, using electronic access to Transfusion as an AABB member, the following data was complied.

In the Administrative and Scientific sections, searches for references to health professionals yielded the following results, i.e., number of search 'hits':

Administrative (Scientific)
  • Physician: 60 (54)
  • Nurse: 37 (11)
  • Technologist: 28 (8)
  • Clinician: 8 (15)
  • Medical director: 6 (2)
  • Pharmacist 1 (0)
  • Perfusionist: 2 (0)
Using the scientific section, the top four would be
* physician-clinician-nurse-technologist

What stands out is how physicians dominate both abstract sections. 

SO WHAT?
It follows that physicians dominate AABB meeting abstracts. They dominate AABB's Board of Directors and certainly dominate the ability to do research. 

AABB's 2012-13 Elected Board (n=19):
  • 13 MDs (68%)
  • 4 Medical technologists (21%)
  • 2 PhDs (11%)
Is it an illusion that nurses and medical technologists are equal to physicians in the TM stratosphere or do they continue to be historical underlings?

AUTHOR COUNTRIES
Founded in 1947, in 2005 AABB changed its name from American Association of Blood Banks to AABB. The change reflected that AABB has members in many countries and includes all of transfusion medicine plus cellular therapies.

In the Administrative and Scientific sections, searches for references to author countries showed that the USA dominates abstract presentations at annual meetings. The AABB website gives this breakdown of meeting abstracts


2013
Abstracts
No.
accepted
Acceptance
rate
Domestic
445
90%
International
215
83%

These numbers make the meeting look very international and do not fit what a quick scan showed.

Administrative section: Most non-USA authors are Canadians with 6 abstracts. Other countries such as Italy have 2 abstracts.

Scientific section: Outside of American authors, Canadians have the most abstracts (sorry, no exact count but based on a quick review Canada is number two). This reflects that it's cheaper for Canadians to attend meetings in the USA than transfusion professionals in Europe, Asia, Africa, and Down Under. It would be interesting to know how many of the 'international' abstracts were from Canadians.

Another major factor influencing AABB attendance is that transfusion professionals from Australia, NZ, and European countries have major conferences of their own to attend:
SO WHAT?
AABB is not as international as it likes to portray itself. Despite boasting of membership from ~80 nations, outside of Americans, Canadians predominate. Its 19-member Board has only three non-Americans: Canadians Graham Sher of CBS and Jeannie Callum of Sunnybrook HSC in Toronto, and Mike Murphy of the UK's NBSBT and Radcliffe Oxford University Hospital.

Annual meeting attendees are mostly Americans, followed by Canadians.

Is it an illusion that AABB is an international organization? Or is it really a NA organization dominated by Yanks, with a few token Canucks? 

AABB ABSTRACTS
Now to the three abstracts selected for this blog. 

