Showing posts with label AABB. Show all posts
Showing posts with label AABB. Show all posts

Sunday, June 30, 2019

I will remember you (Musings on Marion Lewis, an extraordinary Canadian)

On June 27 Julie Payette, Governor General of Canada, announced new appointments to the Order of Canada. Included in the honours was Marion Lewis of Winnipeg, who at age 93 was named an Officer of the Order of Canada (Further Reading).

As my early career was in Winnipeg I was well familiar with Marion Lewis and Dr. Bruce Chown. In 1944, she and Dr. Bruce Chown opened the Rh Laboratory to study and eradicate Rh hemolytic disease of the fetus and newborn (HDFN).

The blog's title is based on a 1995 ditty by Sarah McLachlan.

FROM HUMBLE BEGINNINGS
In 1943 Marion Lewis graduated from high school and trained as a 'medical technician' at Winnipeg General Hospital (now Health Science Centre). In those days there were no post-secondary institutions training what today we call medical laboratory technologists/scientists ('biomedical scientists' in UK and Down Under). As noted, only a year later she was at Winnipeg's Rh Laboratory with Dr. Bruce Chown.

With a Bachelor of Arts degree she became a Full Professor in the Dept of Pediatrics and 2 years later a Professor in  Dept. of Human Genetics. Normally that's reserved for those with MD or PhD degrees. In 1971 Marion shared AABB's Karl Landsteiner Memorial Award with Dr. Bruce Chown in 1971. To me, it's AABB's most prestigious award. And it's not the only AABB award she received.
  • Karl Landsteiner Award
  • Past recipients (Check these TM giants out: Levine, Wiener, Race, Sanger, Morgan, Watkins, Mollison, Dausset, Blumberg, Crookston, Bowman, Issitt, Gallo, Montagnier, et al.)
TIDBITS
It's fascinating that in 1950-51 Marion Lewis needed a break and spent four months at an Italian university studying Italy's language and culture. Then she spent another three months studying in London with Dr. Robert Race and Dr. Ruth Sanger of 'Blood Groups in Man' fame. In 1951 Marion returned to Winnipeg and the Rh Lab. And the rest is history (See her University of Manitoba biography in Further Reading).

Please read Further Reading for Marion's unique career.

Of course, I knew Dr. Jack Bowman of Winnipeg's Rh Lab well as he was the Medical Director of Winnipeg's Can. Red Cross BTS while I still worked there. Wrote a blog when he died in 2005 (Further Reading).

FOR FUN
Chose this Sarah McLachlan song because I will always remember transfusion medicine giants and especially folks like Marion Lewis who rose from humble beginnings to great accomplishments on the strength of intellect, skills, and hard work.
As always, comments are most welcome.

FURTHER READING

Saturday, June 01, 2019

We can work it out (Musings on transfusion association annual meetings)

Last revised: 2 June 2019  (See ADDENDUM below)

INTRODUCTION
As the CSTM annual conjoint meeting with CBS and Héma-Québec is now on May 29 to June 2, I thought I'd muse on annual meetings in general. As readers of this blog will know, I've had a long career in transfusion starting at the bottom without qualifications but being incredibly fortunate in my employers.

I'm an outlier of sorts with atypical views and being an oldster gives me the freedom to say things that colleagues likely would not. Perhaps many may disagree with me on this blog's points. That's okay too as I'd be concerned if all, even most, agreed with me. Included are tidbits I think contribute to quality presentations at meetings.

Professional associations exist to serve and represent the interests of their members, which applies to the three associations I belonged to during my long career as a medical lab technologist turned educator: AABB, CSMLS (includes IFBLS membership), CSTM. The latter two are Canadian organizations, the first American but AABB has branched out to become international, though its headquarters remains in the USA as does its primary focus.

The blog's title is based on a 1965 Beatles ditty, We Can Work It Out.

LESSONS LEARNED
Over the years I've attended many meetings, aka conventions and congresses. With a few exceptions most of all those attended were held in Canada by CSMLS or CSTM. One memorable one (IFBLS) was held in Oslo in 1996. Why memorable? Most of all it was because I met a Norwegian med lab technologist who worked in transfusion and we've been good pals ever since.

To me, that's Lesson #1 of what's important at annual meetings. It's not so much the scientific presentations you hear and what, if anything, you learn from them (commit to long-term memory). Face it, if you read professional journals you're pretty up-to-date on the latest and greatest. During my career the AABB journal Transfusion and similar were kept in the bathroom as a welcome distraction or read while basking outside in Canada's all too short spring, summer, fall.

Of course, I suspect not many transfusion technologists and nurses in the trenches regularly read journals. Take a peak at the index of Transfusion 2019;59(5). How many articles would you read let alone understand?

Today, keeping current also applies to those on social media platforms like Twitter where journals and associations alert folks to the latest developments. But how many of you use Twitter?

LESSON #1: The most valuable benefits of meetings are the interactions with peers, sharing experiences and knowledge that's not in journals or textbooks, including the friendships made. Often such interchanges are shared during a night-out over a meal or glass of wine/beer. Typically, chitchat involves practical and tacit knowledge only gained from experience.
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Pretty certain that Lesson #2 will be familiar to medical lab technologists/scientists world-wide, at least those lucky enough to attend meetings:
  • So many of the presentations at transfusion association meetings are by physicians and researchers, though it's slowly changing. 
What this means is the information and research presented, though significant, is often not particularly meaningful nor of immediate use to those in the trenches, whether transfusion med lab techs, nurses, physicians without university appointments. And being able to use new meaningful learning right away is important to busy adult learners. In continuing education and professional development courses it's critical because 'adults vote with their feet' as the cliché goes.

Indeed, I wonder in the age of the smart phone how many meeting attendees during presentations  spend most of the time checking e-mail, texting and browsing. Suspect it's far too many. Best take is they're live tweeting but no, that's not it.

Reality is that much transfusion research is esoteric, of interest mainly to those involved in similar, narrow research.  Kudos to CSTM for its full day of workshops relevant to front-line professionals.