1. AP123 Transfusion Audits: Looking Beyond the Obvious
Authors: R M Bhavnagri, S M Armstrong, K Sanford. Transfusion Medicine, Virginia Commonwealth University Medical Center, Richmond, VA, USA.
The authors noted that transfusion audits are required by regulatory bodies to assess nursing protocols. They decided to use audits to build better relationships between nursing and blood bank staff. 
They rotated audits among every technologist in the transfusion service. This allowed staff to form relationships with nursing staff on each shift. The result was that relationships between nursing and blood bank staff improved.  
Comment: I really liked this abstract because anything that fosters blood bank and nursing understanding is good.
Is this an illusion? Will nurses and laboratory technologists ever be blood brothers and sisters? Evidence grows that this is so, especially in countries where medical laboratory technologists form a significant portion of transfusion safety officers. [See abstract 3 below.]
2. AP76 Bridging the Gap: The Success of Daily Transfusion Medicine Meetings
Authors: A L Sutton, N K Case, K Sanford.Transfusion Medicine, Virginia Commonwealth University Medical Center, Richmond, VA, United States 
Pathology residents continually rotate through the TM laboratory and it's the responsibility of pathology physicians and medical lab scientists to guide residents through their rotations. A new director noted a communication gap between the lab, residents, and director and implemented daily meetings.
The 20-30 minute meetings are held in the director's office and attendance is mandatory for TM residents, the charge medical technologist, and TM supervisors. 
Meetings have a consistent agenda and include blood product inventories, antibody workups, and much more. They're also an opportunity for residents to ask questions. 
Comment: Daily meetings are a great opportunity to exchange information and keep everyone apprised of current TM activities and issues.  Daily meetings that include the medical director, pathology residents, and medical technologists help bridge communication gaps.  
Equally important, they can lessen status gaps in the health profession pecking order. Disrespecting colleagues is harder when you've spent time with them close-up and know them as people.
Is this an illusion? Do medical directors have the time, let alone the will, to spend 30 minutes in daily meetings with residents and lab staff? Only if they see it as time well spent. One of the value-added benefits would be that it promotes medical technologists becoming an integral part of the health care team. 
3. P11 2012 Transfusion Safety and Patient Blood Management Survey
Authors: C Slapak, K Gagliardi. Community Blood Center/Community Tissue Services, Dayton, OH, United States; Southwestern Ontario Regional Blood Coordinating Network, McMaster University, Hamilton, ON, Canada. 
In 2012~ 40 programs based on an informal network of transfusion safety and patient blood management professionals existed in the USA.  
An online survey was circulated to transfusion safety officers, blood management coordinators, or similar in the USA and Canada  using informal US networks and the Canadian 'Transfusion' mailing list.  
108 professionals replied: 62% from Canada, 32% from US, and 6% from other countries. Almost all Canadian programs have existed for over 5 years (95%) compared to just over half of US programs (54%). 
Professional backgrounds:  
  • nursing (24% Canada, 77% US) 
  • laboratory (72% Canada, 9% US) 
  • 6% physicians or others
The most common words in the position titles were Transfusion Safety (50%).
Training is mainly via professional experience, networking, and attending meetings. Only 8% use a formal TSO training program. 
Comment: Canada has more experience with transfusion safety officers than the USA.The UK and Australia also have more experience than the US. Although the evidence is mostly anecdotal, as in the USA, nursing has no monopoly but tends to dominate TSO positions in the UK, Australia, and NZ. [If this is not so, I'd love to hear from colleagues there.]  For example, from 'Towards Better, Safer Blood Transfusion'. A Report For The Australian Council For Safety And Quality In Health Care (Feb. 2005):
These key individuals have various titles (Transfusion Nurse, Transfusion Nurse Specialist or Consultant, Transfusion Safety Officer, Haemovigilance Officer, Specialist Practitioner of Transfusion). They are usually recruited from nursing backgrounds. They act a vital 'bridge' between the different provider groups engaged in the transfusion 'safety chain', in particular those beyond the hospital laboratory.
In contrast, in Canada medical laboratory technologists outnumber nurses 3 to 1 as transfusion safety officers or equivalent.
Is Canada's experience an illusion? It seems not, but why the preponderance of 'transfusion safety' nurses outside Canada whereas medical technologists here hold their own? An added benefit of a good mix of nurses and technologists is that understanding the daily work realities of each profession grows, and with it, increased respect. 
FOR FUN
Lately, I've listened to many songs written by Canada's Joni Mitchell. The blog's title was selected to reflect the 'we-they' schism between nurses and transfusion service technologists, including the nursing - technologist TSO dichotomy in the rest of the world compared to Canada. 

But other potential illusions include:
  • Are nurses and technologists 'equal' to physicians on the health care team? (where equal means valued and respected equally for their expertise)
  • Is AABB a true international organization? Or more a NA group with delusions of grandeur and global aspirations to promote its standards and associated business line, AABB Consulting Services?
  • Can nurses and technologists one day be blood brothers and sisters, treating each other with respect, even awe, for their respective skills?  
  • Will medical technologists ever become an integral part of the health care team, as respected as professionals with direct patient contact?
Joni Mitchell songs:
  • Both sides now (~600 'cover' versions by other artists and counting)
I've looked at life from both sides now 
From up and down and still somehow 
It's life's illusions I recall 
I really don't know life at all. 
Two other fabulous songs that Joni wrote:
As always, comments are most welcome. And we have some...

Reply #1: Re-Dr. Gwen Clarke's comment below:

Appreciate the feedback. Nice touch to include weekly telecons for colleagues in Edmonton-area hospitals. Like you say, daily meetings help promote communication, a team approach, and opportunities to learn and teach.