LESSON #2: Many presentations at scientific meeting are of minimal value to attendees, especially those who work in the trenches on the front-lines of transfusion, those in the lab and those on the wards. If you're a PhD or MD/PhD researcher and the topic coincides with your interests, the talks are no doubt fascinating.
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Lesson #3 relates to a sad fact of life for many in the trenches. Years ago funding for CE/CPD was scaled back significantly. The result is fewer and fewer attend national meetings (unless local), let alone international ones. Today the cost of airfare and hotels is increasingly exorbitant.

Who can afford it? My guess includes
  • Physicians and researchers who get funding support or earn large salaries, along with those in senior positions. 
    • Bench technologists and front-line transfusion nurses not so much. 
  • Educators and those in health profession unions who get discretionary funds to use for CE/CPD but the funding wouldn't come close covering travel and hotel costs to attend meetings outside their locale. 
  • Some associations fund invited presenters, but not all.
  • An association's board of directors, whose members are volunteers and put in much dedicated time and a tiny perk is funding to attend meetings.
Many transfusion associations/organizations now offer local CE/CPD events across the country or provincially, including CSTM's Education Days. And thanks to the Internet, technology makes webcasts and podcasts possible.

LESSON #3: To what extent have annual meetings become a place for the 'elites' to meet and interact?  By elites, I mean those professionals fortunate to have funding or be wealthy enough to attend if the meeting is not in their locale and schmooze with other elites? It's a question to which I do not have an evidence-based answer, yet suspect it may be true.
~~~~~~~~~~~~~~~~
Lesson #4 has been a pet peeve of mine for ages and relates to the quality of presentations at meetings by the biggies, the so-called 'thought leaders' of a profession. My experience is presentation quality is often awful, bordering on pathetic.

It's one reason I'm so glad that Medical Laboratory Science at the University of Alberta has a communications course that includes how to give presentations and gives students opportunities to practice the skills, including presenting their research projects.

Wish all MSc/PhD graduate and medical education programs included such a course. About physicians, my experience is, if a communication course or any professional development program, is not given by a physician, they devalue it. Apparently only physicians can teach physicians.😞

To me the biggest, common presentation failures include NOT doing the following, relevant to physicians, especially. BTW, the points are basic, equivalent to Presentation 101 courses.
  • Begin with a personal anecdote to grab audience attention immediately and get them to appreciate your authenticity, that you've 'been there, done that,' and dig their professional realities.
  • Explain up-front why the talk is relevant to the audience.
    • For gawd sake, don't keep it a secret.
  • Briefly outline what the talk is about, perhaps even say, if that's not what you expected, feel free to exit now. 
    • Shows you  respect the needs of audience.
  • Mention there will be time at the end for questions, if the person who introduced you did not.
  • Distribute handouts at the end and say that up front. 
    • Include your speaker notes in handouts so the audience has something substantive to take away.
    • In the early days of Powerpoint I don't know how many handouts I brought home from meetings, including making notes on each slide myself, that were all but useless and eventually tossed in a trash can.
    • Fact: If you distribute handouts at the start of a talk, the audience will concentrate on them, not what you are saying.
  • Use mostly graphics in the presentation vs bullet points. It's a way to get folks to listen to what you say.
    • If you use a few slides with bullets, do NOT use complete sentences and, regardless, NEVER read the points word for word unless you want to put the audience to sleep.
  • Forget about using any busy slides you have where the writing is minuscule and unreadable.
    • Just don't, no matter what.
    • Saves you the trouble of cynically apologizing for it being busy.
    • Because obviously you included the slide anyway, thus disrespecting your audience's intelligence. 
  • Throughout the talk refer to the experiences of colleagues and audience members you recognize, and sprinkle the presentation with their work.
    • It's not all about you, it's about those who helped you succeed.
    • Self-deprecating humour, if sincere, is appreciated by listeners.
  • Focus on key points only.
    • Though tempting, do not succumb to presenting all your data and conclusions.
    • Few viewers are as obsessed with the topic as you are.
    • The fewer key learning points, the more they will be remembered because of info overload.
  • At talk's end, briefly tell the audience what you told them and reinforce why it's significant and relevant to them. 
  • Thank the audience for their attention and thank conference organizers for inviting you.
  • With questions at the talk's end, even if you get snarky questions (yep, there are always all-about-me colleagues), try to be gracious, realizing that to most in the audience, the asker is showing themselves in a bad light and you are better than them.
    • Taking the high road always wins.
LESSON #4: Physicians and researchers, at least try to learn how to present well. I realize you could care less as you've gotten away with pathetic presentations forever and have zero motivation to change. But please try to be better because it has many rewards, adds to your reputation.
 ~~~~~~~~~~~~~~~
ADDENDUM
First a disclosure. Folks, for most of my career I was one of the fortunate 'elites' I referenced earlier, mainly by virtue of volunteer positions for professional associations, being an invited speaker at conferences where organizers funded travel and hotel costs, or as a perk of being an educator at a university. 

One thing I noticed in those days of yore versus today's national meetings is that now there seem to be fewer young attendees. Perhaps it's my imagination or just that all professions are aging and those in senior positions are older than before. Or maybe not.

While I hesitate to mention this, one reason could be that younger med lab technologists/scientists may not be as keen as we were in what I call the 'golden age of immunohematology.' Perhaps when considering annual fees, younger folks and many older ones too, wonder if it's worth it, questioning the benefits of membership. That is, they first ask 
  • What will the association and being a member do for me? vs
    • What can I do for my association?
    • How can I give back to my profession?
Or it could be that membership for some has become a financial burden. For example, in Canada registration with provincial regulatory colleges is compulsory for med lab techs,e.g. CMLTO annual fees. In contrast, membership in professional associations is voluntary and annual fees are a bargain in my opinion, e.g., CSTM $120 and CSMLS $167. But if you worked in Ontario and belonged to all three, the total would be $671.20. To me, that's just a tiny percentage of annual salaries and the benefits are many. 

Which brings me Julie Hendry's presentation. Julie is this year's recipient of the CSTM's  Buchanan Award, who included this slide at the end of her talk (click to enlarge - Julie's slide was tweeted by Geraldine Walsh and Clare O'Reilly on Twitter): 

Julie's challenge is a great one for CSTM members and members of all professions. We in the health professions are so lucky. 

FOR FUN
I chose this Beatles song because its lyrics fit the blog's content.
As always, comment are most welcome (and there are some below).

Thursday, November 24, 2016

Don't stop (Musings on government regulation as a TM disruptive force)

Updated: 25 Nov. 2016
November's blog was stimulated by a Dark Report about an Australian conference on medical laboratory professionals exploring disruptive forces in healthcare (Further Reading). 

This will be the first in a series exploring disruptive forces that have and still affect, or will affect, the practice of transfusion medicine (TM) and its diverse practitioners. Each blog will deal with one disruptive force and its related aftermaths.

What is this blog about and why might you want to read it? It requires more than the cursory scan you no doubt give most of the info overload you receive daily. But if you want to understand, truly 'dig' current transfusion realities, please consider giving it a read.

Executive version (over the long haul of all the blogs in the series):
  • At heart, the blogs are designed to combat 'BS baffles brains';
  • Because disruption affects all transfusion professionals, I hope you see its relevance to your practice;
  • Sub-aims include being able to 
    • Differentiate disruptive forces from normal progress;
    • Identify beneficial forces from those worth resisting;
    • Make the most of positive disruptive forces to improve patient care and safety.
In the 'management speak' ubiquitous in blood supplier annual reports, the last aim would be to leverage disruption and create a centre that drives not just leading or bleeding edge innovation but innovation that leads to transformative change.  

The blog's title derives from a 1977 ditty by the Brit-US rock band, Fleetwood Mac.

INTRODUCTION
Disruption has been in the news a lot lately given the unexpected UK Brexit vote and Donald Trump's election as US President. A recent search of Google news stories for ''disruptive forces'' yielded 8,830 hits.

For decades now we've seen disruption in many aspects of our daily lives. A few examples, and I bet you can name even more:
  • Personal computers disrupt mainframes;
  • Apple's Macintosh WYSIWYG OS disrupts command-driven MS DOS; 
  • Internet disrupts everything;
  • Cable TV disrupts the networks;
  • Google disrupts libraries and the publishing industry;
  • Streaming services like Netflix disrupt DVD rental stores;
  • Apple's iPod disrupts music industry;
  • Uber disrupts taxis;
  • Airbnb disrupts hotels.
The list is endless. Disruption is big in the business world too, witness a new McKinsey Global Institute (management consulting firm) report, Ordinary Disruption: The Four Forces Breaking All the Trends: (Further Reading).

No doubt disruption is now established as the next big thing. But it's not new. Disruptive forces have affected clinical laboratories for decades. 

DISRUPTIVE FORCES
So what the heck are disruptive forces? The OED defines disruptive as 'innovative or ground-breaking'.

According to the UK consulting firm, Tomorrow Today Global:
A disruptive forces is not a force that results in incremental changes, improving products or services one step at a time. Rather disruptive forces result in a breakthrough or a step change that transforms society forever. Sometimes the disruption is complete and swift. 
The key here is a true disruptive force does not affect change in baby-steps but rather consists of a big step (innovation) that changes things forever. 

DISRUPTIVE FORCE #1: Tainted Blood Massive Screw-up
Being a medical laboratory technologist who became a transfusion science educator, I found it so tempting to begin with - you guessed it -  either laboratory automation or its latest iteration, molecular typing of red cell antigens and its kissin' cousin, personalized medicine. But I've resisted. 

The first blog will discuss the worldwide 'tainted blood' tragedy of the 1980s and '90s, which resulted in the related disruptive forces of 
  • Krever Inquiry (Royal Commission of Inquiry on the Blood System in Canada);
  • Vein-to-vein responsibility for blood transfusion;
  • Government regulation migrating from blood supplier to hospital transfusion services.
The focus will be on Canada because that's what I know best. But I suspect the transmogrification of blood suppliers and hospital transfusion services was similar in other countries, albeit some progressing faster, some slower than Canada. 

Note that I am an oldster (see 'Life as a blood eater' in Further Reading) and my recall is not perfect. If I inadvertently omit significant events or get things wrong, please comment below or e-mail me. My personal take on the highlights of these disruptive forces follows.

BLOOD SUPPLIERS
In Canada, the Krever Inquiry - 1993-1997 (Further Reading) -  resulting from the HIV and HCV 'tainted blood' scandals, had a huge impact on the blood supplier, the Canadian Red Cross Blood Transfusion Service (CRC-BTS). Krever was an earth-shaking disruptive force that eventually resulted in Canada creating two new blood suppliers in 1998

Goodbye CRC-BTS, hello CBS and H-Q!
THE FALL GUY
Think about it. The blood supplier that had managed Canada's blood system from the get-go in the 1940s was to disappear under a cloud of suspicion. 

In exchange for not bringing the case of Canada's tainted blood scandal to trial, the Red Cross pleaded guilty to violating the Food and Drug Regulation Act by distributing a contaminated, drug (Factor VIII concentrate). The $5,000 fine was the maximum penalty for that charge under the Act. 

Other court cases proceeded against individuals but with no convictions:
In effect,the CRC-BTS was the fall guy (not its complicit government paymasters) for the entire tragedy. Two factors at work were the typical physician sin of paternalism and government secrecy. The panacea was to create new organizations at arms-length from government that would be more transparent. 

Only something NEW could restore the faith of Canadians in the blood system. 

The reality was that the new blood suppliers had many of the same transfusion professionals serving as leaders (medical directors), and the trench workers were the same, mainly medical lab technologists performing blood donor testing.  It's not like experienced, skilled personnel were hanging around like low-lying fruit waiting to be picked.