I've always been struck at how communication failures play a role in so many adverse events in the UK's SHOT reports. For example (from p. 6 of the 2012 SHOT Report):  
The headlines from 2012 reporting are a continued high rate of error related to omission of essential procedural steps and communication failures. 
Suspect that communication improves outside meetings too as it's easier to phone someone you see every day and works both ways for physicians and lab technologists to consult each other more.
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Reply #2: Re-Kate Gagliardi's comment below:

First, about including your abstract (#3 above: Transfusion Safety and Patient Blood Management Survey), my apologies. It's been on my to-do list to write and tell you it was in October's blog, but....

Believe it (or not) it would have happened today. <;-)

Suspect Canada's situation, where many who are not formal 'transfusion safety officers' share bits and pieces of the role, apply universally. 

Appreciate your frank comments on UK's SHOT ('gold standard') vs Canadian and American hemovigilance programs. Reminds me of a 2011 blog:


Sad that it's still relevant 2 years later. I keep looking for published, current data from Canada and USA. Doesn't happen.

About AABB holding meetings on Canadian Thanksgiving, that breaks me up. Case of, "If it didn't happen in USA, it didn't happen"? Unfair to American colleagues but AABB should take note, if only to maximize meeting profits.

As to TSO 'RN vs Medical Technologist' issue, I'd love to hear your views. In the meantime, I'll pursue it on other media such as Canada's TSO "transfusion" mailing list and report back here. 

Thanks again. Your input is much appreciated.  
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4 comments:

  1. Thanks Pat, for another thought provoking blog. You pose the question of whether transfusion docs have time for daily meetings of "the team." Well, in Edmonton, in our regional transfusion service (and the U of A Hematopathology Residency Training program) - indeed we do. For many years now there have been daily blood bank rounds. These rounds are a daily venue for discussion of zone wide blood inventory, difficult serological problems and patient transfusion needs. Attendees include the supervisory blood bank technologists, transfusion docs, transfusion safety coordinators and trainees (including hematopathology residents, hematology, anaesthesia and general pathology residents as well as students or observers from other fields) who are spending time in transfusion or laboratory medicine. these rounds provide an opportunity for us to undertake the daily work of the transfusion service and, at the same time, teach trainees about administrative as well as clinical aspects of transfusion. Once a week we hold these rounds by telecon so that medical and technical staff from all of the area hospitals can participate and update the group about issues or patient care questions that have occured at any hospital in the Edmonton zone. These rounds are an excellent tool to promote a team approach and provide an ongoing teaching and learning opportunity for all participants.

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  2. Thanks, Gwen. You are good! <;-) I've put feedback on the main blog page.

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  3. Kate Gagliardi6:19 PM

    Hey Pat, as usual a thoughtful, and thought provoking blog. My thoughts:
    1) Regular meetings whether it is a day to day transfusion service operation or a conference committee = key to success. I admit I sometimes thought it was only because my skills were lacking that I needed a daily/weekly meeting to organize a successful service or meeting... and then I realized I if smart people like you and Gwen were including it as a strategy (smile) it must be as important as I thought it was.
    2) Thank you for including our abstract in your musings. Sweet! a) Colleen and I connected at an AABB meeting a few years back when I witnessed her trying to do her 30 minute presentation in 10 minutes since the moderator at her session didn't control the progress (let the other presenters take all kinds of time). b) In any case - in reference to the survey - we allowed people to answer whether or not they were in 'formal' TSO roles - which means the Canadian responses not only included many MLTs who do the 'transfusion safety' work but have no title to reflect that - so that is part of the subjectivity of the results. Having said that, I think it means it is an accurate reflection of who is really managing transfusion safety in our scenario.
    3) SHOT/TTISS/US hemovigilance program - no doubt the industry standard is SHOT. No matter what anybody says, the US and Canadian programs are fraught with problems with uptake/compliance with the national program for surveillance.
    4) Is AABB a truly international meeting? Hmm. It is usually at least a North American meeting, at least it was until about 5 years ago when AABB organizers neglected to notice the meeting was occurring on Canadian Thanksgiving. Some of us were rather vocal about this oversight, and I see that the next few years are not on the 2nd weekend of October (and then it flips back to CDN Thanksgiving again). Yes, we are the largest group of international attendees for perhaps obvious reasons, and considering the US capitalist society, I suppose the emphasis on making money at least got some attention.

    If I had more courage I might address the TSO RN vs Medical Technologist issue, but I leave that to others and hope they make time to respond.

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  4. Kate, many thanks for the thoughtful comments. Will reply on main blog, as with Gwen.

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