Regulatory Compliance Project
Meanwhile, in the mid-1990s the Canadian Red Cross initiated a Regulatory Compliance Project whereby standard operating procedures (SOPs) to encompass all operations were to be written and used in all CRC-BTS centres. To implement the SOPs and to maintain the system, a training component was included. SOPs were to comply with current Good Manufacturing Practices (cGMP). 

During this time I taught at University of Alberta, but after hours participated as an external consultant in developing training materials. 

It's worth noting that the transition to SOPs and training - a huge undertaking - happened on the 'disgraced' soon-to-disappear Canadian Red Cross's watch.  

HOSPITAL TRANSFUSION SERVICES
Despite the long history of Quality Systemsthe first I became acutely aware of QSE (Further Reading) and their implications for hospital transfusion laboratories was at the CSTM 2000 annual conference in Quebec City. 

The Canadian province of Quebec had created transfusion safety officers (TSO), initially with both a medical technologist and nurse for 20 designated centres.  [Right click and select 'Translate to English']:
In 1999, following the report of the Krever Commission, a complete reorganization in transfusion medicine was initiated in the province of Quebec. To improve transfusion practice, roles and responsibilities were established for the professionals involved in the management of blood products from blood donor to recipient
Ontario, particularly at the McMaster University Medical Centre in Hamilton, had a few TSOs (CSTM blog - Gagliardi: Further Reading) who had become specialists in QSEs and writing standard operating procedures (SOP). 
And it was at this CSTM meeting I learned of the existence of the BC Provincial Blood Coordinating Office (PBCO), Canada's first PBCO, which had been created ~1998. 

A friend (CSTM blog - Chambers: Further Reading) introduced me to its then medical director as a 'geek' who could potentially manage and coordinate resources for its TraQ program (one of the luckiest days of my life).  

Soon I became aware of the extensive help the PBCO gave to transfusion services throughout BC to help with writing SOPs and training materials. The BC PBCO was ahead of the curve - way ahead of the curve. 
It's fair to say that these BC manuals served as templates for transfusion service SOPS written across Canada and perhaps beyond, particularly in developing nations since they were generously shared online.

Then in 2004 - a huge disruption - The Canadian Standards Association (CSA) published its Standards for “Blood and blood components” (also known as Z902-04). I wrote about it for the BC PBCO's Blood Matters newsletter:
INTERNATIONAL ASPECTS
It's worth noting that the UK's blood system, while not having a Krever-style commission until much later, was quite active and early in producing guidelines for transfusion services via the Red Book.

And the UK and Australia were leaders in creating transfusion safety officers: 
In the USA the AABB had its excellent Technical Standards but being AABB accredited was voluntary. Nonetheless, the AABB Standards served as best practice.

As in Canada, the government (FDA) regulated blood suppliers. I'm unaware about the U.S. situation, but in Canada, until the Krever Inquiry report on the tainted blood tragedy, inspections, if they occurred, lacked rigour. That's the politically correct way of saying government oversight of the blood supplier was a joke. For example, in my 13 years at CRC-BTS in Winnipeg, I cannot recall one inspection having happened. Maybe they did but I doubt it. These days, every staff member in a blood centre is ultra-aware when inspections and audits are to occur.

U.S. regulation and accreditation of blood transfusion labs is a quagmire of multiple bodies, e.g., AABB, FDA, CAP, CLIA, The Joint Commission, ISO 15189, COLA, and many others. Perhaps unfair but my best guess of the on-the-ground situation in U.S. hospital labs in the 20th C comes from graduates of the University of Alberta Med Lab Sci program, when so many went to work in the USA in the 1990s due to no jobs in Canada. 

First, U.S. employers loved them, probably because of their solid experience rotating in clinical labs, generally significantly more time than U.S. grads received. Second, I'll never forget their often humorous transfusion anecdotes. One example: 
  • 'My gawd, Pat they don't even label the test tubes for pretransfusion testing.' 
No doubt the situation is much improved today. Also worth noting is that the USA never had an inquiry into tainted blood scandals similar to Krever. And the U.S. was also late to adopt TSOs and hemovigilance.

SO WHAT DISRUPTION OCCURRED?
First, be aware that before Krever even blood suppliers in Canada did not have SOPS or follow cGMPs. I worked for the CRC-BTS for 13 years as a bench technologist, supervisor, and clinical instructor and the methods used to test donated blood were unwritten. Methods used to crossmatch blood for patient transfusion were also unwritten. New staff learned as surgeons traditionally did: 
  • See one, do one, teach one (Further Reading)
  • Sidebar: After 6 months in Jamaica more or less goofing off, and longing for cooler climes, I wanted to return to CRC-Winnipeg but had to first substitute for a vacationing staff member in CRC-Calgary returning to her family in South America for an extended vacation. 
  • Spent one day watching a technologist perform pretransfusion testing (method was quite different than Winnipeg's) and was asked to do one. Afterwards the lab manager asked my supervisor if I could do the job and her reply was, 
    • 'She's good to go.' That was it. I was now the sole night technologist for CRC-Calgary.
The Winnipeg CRC-BTS also performed pretransfusion testing for all city hospitals (unique in Canada) and many rural ones in Manitoba and NW Ontario. 

Re-SOPs, once I became a clinical instructor for Winnipeg CRC-BTS I spent an entire summer holiday writing SOPs for the transfusion lab. None existed and it seemed a good thing to do, not only for staff but also for students during their clinical rotation in the one transfusion service lab in town. 

What follows focuses on the disruptive impact to hospital transfusion services due to vein-to-vein responsibility for transfusion safety.

SOPs and Competency Training - Med Lab Technologists
As noted post-Krever Canada's blood supplier underwent a tremendous disruptive transformation to cGMPs and training. To those who worked pre-Krever, post-Krever was a different universe. 

The disruptive requirement in transfusion services to have written SOPS and related competency training at first, at least in Canada, applied mainly to medical laboratory technologists. This spawned an entire industry, first via government-funded PBCOs and their equivalents and soon by the need for hospitals or health regions to hire TSOs to educate and train the 'trench workers', whether technologists or the nurses who administered blood transfusions.   

The cost to the public purse was huge (new PBCOs and TSOs), as was the disruption to the daily lives of affected professionals. But having SOPs and training was wonderful because 
  1. They standardized lab methods - learning no longer depended on who taught you.
  2. Your competency - knowledge and practical skills - were documented;
  3. The system became much safer.
Some, like the USA's talented Lucie Berte capitalized and built a successful career around QSEs and SOP development with diverse global clients.

SOPs and Competency Training - Nurses
Soon nurses - those who administer blood transfusion - were affected by the disruption of regulatory requirements. Indeed, hemovigilance programs (also a disruptive force) such as the UK's SHOT show that many errors continue to be clinically related due to human error failing to ensure 'right blood to right patient' at the bedside. 

Checklists and clinical audits of administering blood transfusions are now the norm in many locales. But SOPs and checklists only work if humans follow them.

SOPs and Competency Training - Physicians
The one profession seemingly least affected by the disruption of regulatory requirements are the clinicians (physicians) who prescribe blood transfusion. Blood supplier medical directors, and especially transfusion service medical directors, are affected because they are ultimately responsible for ensuring patient safety. 

Physicians continue to receive minimal education in transfusion medicine (typically a few hours as medical students). Ordering practices may be somewhat controlled and monitored by computerized test-order-entry systems requiring laboratory data to justify ordering blood products and hospital transfusion committees. But do physicians actually do this or do they often leave an order for ward staff to perform? 

In some jurisdictions, more rigorous monitoring of expensive blood products such as IVIg exists. 

But from all I know, despite such monitoring, if physicians want a blood product, they usually get it despite poor clinical indications, especially if they are 'grand poo-bahs' in their hospital. 

That said, blood education is ongoing and jurisdictions such as the NHSBT's Patient Blood Management program report good progress.

SAY WHAT?
I've heard from colleagues that transfusion-related SOPS may have run amok in some locations. Specifically, they now include so many steps and documentation requirements that medical laboratory technologists can get lost in the trees and lose sight of the forest. It's complicated by centralized laboratories in which even staff in the main lab automatically default to asking the transfusion specialist to handle any problem, large or small. But that's a topic for another blog. 

Main point is that too much of a good thing can quickly go wrong.

SUMMARY
In Canada the tainted blood scandal was a disruptive force that led to the Krever Inquiry and the creation of two new blood suppliers as well as the related disruptive force of government regulation, resulting in vein-to-vein monitoring of the entire blood system and the creation of SOPs and competency training for most involved in blood transfusion. 

I say for most because the one profession that's been least affected are the physicians who order blood components and products. They've been affected, more or less so, depending on their locale, but 'least' is the operative word. Correct me if I'm wrong. Why do physicians largely merit a get-out-of-jail-free pass on blood transfusion? 

Medical laboratory technologists and nurses receive SOP training and must show competency before they can perform tasks independently. Every aspect of their technical and clinical job performance is regularly audited. Physicians not so much...

Canadian Blood Services has a great resource, its Clinical Guide to Transfusion. The first chapter explains everyone's responsibilities:
The ordering clinician's first duty is 'To carefully assessing the clinical need for each order'. How effectively is this monitored, I wonder? 

Because of a tragedy that killed 1000s, life as transfusion professionals changed forever in the 1990s. In Canada, the Krever Inquiry led to government regulation requiring SOPs and competency training, which eventually extended to vein-to-vein monitoring of the blood system.

These disruptions were good for all concerned and promoted patient safety, because that's what it's ultimately all about. 

As always, comments are most welcome.

FOR FUN
Couldn't resist this 1977 song by Fleetwood Mac, written by Christine McVie, which became the campaign song of Bill Clinton in the1992 US Presidential election. 
Don't stop, thinking about tomorrow,
Don't stop, it'll soon be here,
It'll be, better than before,
Yesterday's gone, yesterday's gone.
Don't you look back.

FURTHER READING

Dark Daily: In Sydney, Australia, Medical Laboratory Professionals Gather to Explore Disruptive Forces in Healthcare and How Labs Are Using Innovation and New Leadership Approaches to Successfully Transition to Value-Based Care

CSTM blogs - I will remember you:
Canada's Krever Inquiry

Life as a blood eater

Quality System Essentials (in brief)

Kotsis SV, Chung KC. Application of the "see one, do one, teach one" concept in surgical training. Plast Reconstr Surg. 2013 May;131(5):1194-201. 

Monday, May 23, 2016

The In Crowd (Musings on the relevance of transfusion journals)

Stay tuned because updates will occur
May's blog was stimulated a long time ago but returned to me recently when I was cleaning house and tossed out (recycled) several thick issues of the AABB journal Transfusion, which were piled on my computer desk, largely unread after scanning content indices.

The blog's title derives from a 1965 jazz instrumental by the Ramsey Lewis Trio.

Musings focus on the articles I read in Transfusion's May 2016 issue and what this says about the journal's relevance to someone with a medical laboratory technology/science background (me). For context, traditional measures of a journal's relative importance and Transfusion's top 10 cited articles are also discussed. 

The questions I hope to answer: 
  1. What value is the AABB journal to practicing transfusion professionals (as opposed to its value to authors/researchers)?
  2. Why am I (and presumably everyone) getting a paper version of the journal and not being given an option for an e-journal only?
  3. What would my AABB membership fee be if all the costs associated with a paper version of Transfusion were eliminated?
  4. What factors should affect a journal's overall relevance and importance?
The blog is written from a medical laboratory technology perspective, as that's my background, but the issues also relate to nursing and physicians. Regardless of where you live, please ask similar questions of your professional association's journal. For example, 
  • How many papers do you typically read in your transfusion-related professional journal and where - at work on breaks, at home? 
  • Do you scan titles only or a combination titles, authors and abstracts? 
  • Which criteria determine whether you will read a given article?
  • In deciding what to read, how important is an article's direct relevance to your daily work?
  • How many articles, if any, do you read just for curiosity or fun?
Sometimes I wonder of journals even matter anymore but of course they do. And I miss the days when transfusion services regularly held journal clubs during lunch hours, often based on journal articles or conferences, in which all staff participated.

To promote continuity of the blog's ideas, consider reading the blog in its entirety and then return to access linked resources. Bet you can't.

1. AABB JOURNAL 'TRANSFUSION' - BRAGGING RIGHTS

So to begin, here's how most journals measure their worth. On its homepage, Transfusion gives its ISI journal citation ranking under the medical specialty, hematology, as well as its Impact Factor. Both are intended to show the relative importance of individual journals. 

In 2014 Transfusion's ISI Journal Citation Reports© Ranking was 23/68 and its Impact Factor was 3.225. 

So what do ISI Journal Citation Reports© (JCR) Ranking and Impact Factor (IF) mean?
  • JCR Ranking claims to objectively critically evaluate the world's leading journals using statistics. Uh-oh! That's a red flag if there ever was one. Just kidding because, as with any statistical data, users need to use their noggins to assess validity. 
    • With a JCR rank of 23/68, my guess is that Transfusion ranks no. 23 of 68 journals and is in the top third of most hematology journal citations (two-thirds of similar journals have fewer overall citations, whatever complicated statistics are used).
  • Impact Factor is the average number of annual citations recent journal articles have and obviously the higher, the better. As such, it's a proxy for the relative importance of a journal in its field. 
    • With an IF of 3.225, recent Transfusion articles were cited an average of just over 3 times in a year.
But similar to surrogate tests such as elevated ALT and anti-HBc used to screen blood donors for non-A, non-B hepatitis before HCV was identified, issues exist for how well Impact Factors measure relative importance.

For interest, The Impact Factor was devised by Eugene Garfield, who explains its history in a 2006 JAMA article.
As an aside,  I love Garfield, because in my early pre-Internet years in Medical Laboratory Science, MLS subscribed to Current Contents, which I always enjoyed and looked forward to reading. If my memory is correct, each issue began with a fascinating Garfield comments/editorial. [See Further Reading]
2. TRANSFUSION'S TOP 10 CITED ARTICLES
Since 1975 I've been an AABB member and once read 90%+ of Transfusion's articles, but mostly for interest, not because they directly related to my work. 

Most reading was done because I'm curious and love transfusion medicine. After becoming an educator, motivation included the potential to discover 'juicy' tidbits that would interest or amuse students, and Transfusion's articles often did. 

In today's hectic and understaffed work environment, I wonder which of Transfusion's top 10 articles would be read during leisure time, on breaks or after hours, by 
  • Clin lab technologists/scientists in a blood supplier or transfusion service laboratory? 
  • Transfusion and blood conservation RNs?
  • Hematologists/hematopathologists?
I suspect that not many in these three professions would read 3, 7 and 9 below, which is good because only 30% un-read is excellent. As an experiment, please assess which of the following you would read. I've linked the PubMed abstract for each article. 

Please think about which criteria helped decide whether you would read an article or not.

Transfusion's Top Ten Cited Articles: [Author's work location/country]

1. Activity-based costs of blood transfusions in surgical patients at four hospitals. (Shander A, et al) 2010;50:753-65. [USA]

2. Transfusion of older stored blood and risk of death: A meta-analysis. (Wang D, et al) 2012;52:1184-95. [USA]

3. Pathogen inactivation and removal methods for plasma-derived clotting factor concentrates. (Klamroth R, et al) 2014; 54:1406-17. [Germany]

4. Is fresh-frozen plasma clinically effective? An update of a systematic review of randomized controlled trials. (Yang L, et al) 2012;52:1673-86. [UK]

5. Fibrinogen as a therapeutic target for bleeding: A review of critical levels and replacement therapy. (Levy JH, et al) 2014; 54:1389-1405. [USA]

6. Duration of red blood cell storage and survival of transfused patients. (Edgren G, et al) 2010;50:1185-95. [Sweden]

7. Storage lesion: Role of red blood cell breakdown (Kim-Shapiro DB et al) 2011;51:844-51. [USA]

8. The use of fresh frozen plasma in England: High levels of inappropriate use in adults and children. (Stanworth S et al) 2011;51:62-70. [UK]

9. Adoptive transfer and selective reconstitution of streptamer-selected cytomegalovirus-specific CD8+ T cells leads to virus clearance in patients after allogeneic peripheral blood stem cell transplantation. (Schmitt M et al) 2011;51:591-9. [Germany]

10. Transfusion-associated circulatory overload after plasma transfusion. (Narick C, et al) 2012;52:160-5. [USA]

So, what's your health profession and  how many of these top cited papers would you have read? Be honest. As both a lab technologist in the trenches and an educator, I'd have read all but #9.  

3. TRANSFUSION'S MAY 2016 ISSUE
Below are three papers I read in the May issue of Transfusion (Volume 56, Issue 5,pp. 1001–1249) that directly relate to my prior career as a med lab tech/scientist and educator. Yes, only three and I read them out of interest. These days,although retired from real work, my time is even more precious. 

The journal sections each paper is under are included. I've summarized each with a 'So What?' conclusion.

1. TRANSFUSION MEDICINE ILLUSTRATED (pp.1006–7)
Delayed hemolytic transfusion reaction captured by a cell phone camera.Margaret E. Gatti-Mays, S. Gerald Sandler [USA]
So what? The delayed hemolytic reaction was due to anti-Jka and shows a photo of the peripheral blood smear with multiple microspherocytes. Authors encourage physicians to use cell phone cameras to photograph peripheral blood smears and use them in clinical presentations. 
2. IMMUNOHEMATOLOGY (pp. 1182–4)
Anti-Mur as the most likely cause of mild hemolytic disease of the newborn. Sara Bakhtary, Anastasia Gikas, Bertil Glader, Jennifer Andrews [USA
So what? Full term infant had jaundice presumed to be due to anti-Mur, an antibody more commonly found in Asian patients in the USA, and one important to recognize since the Mur+ phenotype has a higher prevalence in this population.
3. LETTER TO EDITOR (pp.1247–8)
Sustained and significant increase in reporting of transfusion reactions with the implementation of an electronic reporting system. Rosanne St Bernard, Matthew Yan, Shuoyan Ning, Alioska Escorcia, Jacob M. Pendergrast, Christine Cserti-Gazdewich [Canada]
So what? In 2009 the authors transitioned from a paper-based to an electronic reporting system (ERS) for suspected transfusion reactions. The user-friendly process did not result in “junk inflations”. Instead reporter suspicions generally concurred with specialist conclusions. Accordingly, they endorse using an ERS for transfusion reaction reporting to improve hemovigilance.
ANSWERING THE QUESTIONS
Here are my answers  - conditioned by my professional experience and biases - to the questions posed about Transfusion. Your answers may differ and likely will.

Q1What value is the AABB journal to practicing transfusion professionals (as opposed to its value to authors/researchers)?
A: Transfusion has value as a good read for anyone who's curious on current 'hot' clinical issues and to educators who must keep up-to-date with the latest and greatest, including esoteric research, which may or may not ultimately translate into something useful to practitioners.
The journal's relevance to the day-to-day working lives of medical laboratory technologists/scientists in laboratories is minimal. Most papers relate to clinical practice (MDs, RNs) or research (PhDs).
Q2Why am I (and presumably everyone) getting a paper version of the journal and not being given an option for an e-journal only?
A: Transfusion is a glossy journal that costs many trees to produce, plus mailing costs, which are not insignificant. I don't need or want a paper copy.  
It's published monthly, plus has supplements of Annual Meeting abstracts and others such as conference proceedings. That's a lot of paper.
For May's issue I read only 7 of 248 pages, ~2.8%, which related directly to my work. And some issues have even fewer articles relevant to my needs and interests.
Q3What would my AABB membership fee be if all the costs associated with a paper version of Transfusion were eliminated?
A: My 2016 AABB membership cost $124 USD, which at the time I paid was $170.27 CDN. Sure, membership is a good deal, less than 50 cents/day.
But how much of this does AABB pay per member to Transfusion's publisher, Wiley? Darned if I or any member knows.
Academic publishers such as Wiley and its subsidiaries, e.g., Wiley-Blackwell,  surely make most money from advertisers and libraries. It's interesting that they've been under pressure recently for being an oligarchy that gouges cash-strapped university and college libraries. [See Further Reading]
Q4. What factors should affect a journal's overall relevance and importance?
A. To me, Transfusion's relevance should relate not only to its citation ranking or impact factor. Rather, a key factor is how many articles in each issue busy transfusion professionals will actually read because they relate to their day-to-day jobs.   
Yes, it's easy to dismiss my views because immunohematology (beloved to med lab techs/scientists) is a dying art and increasingly irrelevant. But how many papers in the 2016 May issue would time-strapped nurses and physicians read in their spare time? You decide.
Transfusion comes with AABB membership. Shouldn't its content reflect the needs of ALL members, at least according to their membership percentage?
SUMMARY
Just a few of the many issues I'd love AABB to address:

1. AABB, please allow members to opt out of receiving a paper copy of Transfusion and please decrease membership fees accordingly. 

2. AABB seems an association mainly for physicians. Is it? Why does its journal offer only continuing MEDICAL education credits for reading select articles and successfully completing a test on the content? I think I know why...

Cannot help but wonder what percentage of AABB's membership constitutes physicians vs PhD researchers vs medical lab scientists vs nurses vs administrators. Transparency please. We'd love to know.

3. Never mind med lab technologists/scientists, how about more Transfusion articles relevant to nurses? They increasingly play a key role in our profession. 

Of course, I know from experience that asking AABB or any large organization such questions is pretty much useless and akin to pissing in the wind. Would love to be proven wrong.

FOR FUN
I decided to use 'The In Crowd' in the blog's title for these reasons:

1. It's a laid-back, simple tune that's easy to listen to. Indeed, over the years I've listened to it for many hours because I bought the Ramsey Lewis album of the same name many moons ago. 
2. Although it's an instrumental version, the lyrics fit with the blog's theme of promoting a journal based on its relative ranking and impact. Hey dude, don't ya wanna publish in the 'In Crowd' journal Transfusion?
I'm in with the in crowd.
I go where the in crowd goes.
I'm in with the in crowd.
And I know what the in crowd knows.
Tidbit: I've got this album somewhere if I could only recall where I stashed the few 331⁄3 rpm vinyl records I've kept.  
  • The In Crowd (The Ramsey Lewis Trio vinyl album, recorded live at the Bohemian Caverns in Washington, D.C. in 1965)
As always, comments are most welcome. 

FURTHER READING
Academic publishers reap huge profits as libraries go broke (CBC, June 15, 2015) 
Larivière V, Haustein S, Mongeon P. The oligopoly of academic publishers in the digital era. PLoS ONE 10(6): e0127502. E-pub: June 10, 2015 (Free full text)
Just for fun
Confession: I've included these just so I have a record and can read on some long winter nights.

The writing of Eugene Garfield, including
Essays of an Information Scientist:1962 - 1973 
Essays of an Information Scientist:1974 - 1976 
Essays of an Information Scientist:1977 - 1978 
Ex:  Humor in Scientific Journals and Journals of Humor

Sunday, November 15, 2015

Look what they've done to my song, Ma (Musings on misuse of Twitter)

Updated: 16 Nov. 2015
November's blog was motivated by monitoring the AABB's twitter account during and after the 2015 Annual Meeting in October. 

The blog's title derives from a 1970 ditty by Melanie Safka, known professionally as Melanie. 

As an AABB member since 1975 (40 years), and being an early adopter of social media (mailing lists as of 1994 and Twitter since 2011), I'm naturally interested in how professional associations use social media. [FYI: Tried Facebook and hated it.] 

Be aware that you can follow Twitter accounts without being on Twitter. It's a good way to keep current on the latest transfusion news. Just bookmark (favorite) an account and visit daily, weekly, whatever suits your needs.

Why read the blog? Maybe to see what Twitter's all about? Or  how you as an individual or member of a transfusion-related professional association may want to use it to benefit the profession? To read the blog takes 5-10 minutes out of a 1440 minute 24 hours (maximum of ~0.7%).

AABB BACKGROUND
For interest, the AABB is one of the largest transfusion medicine related professional associations in the world, if not the largest, at least in the West. A few statistics from AABB's 2014 Annual Report:

AABB has more than 5000 members:
  • 5,420 Health Care Professionals
  • 1,294 Physicians
  • 149 Residents
  • 29 e-Members
  • 298 Emeritus Members
I'd guess non-physician AABB individual members are mostly medical laboratory technologists/scientists.

AABB's Transfusion had almost 500,000 articles downloaded. That's impressive and I'm curious who's doing all the downloads.

AABB revenue ($US) from 
  • Dues: $3,084,744
  • Annual meeting: $3,956,264
  • Print sales: $2,577,601
  • Education: $5,065,813
Let's agree that AABB is a huge professional association. If you read the annual report, you will see that expenses are also large.

AABB MEETING/POST-MEETING TWEETS
With that as background, let's examine recent @AABB activity. Tweets during the annual meeting, Oct. 24-27, 2015, are summarized as follows. Non -substantive tweets are those that are 'me too' or thanks.

Day (Date): Number of tweets (n,% non-substantive)
Day 1 (Oct. 24): 47 (7, 15%)
Day 2 (Oct. 25): 48 (9, 19%)
Day 3 (Oct. 26): 29 (3, 10%)
Day 4 (Oct. 27): 30 (7, 23%)
Total = 154
Average tweets each day = 38.5. Non-substantive tweets over 4 days: ~17%
Post-meeting (28 Oct. - 14 Nov)
17 days of tweets: 32 tweets with 11 thanks 
Average tweets each day = 1.8. Non-substantive tweets over 17 days: ~34% 
See @AABB 2015 Annual Meeting tweets  (Non-substantive tweets in pale green)

NOTE: You can access tweets that include https:// as follows:
  • Highlight the URL, e.g., https://t.co/WAox1aGgm8 in the first tweet 
  • Don't include the "
  • Right click highlighted text
  • Select 'Go to https://t.co/WAox1aGgm8'
So what do AABB's tweets reveal about how health-related professional associations use Twitter?

MUSINGS
Twitter's Background
First, be aware that Twitter  - founded in 2006 - is a relative Johnny-come-lately to social media. Twitter didn't take off until years later and Twitter's 500 million users pale compared to Facebook's claimed 1 billion+ users. 

Twitter is popular, even indispensable in crises, because you discover what's happening before it's on live news channels. Indeed, news media now identify what's happening via Twitter. During the latest Paris terrorist attacks, I saw breaking news on Twitter before it appeared on CBC, BBC, CNN. 

Yet, many health professionals do not use Twitter at all. They learned Facebook and are unwilling to endure Twitter's learning curve. Plus many see Twitter's 140 character limit as meaning it's mickey mouse, only about tweeting what you had for breakfast, as if anyone cares.

Indeed, many professional associations do not know how to use Twitter to maximum advantage, likely because they see it of minimal value, albeit something they need to do if they want to be considered 'with it'. 

AABB vs Other Associations
As a large organization, AABB has a relatively active Twitter account compared to much smaller transfusion medicine associations, those with fewer resources, such as BBTS  and CSTM, both of which tend to post more substantive tweets. To my knowledge, ANZSBT isn't on Twitter.

Designated Person Tweeting
I know from one of my Twitter accounts, @transfusionnewsthat tweeting substantive news to interest others requires time, effort, and discernment. It definitely helps to have the time and motivation to share significant 'goodies' but especially to have a transfusion background.

Would love to know who tweets for AABB. A paid staff member? Transfusion background required? What guidelines, if any, are provided regarding suitable content and frequency?

Bottom Lines
AABB is to be commended for maintaining an active Twitter account. That many tweets thank folks is also commendable and creates goodwill. 

But...and there's always a 'but' in my blogs...If I were tweeting for AABB, I'd include many more substantive tweets. Many of the @AABB tweets that I did not categorize as 'me too' and 'thanks' were not particularly substantive. 

What do I mean by 'substantive'? Tweets that are significant and meaningful to users and useful in their professional lives. Information and resources they didn't otherwise know about and are grateful for.

Because that's the beauty of Twitter. Despite it's 140 character limit, it's a wonderful medium for disseminating useful information quickly to many users. Yes, it should be fun and foster goodwill but mostly distribute information to those interested. That's one of Twitter's key strengths. 

Another is Twitter's ability to provide feedback and opinions. Yet few professional organizations use it for that. For example, I've never seen a professional organization use a poll or ask followers important questions. 

Yes, AABB's tweets during its annual meeting and thereafter were touch-feely but disappointed. From a huge organization I expect more. 

As Napolean said, 'If you're going to take Vienna, take Vienna'. Similarly, if you're on twitter, use it wisely to good advantage.

FOR FUN
This song written and recorded by Melanie Safka for her 1970 'Candles in the Rain' album fits the blog because it expresses how I feel about professional associations that misuse Twitter. 

Not abuse, just misuse. The blog is meant to be food for thought for how we can all improve our tweets so that busy professionals find them more useful.

Need I mention that I love this song for its clever lyrics?
Or try this fun duet: 
Look what they done to my song, ma.
Look what they done to my song.
Well it's the only thing
That I could do half right
And it's turning out all wrong, ma.
Look what they done to my song.

As always, comments are most welcome.

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